ANATOMY AND PHYSIOLOGY Functions of the gastrointestinal (GI) system:

* Process food substances

* Absorb the products of digestion into the blood

* Excrete unabsorbed materials

* Provide an environment for microorganisms to

synthesize nutrients, such as vitamin K

Mouth Contains the lips, cheeks, palate, tongue, teeth,

salivary glands, muscles and maxillary bones

• Saliva contains the amylase enzyme (ptyalin)

that aids in digestion

• Mechanical and chemical digestion originate here

Esophagus A muscular tube, about ten inches long

Carries food from the pharynx to the stomach

Upper esophageal sphincter (UES)

Lower esophageal sphincter (LES)

Stomach A hollow muscular pouch

Secretes pepsin, renin, lipase, mucus and hydrochloric

acid for digestion

• Mixes and stores chyme

• Secretes intrinsic factor necessary for absorption of

vitamin B12

Small Intestine (3) Main Functions:

Movement (mixing & peristalsis)

Digestion of food

Absorption of nutrients

Small Intestine Duodenum: Contains the openings of the bile and

pancreatic ducts and is approximately 12 inches long

Jejunum: Approximately 8 feet long

Ileum: Approximately 12 feet long

Terminates into the cecum

Small Intestine Chyme, in liquid or semiliquid form, enters the

duodenum through the pyloric sphincter

Bile and pancreatic secretions enter the duodenum through the common bile duct

Large Intestine (3) Main Functions:

Movement

Absorption

Elimination

Large Intestine Consists of the cecum, colon, rectum and anus

Absorbs fluids, synthesizes Vitamin K using intestinal bacteria and stores fecal material

Chyme becomes more solid as the intestinal wall of the colon absorbs water and wastes

Defecation is the movement of feces from the rectum through the anal sphincter

Approximately 5 to 6 feet in length

Large Intestine (Colon) Ascending

Transverse

Descending

Sigmoid

Rectum

Assessment Findings History

Culture

Inadequate diet

Change in bowel habits

Constipation

Diarrhea

Flatus

Assessment Findings Cont. Indigestion/heartburn

Abdominal pain

Dysphagia

Loss of appetite

Unintentional weight loss or gain

Objective Data Associated With GI Disorders

Weight changes

Abnormal color and consistency of stool

Melena

Clay-colored stool

Frothy stools

Occult blood in stool

Abnormal bowel sounds

Objective Data Associated With GI Disorders

Abdominal distention

Rectal bleeding

Jaundice

Edema

Hematemesis

Anorexia

Changes in skin

Diagnostic Tests And Procedures Upper GI tract study (barium swallow):

Teaching preprocedure ?

Teaching postprocedure?

Diagnostic Tests And Procedures Lower GI tract study (barium enema)

Teaching preprocedure?

Teaching postprocedure?

Diagnostic Procedures Upper GI fiberoscopy:

Esophagogastroduodenoscopy (EGD)

Following sedation, an endoscope is passed down the esophagus to view the gastric wall, sphincters and duodenum; tissue specimens can be obtained

Diagnostic Procedures Pre-procedure:

NPO for 6 to 8 hours prior to the test

A local anesthetic (spray or gargle) is administered along with midazolam (Versed) which provides conscious sedation and relieves anxiety just before the scope is inserted

Atropine may be administered to reduce secretions and glucagon may be administered to relax smooth muscle

Diagnostic Procedures Client is positioned on the left side to facilitate saliva

drainage and to provide easy access of the endoscope

Airway patency is monitored during the test and pulse oximetry is used to monitor oxygen saturation; emergency equipment should be readily available

Diagnostic Procedures Post-procedure:

NPO until the gag reflex returns (1 to 2 hours)

Monitor for signs of perforation (pain, bleeding, unusual difficulty in swallowing, elevated temperature)

Maintain bed rest for the sedated client until alert

Lozenges, saline gargles, or oral analgesics can relieve minor sore throats after the gag reflex returns

Diagnostic Procedures Proctoscopy and Sigmoidoscopy: Use of a flexible

scope to examine the rectum and sigmoid colon; client is placed on the left side with the right leg bent and placed anteriorly

Biopsies and polypectomies can be performed

Pre-procedure: Enemas until the returns are clear

Post-procedure: Monitor for rectal bleeding and signs of perforation

Diagnostic Procedures Fiberoptic Colonoscopy:

A fiberoptic endoscopy study in which the lining of the large intestine is visually examined; biopsies and polpectomies can be performed

Cardiac and respiratory function is monitored continuously during the test

Performed with the client lying on the left side with the knees drawn up to the chest; position may be changed during the test to facilitate passing of the scope

Diagnostic Procedures Pre-procedure:

Adequate cleansing of the colon is necessary as prescribed by the physician

A clear liquid diet is started 12-24 hours before procedure

NPO 6-8 hours before procedure

Midazolam (Versed) IV is administered to provide sedation

Diagnostic Procedures Post-procedure:

Provide bed rest until alert

Monitor vital signs

Monitor for signs of perforation

Instruct the client to report any bleeding to the physician

Instruct client may experience abdominal fullness and cramping even a few hours after

Diagnostic Procedures Laparoscopy:

Performed with a fiberoscopic laparoscope that allows direct visualization of organs and structures within the abdomen; biopsies may be obtained

Diagnostic Procedures Paracentesis:

Transabdominal removal of fluid from the peritoneal cavity for analysis

Diagnostic Procedures Pre-procedure:

Obtain informed consent

Void prior to the start of procedure to empty bladder and to move bladder out of the way of the paracentesisneedle

Measure abdominal girth, weight and baseline vital signs

Client is positioned upright on the edge of the bed with the back supported and the feet resting on a stool

Diagnostic Procedures Post-procedure:

Monitor vital signs

Measure fluid collected, describe and record

Label fluid samples and send to the lab for analysis

Apply a dry sterile dressing to the insertion site; monitor site for bleeding

Diagnostic Procedures Measure abdominal girth and weight

Monitor for hypovolemia, electrolyte loss, mental status changes or encephalopathy

Monitor for hematuria resulting from bladder trauma

Instruct the client to notify the physician if the urine becomes bloody, pink or red

Fecal Occult Blood Test Lab test using a reagent

Analysis for blood in stool

Blood Tests CBC

PT

Electrolytes

AST, ALT, Amylase, Lipase, Bilirubin

Abdominal Assessment Inspect for skin color, symmetry and abdominal

distention

Auscultate for bowel sounds

Percuss for air or solids

Palpate for tenderness

Bowel Sounds Auscultate bowel sounds before percussion and

palpation

Normal bowel sounds occur 5 to 30 times a minute or every 5 to 15 seconds

Auscultate in all abdominal quadrants

Listen at least one full minute in each quadrant before assuming sounds are absent

GI Pharmacologic Management Proton Pump Inhibitors

Antacids

Histamine H2 Receptor Antagonists

Anticholinergics

Mucosal Barrier Fortifiers/Cytoprotectants

Prostaglandin Analogues

Antiemetics

Laxatives/Bowel Cleansers *Antimicrobials

Antidiarrheals *Prokinetics

Gastroesophageal Reflux Disease (GERD)

Definition:

Backflow (reflux) of gastric or duodenal contents into the esophagus and past the lower esophageal sphincter(LES)

GERD (Etiology) Impaired LES

Increased intra-abdominal pressure (obesity, pregnancy, constricting waistline, bending over and ascites)

Alcohol ingestion

Smoking

GERD (Etiology) Cont. Gastric distention from large meals

Delayed gastric emptying

Certain foods

Nasogastric tube placement

Meds- calcium channel blockers, anticholinergics and nitrates

GERD Pathophysiology Reflux occurs when LES pressure is deficient or when

pressure within the stomach exceeds LES pressure (heartburn)

Acidic contents cause injury and inflammation to esophageal mucosa

GERD (Assessment Findings) Dyspepsia (pyrosis or heartburn) in epigastric region,

may radiate to jaw or arms, occurs after meals

Pain worsens with lying down or bending over

Hypersalivation

Regurgitation

Dysphagia and Odynophagia

Belching

Nausea

GERD Diagnostic Tests Esophageal acidity 24 hour test- reveals reflux

Endoscopy- allows visualization and confirmation of pathologic changes in the mucosa

Esophageal manometry- evaluates LES pressure

GERD Medical Management:

Diet- small frequent meals, avoid meals before bedtime

Diet therapy

Position upright during and after meals, sleep with HOB elevated

Smoking/Alcohol Cessation

GERD (Drug Therapy) Inhibit gastric acid secretion

Accelerate gastric emptying

Protect the gastric mucosa

Examples:

Antacids- Maalox

H2-antagonists- Tagamet, Zantac

Proton pump inhibitors- Prilosec, Prevacid

Prokinetics- Reglan

GERD

WHAT IS A SERIOUS COMPLICATION OF GERD?

GERD NURSING INTERVENTIONS???

(Health Promotion to avoid surgery)

GERD Procedures Endoscopic therapies:

Stretta procedure

BESS procedure

Surgical Procedure:

Laparoscopic Nissen Fundoplication (LNF)

Hiatal Hernia Also known as esophageal or diaphragmatic hernia

A portion of the stomach protrudes or herniatesthrough the diaphragm and into the thorax

It results from weakening of the muscles of the diaphragm and is aggravated by factors that increase abdominal pressure, such as pregnancy, ascites, obesity, tumors and heavy lifting

Sliding vs. Rolling

Hiatal Hernia Complications include ulceration, hemorrhage,

regurgitation and aspiration of stomach contents, strangulation, and incarceration of the stomach in the chest with possible necrosis or peritonitis

Hiatal Hernia Assessment Findings:

Heartburn

Regurgitation or vomiting

Dysphagia

Feeling of fullness

Pain

Belching

Hiatal Hernia Implementation:

Medical and surgical management is similar to that for GERD

Provide small, frequent meals and minimize the amount of liquids

Advise the client not to recline for several hours after eating

Nissen procedure, if needed

Esophageal Cancer Usually squamous cell or adenocarcinoma

Commonly found in the upper third of the esophagus

Early spread to the lymph nodes is common

Esophageal Cancer (Silent Tumor) Contributing factors include:

Heavy use of tobacco and alcohol

Chronically low intake of fresh fruits and vegetables

Chronic irritation- GERD or chronic gastritis

Obesity

Malnutrition

Esophageal Cancer Assessment Findings:

Dysphagia

Odynophagia

Feeling of food sticking in throat

Nocturnal aspiration

Regurgitation

Esophageal Cancer Assessment Findings Cont.:

Eventually inability to swallow liquids

Changes in bowel habits

Chronic cough with increasing secretions

Nausea/Vomiting

Anorexia

Weight loss

Esophageal Cancer- Diagnostics Barium Swallow- (done first)

EUS- (definitive)

EGD

PET Scan

CT Scan

Esophageal Cancer Treatment:

Nutrition therapy

Swallowing therapy

Antineoplastic agents, radiation or combo

Photodynamic therapy

Esophageal dilation

Surgery to resect tumor

Gastrotomy to maintain nutrition

Esophageal Cancer Nonsurgical Management???

Esophageal Cancer Surgical Management:

Esophagectomy- the removal of all or part of the esophagus

Esophagogastrostomy- the removal of part of the esophagus and proximal stomach

Esophageal Cancer Preoperative Care: (Teaching)

Stop smoking

Nutritional support (supplementation)

Monitor weight

Monitor I & O

Meticulous oral care

TCDB

Esophageal Cancer Preoperative Care: (Teaching) Cont.

Post-op respiratory care

The number and sites of all incisions and drains

The placement of a jejunostomy tube

May need chest tubes

The need for IV infusion

The purpose of the NG tube

WHAT ARE NASOGASTRIC TUBES USED FOR?

Esophageal Cancer

THE PATIENT WILL HAVE AN NG TUBE DURING THIS SURGERY, WHY?

Esophageal Cancer NURSING INTERVENTIONS FOR NG TUBE AFTER

SURGERY???

Esophageal Cancer NURSING INTERVENTIONS AFTER SURGERY???

Esophageal Cancer DISCHARGE INSTRUCTIONS AFTER SURGERY???

Gastritis Inflammation of the stomach or gastric mucosa

Acute: caused by the ingestion of food contaminated with disease-causing microorganisms or food that is irritating or too highly seasoned, the overuse of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDS), excessive alcohol intake, local irritation from radiation therapy, caffeine, the bacteria Helicobacter Pylori

Gastritis Chronic: caused by benign or malignant ulcers, or by

the bacteria Helicobacter pylori; may also be caused by autoimmune diseases, dietary factors, medications, alcohol, smoking, or radiation

The result is hypermotility of the GI tract, leading to altered secretions of fluids and electrolytes

Increased risk for gastric cancer

Gastritis (Acute) Assessment Findings:

Rapid onset of epigastric pain or discomfort

Nausea and vomiting

Hematemesis

Gastric hemorrhage

Dyspepsia

Anorexia

Gastritis (Chronic) Assessment Findings:

Vague complaint of epigastric pain that is relieved by food

Anorexia, Nausea or Vomiting

Intolerance of fatty and spicy foods

Vitamin B12 deficiency/pernicious anemia

Gastritis Diagnostic Test:

EGD with biopsy

Surgical Intervention- None

* Unless bleeding or ulceration (partial gastrectomy, pyloroplasty, vagotomy or total gastrectomy)

Gastric Surgery Descriptions:

Vagotomy- surgical ligation of the vagus nerve to decrease the secretion of gastric acid

Pyloroplasty- enlarges the pylorus to prevent or decrease pyloric obstruction, thereby enhancing gastric emptying

Gastroduodenostomy- (Billroth I)- surgical removal of the lower portion of the stomach with anastomosis of the remaining portion of the stomach to the duodenum

Gastric Surgery Gastrojejunostomy- (Billroth II)- partial gastrectomy

with remaining segment anastomosed to the jejunum

Esophagojejunostomy- (Total Gastrectomy)- surgical removal of the entire stomach with a loop of the jejunum anastomosed to the esophagus

Gastritis NURSING INTERVENTIONS???

Peptic Ulcer Disease (PUD) An ulceration in the mucosal wall of the stomach,

pylorus, duodenum, or esophagus, in portions that are accessible to gastric secretions; erosion may extend through the muscle

May be referred to as gastric, duodenal, or stress ulcers, depending on location

The most common peptic ulcers are gastric ulcers and duodenal ulcers

Peptic Ulcer Pathophysiology:

Increased emptying time of gastric acid from the gastric lumen into the small intestine causes an inflammatory reaction with tissue breakdown

Combination of hydrochloric acid and pepsin destroys gastric mucosa

Peptic Ulcer Causes:

Drug induced: NSAIDS, ASA, Corticosteroids, etc.

Infection- Helicobacter pylori

Smoking

Alcohol abuse

Gastritis

Caffeine

Stress

Gastric Ulcers Assessment Findings:

Gnawing, sharp pain in or left of the midepigastricregion 30-60 minutes after eating

Hematemesis

Pain that is increased from eating

Duodenal Ulcers Assessment Findings:

Burning pain one and a half to three hours after eating and during the night

Pain that is often relieved by eating

Melena

Gastric Ulcers Diagnostic Test Findings:

Decreased HGB & HCT

Fecal occult blood- positive

EGD

Peptic Ulcers Complications:

Hemorrhage

Perforation

Pyloric Obstruction

Intractable Disease

Peptic Ulcers Surgical Implementation:

Surgery is performed only if the ulcer is unresponsive to medications or if hemorrhage, obstruction, or perforation occurs

Peptic Ulcers NURSING INTERVENTIONS???

Gastrointestinal Bleeding Assessment Findings:

Coffee-ground vomitus

Tarry stools or frank blood in stools

Melena

Decreased B/P

Gastrointestinal Bleeding Assessment Findings Cont.:

Increased weak and thready pulse

Decreased HGB and HCT

Vertigo

Acute confusion (in older adults)

Dizziness

Syncope

Gastrointestinal Bleeding Common causes of upper GI bleeding:

Esophageal cancer

Esophageal varices

Gastritis

Gastric ulcer

Gastric cancer

Duodenal ulcer

Gastrointestinal Bleeding Common causes of lower GI bleeding:

Ulcerative colitis

Polyps

Colon cancer

Diverticulosis/Diverticulitis

Rectal cancer

Hemorrhoids

Peptic ulcer disease

Crohn’s disease

Gastrointestinal Bleeding Interventions:

Hypovolemia management

Bleeding reduction/Non-Surgical management:

Nasogastric tube placement

Saline/water lavage

Gastrointestinal Bleeding Interventions Cont.:

Endoscopic therapy (EGD)

Acid suppression

Surgical Management:

Minimally Invasive Surgery via Laparoscopy

vs. Conventional Surgery

Gastric Cancer Definition:

Malignant neoplasms in the stomach

Gastric Cancer Pathophysiology:

Unregulated cell growth and uncontrolled cell division result in the development of a neoplasm

Tumor usually develops in the distal third of stomach and metastasizes to the abdominal organs, lungs and bones

Most common neoplasm is adenocarcinoma

Gastric Cancer Causes:

Infection with H. pylori

High intake of salty and smoked foods

Chronic gastritis

Pernicious anemia

Gastric ulcer

Smoking and alcohol consumption

Gastric Cancer Assessment Findings: (Early)

Indigestion

Feeling of fullness

Epigastric, back, or retrosternal pain

Abdominal discomfort initially relieved with antacids

Gastric Cancer Assessment Findings: (Advanced)

Nausea and vomiting

Progressive weight loss

Palpable epigastric mass

Enlarged lymph nodes

Weakness and fatigue

Obstructive symptoms

Iron deficiency anemia

Diagnostic Lab Test Findings Fecal occult blood positive

CEA positive

Decrease in HGB and HCT

Diagnostic Tests EGD

EUS

CT scan

PET

MRI

Gastric Cancer Nonsurgical Management:

Depends on stage of disease

Chemotherapy

Radiation

Side effects

Gastric Cancer Complications:

Obstruction

Ulceration

Metastasis

Gastric Cancer Surgical Management:

Total gastrectomy

Partial gastrectomy

MIS (minimally invasive surgery)

Palliative resection

Preoperative Care/Teaching Patient and family teaching

Enteral supplements

TPN (Total Parenteral Nutrition)

Explain the post-op need for drainage tubes, surgical dressings, O2 therapy, IV therapy and pain control

Start IV

Administer pre-op meds

Insert foley catheter

Insert NG tube

Postoperative Care/Teaching Assess cardiac and respiratory status

Assess pain and administer meds as prescribed

Inspect surgical site

Reinforce turning, coughing and deep breathing

Administer IV fluids as prescribed

Semi-fowlers position

Assess for return of peristalsis

Postoperative Care/Teaching Cont. Activity as tolerated

Monitor VS, I&O, pulse ox, labs

Monitor NG drainage

Do not reposition or irrigate NG tube!

Weigh patient daily

Increase food intake gradually

Eat six small meals daily

Gastric Cancer Surgical Complications

Hemorrhage

Infection

Dehiscence

Disruption in patency of NG tube

Dumping syndrome

Discharge Health Teaching After Gastric Surgery

???

NG Tube Feedings Confirm placement prior to using

Maintenance

Medications

Residuals

NG Tube Feedings Nausea, vomiting or bloating:

Large residuals- withhold or decrease feedings

Medications- review meds and consult MD

Rapid infusion rate- decrease rate

NG Tube Feedings Diarrhea:

Reduce rate

Administer at room temperature

Constipation:

Provide adequate hydration

Use formula with fiber

NG Tube Feedings Aspiration and gastric reflux:

Verify placement

Check residuals

Keep HOB elevated 30-40 degrees

NG Tube Feedings Occluded tube:

Flush more routinely

Try to use liquid medications

NG Tube Feedings Displaced tube:

Re-tape tube

Check placement