Amy Parrales

Ruth’s lecture

Gastrointestinal system
Part I

I. Anatomy and Physiology

A. Function: 30 feet long

Supply nutrients to the body

B. Parts:

1. Mouth = teeth, gums, lips, buccal cavity, salivary glands:

produce amylase that starts the digestive process; produce approx.
1 liter/day

2. Pharynx= connected to auditory tubes

3. Epiglottis= little trap door that keeps food from going into the
lungs

a) Import with someone with a tube feeding or swallowing

probs: potential for aspiration

4. Esophagus= tube from pharynx to stomach; transports food

from one point to another; At END = LES =lower esophageal
sphincter; incompetence leads to problems

5. Stomach= functions: a. stores food, b. mixes food with gastric

secretions, c. empties contents into the small intestine
A. Absorption from the stomach:
• Water
• Alcohol
• Electrolytes
• Few drugs
B. Three main parts of the stomach
Lesser curvature and greater curvature
Fundus
Body
Antrium
C. At end of stomach: pyloric sphincter as relaxes allows
small amts of food to pass to small intestine
D. Rague: small folds inside the stomach containing small
glands that secrete enzymes to breakdown food
E. Glands that secrete:
1. Chief cells: have pepcinigen
 2. Parietal cells: secrete hydrochloric acid (breaks down food
and kills bacteria), water and INTRINSIC FACTOR: promotes
absorption of COBALAMIN in the small intestine (distal end)

6. Small intestine: approx. 23 feet long

A. Three parts:
• Duodenum= 1st part
• Jejunum= 2nd part
• Ilium= 3rd part
• Illiosecal Valve: between the large intestine to the
large intestine
• Villi: Functional unit; all the little folds; major
surface area for absorption
i. Contain goblet cells
ii. Mucus and epithelial cells
iii. Intestinal digestive enzymes
• Digestion is the physical and chemical breakdown of food so that it can be
absorbed and utilized by the body
Started in the mouth (chew); add amylase; in stomach pepcinigen is
added which breaks down protein; BUT HCL acid helps convert to pepcin which
starts the initial breakdown of protein:

Composition of the food depends on how long it is in the stomach

1. Carbs: breaks down the fastest changed to monosaccarides,
2. Proteins break down to amino acids
3. Fats: slowest the break down; changed to glycerol and fatty acids
a. Complete breakdown with bile that is made in the liver ; stored in
the gallbladder; bile is released to help break down fats
CHYME: when food is broken down in the stomach
• HCL acid is neutralized by the secretions in the pancreas
• Absorption is transfer of food across intestinal wall so it can be used by
the body; mostly the small intestine
• Into large intestine about 6 feet long
• Secum has appendix for absorption of fluid and electrolytes
• Goes to colon:
o 4 parts
 Upper right: Ascending, Transverse, descending, lower left,
to sigmoid
Rectum
Anus

• Large Bowel: reservoir for feces

o Peristalsis is much slower in large intestine
o Does secret mucus (acts as lubricant)
o Microorganisms in colon – that breakdown proteins that were
digested in small intestine= these proteins are dominated by
bacteria and leave
o **AMONIA** (liver) goes to liver and is converted to UREA
 Bacteria also synthesizes Vit K and some vit B
  Bacteria also causes gas

• Peristalsis- called Haustral Churning in large intestine

o Food stimulates peristalsis
o Teach to train the bowel 1 hr after eating breakfast

• Defecation – reflex-
o Feces pressure stimulates nerve endings
o Sphincters relax and you have elimination
o Try to meet the urge or the large intestine will continue to absorb
water and CONSTIPATION will result
o *Val salva maneuver- bearing down to have BM; monitor with
cardiac pts, head injuries can lead to heart attack
 Head surgeries at risk
 Hemorrhoids>
 Liver cirrhosis > }Could cause bleeding
 Poor hypertension >
 Treatment: stool softeners (COLACE)

• Affects of Aging
o Alcohol
o Tylenol
o Chloroform
o Mercury
o Nalfane
o Thiazide diuretics
o Laxative use/ abuse
o Antacids
o Alka-Seltzer
o Abd surgeries
o OTC’s
o What they use for GI probs = Baking soda (could cause Alkalosis)
o Blood transfusions

• Diagnostic studies; treated with massive doses of laxatives prior

o Barium swallow
o EGD
o Barium enema
o Sigmoidoscopy
• Radiological studies
1. Barium- X-ray study
As a swallow (upper GI)
Or enema (lower GI)
-must be cleaned out (food and feces)
- post op pt needs to be given LAXATIVES to clean out remaining
Barium
- Barium will harden if not removed with laxatives
- monitor BM’s
 2. Oral: Cholestytograms
3. Ultrasounds
-high frequency waves to monitor for tumors of changes
4. Nuclear Imaging
- shows size and shape and where it is positioned
5. Endoscopic tube to look in
- Upper GI- pt given continuous sedation (spray in the back of the
throat
- Monitor- check for GAG reflex (PC: aspiration, pneumonia)
6. Colonoscopy: with fiber optic scope
- can go all the way to the illeal secal valve
-assess for hole in the bowel or bleeding
7. Proctosigmoidoscopy- rigid scope
-not used as much anymore
- 22 cm long, inserted and air is pumped in to dilate the bowel
8. Laparoscopic Exam: look around outside the bowel- peritoneal cavity to
find a diverticulum

******Be sure all permits are signed********

9. EGD: must spill out

Labs:
***Blood chemistries
-Serum Amylase- involved in acute pancreatitis
-Serum Lipase- involved in Pancreatitis
***Gastric Analysis – NG tube to aspirate gastric contents and test pH of stomach
(do yourself or send to Lab)
***Fecal analysis- stool specimens sent to lab for blood, mucus, pus, parasites,
and/or fat content.

• Nutrition: ( failure to thrive) try to starve themselves

o Calories are needed to survive
 Malnutrition= excess or deficit or basic imbalance
• Deficit: not enough food
• Excess: eats too much of the wrong things, not
receiving Vitamins and minerals needed; Not getting
enough of the essential nutrients
• Protein Caloric Malnutrition-
o Primary PCM, nutritional needs not being met
o Secondary PCM; alteration in digestion,
ingestion, absorption, or metabolism
-BM comes out undigested
-examples GI obstruction, malabsorption
syndrome, infections,

Disease process
• Marasums: More common in 3rd world countries; as a
result of concomitant deficiencies; when pt is not
taking in enough calories and protein
 • Kwashiorkor: when protein intake is not enough due
to a catabolic even (superimposed) body can not use
the protein you are taking in

Satiety= fullness with few bites; bloated after eating

Gastro Esophageal Reflex disease: when the contents of the stomach bubble back
into the esophagus…too much acid; the LES sphincter is incompetent

I. Predisposing factors
1. Hiatal hernia
2. Incontinent LES ****primary***
3. Decrease esophageal clearance
4. Decreased gastric emptying

II. Clinical manifestations

1. hyrosis: Heartburn **most common** REFLUX burns and irritates

esophagus below the breast bone and spreads upward to throat and
jaw (assumed heart attack)
a) Can be relieved with milk, alkaline substances **antacids**,
sometimes even water
b.)sometimes can even cause pulmonary symptoms in severe
cases; bleeding coughing or dyspnea; when developing the
pulmonary symptoms they are secondary to the aspiration=
acid reflux has gone down wind pipe = risk for aspiration
pneumonia
c.) Signs and symptoms:
• sore throat
• early saiety- early feeling of fullness
• feel bloated after they eat
• N/V

2. Regurgitation: effortless return; LES incompetent

a) LES is not closing tight enough or it is relaxed

b) Esophagus will become burned and will form scar tissue

and ulcers; will cause lack of function

c) Stricture- constriction of esophagus; delayed emptying

can become

3. Baritis Esophagus- hiatal hernia

****pre- Cancerous Lesion******
High – total gastrectomy,
Risk for aspiration
 (1) Diagnostic studies
-barium swallow
- X-ray
- esophgostopy= just looking at esophagus and stomach
• Collaborative care
o 4 phases
1. 1 modify life style
• Elevate HOB
2. Start with increased protein, low fat diet
3. DRUGS:
• Antacids- Gavison/ or Gastron?
(know some others)
• Cholinergic
• Antisecretory agents – Sendimine,
Tagament, Zantac
• Prokinetic Drug Therapy – Prupulsive
*(makes the stomach is empty faster)
• ***Strongest drug therapy:
• Proton Pump Inhibitors- Prilosec,
Prevacid
• Cerafate- lilac/lavender colored
dissolves very quickly! To coat
lesions(ulcers) **Given before
meals****
• Urecholine- increases LES pressure,
makes it squeeze to prevent reflux
from happening
Teach awareness of antacid use (side effects) – want
to have a minimal side effect
- Aluminum will cause constipation
- Anticipate magnesium causing diarrhea
Some have both and neutralize side effects
Treatment:
• stop smoking,
• don’t drink alcohol
• after eating sit up
• ANTIREFLUX surgery

III. Hiatal Hernia – stomach comes back into and above diaphragm
A. Types
1. Rolling= esophagus only on one side above diaphragm
2. Sliding = both sides and more common
B. Cause- unknown:
 Greater # in obese people
 Pregnant ladies
 Pts with ascities } All cause back pressure
 Major abd tumors
 Tight corsets, girdles
  Heavy lifting
C.Signs and symptoms: same as GERD
 Reflux
 Burning
 Mimic gallbladder disease
 Heart attack
 *some pts have NONE

D. Complications
 Hemorrhage
 Stenosis- tissue becomes rigid and cracks
 Strangulation= really need surgery

E. Diagnostic studies:
 Usually confirmed with X-ray
 Barium swallow
 Fluoroscopy
F.Therapy
 Find Cause and treat it
Loose weight
 Surgical intervention
GOAL to stop the reflux
Pulls stomach back down and apply sutures
3names for surgery for hiatal hernia
1. NISSEN Suntoclication
2. Hill Gastroplexy
3. Belsy’s Sutoclotation
G. Post-op care
1. Prevent respiratory complications **do not cough too hard!
2. Adequate fluids
3. NG tubes to keep stomach empty to allow stomach to heal= if pt
takes it out call MD to put it back it because you don’t to want to
catch the sutures; start on clear liquids and advance slowly
H. Esophageal Cancer
1. Predisposing factor is barits esophagus!!
2. Prognosis is VERY VERY poor because it is diagnosed so late
3. Total Gastrectomy
a. Malnutrition because not intrinsic factor or HCL acid to break
down foods, vitamins will go to the ileum
No stomach no intrinsic factor or HCl acid!!

Gastrostomy tube - = PEG tube

***********Zanker’s Diverticulum**********special!
Fills with food and sits there and empties back into the esophagus

Drugs:
 Parlodel: bromocrpione masylate-
o Dopamine antagonist
o Treatment of hyperpituitarism, acromegaly, gigantism
o Surgical treatment: transsphenoidal hypophysectomy
o Side effects: *******Orthostatic Hypotension and GI upset******

 Declomycin
o Treatment of SIADH
o Contraindicated with pregnancy
 Lithium:
o Interfere with kidneys response to ADH
o Not used as much due to toxicity

 Desmophession:
o Treats SIADH, replaces ADH, IV/ SQ
 Calcitonin:
o treats thyroid- decreased serum Ca and Phosphate
o inhibiting resorption of bane (opposite PTH)

 Sinthoid
o Do NOT give if heart rate is greater than 100
I. Pancreatic Disease

A. Complications Associated with Duodenal Ulcers

1. Hyperparathyroidism

2. *Zolinger-Ellison Syndrome !!%$#@-have a brief knowledge of

this!!!

3. Chronic renal failure

B. Clinical manifestations

1. Burn

2. Cramping

3. Pain 2-4 hrs after meal [1-2 hrs peptic or gastric]

4. Mid- noon, mid-afternoon, middle of the night pain

5. Pain periodic and episodic

6. High recurrence

C. Complications

1. Hemorrhage

2. Perforation

3. Obstruction

D. Peptic Ulcers:

1. Develop in the presence of HCL acid

2. Where the pH is 2-3 (stomach’s very acidic)

3. In the stomach pepcinigen is converted to pepcin

4. When eat the ph is raised and pepcin can’t work to break down
food

5. (Why people with gastric ulcer feel better when they eat and
worse when the stomach is empty)

6. Stomach mucosal layer is very protective

a) -designed that HCL acid will not eat through it

b) -is replaced every 3-2 days

 7. Mortality rate is higher with Gastric ulcers that Duodenal ulcers

a) Generally occur at 50-60 years of age (major factor!!)

II. H-Polori (helicobacter polori)

A. Found in peptic ulcers

1. More often found in older adults

2. Protects itself with Urase (secretes this protective cover)

3. Seen more in 3rd world countries and low economic status

4. Has been related to crowded places (under developed countries
living conditions) and Poor sanitation

5. Is believed that you pick this up as a child

6. More prominent in unsanitary places= higher incidence

7. Unknown if it is Familial (genetic)

8. About 1% of gastric ulcers become malignant

B. Stress ulcers

1. Can develop in about 12 hours because all blood has been

shunted away (still putting out HCL acid which is eating up the
stomach)

2. How to stop bleeding ulcers= pepcid; drugs that will stop/slow

the flow of stomach acids to neutralize the stomach (if pH is less
than 4 would give drug)

3. Duodenal ulcer account for about 80% of all ulcers

4. H-polori account for about 95-100% of all ulcers !Big factor!

5. Hpolori can be present be not cause ulcers and if you have it will
be given tons of antibiotics to try to kill it

6. Lining of the stomach develops eroded spots and the H-polori

tends to go under the lining and hide there=antibiotics do not go
straight to the blood supply
 7. Complications for ulcers gastric and duodenal

a) **most lethal complication and common is perforation

b) Will see more perforations with duodenal than with gastric

c) The more lethal with gastric perforations (more will die with
gastric perforation because of the age factor)

(1) Clinical manifestations of perforation:

(a) Sudden intense abdominal pain

(b) Abdomen will become absolutely rigid because

the stomach contents are spilling and the abd cavity/
wall is trying to keep it from sloshing around and
wants protect everything that is inside (no poking)

(c) Shallow respirations (b/c of pain)

(d) No bowel sounds

(e) Can develop peritonitis in 6-12 hours which can

lead to a paralytic illius

C. Other complication: Gastric Outlet Obstruction

1. Ulcer and heals, over and over and scar tissue develops and
pulls the skin tight

a) Pts always feel better when they vomit

b) c/o constipation

c) **IF YOU EAT YOU POOP**

2. Signs and symptoms:

a) ABD may become distended with perforation

b) May become hyperactive

c) May see peristaltic movement running from the left to right

3. Diagnostic studies:

a) Fiberoptic endoscopy: scope to look

(1) Need to be very aware of gag reflex; chance of aspiration;

ensure that the numbness has subsided
 b) Barium swallow (endoscope needs to be done 1st

c) Gastric analysis, some physicians say this is a questionable value

because the pH of the stomach is constantly changing

4. Labs:

a) CBC

b) Urinanalysis

c) Liver enzymes

d) Serum amylase

e) Stool exams for occult blood

5. Pt Care

a) Acute situations:

(1) 1st Try to make the pt comfortable

(2) if acute flair, will try to get stomach pH up and stop the
burning;

(3) if perforation, have to stop the spill of gastric contents

(4) NG tube

(5) If hemorrhage: will have to replace fluids and blood

volume

b) Antibiotics because H-polori is such a big factor

c) Quick surgery= over sew or patch of the omentum/apron

(between the intestines and the abdominal wall; as a protective layer)

(1) If pt has gastric outlet obstruction; they want to

decompress, this is where they will get the NG tube and correct
the fluid imbalance

6. Drugs

a) Antacids

b) Histamine H2 receptor antagonist

(1) Tagament, Zantac, and pepcid

c) Proton Pump inhibitors

(1) Prilosec and prevacid

d) Antibiotic therapy

e) Anticholinergic drugs

f) Cerafate

(1) Lilac colored that dissolves immediately

(2) Adheres to raw tissue to coat ulcerative area

(3) Be given before a meal to give it a chance to coat

 g) Thyroid should be taken 1 hour before breakfast

h) Iron should be taken with breakfast, but not with coffee or eggs
or milk

D. Surgical Treatment for Ulcers:

1. Partial gastrectomy- removal of a portion of the stomach

2. Vasogotmy- cut the vagus nerve that comes down to the

stomach to stop or slow the stimulation to secrete HCL acid

3. Poloriplasty- surgical enlargement of the pyloric sphincter

(allows the food to pass through and empty into the small intestine

a) V&P- both

4. *Billroth I- remove the distal 2/3rds of the stomach and

anastamose to the stump of the duodenum (no longer have the
antrum or HCL acid to pull in and creates problems
---GASTRODUODENOSTOMY***--

5. *Billroth II- remove the distal 2/3rds of the stomach and

anastamose to the side of the intestines, leaves the stump of the
duodenum which is very necessary because it is where the bile and
pancreatic enzymes are brought in---GASTROJEJUNOSTOMY***--
stomach goes to the jejunum

E. Post-op Gastric resection

1. NG Tubes

a) Levine tube (single lumen must be for intermittent suction

b) Salem sump air port, lumen comes down to stomach, for

continuous suction

c) **IF PT PULLS OUT NG TUBE NOTIFY MD TO

REINSERT**

2. Complications

a) Dumping syndrome: direct result of removal of the stomach;

pyloric sphincter (which keeps food from refluxing and allows small
bolus of food) is incompetent

(1) Is more common in Billroth II

(2) When food goes to the stomach it is usually converted to

chyme with HCL acid; without the pyloric sphincter, large
bolus of food ( hypertonic) draws in fluid and becomes larger
 which increases peristaltic movement and causes diarrhea
right after eating

(3) Nursing interventions

(a) Encourage eating smaller portions

(b) Eat more often

(c) Do not drink liquids with meal- drink 1-2 hrs

after meal

b) Post Pradial Hypoglycemia

(1) Variant of dumping syndrome

(2) Eating makes blood sugar increase but when stop eating it
drops (cautious)

c) Bile Reflux gastritis

(1) Sphincter removed or bypassed causing bile reflux to occur

 3. Post- op care

a) Turn, cough LIGHTLY, and deep breath

b) Will have NG tube

III. Cancer of the stomach:

A. Incidence is declining, less than 10% survive 5 years after they are
diagnosed

B. Is so lethal because the stomach is so vascular

C. People don’t realize they have it because symptoms are so much like a
peptic ulcer

D. Labs:

1. CEA= Cancino Embryonic Antigen –only if CA runs in the family

a) 1st test doesn’t really tell a lot, it is only a BASELINE-CA

marker

b) 2nd (1-3 yrs later) increased level from the baseline indicates CA
is found somewhere in the body

c) 3rd Once CA is found and removed another test is drawn and the
level should be decreased if all CA was removed

E. Total Gastrectomy- must create a pouch in the large intestine

F. Nutritional supplements

1. Ensure, Boost, high protein shakes

G. Nursing Care

1. NG tube or PEG (Precutaneous Endoscopic Gastrostomy)

a) Tube feedings are for pts who can still digest food just can’t eat it

(1) Can be continuous, bolus, or intermittent

b) Need to ensure that adequate water is given to keep to body

hydrated

c) Will check residuals every 2-4 hrs

(1) Before meds

(2) d/c feedings

 (3) *!!Aspirate and the PUT IT BACK!!!!*

2. Dob Hof

a) Goes into the small intestine beyond the pyloric sphincter

b) Not accurate residuals

c) Medication must be completely liquid- rinse with 20-30 mls q hr

d) Need chest X-ray to verify placement

e) Comfortable for pt

3. Decompression Tube- (in a large bowel resection)

a) In thru the nose and down to bowel and fold the bowel over it, 2
lumens; ( used to fill these with mercury)

b) used for suction of gas/ deflation tube

c) 2 types:

(1) Baker Nelson

(2) Mille Abbot- a canter tube

IV. critical care= give feeding usually continuous

 1. Jejunostomy tube-

a) In through the abdominal wall into the jejunum

b) Do NOT allow to clot off!

B. Feeding the pt

1. Raise HOB

2. Check placement

3. Check patency

4. Check Dr.’s orders

5. Rinse after

6. ALWAYS check Residual volume

C. Complications

1. Aspiration = keep HOB elevated at least 30 degrees

2. Diarrhea

3. Constipation (used to feed with pressure bolus to increase

peristalsis**don’t do it anymore

4. Dehydration – pt’s think they don’t have to drink

5. TPN- method of feeding for pts who can NOT tolerate anything
thru GI

a) 10% or less in bag

b) Most common start at 50% glucose (can go as high as 80%);

1000mls total = 500mls amino acids + 500mls glucose

c) **be sure to get base line blood sugar –q2-4 hrs and progress to
q6

d) $1800-$3000 per day

V. Obesity

A. Surgical treatment

1. Vertical banded Gastroplasty:

a) Go in and Wrap the stomach in a little net to make it smaller so

they can not take in as much food

2. Roux-En-Y:

a) Is a Gastric bypass type surgery; bypassing 90% of the small

intestine

b) Small intestine has a loss of nutrients

3. Bilio Pancreatic Diversion

a) Don’t do very much anymore

b) Very severe surgery which caused too much trauma to the body

4. Caution with pts who suffer from bulimia and anorexia***monitor

for

VI. Lower GI problems

A. Diarrhea

1. NOT a disease it’s a symptom

2. = increase in frequency, volume, or looseness in stools

3. Types

a) Acute: associated with laxatives on a short term use or picked up

an infection

b) Chronic: more that 2 weeks

4. Can be life threatening- due to severe dehydration

5. Diagnostic studies

a) 1.physical and history

b) Check labs

6. Care based on replacing fluids

a) Gatorade
 b) Pedialite

c) IV

d) Antidiarrheal agents (Imodium and lomotol)

7. Infectious diarrhea

a) **DO NOT give antiperistaltic medication! Do not slow

peristalsis, the bug will continue to proliferate and grow and cause
the bowel to rupture

b) Antibiotics used for certain bacteria =99% of antibiotics cause

diarrhea

(1) Flagyl: for use in the bowel, for surgery (sterilize with
neomyocin)

8. Clostridium Deficil/ C-Def

a) Smells very bad!; will spread easily because of inadequate hand

washing (nonsocmial infection)

b) Treated with Vancomyocin(which causes diarrhea) then Flagyl

9. Fecal incontinence involuntary passage of stool;

a) Causes:

(1) After a hemhrroidectomy

(2) No sphincter to control

(3) Can NOT stop flow when they get diarrhea

(4) Impaction when it squeezes by the blockage it is liquid

(smears

b) Nursing care

(1) Be supportive and helpful

10. Constipation

a) The normal consistency of the stool is much firmer than normal

b) Causes

(1) Not enough fiber

(2) Not enough fluids

 (3) Lack of exercise

(4) Medications

c) Potential for developing

(1) Hemorrhoids= dilated blood vessel from straining to have

BM

(2) Diverticulosis

(3) Perforate the bowel

11. Abdominal Pain

a) Types:

(1) Acute abdomen

(a) Talk to pt: where, how long, describe it

(b) Signs and symptoms

(i) Tender to the touch

(ii) N/V

(iii) Flatulence

(iv) Tired

(v) Fever

(vi) Increased abdominal Girth(ask if the

distended tummy is normal to them)

(c) Diagnostic studies

(i) CBC

(ii) UA

(iii) Abd X-ray

(iv) Pregnancy test

(v) Sometimes an exploratory lap/surgery;

appendectomy of normal appendix have been
done
12. Abdominal trauma

a) Gunshot wound, stab sound, blunt trauma…

b) Must look to find the path of the wound

c) Signs and symptoms:

(1) Taut abd, guarding, splint (holding it), vomit, bloody urine

d) Penetrating traumas must go to surgery to RUN THE BOWEL

to find holes and avoid spillage of the bowels

e) Diagnostic studies

(1) CBC

(2) UA

13. Inflammation in ABD

a) Appendicitis

(1) In the LRQ- blind pouch in the secum, right where the
large and the small bowel join

(2) Clinical Manifestations:

(a) c/o of pain in the periumblical pain and begin to

localize at McBerny’s point (incision LR abdomen=
½ b/t umbilicus and the iliac crest

(b) localized and rebound tenderness; tippy toe drop

(3) Surgical treatment

(a) Appendectomy

(i) Post-op care

(a) TCD

(b) Antibiotics

(c) Keep HOB elevated to limit the

surface area of edema

(d) Let them position themselves

position themselves to comfort

(b) If appendicitis is suspected:

 (i) DO NOT put heating pad on- warmth will
cause the spread of inflammation because it is
pulling in fluid in and rupture

(ii) NEVER give an enema

(c) Peritonitis:

(a) Is a chemical or bacterial irritation

inside the abd cavity

(d) Signs and symptoms

(i) c/o pain, tender, abd will be taut to rigid

(e) If it is suspected : find the cause (can be a very

exhausting process) and treat it

(f) Gastroenoritis

(i) Inflammation of stomach and small intestine

(g) Irrital Bowel Syndrome (IBS)

(i) Is a Symptom complex of recurrent and

intermittent abd pain associated with alteration
In bowel function

(h) Irrital bowel disease

(i) 2 types

(a) Crohn’s disease

(b) Ulcerative colitis

(i) Similarities:

(ii) Both have remissions

and exacerbations

(iii) Both are chronic and

recurrent

(iv) Can be very debilitating

(v) Clinical manifestations

might vary

(vi) Cause is unknown

(vii)Tends to be familial
Ulcerative colitis:

• Inflammation of the colon and the rectum

• Age tends to hit age groups: 15-25 and 50-80

• Incidence is higher in females

• Seen more in Jewish upper-middle class urban populations

• Inflammation is diffuse and involves the mucus and the sub-mucosa

• *****disease usually starts in the rectum and sigmoid colon and spreads
upward in a continuous fashion

• Can have multiple abscesses develop in the inflamed area

• Ulcers bleed and cause diarrhea

• Major sx:

• Bloody diarrhea (1-2 up to 10-20 per day)

• Pain (mild to severe)

• Complications

• Dehydration

• Hemorrhage

• Strictures

• Perforate because walls have become weakened

• Dilated colon

• Has for 10 yrs or more tend to have an increased incidence of colon cancer

• Usual Labs:

• CBC

• UA

• Sygmoidoscopy

• Drug therapy:
 • Sulfasalozine; helps to keep it in remission; then dr will taper off drug and
can take up to a year to allow the body to take over

• 15-20% of the pt’s have a bowel resections

• May lead to lead and zinc deficiency in the body

• If caught early enough this one can be cured with surgery

Crohn’s Disease/ Regional Enteritis:

• Can occur at any age- most common is 15-30

• Not seen as often as ulcerative colitis

• ***happens in SEGMENTS of bowel**

• Can affect any part of the GI tract

• Clinical manifestations

• Depends on section of the bowel involved

• Principle sx: Pain and diarrhea

• ***biggest complication is FISTULAS development

• Sometimes from bowel to bladder or peritoneal cavity or within itself

• Impaired absorption of Vitamins A,D,E, and K

• Diagnostic Studies:

• Usual..CBC, UA, scope

• Drug treatment: antibiotics, anticholinergics, antidiarrhea,

immunosuppressants, corticosteroids

• Sulfasalozine- esp when large bowel is involved

• Corticosteroids if small intestine

• Flagyl if peritoneal area

• Nutrition- TPN to keep the bowel completely quiet

• *Elemental diet: low residue, low roughage, low fat, high calorie, high
protein (nutrients without irritating the bowel)
 • If terminal illium is involved,( cobalamine that works with intrinsic factor
in the fundus of the stomach) these are the people end up with pernicious
anemia because they can’t get the Vitamin B12, and end up with vitamin
B12 shots

• **SURGERY CAN NOT CURE CRONH’S**

• Avoid laxatives and asprin

VII. Intestinal obstruction

A. Where the contents of the bowel tend to not get through

B. Can be mechanical:

1. Adhesions ; post-op can form fiberous bands of tissue that wrap

around the bowel and not let anything through

2. Hernia- is a defect and the bowel can loop through it then you
can have the potential of the defect getting a spasm in it and pulling
close and not allow intestinal contents through;

3. Neoplasms, Growths and tumors: can cause obstruction

4. Intussusception- is a telescoping of a bowel on itself, bowel

folds, rolls back on itself

a) Reduce by proctiscopesigmoidiscope: where they inflate air to

open the bowel or bowel resection

b) Cause is unknown

5. Mesenteric occlusion; mesentery is on the back of the abd wall

comes out and intestine is attached to the end; if clot can block a
blood vessel ;resection above the clot, p

6. Volovulus: twisting of the bowel on itself where the intestinal

contents can not pass in or out of the loop and it just sit there and
can cut off the blood supply and cause it to die if it squeezes tight
enough; dead bowel can cause an obstruction

7. Polyps – will protrude into the lumen of the bowel

a) Flat or sessile

b) Pedunculated Polyp- like a skin tag

c) Types

(1) Hyperplastic- noncancerous

 (2) Andenomitis- very closely linked to andenocarcinoma;
precancerous

d) If the diagnosis is familial anednomitis polytosis; scope has

removed and confirmed: chances of developing colon/rectal cancer is
at 100%

(1) Generally around 40 yrs of age

(2) If diagnosed with, children need to be checked as teenagers

e) Surgeries depend on where it if found

(1) Right Hemicolectomy; includes secum ascending colon,

and part of the transverse colon

(2) Left hemicolectomy across the transverse colon and down

the descending to the sigmoid

(3) If cancer is with in 5cm of the anus and ABDOMINAL-

PERITONEAL RESECTION: the end of the bowel is out to
the skin where they will have a permanent colostomy and
remove the lower end of the colon and anus
VIII. Ostomies

A. Illiostomy- stool comes out watery (illium is brought out)

B. Secostomy- watery (secum)

C. Colostomy-can be formed, colon is brought out; don’t always have to

wear a bag

D. Double barrel: made ostomy from lower and upper parts of bowel; then
when pt has healed back to surgery to anastomose the two together

E. Loop Ostomy: bring the loop of bowel and place a rod to hold it, then
after healing they will put it back inside

1. Care:

a) **Look at the skin integrity, should be pink and moist

IX. Diverticulitis/Diverticulosis

A. Dr.s feel that it is related to low Fiber and increase in carbs in diets

1. Transit time through the colon becomes very slow(no fiber, no

bulk) the stools becomes hard and presses on the wall of the bowel
and dilated it and stretches the lumen of the bowel; over stretching
will cause it to tear and separate this allows to an out pouching of
the bowel in that area, and stool can irritate and go back in to the
bowel or perforate and again have spilled intestinal contents

B. Diverticuli- is the gastric out pouching of the bowel

C. If this perforates:

1. Abscess formation

2. Fistula formation

3. Bowel obstruction

4. Urethral obstruction

5. Bleeding

D. Clinical manifestations:

1. Some pts have NO signs

2. *unbelievable pain

3. Might have diarrhea or constipation

 E. Nursing care:

1. Be aware of diet; Nothing HARD that can get stuck in the

diverticula and create excessive pressure and cause rupture:

a) Strawberry seeds, peanuts, popcorn, corn, bananas, kiwi

X. Hernias

A. Inguinal canal- **most common** in lower abdomen (seen mostly in

men)

B. Uterus- mostly in females

C. Femoral canal- groin of the leg

D. Central or incisional- at a site where you have had surgery

E. Umbilical- defect at umbilical site

XI. Malabsorption syndrome:

A. Gastrectomy, diverticulitis, resection: candidates for malabsorption,

because they don’t have enough bowel to supply the nutrients

B. *if one of the digestive enzymes is not present they need replacement

XII. Short Bowel Syndrome:

A. Where so much of the bowel has been removed that you don’t have
enough to do what needs to be done and have

XIII. Ano-rectal problems

A. Hemrrhoids: created by extreme pressure

1. Internal above internal sphincter; rubber band ligation: will

become necrotic and fall off

2. External outside the sphincter, can put a clamp on and remove

3. Signs and symptoms:

a) Bleeding, can rupture

4. Nursing care:

a) Increase fiber

b) Increase fluid intake

c) Ointments
 (1) Preparation H (anesthetic to numb)

XIV. Anal Fissures

A. =crack in the anal wall

B. Difference b/t fistula( false track where the stool comes out around
the sphincter to outside

C. Nursing care

1. Keep stool soft

2. Increase fiber

3. Increase fluids

D. Surgical tx:

1. Metal probe inserted and cut down and allow it to heal from the
inside out

XV. Pilonidal sinus

A. Is located at the base of the back (a blind pouch)

B. All have that area, but people who do a lot of sitting with vibration or
irritation (truck drivers)

C. Is an area that has not turned out completely and begin to drain
purulent fluid and it STINKS;

D. Surgical tx:

1. Will make incision and allow to heal from inside out

E. May have hair and teeth

For Test:

Know Medications orders

Differences (signs and sx), curing?, females in higher middle class, cronhs and
ulcerative colitis

Total gastrectomy probs: nutritional, dumping syndrome, A,D,E, K vit deficiencies,

without fundus= lack of intrinsic factor

Ostomies how to care for them

Tubes

medications