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GASTROINTESTINAL SYSTEM NOTETAKING GUIDE Concepcion Binamira Clemea, RM,RN FUNCTIONS: Ingestion Peristalsis Digestion Absorption defecation PHYSIOLOGY:


Digestion starts from the entrance of food into the mouth Mechanical digestion occurs through mastication Chemical digestion occurs through the action of AMYLASE (ptyalin) which breakdown starches into monosaccharides Deglutition (swallowing) occurs once the food is broken down into small pieces & well mixed with saliva (food bolus)

Serve as passage for food bolus from the mouth to stomach by peristalsis Distal end is guarded by LES (cardiac sphincter) that prevents gastric reflux

Functions: Secretions, Chemical digestion, Protection, Absorption, Control passage of chyme into the duodenum
Small Intestine

6 meters long 3 parts: duodenum (10), jejunum (8 feet), ileum (12 feet) Ileocecal valve connects small intestine to large intestine Villi- site of nutrient absorption Intestinal glands or CRYPTS OF LIEBERKUHN secretes intestinal digestive enzymes Chyme- digested contents of small intestine Functions: Mucus secretion -goblet & duodenal (Brunner) cells, Secretion of enzymes, Secretion of hormones, Chemical digestion, Absorption, Motor activites

Large Intestine

Extends from ileocecal valve to the anus 5-6 ft long (1.5 m) 4 parts: cecum, colon (longest), rectum, anus Vermiform appendix attached to cecum Parts of Colon: ascending, transverse, descending, sigmoid

Internal (smooth) & external (skeletal) sphincter control the opening of anus
Large Intestine

Haustral churning, peristalsis (3-12 contractions/min) Mucus secretion Reabsorption of water, Na, Cl (800-1000cc of water) Vitamin synthesis (Vit K, B12, folic, B2, biotin, nicotinic acid) Formation of feces (3/4 water & solid) Defecation

DIAGNOSTIC PROCEDURES VIEWING UPPER GI Upper GI Series Upper GI Endoscopy Abdominal CT Scan UPPER GI SERIES (BARIUM SWALLOW) X-ray test to determine the upper digestive tract (esophagus, stomach, & small intestine) Pretest NPO x 6-8 hours No smoking Post fluid intake Laxative Monitor stool white colored stool Notify MD if no stool x 2 days Observe for fecal impaction: distended abdomen, constipation BaSO4: Chalkish taste, Odorless, Insoluble , No worries of absorption ALERT: make sure there is _________ to determine any obstruction Is smoking contraindicated? Abdominal CT Scan pictures taken by specialized X-ray machine for looking at solid organs, such as liver, pancreas, spleen, kidneys, and adrenal glands for viewing large blood vessels that pass through the abdomen For finding lymph nodes in the abdomen Abdominal CT Scan Pretest NPO 6-12 hours


Contrast agent may be used Assess for allergy to dye, if pregnant, or if taking insulin Explain clients role during procedure Diuresis should be expected Drink @ least 1 glass of water an hour after procedure

UPPER GI ENDOSCOPY direct visualization of the esophagus, stomach, & upper duodenum using an endoscope Also known as EGD (esophagogastroduodenoscopy) Pretest: Upper GI Endoscopy Consent NPO 8-12 hours Anesthesia by spray or gargle LSP or Sims (WHY) Stand by emergency kit Stop taking ASA or NSAIDS before test Meds Local anesthesia Sedation Anticholinergic (Atropine SO4) Post-test: Upper GI Endoscopy Bed rest until alert LSP Sore throat is expected Maintain on NPO Administer analgesics & gargle Watch out for complications Aspiration (respiratory distress) Perforation Bleeding (hematemesis) Fecal Occult Blood/ GUAIAC TEST Detects blood in the stool Indicates BLEEDING PRETEST Do not consume for 3 days prior to the test red meat Cantaloupe Any blood containing food Uncooked broccoli

Turnip, radish, or horse radish Discontinue drugs that can interfere with the test: ASPIRIN, VIT C, steroids, indomethacin, colchicine

Gastric Analysis Measures secretion of HCl & pepsin PRETEST NPO x 12 hours NGT is inserted & connected to suction Gastric contents collected every 15 min -1hr RESULTS HCl ZES, Duodenal Ulcer Decrease HCl gastric Ca, pernicious anemia VIEWING LOWER GI Anoscopy Barium Enema LGI Endoscopy proctosigmoidoscopy colonoscopy BARIUM ENEMA An X-ray test used to examine the lower digestive tract (colon & rectum) Pictures are taken after rectal instillation of barium sulfate ( a radiopaque contrast medium) BARIUM ENEMA Pretest low residue diet x 1-2 days Clear liquid diet PM Admininster laxative HS NPO x 6 hours Cleansing Enema AM Post-test fluid intake Administer laxatives Monitor stool clay colored stool Notify MD if no stool x 2 days PROCTOSIGMOIDOSCOPY Pretest Clear liquid diet 24 hrs before Administer cathartic/ laxative as ordered NPO x 6 hrs Cleansing Enema in AM


Position: Knee chest/ lateral

Supine for few minutes Assess for signs of perforation: bleeding, pain, fever Hot Sitz bath for discomfort COLONOSCOPY used to view the interior lining of the large intestine using a small camera called a colonoscope (flexible fiber optic tube) Pretest: Colonoscopy Low Residue diet x 1-2 days Clear liquid diet PM Administer laxative HS NPO x 6 hrs Cleansing Enema in AM Position: LSP with knees flex Post-test: Colonoscopy Bed rest Signs of perforation: severe abdominal pain, hematochezia

a disorder in which the lower esophageal sphincter does not relax when food passes down the esophagus to the stomach FAILURE TO RELAX Characterized by progressively increasing dysphagia Common in 20-30 y/o individuals Etiology Unknown Pathophysiology: Impaired motility of lower 2/3rds of the esophagusLES fails to relax normallyImpaired profusion & constricted LESAccumulation of food within lower esophagus Signs & Symptoms: dysphagia Substernal pain Regurgitation Diagnostics: Barium Swallow Endoscopy Manometry Bernstein Test (Acid Perfusion Test)

Medications anticholinergics Nitrates Ca channel blockers Antacids (for pain) Diet small frequent feedings Semi soft warm foods Avoid hot, spicy, iced foods Alternative Positions remain upright after feeding Avoid restrictive, tight clothing Sleep with HOB elevated Surgical Management Esophageal Dilation Esophagomyotomy (Hellers Procedure) after surgery, patients may have PEG or PEJ tube inserted


backward flow of gastroesophageal contents into the esophagus Due to INAPPROPRIATE RELAXATION of LES in response to unknown stimulus Can lead to adenocarcinoma, Barretts esophagus, stricture FAILURE TO CONTRACT CAUSES: changes in LES control with aging obesity delays in gastric emptying diet (fatty foods, alcohol, caffeine, chocolate0 Drugs (colchicine, beta blockers, nitrates, theophylline, anticholinergics) Esophagogastroduodenoscopy/EGD or upper endoscopy.) ASSESSMENT: heartburn Worsening pain when they bend over, strain, lie flat; occurs AFTER EACH MEAL & last for up to 2 hours Coughing, hoarseness, or wheezing @ night Regurgitation Sensation of warm fluid travelling upward to the throat & leaving a bitter, sour taste in the mouth Dysphagia & odynophagia Primary Nursing Diagnosis: pain r/t esophageal reflux & esophageal inflammation

Interventions: Relieve pain: antacids Avoid straining, bending, heavy lifting, stooping, coughing Position: upright before & after eating (1-2 hrs HOB elevated when asleep Do not eat @ least 3 hrs before bedtime reduce weight if obese Interventions: avoid, tea, fatty foods, caffeinated beverages, chocolate, nicotine, alcohol, & peppermint, cola, smoking, spicy,& acidic foods No evening snacks Small frequent feedings (4-6 meals) Eat slowly & chew food properly Avoid tight, constrictive clothing CHON intake, Increase fiber SURGERY: Nissen Fundoplication (gastric wrap around) Hills repair Belseys repair


ASSESSMENT: dull, gnawing,burning pain in the epigastrium or back Pale mucous membrane & skin Bright red stools Epigastric tenderness Duodenal 30-60 y/o,common in male 80% of PUD Hypersecretion of HCl Weight gain Gastric 50& above, equal M:F 15% of PUD Normal-hyposecretion of Hcl Weight loss hr by after meal; food but by

Pain 2-3 hrs after meal; awakened Pain -1 @ night; RELIEVED by FOOD UNRELIEVED vomiting Vomiting uncommon Less bleeding; perforate Malignancy rare more likely Common

to Bleeding more likely occasionally

O Executive or competitive

A Low socioeconomic status

TEST For H. Pylori Antibody detection Urea breath test Fecal antigen testing PERFORATED PEPTIC ULCER severe epigastric pain May radiate to back or shoulders Peritoneal signs (S&Sx pf peritonitis) PREFFERRED Dx for PUD: EGD SURGICAL MANAGEMENT: vagotomy resection of vagus nerve Dec PNS stimulationdec HCl sercetion dec gastric motility pyroplasty Surgical dilatation of the pyloric sphincter Improve gastric emptying of acid chyme Subtotal gastrectomy Antrectomies Removal of 50% of the lower part of thestomach TYPES OF ANTRECTOMIES billroth I (gastroduodenostomy) billroth II (gastrojejunostomy) bypasses duodenum Postop Teachings: Tell patient what to expect if infection occurs: pain, redness, swelling, discharge After Billroth II procedure, client may develop S &Sx of Dumping Syndrome COMPLICATIONS OF GASTRECTOMY bleeding Hypovolemic shock F&E imbalance Malabsorption syndrome Pernicious anemia Dumping syndrome-most common Lung Complications high abdominal incision

1st 24 hrs- atelectasis 72 hours- pneumonia, bronchitis

rapid evacuation of gastric contents SIGN & SYMPTOMS: dyspnea Dyspepsia diaphoresis dizziness/vertigo tachycardia Weakness Pallor Abdo fullness Nausea, diarrhea, cramps, borborygmi LATE hypoglycemia MANAGEMENT: Take fluids in between meals, none with meals Eat smaller amounts more frequently in a semi-recumbent position Eat a low CHO diet, high CHON & moderate fat foods Avoid refined sugars (sweets) esp simple sugars Lie down after meals for 30 mins Take anticholinergic drugs 30 mins before meals as prescribed

--inflammation of gastric mucosa TYPES Acute/Severe Gastritis (Erosive) --acute hemorrhagic lesions --stress ulcers --Aspirin, NSAIDs --alcohol --food products Chronic Gastritis Type A (Non-erosive) --autoimmune --inovolves body & fundus of stomach --pernicious anemia, gastric Ca, atropic gastritis Chronic Gastritis Type B (Non-erosive) --H pylori infection ASSESSMENT:

nausea, anorexia Sour taste in the mouth Belching Crampy pain MANAGEMENT: Watch out for signs of bleeding coffee ground vomit CBC if pernicious anemia is suspected Antacids, H2 anatagonist, antibiotics ANTI-ULCER DRUGS (HAMAP) TYPE Histamine receptor antagonist Antacids EXAMPLE Tagamet (Cimetidine) Zantac (Ranitidine) Pepcid (Famotidine) Azid (Nizatidine) Aluminum Hydroxide Mg hydroxide (Milk Magnesia) Maalox Carafate (sucralfate) Amoxil, tetracycline of When to be taken With food or 1 hr after meal

1 hour after meal with liquid

Mucosal Protectant Antimicrobials Proton Inhibitor

Before meals, bedtime As prescribed, usually after meals After meals

Pump omeprazole

inflammation of the appendix CAUSES: Obstruction fecalith (hard mass of feces) Foreign body Fibrous disease Parasites Low fiber diet High intake of refined CHO Pathophysiology: InflammationIncrease intraluminal pressureLymphoid swelling, decrease venous drainage, thrombosis, bacterial invasionAbscessGangrenePerforation (24-36 hours)peritonitis

ASSESSMENT: epigastric or periumbilical pain that eventually localizes @ RLQ RLQ rebound tenderness Pain @ McBurneys point (+) Rovsing Test (palpate LLQ causes pain @ RLQ Psoas sign Obturator sign Primary Nursing Diagnosis Acute pain r/t inflammation Risk for infection R/t surgical incision PSoas Sign

Obturator Sign

An increase in pain from passive extension of the right hip joint that stretches the iliopsoas muscle Place right hand above right knee of the patient. Have the patient flex right knee against resistance. Alternatively, have the patient turn to side, extend right leg at right hip. Pain with maneuvers suggests irritation of Psoas muscle Flex patients right thigh at hip with right knee bent. Internally rotate the leg at the hip. Pain elicited suggest irritation of obturator muscle.
MANAGEMENT: Pharmacologic mngt (antibiotics, analgesics) Fluids (IV therapy) NPO Bed rest Cold application over the abdomen Appendectomy AVOID UHELP in APPENDICITIS!!!!!!! Unnecessary palpation Heat application Enema Laxative Pain relief/meds PREOP TEACHING spinal anesthesia Avoid: heat application, laxative, enema Reduce anxiety Instructions on Splinting incision site with pillows during coughing, DB & moving encourage DBCE 10x every 1-2 hrs for 3 days

POSTOP TEACHING If ruptured (peritonitis): Semi fowlers If unruptured: flat on bed for 6-8 hrs Note color, amount of drainage, approximation of wound edges NPO until peristalsis returns Resume ADL within 2-4 weeks






Also known as spastic colon A poorly understood syndrome of diarrhea, constipation, flatus & abdominal pain Excessive spasm & peristalsis lead to constipation, diarrhea or both ALTERNATING BOUTS of DIARRHEA & CONSTIPATION CAUSES: exact cause remain UNKNOWN ASSESSMENT: abdominal pain or discomfort Alternating bouts of diarrhea & constipation Pain may increase after eating and be relieved after a bowel movement Normal oral mucosa No inflammation Primary Nursing Diagnosis Acute pain r/t abdominal cramping Management: Treated by combination of drugs, diet & attempts to establish an exercise routine that promote normal bowel function NO SPECIFIC TXT INDEPENDENT NURSING ACTION: Encourage to eat meals @ regular intervals Diet should include 30-40 g of fiber each day Drink 8 glasses of water daily Avoid: alcohol, caffeine,& other irritants

CAUSES Low fiber diet Pathophysiology:

Low fecal volume in the colonincreased Muscular contractions to push stool increased intraluminal pressureDecreased muscle strength wallDiverticula Entrapment of fecal material & bacteriaInflammation & infectionScarringAbscessBleedingPerforationperitonitis ASSESSMENT: Pain in LLQ relieved may be bowel movement Bowel irregularities Rectal bleeding Mild/ low grade fever Elevated WBC Chronic constipation with episodes of diarrhea DIAGNOSIS Barium enema Sigmoidoscopy colonoscopy NURSING INTERVENTIONS: NPO if with massive bleeding/peritonitis acute/severe Bed rest clear liquids to rest bowel Low fiber/roughage/ residue diet; low fat IVF, antibiotic, analgesics, anticholinergic (Pro-Banthine) NGT insertion mild High fiber/ residue/roughage diet, low fat Hydration: 2-3L/day Avoid nuts & seeds Stool softeners as ordered


CROHNS DISEASE Granulomatous colitis or regional enteritis Chronic, nonspecific inflammatory disease Commonly occurs in TERMINAL ILEUM, JEJUNUM, and colon Ulcers occur solitary or not continous CAUSES No specific cause Could be: virus, bacterium, autoimmune, diet ASSESSMENT: CROHNS DISEASE Mild, nonbloody diarrhea

Fatigue, anorexia As disease progresses, more severe, constant abdominal pain that typically localizes in RLQ, more severe fatigue, moderate fever Weight loss Dx EXAM: CROHNS DISEASE Barium Swallow PHYSICAL EXAM: CROHNS DISEASE Malnutrition Dehydration Dry skin Dry mucous membranes Poor skin turgor Weakness Hyperactive bowel sounds PRIMARY NURSING DIAGNOSIS Alteration in Nutrition: less than Body Requirement r/t anorexia, diarrhea,& decreased absorption of the intestines MANAGEMENT: CROHNS DISEASE Bowel REST Medications NSAIDs Mesalamine (5-ASA) Sulfazalazine & steroids Antidiarrheals Loperamide Antibiotics Metronidazole (Flagyl) Immunosuppresive agents Azathioprine (Imuran) 6 mercaptopurine INDEPENDENT NURSING ACTION: CROHNS DISEASE Maintain F&E balance Hydration: 3L fluids/day unless CI Plenty of rest & relaxation Reduce stress Proper diet: HIGH CHON, LOW RESIDUE, low fat, high CHON Possible complications: abscess, fistula, hemorrhage, or infection Can result to MALABSORPTION syndrome

chronic IBD of the COLON

Begins in the RECTUM & SIGMOID COLON & gradually spreads up to the colon in a CONTINUOUS pattern Multiple ulcerations & abscesses form @ the inflamed areas Can lead toCOLON Ca Dx: COLONOSCOPY with BIOPSY ASSESSMENT: ULCERATIVE COLITIS Numerous episodes of BLOODY DIARRHEA Abdominal pain & cramping that is relieved by defecation Fatigue Anorexia Weight loss Fever Rectal bleeding- predominant PRIMARY NURSING DIAGNOSIS: Alteration in Nutrition: Less than body Requirement r/t anorexia, diarrhea, & decreased absorption in the intestines MANAGEMENT: ULCERATIVE COLITIS IV fluids BT Low residue, low fat, HIGH calorie, HIGH CHON, lactose free diet Drug therapy NSAIDs Mesalamine (5-ASA); Sulfazalazine steroids-BEST; LIFETIME Immunosuppresant Azathioprine (Imuran) 6 mercaptopurine INDEPENDENT NURSING ACTION: ULCERATIVE COLITIS promote patient physical & emotional support Discuss measure to decrease LIFE STRESSORs Promote mental comfort Provide ways to prevent future episodes of inflammation (REST, RELAXATION, STRESS REDUCTION, WELL BALANCED DIET Avoid triggering factors: FATIGUE, STRESS< EXERTION

65%- rectum, sigmoid colon, descending colon 25%- cecum & ascending colon 10%- transverse colon

CAUSES: Unknown Age

RISK FACTORS: Family hx of colorectal Ca Hx of ulcerative colitis, polyps,crohns Diet low in fiber, high CHON, high fat & refined CHO Obesity, DM, alcoholism ASSESSMENT: Right Colon Ca Melena Palpable mass Anorexia Anemia Abdominal pain above umbilicus Left Colon Ca Empty rectal vault Urge to defecate Rectal bleeding Rectal fullness Pencil, ribbon shaped stool Sensation of incomplete bowel emptying tenesmus EARLY DETECTION OF COLORECTAL Ca DRE annually after age 40 Occult blood test yearly after age 50 Proctosigmoidoscopy every 5 years after age 50, following 2 negative reults of yearly examination PRIMARY NURSING DIAGNOSIS Pain r/t tissue injury from tumor invasion & surgical incision SITE OF METASTASIS Liver MANAGEMENT: Surgery-primary treatment Hemicolectomy Abdomino-Perineal Resection (APR) Involve 2 incisions: Lower abdomen incision to remove sigmoid; perineal incision to remove rectum T- binder used to secure perineal dressing Necessitates PERMANENT COLOSTOMY Adjuvant therapy (chemotherapy/ radiation therapy) FLUOROURACIL PREOPERATIVE Bowel Prep 24 hours before surgery

Clear liquid diet, cathartics, cleansing enema Oral & IV antibiotics Neomycin SO4 Vit C & K POSTOPERATIVE Provide comfort Monitor V/s, drainage NGT for gastric decompression until bowel sounds return TYPES OF COLOSTOMY: --an opening anywhere along the length of the colon to the exterior surface creates an artificial anus TYPES OF COLOSTOMY: Ascending Colostomy --stoma on right abdomen; feces is watery Double Barreled Colostomy --both ends of transected colon is brought out the peritoneum & skin & sutured --left stoma: distal stoma: drains mucus --right stoma: proximal stoma: drains feces Loop Colostomy --loop of colon is brought out onto the abdominal cavity --a plastic rod or ostomy bridge is placed under the loop to hold it out on the exterior abdominal wall Descending & Sigmoid Colostomy --stoma on left abdomen --feces is well formed or solid CARE OF CLIENTS WITH COLOSTOMY Care of the Skin Skin Barriers ( Karaya prep) Avoid mineral oil, talcum powder Cleanse skin with mild soap & water Care of the APPLIANCE/ POUCH Remove content during sensation of pressure or fullness & 1/3-1/2 full Must be snugly fitted Life Span of POUCH: 5-7 days Change every 5-7 days; STAT if leaking Drains feces, mucus, flatus CARE OF CLIENTS WITH COLOSTOMY Acceptance of Body Image Care of the Stoma bright red-beefy red If dusky, dark brown necrosis

Painless Slightly elevated (1/2-3/4 inch) Edematous for 3 days Drainage start @ 4-7 days after surgery Small amt of stomal bleeding is common (serosanguinous) CARE OF CLIENTS WITH COLOSTOMY Avoid food high in fiber, gas forming foods (dairy products, seasoned foods, fish, cabbage, celery, cauliflower, eggs, colas, nuts, drinking on straw & chewing gums) Charcoal or bismuth carbonate Reduce odor: yogurt, parsley, spinach, buttermilk, cracker, toast, cranberry juice Rinse pouch with tepid water or weak vinegar solution COLOSTOMYIRRIGATION Stimulate bowel emptying Enema through the stoma Initiated 5-7 days postop Semi fowlers; if ambulatory: sitting on a toilet bowl; bedridden: lateral Perform at the SAME TIME each day; 1 hour PC COLOSTOMYIRRIGATION Solution: 500-1000cc of warm NSS & hypotonic solution Insert not >4 Height: 18 Lubricate: 8cm Catheter: Fr 22-24 CRAMPS: Stop temp & start @ slower rate

Swelling & distention of veins in the anorectal region May bleed or cause pain or itch TYPES Internal External CAUSES Occupations that require prolonged sitting or standing Anorectal infections Anal intercourse Pregnancy Hepatic disease such as cirrhosis, amoebic abscesses, hepatitis, RSCHF Loss of muscle tone Obesity

Constrictive clothings Chronic constipation ASSESSMENT: History of anal itching Blood on the toilet tissue after BM Anorectal pain or discomfort PHYSICAL ASSESSMENT: DRE or anoscopy Inspect the patients anorectal area PRIMARY NURSING DIAGNOSIS Pain (acute or chronic) r/t swelling & prolapse MANAGEMENT (conservative) Application of cold packs to the anal region Sitz bath for 15 mins twice a day Dibucaine ointment HIGH FIBER DIET, FLUIDS Stool softeners as ordered Avoid spicy, hot foods Avoid prolonged sitting, standing Anal area cleanse by dabbing instead of wiping; use moistened cleansing tissues rather than standard toilet tissues MANAGEMENT Sclerotherapy Elastic band ligation Cryosurgery hemorrhoidectomy MANAGEMENT Preop: HEMORRHOIDECTOMY Low residue diet Stool softeners Postop: Void within the 1st 24 hours check dressing for excessive drainage/bleeding Spread petroleum jelly on wound site & apply wet dressing MANAGEMENT Postop: HEMORRHOIDECTOMY Position patient for comfort Sitz bath 3-4x a day aNALGESIC before initial defecation Explain that 1st postop BM is painful

HE: Prevent by increase fluid intake, high fiber diet

2 types: Sliding Paraesophageal/rolling CAUSES Muscle weakness Aging process Congenital muscle weakness Obesity Trauma Surgery Prolonged increased in intraabdominal pressure ASSESSMENT: Heartburn Dysphagia/ odynophagia Dyspnea Abdominal pain Nausea & pain Gastric distention, belching, flatulence Interventions: Relieve pain: antacids Avoid straining, bending, heavy lifting, stooping, coughing Position: upright before & after eating (1-2 h; HOB elevated when asleep Do not eat @ least 3 hrs before bedtime reduce weight if obese avoid, tea, fatty foods, caffeinated beverages, chocolate, nicotine, alcohol, & peppermint, cola, smoking, spicy,& acidic foods No evening snacks Small frequent feedings (4-6 meals) Eat slowly & chew food properly Avoid: --anticholinergics --calcium channel blockers --xanthine derivatives --diazepam --beta blockers MEDS --antacids --antiemetics --h2 receptor antagonists

Anatomy & Physiology Anatomy & Physiology LIVER Largest organ of the body Functional unit: lobules Functions: Stores excess CHO as glycogen Ammonia conversion Synthesis of plasma proteins Stores copper, vit ADEK Detoxification Produces BILE Produces heparin, thrombin, prothrombin Kupffers cells Excretion of bilirubin Excretion of adrenocotical hormones Anatomy & Physiology FUNCTIONS Exocrine: acini cellsproduces pancreatic juices Endocrine: alpha & beta cells Beta insulin Alpha glucagon Anatomy & Physiology: Gall Bladder FUNCTIONS: 4-inch sac with a muscular wall that is located under the liver. reservoir/storage and concentrates bile Cholecystokinin release when food enters the small intestine. Cholecystokinin signals the gallbladder to contract and deliver bile into the intestine. GASTROINTESTINAL HORMONES DIAGNOSTIC PROCEDURES Endoscopic Retrograde Cholangiopancreatography (ERCP) Used to identify the presence of stones, tumors or narrowing in the biliary & pancreatic ducts After the endoscope is placed, a catheter is advanced which will inject a contrast agent through the ducts DIAGNOSTIC PROCEDURES Endoscopic Retrograde Cholangiopancreatography (ERCP)

Pretest: NPO x 6 hrs LSP Assess allergy to iodine Stand by emergency kit Meds: Local anesthesia, Sedation, AtSO4 DIAGNOSTIC PROCEDURES Endoscopic Retrograde Cholangiopancreatography (ERCP) Post-test: Bed rest until alert Assess for gag reflex Administer analgesic & gargle Monitor for bleeding: frequent swallowing, melena, hematemesis Monitor for signs of perforation: severe abdominal pain DIAGNOSTIC PROCEDURES LIVER BIOPSY A procedure to obtain sample of liver tissue so that it can be examined under microscope Useful for determining the cause of hepatitis Used to diagnose Ca in the liver DIAGNOSTIC PROCEDURES Preop: Liver Biopsy Consent NPO post midnight Note coagulation tests Position: supine with arms raised DURING: Inhale & exhale deeply several times, hold breath on expiration DIAGNOSTIC PROCEDURES POSTOP: LIVER BIOPSY Monitor VS (BP,PR) for signs of bleeding/shock Bed rest for 24 hours Report abdominal pain Right lateral position with pillow under the costal margin Assess for signs of bleeding Avoid coughing, straining Avoid strenuous activities for 1 week PARACENTESIS (Peritoneal TAP) Aspiration f fluid via needle in the abdominal cavity (500-1000cc) Preop:

Consent V/s Weigh EMPTY bladder Position: sitting/upright with feet resting on foot stool PARACENTESIS (Peritoneal TAP) Postop: Weigh Abdominl girth RR, PR, UO,V/S (BP) for signs of shock Report abdominal pain (rigidity) PERITONITIS Report if URINE is BLOODY, PINK or RED

LIVER Largest organ of the body Functional unit: lobules Functions: Stores excess CHO as glycogen Ammonia conversion Synthesis of plasma proteins Stores copper, vit ADEK Detoxification Produces BILE Produces heparin, thrombin, prothrombin Kupffers cells Excretion of bilirubin Excretion of adrenocotical hormones

Chronic liver disease characterized by destruction of the functional liver cells which leads to cellular death CAUSES: Hepatitis (26%) Alcohol abuse Hepatitis C+ alcohol abuse Malnutrition Drugs Infection Biliary obstruction RSCHF

Chemical toxins DRUG INDUCED LIVER DISEASE Chlorpromazine- reversible cholestasis Ethanol-fatty liver, cirrhosis Acetaminophen/ Carbon Tetrachloride- acute liver cell necrosis Estrogens- hepatocellular adenoma (benign) Aflatoxin Hepatitis B & C-heaptp cellular carcinoma LIVER CIRRHOSIS TYPES: Laennecs cirrhosis Postnecrotic cirrhosis Biliary Cirrhosis Cardiac cirrhosis Pathophysiology: LAENNECS CIRRHOSIS ALCOHOl causes changes fatty infiltration of hepatocytes liver cell necrosis & scarringinfammation subsides but fibrosis increases liver distortionstructural & vascular changes compression of portal vein obstruction portal hypertension Pathophysiology: BILIARY CIRRHOSIS Chronic obstruction pressure in the hepatic duct accumulation of bile areas of necrosis edema, fibrosis & hepatocellular destruction scarring hepatomegaly Pathophysiology: CARDIAC CIRRHOSIS Enlarged liver congested venous blood flow failure of the heart to pump blood to different areas of the body congestion causes anoxia to liver necrosis & fibrosis

ASSESSMENT FINDINGS:LIVER CIRRHOSIS EFFECTS OF PORTAL HYPERTENSION Esophageal varices Splenomegaly hemorrhoids Caput medusae Ascites Dependent edema OTHER manifestations: Males: ( estrogen) decrease libido, gynecomastia, impotence, fall of body hair, atrophy of testicles Female ( androgen): virilization

Asterixis liver flap Hepatic encepalopathy Anemia Fetor hepaticus Spider nevi Bleeding tendency Edema Clay colored stool; tea colored urine Pruritus RUQ pain Primary Nursing Diagnosis: Fluid volume excess related to retention Management: ASCITES Monitor I & O, abdominal girth Low Na, decrease fluids Diuretics, albumin as ordered HOB elevated Assist in paracentesis ESOPHAGEAL VARICES Avoid shouting, yelling, screaming Straining,bending, stooping, hot spicy foods, lifting heavy objects Sengstaken Blakemore tube insertion Vasopressin for bleeding DECREASE AMMONIA FORMATION Low protein, high calorie Lactulose- rduce formation of ammonia & facilitate excretion Neomycin Sulfate- reduce colonic bacteria Tap water or NSS-remove digested from the colon Avoid sedatives, acetaminophen Avoid ASA Eliminate ALCOHOL Prevent injury/trauma CBR DBCE & repositioning every 2 hours Lotion & massage areas of the skin

Gall Bladder
FUNCTIONS: 4-inch sac with a muscular wall that is located under the liver. reservoir/storage and concentrates bile

Cholecystokinin release when food enters the small intestine. Cholecystokinin signals the gallbladder to contract and deliver bile into the intestine.


Cholelithiasis is the Stone formation in the gallbladder Cholecystitis is the inflammation of gall bladder wall (acute/chronic) Choledolithiasis is the formation of stones in the common bile duct CAUSE: UNKNOWN Predisposing Factors: 8 Fs Female Fat Fair (caucasian) Forty Fertile (multigravida, OCP) Fil-Hispanic Familial Fried foods Pathophsiology: GallstonePressure obstructionBile stasis ASSESSMENT: Mild intolerance to fatty food N&V, flatulence, fever BILIARY COLIC:RUQ pain after ingestion of fatty foods Clay colored stool Steatorrhea Positive Murphy sign- splinting of respiration during inspiration & liver palpation Jaundice Pruritus Tea colored urine Primary Nursing Diagnosis: Acute pain r/t obstruction & inflammation Management Acute: NPO if inflammation subsides: low fat Meperidine HCL Bile salts: chenodiol/ ursodiol after meals CHOLECYSTECTOMY Preop:

IV Fluids DBCE Vitamin K injection Postop: Low or Semi fowlers NGT DBCT Ambulation 24 hours postop CBD EXPLORATION T-TUBE Purpose: drain bile Brownish red for 1st 24 hours 300-500 cc of bile drainage during 1st 24 hours is expected Drainage bottle should be placed IN BED at the level of incision; to drain excess bile only, not all bile DISEASES OF PANCREAS Anatomy & Physiology FUNCTIONS Exocrine: acini cellsproduces pancreatic juices Endocrine: alpha & beta cells Beta insulin Alpha glucagon PANCREATITIS --Acute or chronic inflammation of the pancreas CAUSES: Alcohol abuse-#1 Biliary obstruction Autoimmune Intestinal diseases Drugs: AntiHPN, diuretics, OCP, antimicrobials, immunosuppresants Pathophysiology: Damage to pancreatic cellsInflammationEdema of pancreas & pancreatic duct Obstruction to the flow of pancreatic enzymesAUTODIGESTIONFatty necrosis, ulcerations, hemorrhage, infection ASSESSMENT: Knifelike, twisting, deep severe abdominal pain in the midepigastrium or umbilical region Pain begins 12-48 hours after excessive alcohol intake Nausea & vomiting

Severe dehydration (SHOCK) Weight loss Hypocalcemia Hyperglycemia Jaundice; gray, foul smelling, foamy stools Tea colored or foamy urine

DIAGNOSTICS: Serum amylase & lipase PHYSICAL EXAMINATION Grey-turners sign Cullens sign Primary Nursing Diagnosis Pain (Acute/Chronic) r/t inflammation, edema, peritoneal irritation Management: Relieve pain: meperidine HCL IV fluids (LRS) Ca supplement & Vit D Blood glucose monitored; Insulin Acute: NPO then bland, low fat diet Bedrest Pancreatic enzyme BEFORE MEALS Avoid stimulants: alcohol, caffeine, spicy foods, heavy meals,

A=oral-fecal/acute hepatitis/ infectious hepatitis B=blood hepatitis/ serum hepatitis C=chronic hepatitis/non A-, non B, post transfusion hepatitis D=Dependent hepatitis E=oral fecal All bowels=oral fecal route; consonants=blood Thank you!!!