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Gastrointestinal Disorders
PN 4
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Changes through the lifespan
• Relatively immature at birth
• Teeth at 6-7 months
• Peristalsis slows to allow formed stool at 8 months
• Stomach acidity increases at 1-5 yrs
• Bowel control
• Stomach capacity increases; weight issues at 6-12 years
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Lifespan
• Stomach capacity, increased acidity and peristalsis adult like at 13-19 years
• Stomach capacity 2000 to 3000 age 20-45• Obesity common• Caloric needs decrease age 46-64• Stress = ulcers or reflux• Increase gallbladder problems• Taste buds begin atrophy = loss of sweet• Liver begins to decrease size
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Lifespan
• Age 65+ mucosa atrophies and secretions decrease
• Gag reflex weakens• Dental disease• Decrease hydrochloric acid and other
enzymes• Decrease of absorption of vitamins and
nutrients• Decreased motility, and nerve impulses
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Alimentary Canal
Begins at Pharynx; Ends at Anus
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GI Track
Continuous structure beginning with the oral cavity terminating with the anal sphincter
Carries out activities of:• ingestion, • movement or passage of food, • digestion, • absorption and • removal of waste (defecation)
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Assessment
• Family
Meds
• Travel
Diet
• Smoking
• Pain “1- 10”Other
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It begins with the mouth
• Lips, tongue, cheeks, teeth, taste buds and salivary glands prepare food for eventual absorption.
• Saliva contains mostly H2O; enzymes and electrolytes = 1000 to 1500 mL/day
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What can go wrong?
• Stomatitis (primary and secondary)
• Leukoplakia and Erythroplakia
• Cancer
• Acute and Post irradiation Sialadenitis;
• Dental problems
• Facial fractures
• Lack of taste or smell
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Pharynx
• Better known as the throat
• Beginning of the esophagus
• Tongue and saliva make ball of food called a bolus
• When you swallow the bolus bounces off the epiglottis and is diverted from the larynx and falls into the esophagus
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Esophagus
• Two sphincters UES and LES
• 24 cm long
• Peristalsis moves bolus into
stomach
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Esophagus
– Essential role in the ingestions of food and liquids
– Disorders can be inflammatory, mechanical or cancerous
– Esophageal disorders may mimic those of a variety of other illnesses because of its proximity to neighboring organs
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What can go wrong?
• GERD
• Hiatal Hernia (sliding and rolling)
• Achalasia
• Cancer
• Diverticula
• Varicies
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Gastric Reflux Disease (GERD)
Backward flow of GI contents = exposure of esophagus to gastric/duodenal contents = inflammatory changes of esophageal mucosa
Reflux esophagitis Pathophysiology
Incompetent lower esophageal sphincter (LES) Irritation due to refluxate Abnormal esophageal clearance Delayed gastric emptying
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Gastric Reflux Disease-Clinical Manifestations
Dyspepsia (heartburn) Regurgitation Hypersalivation Dysphagia/odynophagia Other
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Diagnostic Tests
• Barium swallow
• Upper endoscopy
• 24-hour ambulatory pH monitoring
• Esophageal manometry
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Gastric Reflux Disease-Interventions
Nonsurgical (conservative) management Diet therapy Client education Lifestyle changes Drug therapy
1. Antacids
2. Histamine receptor antagonists
3. Other drugs
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• Surgical management
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Hiatus Hernia
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Hiatal Hernia (Diaphragmatic Hernias)
Protrusion of stomach through esophageal hiatus into the thorax Asymptomatic or S/S similar to GERD Sliding hernia
Most common Esophageal reflux and complications
Rolling hernia Slow bleeding resulting from venous obstruction Iron deficiency anemia
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Hiatal Hernia-Interventions
Nonsurgical management Similar to GERD Client education
1. HOB 8 to 12 inches
2. Remain several hours after eating
3. Avoid straining or excessive vigorous exercise
4. Refrain from wearing tight constrictive clothing
Surgical management
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Stomach
• Few diseases affect stomach
• Those that do can be serious
• Pear-shaped; hollow; can distend
• Parts include: cardiac, fundus, body, antrum and pylorus
• Interior composed of rugae; glands that secrete gastric juice
• Food and gastric juice = chyme
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What can go wrong?
• Most common include: gastritis; peptic ulcer; Zollenger-Ellison syndrome and Cancer
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Gastritis
• Inflammation of the gastric mucosa
• Erosive or non erosive
• Acute or chronic
• Auto digestion of the stomach
• Chronic associated with risk of gastric cancer
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Prevention
• Avoid increased amts of alcohol and smoking
• Caution when taking ASA, NSAID’s, corticosteroids
• Avoid excess caffeine • Avoid contaminated foods• Workplace hazards such as lead and
nickel• Seek medical help for Sx
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Stress Ulcers
• Result from a “stress” situation
• Multiple and superficial
• May be asymptomatic until massive, painless gastric bleeding occurs
• What would you see in your client?
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Peptic Ulcer Disease
• Common; caused by acid-protective barrier imbalance
• Associated with NSAID drugs and Helicobacter pylori (H pylori) infection
• Gastric and duodenal
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Gastric Ulcers
• Usually solitary and small
• Caused by ingested substances; H pylori and chronic bile reflux
• Bleeding may occur
• Pre-malignant so follow up needed
• Diagnosed with ba swallow; endoscopy; bx
• Sx include epigastric pain
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Peptic Ulcer Disease
Gastric Deep and penetrating Occur on lesser curvature of stomach
Duodenal 95% occur in first portion of duodenum Deep, sharply demarcated lesions Penetrate through mucosa and submucosa into
muscle layer 95% to 100% due to H. pylori infection
Stress ulcers
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Duodenal Ulcer• Usually in the pyloric region
• Type O blood type (genetic)?
• H pylori; alcoholic; hyperparathyroid; COPD; renal failure; chronic pancreatitis
• “pain-food-relief” pattern
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Signs and Syptoms
Epigastric tenderness With perforation
Rigid, board-like abdomen Rebound tenderness Hyperactive bowel sounds, that may diminish
Dyspepsia (indigestion) Melena Gastric ulcer pain/vomiting S/S fluid volume deficit
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Associated Nsg Diagnosis
Acute pain Risk for deficient fluid volume Ineffective therapeutic regimen management Ineffective coping Imbalanced nutrition Disturbed sleep pattern Risk for injury
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Complications
Hemorrhage Most serious complication Most common in older adults with gastric ulcers
Perforation Pyloric obstruction Intractable disease
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Pharmacological treatment
Hyposecretory drugs Antisecretory agents H2-receptor antagonists
Prostaglandin analogs Antacids Mucosal barrier fortifiers
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Gastric Cancer
• Survival rate poor; greater if diagnosed early
• Etiology factors: ulcers, nitrates in food, type A blood,
• Early metastasis to lymph nodes in region• Dx with biopsy• S & S: loss of apetite; wt loss; abd pain;
vomiting; change in bowel habits; anemia; blood in stool; massive hemorrhage.
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Dumping Syndrome
Constellation of vasomotor symptoms after eating caused by: Rapid emptying of gastric contents into small intestines Fluid shift into gut Abdominal distension
Early symptoms occur within 30 minutes of eating Late dumping syndrome 90 minutes to 3 hours
after eating Managed by dietary measures
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Moving to the Small BowelConditions of the small bowel
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Small & Large Bowel
• Cancer• Polyps• Diverticulitis• Colitis• Irritable Bowel• Hemorrhoids• Obstruction• Hernia
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Parasites
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Malabsorption & Maldigestion
• Most nutrient absorption occurs in small intestine
• Malabsorption refers to inadequate mucosal absorption of ingested water and nutrients;
• Maldigestion refers to inability to absorb foodstuff because it has not been broken down properly
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Celiac or Gluten Intolerance
• Gluten proteins have antigenic properties• Frequent foul smelling stools with a fatty or
greasy appearance• Wt loss; malabsorption of vitamins • Muscle wasting• Diet that removes barley; wheat; rye and
oats = less malabsorption• Usually diagnosed in children who fail to
thrive
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Inflammatory: Enteritis
• Caused by bacteria; virus; parasites or allergic reaction
• Usually returns to normal when precipitator is removed
• Vomiting and/or diarrhea
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Inflammatory Bowel (Crohn’s)
• Idiopathic, chronic, inflammatory disease
• Affects any segment of the GI tract; most common terminal ileum or colon;
• S & S vary; Diarrhea dominant; fever and RLQ pain
• Stress and personality factors
• Wt loss, occult blood, N & V, fistulas and peritonitis
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Moving to the Large BowelProblems with the Colon
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Paralytic ileus
• Functional obstruction of bowel (S or L)
• Lack of proulsive peristalsis; absence of bowel sounds and distention
• Causes: anesthesia; peritonitis; appendicitis; interruption of nerve supply; abd injury or surgical manipulation; intestinal ischemia and electrolyte imbalance (which one?)
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Colorectal Cancer
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Colorectal Cancer
Most prevalent in patients over the age of 50 70% occur in the right side of the proximal colon Liver is the most frequent site of metastasis Complications
Obstruction/perforation Peritonitis Abscess formation Fistula formation to bladder/vagina
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Etiology
Genetic predisposition Personal factors
Age Polyps
Dietary factors Decreased bowel transit time High-fat diet Chemical mutagens Refined carbohydrates
Inflammatory bowel disease
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Signs and Symptoms
Rectal bleeding Anemia Changes in stool Symptoms of obstruction Gas pains, cramping, incomplete evacuation Hematochezia Straining to pass stools/narrowing of stools Mass lower right quadrant Changes in bowel sounds
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Nursing Diagnosis
Pain Disturbed body image Compromised family coping Imbalanced nutrition Fear Powerlessness Alteration in bowel elimination
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Colostomy sites
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Bowel Obstruction
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Signs and Syptoms
Midabdominal pain or cramping Vomiting: bile/mucus Obstipation/diarrhea Colicky abdominal pain Alternations in bowel patterns Abdominal distention/peristaltic waves Borborygmi Decreased to absent bowel sounds Abdominal tenderness
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Intestinal Obstruction
• When blockage occurs, gas and air cause distention proximal to obstruction
• Secretions begin to pool = more distention
• Bowel wall edema = 3rd spacing
• Decrease blood supply = infarction, ischemia, necrosis, perforation, peritinitis.
• Hypovolemic shock, septic shock, very ill
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Other Conditions
• Hernia’s
• Megacolon
• Diverticular Disease
• Ulcerative Colitis (different to crohn’s)
• Hemorrhoids
• Polyps
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Irritable Bowel
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Liver, Pancreas and Gallbladder
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Liver: Cirrhosis
Chronic, progressive Irreversible reaction to hepatic
inflammation/necrosis Alteration in vascular system/lymphatic bile duct
channels Types:
Laënnec's or alcoholic Postnecrotic Biliary Cardiac
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Complications of cirrhosis
Portal hypertension Ascites Bleeding esophageal varices Coagulation defects Jaundice Portal-systemic encephalopathy (PSE) with hepatic
coma Hepatorenal syndrome
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Signs and Symptoms
Early signs Generalized weakness Weight loss GI symptoms Abdominal pain/liver tenderness
Late signs GI bleeding Jaundice Ascites Spontaneous bruising
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Hepatitis
Widespread inflammation of liver cells Most common viral hepatitis Five major categories of viruses
Enteral forms1. Hepatitis A and E
2. Transmitted by fecal-oral route
Parenteral forms1. Hepatitis B, C, D
2. Transmitted through venous blood/sexual contact
Acute or chronic
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Etiology
Hepatitis viruses Drugs, chemicals, toxins Blood transfusion reactions Hyperthyroidism Ingestion of ethyl alcohol (ETOH) Wilson's disease Other viruses: Epstein-Barr, cytomegalovirus,
yellow fever
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Disorders of the GB
Cholecystitis Acute
1. Inflammation of gallbladder
2. Gallstones/bacterial invasion via lymphatic or vascular routes
Chronic1. Repeated bouts of acute cholecystitis
2. Gallstones usually present
3. Pancreatitis/cholangitis
Cholelithiasis Cancer of gallbladder
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Gall Stones
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Biliary Lithotripsy
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Disorders of the Pancreas
Acute Inflammatory process of the pancreas Premature activation of pancreatic enzymes Destruction of ductal tissue/pancreatic cells Autodigestion/fibrosis of pancreas Pathophysiologic processes
1. Lipolysis2. Proteolysis3. Necrosis of blood vessels4. Inflammation
Theories of enzyme activation Chronic
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Acute Pancreatitis
Abdominal pain Midepigastric/left upper quadrant Radiates/intense, continuous Affected by position
Generalized jaundice Gray-blue discoloration of abdomen/periumbilical area
(Cullen's sign) Gray-blue discoloration of flanks (Turner's sign) Decreased bowel sounds/paralytic ileus Tenderness, rigidity/guarding Palpable mass Elevated temperature/tachycardia/ B/P
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Chronic Pancreatitis
Progressive, destructive Remissions/exacerbations Inflammation/fibrosis Repeated episodes of alcohol-induced acute
pancreatitis Types of chronic:
Calcifying pancreatitis (CCP) (alcohol-induced) Obstructive pancreatitis