Gastrointestinal, Hepatic and

Pancreatic Disorders
Assessment
A. History of Problem
B. General Appearance
1. Thin, emaciated
2. Obese
3. Skin turgor,poor
C. GI system
1. Nausea and vomiting , what precipitates it ,
what relieves it, appearance and
characterisitcs
 2. Pain: location,precipitating factors, what
relieves it, how long ,characteristics and
quality
3. Elimination pattern : patterns and
consistency of stools , laxative use
4. Nutrition: intake and output, difficulties in
swallowing ,likes and dislikes(consider
cultural diversity) , normal intake per day
D. Examination of Abdomen
1. Inspection
2. Auscultation
3. Percussion
4. Palpation
E. Associated symptoms: flatus, eructation,
 Diagnostic Procedures
A. Upper GI
1. Method: barium swallow
2. Purpose: assessment of esophagus and
stomach
3. NPO 6-8 hours before procedure
4. Laxative after use
5. Follow up x-ray after procedure
B. Lower GI
1. Method: barium enema
2. Purpose: assessment of large colon
3. Liquid before procedure
4. Laxative before and after procedure
5. Initially, feces will be white .Should be
During the procedure, you will drink a barium
preparation- a chalky drink with a consistency of a
milk shake, the barium can be seen on an x-ray as
it passess through the digestive tract
instillation of barium contrast through the rectum
into the the abdomen, after which an x-ray of the
colon is taken.
C. Endoscopy(Gastroscopy,
Esophagogastric Duodenoscopy)
1. method: visualization of the inside of the
body by means of a lighted tube
2. Purpose: assessment of esophagus and
stomach
3. Gag reflex inactivated
4. NPO 6-8 hours before procedure
5. Resume diet only if gag reflex returns
6. Complications: perforation, bleeding,
bloating
D. Sigmoidoscopy/ Colonoscopy
1. Method: endoscope inserted through anus
2. Purpose: assessment of sigmoid colon
E. Analysis of Gastrointestinal Secretions
1. Stool Analysis:
a. Method: culture, fat analysis, guiac- no aspirin
(ASA), NSAID, redmeat, Vit C for 3 days before
b. Purpose: assessment for bacteria,virus, ova,
parasites,malabsorption, blood
c. do not refrigerate stool samples, organisms
present could be killed.
F. Evaluation of Gallbladder and Liver
1. Cholecystogram(Gallbladder series)
a. Method:dye conjugated in the liver and excreted
into the bile that outlines the gall bladder
b. Purpose; assessment of gallstones, proper gall
bladder function
c. check for allergy to iodine and seafood
d. Telepaque tablets 12 hours before test
Contrast tablets are swallowed to help visualize the
gall blasser on x-ray
Intravenous cholangiogram: Abbreviated IVC. A radiologic
procedure used primarily to look at the larger bile ducts in
the liver and the bile ducts outside the liver. IVC can be used
to locate gallstones within the bile ducts and identify other
causes of obstruction to the flow of bile. For an IVC, an
iodine-containing dye is injected intravenously. The dye is
removed from blood by the liver which excretes it into the
bile. The dye outlines the bile ducts and any gallstones that
 d. NPO after midnight
e. Less commonly performed than ultrasound
2. Cholangiogram
a.Method: bile ducts visualized
b. Check for allergy to iodine and seafood
3. Ultrasound of Gallbladder and Liver
a. Strict NPO after midnight prior to procedure
b. Able to visualize if stones are present
G. Flat Plate of the Abdomen
1. No preparation
2. Gives an overall impression of the
abdominal cavity
Flat plate
Liver biopsy
H. Liver Biopsy
1. Method: removal of liver tissue to rule out
lliver disease
2. Obtain consent and results of hemostasis
tests before biopsy
3. Usually performed under fluoroscopic
guidance
4. Two weeks prior , client must discontinue
aspririn, NSAIDS and anticoagulants
5. NPO after midnight
6. Position on the left side before biopsy
7. Position on the right side after biopsy for 2
hrs.
8. Prescribed for prescribed time after biopsy
I. Paracentesis
1. Removal of fluid accumulated in the
peritoneum
2. Indicated when ventilation is
impaired,abdominal discomfort
a. Therapeutic: to relieve shortness of breath when
ventilation is impaired
b. Diagnostic: to examine contents of peritoneal
fluid
3. Void immediately after the procedure
4. During the procedure: sitting up with feet
resting on stool
5. Fluid should be removed slowly over 30-90
minutes , generally < 1500 cc
6. Bed rest after the procedure
7. Observe for complications:
Paracentesis
J. Liver Function Tests
1. Alkaline phosphatase
a. Elevated in cardiac disorder, bone disease,
biliary obstruction
b. enzyme found in the liver tissue
c. Released during liver damage
2. Prothrombin time
a. Value is prolonged during liver damage
b. Assess extrinsic clotting process
3. Blood Ammonia : assess liver's ability to
deaminate protein products
4. Serum transaminase studies
a. Elevated in liver disease
b. SGOT, SGPT, LDH, AST, ALT
5. Cholesterol
6. Bilirubin
a. Direct: indicative of pre-hepatic cause
b. Indirect: Indicative of post hepatic cause
 Gastrointesinal Intubation
A. Types:
1. Nasogastric tube: decompression of stomach
2. Salem pump- for continuous or itermittent
suction prevents trauma
3. Miller-Abbot/ Anderson : intestinal suction
4. Ewald- removal of secretions through the
mouth
5. Sengstaken – Blakemore: for treatment of
esophageal varices
NGT

Miller abbot

Salem sump
Ewald

Sengstaken

Sengstaken blakemore
B. Nasogastric Tube Feeding/ Suction
1. Feeding Tubes Nursing Interventions
a. assess placement before each feeding in
continuous feeding
b.semi-fowler's position
c. check for residual; always refeed unless amount
increases
d. nose and mouth care
e. hold for aspirates of >100cc, recheck in one hour
f. replace aspirated contents to prevent metabolic
alkalosis
2. Suction Tube Nursing Intervention
a. should drain stomach contents
b. over time should see a decrease in volume of
drainage
c. always irrigate with normal saline
C. Gastrostomy Tube
1. Anterior wall of the stomach is sutured to
the abdominal wall
2. Primarily placed for long term feeding
D. Percutaneous Endoscopic gastrostomy
(PEG)
1. No need to check for placement
2. Primarily placed for long term feeding needs
3. Preffered over gastrostomy tube because of
ease of insertion and care
4. Make sure tube is anchored continuously
with ring at same number point on tube .This
assure that the stomach is clearly anchored
to the abdominal wall and decrease the
chance of complications.
the difference between the g tube and Peg tube is the way it is
inserted, in Peg tube,the procedure starts of with EGD(
esophagogastroduodenoscopy) ,where they look at the
stomach from the inside, then shine a light through, if the
light is visualized,then a small stab wound is inserted, and
the catheter can be placed that way. In the regular G-tube, is
normally placed in the OR and requires a surgical procedure
E. Total Parenteral Nutrition(TPN)
1. Definition:intravenous administration of a
hypertonic solution of glucose ,nitrogen and
other nutrients to achieve tissue synthesis
and anabolism; lipids may be given as
supplement,provides 3,000-4,000 caloriesper
day.
Note: any concentration of glucose greater
than 10 percent must be given through a
central intravenous line.
2. Indications for use
a. inability of the gastrointestinal tract to
absorb nutrients adequately( eg.
Gastrointestinal obstuction, paralytic ileus,
bowel resection,ulcerative colitis etc)
 b. Inability to take food by mouth(eg.
Neurosurgical problem:coma,anorexia
nervosa)
c. Excessive nutritional needs that cannot be
met by the usual method(eg. Burns, multiple
fracture, carcinoma being treated with
chemotherapy or radiation therapy,severe
infection)
3. Nursing Interventions
a. Chest X-ray immediately after subclavian
line insertion for proper placement
b. Assess weight, baseline electrolytes, blood
glucose, zinc and copper level before
treatment begins.
c. Maintain aseptic (sterile)technique during
d. Maintain infusion rate , do not increase or
decrease rate without order, may cause hypo
or hyperglycemia
e. Assess weight daily ,should maintain or
increase weight while receiving TPN
f. monitor for complications
1. Infection-filters and tubing changed with every
bottle
2. Hypogycemia or hyperglycemia
3. Air embolism: Never open central line to
air.Chance of air embolism is decreased with
multiple lumen set-ups.When central line is set up
or opened,have client perform valsalva maneuver
and place it in trendelenberg position.
4. Pneumothorax especially during insertion
5. Zinc deficiency
 6. fluid overload
7. Hyperglycemic,hyperosmolar nonketotic coma
g. Gradual increase in rate of solution when
discontinuing therby avoiding hypoglycemia
h. Continually evaluate effectiveness of
therapy. Seek consultation if it is not
effective.
 Hiatal Hernia
A. Definition:portion of the stomach
herniated through the esophageal hernia
of the diaphragm

B. Manifestations
1. Heartburn
C. Nursing Interventions
1. Small frequent meals
2. Upright position during and after meals
3. Head of bed elevated
4. Antacids
5. Avoid anticholinergic drugs
6. Reduce intrabdominal pressure by avoiding
lifting and tight clothes around the waist
7. Avoid coughing
8. Reduce spicy food intake- irritants
 Duodenal and Gastric Ulcers
A. Types of Ulcers
1. Chronic gastric and duodenal ulcers
2. Stress ulcers
a. Maybe caused by physical as well as
psychological stress
b. Burns cause Curling's ulcer , a complication from
sever burns when reduced plasma volume leads
to sloughing of the gastric mucosa.
c. Steroid therapy
1. usually occurs atleast 1-2 weeks after sterss
2. no pain
3. may be diagnosed due to gastric bleeding and
resulting low hemoglobin and hematocrit
Comparisson of Chronic Gastric
and Duodenal ulcer
CHRONIC GASTRIC CHRONIC DUODENAL

Age: Usually 50 years or more Usually 25-50 years

Sex: M:F 2:1 M:F 3:1
Incidence : 20 % 80%
General Malnourished Well nourished
nourishment:
Etiology factors: Excessive ingestion of Most result from Helicobacter
salicylates, smoking pylori infection,smoking,O
blood type
Acid production in Normal to hypo secretion hypersecretion
the stomach:
Location Lesser curvature Within 3 cm of pylorus
Pain 1/2- 1 hour after meal,rarely 2-3 hours after meal;night,
at night. early morning.
-Relieved by -Ingestion of food relieves
vomiting.Ingestion of food pain
does not help ,sometimes -Pain is gnawing sensation
causes pain sharply localized in mid-
epigastrium or in back
 CHRONIC GASTRIC CHRONIC DUODENAL

Vomiting Common : caused by Uncommon

pyloric obstruction either by
muscular spasm of pylorus
or mechanical obstruction
from scarring
Hemorrhage Hematemesis more Melena more common than
common than melena hematemesis
Malignancy possibility Usually less than 10 % None

Complications Hemorrhage and Hemmorhage , perforation

perforation and obstruction

Ulcerogenic drugs Salicylates, same

butazolodin,,steroids
B. Nursing Interventions
1. Major goal is to prevent complications and
allow ulcer to heal
a. Rest: physical and mental; lower stress
b. Eliminate stimulants: caffeine, alcohol, spicy
foods, cigarette smoking
c. Diet has no therapeutic effect: milk may be used
but is not recommended
d. Antacid: aluminum hydroxide(Amphojel)
magnesium carbonate (Maalox)
e. Cimetidine (Tagamet): decrease acid production
f. Ranitidine (Zantac) : decreases acid production
g. Sucralfate (Carafate): protects lining of stomach
h. Omeprazole(Prilosec): heals ulcer
C. Gastric resection
1. Types
a. Billroth 1 (gastruduodenostomy)
b. Billroth 11 (gastrojejunostomy
c. total gastrectomy: will cause pernicious
anemia
Gastrectomy
2. Nursing Interventions
a. NG tube in place: do not move as it may
stimulate bleeding at the surgical site
b. Evaluate need for KCL in IV to prevent
metabolic alkalosis
c. NPO until suture is totally healed
d. Assess drainage: will initially be sanguineous
but should change in 2-3 days
3. Complications
a. Hemorrhage
b. Pulmonary
c. Dumping syndrome: due to rapid entry of
food into the jejunum without proper mixing
and normal digestive process of duodenum
1. Early: 5-30 minutes after eating,verrtigo,
sweating, diarrhea, nausea due to fluid shift
2. Late: 2-3 hours after eating ,hypoglycemia
occurs due to excess insulin secretion
3.Intervention: avoid salty , high carbohydrate
meals, eat small frequent meals,avoid liquid with
meals,lie down after meals (30-60 min),avoid
antispasmodics, eat high protein, high fat,low
carbohydrate meals . No fluids for one hour
before, with or 2 hours after meals
d. Major complication : Peritonitis
 COMPARISON OF CHRON'S DISEASE AND
ULCERATIVE COLITIS
CHRON'S DISEASE ULCERATIVE COLITIS
Small Bowell Large Bowel
Pathology : Transmural : primarily Mucosal ulceration of the
involving ileum and right lower colon and rectum
colon
Age : 20-30, 40-50 20-40
Etiologic factors: Unknown , genetic, Jewish Unknown familial, Jewish
Bleeding : Usually not Common , sever
Perianal involvement Common Rare ,mild
Fistulas Common Rare
Rectal involvement 20 % 100%

Diarrhea Less severe Severe

Abdominal pain after eating Yes Yes

Weight loss Yes yes

 CHRONS'S DISEASE
Treatment: Steroids :
sulfazaline(Azulfidine)
hyperlimentation:partial or
complete colostomy &
ileostomy and anastomosis
History: Deteriorating, progressive
Complications : Scarring, obstruction
ULCERATIVE COLITIS
Steroids : sulfazaline
(Azulfidine)
-partial or complete
colostomy and
proctolectomy % ileostomy
Exacerbations, remissions
Perforation, susceptible to
cancer, toxic megacolon,
fistulas obsruction, abscess
Chron's disease
Ulcerative colitis
 Diverticulosis and Diverticulitis
A. Definition:
1. Outpouching of the colon is deverticulosis
2. When the outpouching is infected, it is called
diverticulitis.
3. Problem: the pouch gets filled with feces,
becomes inflamed, can obstruct and
perforate leading to peritonitis
B. Nursing Interventions
1. Prevent by increasing fiber in diet
2. Avoiding all seeds
3. Preventing constipation by using bulk agents
and increased water
 Bowel Obstruction
A. Definition: anything that obstructs the
bowel; iflammation, tumor
B. Manifestations:
1. Increased bowel sounds proximal to the
obstruction
2. No stool
3. Pain
4. Distention
5. Vomiting (projectile from reverse peristalsis)
6. Hypovolemia and shock
C.Nursing Interventions
1. Intestinal tube: refer care to the preceding
section
2. Ambulation
3. Treat cause and relieve
4. Surgical intervention: colon resection
 Comparisson of colostomy and
ileostomy
COLOSTOMY ILEOSTOMY
Defined: Portion of the colon brought to the Portion of the ileum brought to the
abdominal wall abdominal wall creating a
permanent opening for exit of
waste products
Areas : Involved large bowel Involves small bowel

Indications : Inflammatory or obstructive Chron 's disease

process of the lower intestinal
tract;trauma to the intestinal Ulcerative colitis
tract;cancer of the rectum or
sigmoid colon where anastomosis
is not possible
Stool : Semiformed to formed Liquid

Control Maybe controlled by diet and/or No control, must wear appliance

irrigation depending on the at all times
location in the colon,maybe able
to control evacuation
Nursing Interventions
1. Preoperative care
a. emotional support(anticipatory grieving)
b. client teaching concerning impending
surgery(ileostomy/colostomy)
2. Postoperative care
a. general postop care
b. psychological support
c. NG tube
d. observe stoma, surrounding tissues and
type of secretion( should be pink, above skin
level; may have bloody discharge at first)
e. teach self care to client
1. type of equipment to use and how
2. skin care
3. diet: decrease fat and odor forming foods
 Comparisson of Hepatitis
A;Hepatitis B;Hepatitis non-
A;non-B;Hepatitis
HEPATITIS
(Infectious
A HEPATITIS B C
HEPATITIS HEPATITIS
(Serum hepatitis) NONA;NO
C

hepatitis) NB
Cause - virus transmitted -virus transmitted -thought -transmitted via blood,
by fecal-oral through similar to by personal contact &
contact;often seen percutaneous or type B possible fecal oral
during oral exposure to route
floods,earthwakes the blood of person -hepatitis C causes
with Hepa B 4% of hepatitis cases;
causes 90% of
posttransfusion
hepatitis
-risk factors are the
same with hep B
Manifest -flu-like, upper -similar to type A -same as -same as type B,may
ations respiratory without respiratory type B lead to need of liver
infection,headache, symptoms tranplantation(30%)
malaise,jaundice,d
ark urine,liver
tenderness
Nursing -enteric -same as type A -same as Same as type B
precautions,bed except “blood type B
rest,low fa precaton”instead of
 HEPATITIS A HEPATITIS B HEPATITIS HEPATITIS C
(Infectious (Serum NONA;NON
hepatitis) hepatitis) B

Prevention Good sanitation;if Mandatory Same as No sharing of

in contact with screening of type B needles by drug
infected blood donors-use users;care to avoid
client,administer of disposable accidental needle
serum immune needles and sticks(health care
globulin within 2- syringes;administ workers);safe
7 days; Hep A er Hepatitis B sexual practices
vaccine is immune globulin
available 2- 7 days after
exposure.Hepatit
Note: vaccine s B vaccine:
protects at least series of 3
10 yrs injections after 6
months
 Liver Cirrhosis
A. Definition: liver cells destroyed and
replaced by scar tissue;cause not clear ,
frequently seen in alcoholics but also
occurs in non-alcoholics; associated with
nutritional deficiency with decreased
protein intake
B. Functions of the Liver
1. synthesis of clotting factors(fibrinogen,
prothrombin, factor VII,IX,X)
2. metabolism of
hormones(aldosterone,antidiuretic hormone,
estrogen, testosterone)
3. synthesis of albumin
 5. protein metabolism
6.fat metabolism through bile production
7. filter action, especially drugs
8. blood storage
C. Manifestations: these would be the same
for a client with liver failure from other
causes also, except for the enlargement
of the liver and the alcohol related
psychosis
1. Early stage
a. enlarged liver with fatty infiltration
b. jaundice
c. GI disturbances
2. Late stage
a. liver becomes smaller and nodular
b. spleen enlarges: anemia
c. ascites, distended abdominal veins, back-up
of pressure in the portal system
d. bleeding tendencies, decreased Vit K and
prothrombin
e. Wernicke- Korsakoff psychosis: alcohol
related
r/t thiamine/niacine deficiency and increase NH3
level
f. esophageal varices(painless
condition),internal hemorrhoids, back up of
pressure in the portal area
g. dyspnea from ascites and anemia
3. End stage
a. Hepatic encephalopathy stages
1. Prodromal: slurred speech, vacant stare, restless,
involves neuro deterioration
2. Impending: asterixis, apraxia, lethargy, confusion
3. stuporous: noisy, abusive, somnolence
4. coma: positve babinski, fetor hepaticas,
decorticate/decerebrate posturing
b. Convulsions
c. death
d. Nursing Interventions:goal is treating the
manifestation and maximizing liver
functions
1. encourage client to rest
2. avoid hepatotoxic drugs and alcohol
3. high calorie, low protein(20-40g/day),low fat,
low sodium(maintain protein restrictions
during stage 1 and II of encephalopathy, no
protein allowed durig stages III and IV
4. fat soluble vitamin supplements, folic acid
may need to be given IV
5. restrict fluids
6. albumin IV
7. weigh client daily
9. skin care: cool temperature, aveeno baths,
lulbricate
10. monitor I and O
11. assess for bleeding, hemorrhoids
12. diuretics: spironolactone(Aldactone),
furosemide( Lasix)
13. Neomycin: reduces intestinal bacteria,
thereby decreases breakdown of protein
reducing ammonia levels
14. Lactulose(Heptalac): decrease ammonia
levels
15. thiamine daily
 Esophageal varices
A. Definition: esophageal varices are
dilated veins found in the lower
esophagus that occur secondary to portal
hypertension;bleeding may result
because of coughing,trauma or vomiting,
bleeding esophageal varices is a medical
emergency
B. Nursing Interventions
1. maintain client airway before inserting
sengstaken-blakemore tube
2. care of client with sengstaken blakemore
tube
a.maintain traction and manometer pressure of 40
mmHg
b. keep scissors by bed side( to cut the tube in
emergency)
c. oral suctioning,mouth care; cannot swallow
saliva or will aspirate
d. deflate gastric balloon every 24-36 hours ;usually
deflate esophageal balloon every 12 hours as
ordered
3. semi folwer's position
5. monitor intake and output
6. Vit K
7. vasopressin(Pitressin) : vasoconstrictor
8. endoscopic sclerotherapy
a. sclerosing agent introduced via endoscope
b. thromboses and obliterates the distended veins
 Gall bladder disease
A. Definition:
1. inflammation of the gall bladder
2. cholelithiasis: stones in the gall bladder
3. at risk: 4 F: fair, fat, forty, fertile( oral
contraceptive users)
B. Manifestations:
1. right upper quadrant or epigastric pain,
shoulder pain
2. nausea and vomiting
3. fat intolerance
4.. Murphy's sign: have client take deep breath
and palpate the the right subcostal area. If
the client has extreme pain and stops
breathing on ispiration , this is a + murphy's
sign and indicative of acute cholecystitis
5. jaundice indicates obstruction
C. Nursing Intervention
1. Relieve pain-meperidine(Demerol). Do not
use mophine, will case spasm and more pain
2. Maintain fluid and electrolytes balance
3. Administer antiemtic prn
4. Maintain low fat diet
D. Cholecystectomy: postoperative
1. Nursing care same as abdominal surgery
2. Penrose drain in gall bladder area
3. T-tube to gravity after cholecystectomy and
chole-dochostomy
4. Resume regular diet as tolerated
Penrose drain(rubber)

T-tube
 Pancreatitis
A. Definition: inflammation brought about
by the digestion of this organ by the
very enzymes it produces.Clients at
greater risk are those suffering
from alcohol abuse,clients with other
liver and gall bladder diseases.
B. Manifestations:
1. extreme upper abdominal pain radiating into
the back
2. persistent vomiting
3. abdominal distention
4. weight loss
5. steatorrhea: fatty stool, bulky pale, foul
 6. elevated serum amylase and lipase
7. pleural effusion
C. Nursing Interventions: rest the organ
1. administer anticholinergics,antacids,
pancreatic extracts: pancrelipase(Viokase)
2. NPO with NGT in place: no ice chips osr hard
candies as these will stimulate the pancreas
3. IV fluids: may require TPN in moderate or
severe cases
4. Provide meperidine (Demerol) for pain relief
5. Administer fat soluble vit
5. Home care management/teaching
no alcohol or caffeine, infusion of IV fluids, signs
and symptoms to report( fever, nausea, vomiting)