GI

tract 23-26 foot-long pathway that extends from the mouth thru the esophagus, stomach, intestine and anus

 FUNCTIONS
-

: To break down food particles into the molecular form for digestion To absorb into the bloodstream the small molecules produced by digestion

 To

eliminate undigested & unabsorbed foodstuff & other waste products from the body
Provide environment for microorganisms to synthesize nutrients such as Vit. K

 Start

of digestion - chewing Saliva 1st secretion that comes in contact with food - secreted from submaxillary, parotid & sublingual glands - contains ptyalin (salivary amylase) digest starch

 Swallowing

voluntary act - regulated by medulla oblongata (swallowing center)

 Stomach

stores & mixes food with secretions -Gastric fluid (2.4L/day)- secretes HCl; break down foods & destroy most ingested bacteria - Contains pepsin enzyme for CHON digestion

Intrinsic factor secreted by gastric mucosa to combine with Vit B12 to be absorbed in the ileum Peristalsis & contraction of pyloric sphincter enter of partially digested food in the small intestine Chyme- food mixed with gastric secretion

 Pancreas,

liver & gallbladder PANCREAS contains pancreatic secretion with alkaline pH neutralizes acid entering duodenum - serves as Exocrine & endocrine gland

 Pancreatic

enzymes: - Amylase digests starch to maltose - Maltase reduce maltose to glucose - Lactase split lactose to galactose & glucose - Nucleoses split nucleic acid to nucleotides - Enterokinase activates trypainogen to trypsin

LIVER largest gland in the body - contains Kupffers cells remove bacteria in the portal circulation - removes excess glucose & amino acids from the portal blood - synthesize glucose, amino acids & fats

- stores & filters blood (200-400ml) - stores Vit. A, D, B and iron - secretes bile for emulsifying ingested fats (500-1000 ml/day) GALLBLADDER- stores & concentrates bile - it contracts to force bile into the duodenum - Sphincter of Oddi guards the entrance into the duodenum

 Primary

function: Absorption Secretes the ff: - Mucus coats the cell & protects the mucosa - Hormones control rate of intestinal secretions & influence GI motility - Electrolytes - Enzymes

types of contraction in the small intestine: 1. Segmentation produces mixing waves that move contents back & forth in churning motion 2. Intestinal peristalsis propels the content of small intestine into the colon

Two

 Primary

function: reabsorption of water & electrolytes Bacteria make up major component of the contents of large intestine Electrolyte solution (bicarbonate) & mucus colonic secretions that are added to residual material in the colon

 Feces

undigested foodstuff, inorganic material, water & bacteria - 75% fluid & 25% solid material Flatus contains methane, hydrogen sulfide & ammonia (150 ml)

 Defecation

is a spinal reflex (parasympathetic nerve fibers) that can be inhibited voluntary by keeping the external anal sphincter closed Contracting abdominal muscle facilitates emptying of the colon Normal defecation: once daily

Pain - Character, duration, pattern, frequency, location, distribution of referred pain 2. Indigestion - Upper abdominal discomfort or distress associated with eating
1.

3. Intestinal gas - Belching expulsion of gas from the stomach thru mouth - Flatulence expulsion of gas from the rectum * Excessive flatulence may be a symptom of gallbladder disease or food intolerance

4. Nausea & vomiting - triggered by odor, activity or food intake - Emesis/vomitus contains undigested food particles or blood (hematemesis)

5. Change in bowel habits & stool characteristics - may signal colon disease - Diarrhea abnormal increase in frequency & liquidity of stool - Constipation decrease in frequency of stool; or stools that are hard, dry, and of smaller volume than usual

 Stool

color can be greatly affected by medications & certain foods Melena- black tarry stool - upper GI bleeding Hematochezia fresh blood in the stool - lower GI bleeding

 Includes

assessment of mouth, abdomen & rectum Abdomen Inspection, auscultation, percussion, palpation (IAPP) Inspect for skin color, abnormalities, contour, and distention

 Bowel

sounds heard every 5-20 seconds - HYPOACTIVE 1-2 sounds in 2 minutes - HYPERACTIVE - 5-6 sounds in < 30 sec - ABSENT no sound in 3-5 minutes

 Tympany

or dullness heard during percussion Note for rebound tenderness during palpation

 Use

of high frequency sound waves Image of abdominal organs & structures is produced on the oscilloscope Useful in detecting cholelithiasis, cholecystitis, appendicitis & diverticulitis

 Advantage:

requires no ionizing radiation, no side effects & inexpensive Disadvantage: cannot be used to examine structures that lie behind bony tissues

 Maintain

pt on NPO 8-12 hours before the test decrease amount of gas in the bowel Fat-free meal in the evening before the test for gallbladder studies

 Inspecting

for consistency, color, parasites, fat, nitrogen, food substances & testing for occult (not visible) blood Some specimen requires certain diet to be followed

 Upper

gastrointestinal fiberoscopy Following sedation, an endoscope is passed down the esophagus to view the gastric wall, sphincters & duodenum Tissue specimen can be obtained

 The

client must be NPO for 6-12 hours before the test A local anesthetic is administered along with midazolam IV (provides conscious sedation & relieves anxiety) just before the scope is inserted

 Position

the client left side to facilitate saliva drainage & provide easy access of the endoscope Airway patency is monitored during the test & pulse oximetry is used to monitor oxygen saturation Emergency equipment should be readily available

 Client

must be on NPO until the gag reflex returns (1-2 hours) Monitor for signs of perforation (pain, bleeding, unusual difficulty swallowing, elevated temp) Lozenges, saline gargles or oral analgesic can relieve minor sore throat after the gag reflex returns

 It

requires the use of flexible scope to examine the rectum & sigmoid colon Client is placed on the left side with the right leg bent Biopsies & polypectomies can be performed

 Preprocedure:

Enemas are given until the returns are clear Postprocedure: Monitor for rectal bleeding & signs of perforation

Examination of upper GIT under fluoroscopy after the client drink barium sulfate PREPROCEDURE: NPO post midnight before the day of the test


1. 2. 3.

POSTPROCEDURE: A laxative may be prescribes Instruct the client to increase OFI to help pass the barium Monitor stool for passage of barium (stool may appear chalky white) because barium can cause bowel obstruction

Analysis of gastric juice To know the secretory activity of the gastric mucosa & presence of gastric retention for client with pyloric or duodenal obstruction.

NPO 8-12 hours before the procedure Drugs that affect gastric secretions are withheld 24-48 hours before the test.

NGT is inserted entire stomach content are aspirated by gentle suction into a syringe & gastric samples are collected every 15 min for the next hour Gastric acid stimulation test is usually performed in conjunction with gastric analysis.

Back-flow of gastric or duodenal contents into the esophagus

Incompetent lower esophageal sphincter Pyloric stenosis Motility disorder Aging

Pyrosis (burning sensation in the esophagus) Dyspepsia (indigestion) Regurgitation Dysphagia (difficulty swallowing)

Odynophagia (pain on swallowing) Hypersalivation Esophagitis

Endoscopy Barium swallow Ambulatory 12 to 36-hour esophageal pH monitoring

Low fat diet avoid caffeine, tobacco, beer, milk, spicy foods & carbonated drinks Avoid eating or drinking 2 hours before bedtime Maintain normal body weight Avoid tight fitting clothes Elevate head of bed 6-8 inch blocks & upper body on pillows.

Antacids Histamine receptor blockers (e.g. Ranitidine) Proton pump inhibitor (e.g. Omeprazole) Prokinetic agents (e.g. Domperidone)

FUNDOPLICATION - Wrapping of a portion of the gastric fundus around the sphincter area of the esophagus - Can be performed by laparoscopy

Presence of opening in the diaphragm thru which the esophagus passes becomes enlarged & part of the upper stomach tends to move up into the lower portion of the thorax.

1.

SLIDING (TYPE I) - Occurs when the upper stomach & gastroesophageal junction are displaced upward & slide in and out of the thorax

2. PARAESOPHAGEAL HERNIA (TYPE II,III,IV) - Occurs when all or part of the stomach pushes thru the diaphragm beside the esophagus

SLIDING HERNIA: - Heartburn - Regurgitation - Dysphagia * 50% asymptomatic

PARAESOPHAGEAL HERNIA Feels a sense of fullness after eating May be asymptomatic Absence of reflux

Hemorrhage Obstruction strangulation

X-ray studies Barium swallow Fluoroscopy

MEDICAL: Frequent small feedings Avoid lying 1 hour after eating Elevate head of head 4-8 -inch blocks SURGICAL: - Repair of hernia

Absent or ineffective peristalsis of the distal esophagus accompanied by failure of the esophageal sphincter to relax in response to swallowing.

Dysphagia primary symptom Heartburn Chest pain

X-ray Barium swallow CT Scan Endoscopy MANOMETRY confirmatory test - esophageal pressure is measured by radiologist or gastroenterologist

Instruct pt to eat slowly and drink fluids with meals. Calcium channel blocker & nitrates temporary measure to decrease esophageal pressure & improve swallowing

BOTOX (Botolinum toxin) injection to quadrants of esophagus via endoscopy PNEUMATIC DILATION stretch the narrow area of esophagus

ESOPHAGOMYOTOMY - Performed thru laparoscopy - Separates esophageal muscle fibers

Outpouching of mucosa & submucosa that protrudes thru a weak portion of musculature

ZENKERS DIVERTICULUM (PHARYNGEAL POUCH) most common type - people older than 60 yrs old Other types: midesophageal, epiphrenic & intramural diverticula

Dysphagia Fullness in the neck Belching Regurgitation of undigested foods Gurgling noises after eating Halitosis Sour taste in the mouth

Barium swallow Manometric studies

* Avoid esophagoscopy & NGT Insertion

DIVERTICULECTOMY - Surgical removal of diverticulum MYOTOMY the muscle is dilated or released surgically OTOLARYNGOLOGIST head & neck surgeon

 Inflammation of gastric mucosa Acute or chronic

ACUTE GASTRITIS: - Contaminated foods - Spicy foods - Overuse of aspirin & NSAIDS - Excessive alcohol intake - Bile reflux - Radiation therapy - Ingestion of strong acid or alkali

CHRONIC GASTRITIS: - Benign or malignant ulcers of stomach - Helicobacter pylori - Associated with autoimmune disease - Use of caffeine - NSAIDS - Smoking - Reflux of untestinal content in the stomach

ACUTE: Abdominal discomfort Headache Nausea & vomiting Anorexia hiccups

CHRONIC: - Anorexia - Heartburn - Belching - Sour taste in the mouth - Nausea & vomiting - Evidence of malabsorption of Vit. B12

ENDOSCOPY Upper GI series Biopsy & histologic exam of tissue specimen for H. pylori

ACUTE: Instruct the pt to refrain from alcohol & food until the symptoms subside Non-irritating diet Parenteral fluids Analgesics & Antacids (e.g. Maalox) Nasogastric intubation

CHRONIC: - Modifying the diet - Promoting rest - Reducing stress - Antibiotic- for H. pylori - Proton pump inhibitor

Assessment: Pt history s/sx, 72-hour diet recall, hx of previous disease, medications taken

Nursing Diagnosis; - Imbalance Nutrition less than body reqts r/t inadequate intake of nutrients - Risk for imbalance fluid volume r/t insufficient intake & excessive fluid loss subsequent to vomiting - Acute pain r/t irritated stomach mucosa - Anxiety r/t treatment

NPO until symptoms subside Monitor IV therapy Discourage the intake of caffeinated beverages, alcohol & smoking

Daily I&O monitoring IV fluids are prescribed at 3L/day Assess electrolyte values

Instruct client on the diet to avoid irritation of gastric mucosa Instruct about medications as prescribed Assist in non pharmacologic pain mngt

Use a calm approach to assess the client. Answer all questions as completely as possible. Explain all procedures & treatments to clients level of understanding.

An excavation (hollowed-out area) that forms in the mucosal wall of the stomach, in the pylorus, duodenum & esophagus Gastric, duodenal, esophageal depending on location

DUODENAL Incidence: Age: 30-60 Male:female = 2-3:1 80% are duodenal

GASTRIC Usually 50 and over 1:1 15% are gastric

DUODENAL - Hypersecretion of HCl - Weight gain - Pain occurs 2-3 hours after meal - Ingestion of food relieves pain

GASTRIC - Hyposecrretion of HCl - Weight loss - Pain occurs to 1 hour after meal - Vomiting relieves pain

Vomiting is uncommon Bleeding less likely, if present melena is common More likely to perforate than gastric ulcer

Vomiting is common Bleeding more likely hematemesis

DUODENAL Malignancy possibility: Rare

GASTRIC Occasionally

Risk factors: H. pylori, alcohol, smoking, cirrhosis, stress

H. pylori, gastritis, alcohol, smoking, NSAIDs, stress

Physical exam: pain, epigastric tenderness, abdominal distention Barium study of upper GI Endoscopy Biopsy Stool exam for occult blood

Combinations of the ff: -Antibiotics - Proton pump inhibitor - bismuth salts H2 receptor antagonist & proton pump inhibitor for NSAIDs induced ulcer & not associated with H. pylori

Reduce environmental stress Smoking cessation Dietary modifications: -Avoid extremes of temp. - Avoid overconsumption of meat extracts, coffee, alcohol & other caffeinated beverages & diet rich in milk & cream

VAGOTOMY BILLROTH I BILLROTH II

ASSESSMENT: Describe the pain, methods used gto relieve pain Describe emesis if present 72-hour food recall Lifestyle & medications Vital signs tachycardia & hypotension

DIAGNOSIS Acute Pain r/t the effect of gastric acid secretion on damaged tissue Imbalance Nutrition r/t changes in diet Anxiety r/t coping with an acute disease Deficient Knowledge about prevention of symptoms & management of the condition

RELIEVING PAIN Taking prescribed medications. Avoid aspirin, foods that contain caffeine Meals should be eaten regularly Relaxation techniques

MAINTAINING OPTIMAL NUTRITIONAL STATUS Assess for malnutrition & weight loss Advise to comply on medication regimen & dietary restrictions.

Sudden illness that occurs after ingestion of contaminated food or drink. BOTULISM - serious form of food poisoning that requires continual surveillance.

Nausea Vomiting Diarrhea

Food, vomitus, gastric contents, serum & feces are collected for examination Monitor VS, sensorium, CVP (if indicated) & muscular activity Monitor for electrolyte & acid-base imbalance Antiemetic given parenteral

Aspiration of stomach content & washing out of stomach by means of a large-bore gastric tube. Contraindicated for acid or alkali ingestion, seizures or after ingestion of hydrocarbons or petroleum distillates

Urgent removal of ingested substance or decrease systemic absorption Empty the stomach before endoscopic procedure To diagnose gastric hemorrhage & to arrest hemorrhage

Increased frequency of bowel movement ( more then 3x per day) Increased amount of stool ( more than 200 g per day) Altered consistency (looseness) of stool

Increased intestinal secretions Decreased mucosal absorption Altered motility

Irritable Bowel Syndrome (IBS) Inflammatory Bowel Disease (IBD) Lactose Intolerance

ACUTE - Associated with infection - Self-limiting CHRONIC - Persist for loger period of time - May return sporadically

Medications (laxatives, thyroid hormone replacement, antibiotics, chemotherapy, antacids) Tube feeding formula Metabolic & endocrine disorders (DM, Addisons) Viral or bacterial infection (Dysentery, shigellosis, food poisoning)

Anal sphincter defect Zollinger- Ellison syndrome Psralytic ileus Intestinal obstruction AIDS

Increased frequency of stool fluid content of stool Abdominal pain or cramps Abdominal distention Intestinal rumbling (borborygmus) Anorexia Thirst Tenesmus (ineffectual straining

Stool Exam CBC Endoscopy Barium enema

Dehydration Cardiac dysrhythmia

Antibiotic Anti-inflammatory Antidiarrheal IV therapy

Assess & monitor the characteristic & pattern of diarrhea Health history Abdominal auscultation & palpation Obtaining stool samples

Encourage bed rest. Advise intake of liquids & foods low in bulk Bland diet of semi solid & solid foods Avoid caffeine, carbonated drinks, very hot or very cold foods, milk products, fat, whole grain, fresh fruits & vegetables

Administer medication as prescribed. Monitor electrolyte levels Report immediately presence of dysrhythmia or change in LOC

Abnormal infrequency or irregularity in defecation Abnormal hardening of stool that makes the passage difficult or painful Decrease in stool volume Retention of stool in the rectum for a prolonged period

Medications (tranquilizer, antidepressant, antiHPN, opioids, antacid with aluminum, iron) Rectal or anal disorder ( hemorrhoids) Obstruction (e.g.cancer of bowel)

Metabolic, neuroligic & neuromuscular condition (DM, Hirschsprungs disease, Parkinsons, multiple sclerosis) Endocrine disorders (hypothyroidism, pheochromocytoma) Lead poisoning Connective tissue disorders (eg. SLE)

Weakness immobility fatigue inability to increase intra abdominal pressure (emphysema) Low fiber diet Inadequate fluid intake Lack of exercise Stress

Abdominal distention Borborygmus from passage of gas thru the intestine Pain & pressure Decrease appetite

Headache Fatigue Indigestion A sensation of incomplete emptying straining at stool Elimination of small-volume, hard, dry stools

Petients hx Physical exam Barium enema Sigmoidoscopy Stool exam Occult blood

Hypertension Fecal impaction Hemorrhoids Megacolon (dilated colon)

Bowel habit training Increased fiber & fluid intake Use of laxatives Routine exercise

Patient education of the ff; Maintaining regular pattern of elimination Ensuring adequate intake of high fibers & fluids Learn method to avoid constipation Relieving anxiety Avoiding complications

Presence of spastic bowel contraction One of the most common GI problems Common in women Cause is unknown

Heredity Psychological stress (depression, anxiety) High fat diet Alcohol intake Smoking

Alteration in bowel patterns constipation, diarrhea or combination of both Pain, bloating & abdominal distention Pain is precipitated by eating and relieved by defecation

Stool exam Barium enema Colonoscopy Manometry

High fiber diet Exercise Stress reduction program Antidiarrheal drugs Andtidepressant Anticholinergic & calcium channel blocker decrease smooth muscle spasm, cramping & constipation

Involuntary passage of stool from the rectum Factors: - Ability of the rectum to sense and accommodate stool - Amount & consistency of stool - Integrity of the anal sphincter & musculature - Rectal motility

Minor soiling Occasional urgency & loss of control Complete incontinence Poor control of flatus Diarrhea Constipation

Rectal examination Sigmoidoscopy Barium eenema CT Scan

Treat the diarrhea or fecal impaction Biofeedback Bowel training program

Surgical reconstruction Sphincter repair Fecal diversion

Setting schedule for bowel training Maintain skin integrity Assist in the use of incontinence briefs

Presence of blockage that prevents the normal flow of intestinal contents through the intestinal tract

1. -

MECHANICAL OBSTRUCTION Intraluminal or mural obstruction from pressure of intestinal wall E.g. intussusception, polypoid tumor & neoplasm, stenosis, stricture, adhesion, hernia & abscess

2. FUNCTIONAL OBSTRUCTION - The intestinal musculature cannot propel its content along the bowel - E.g. amyloidosis, DM, Parkinsons disease

Intestinal contents, fluid & gas accumulate above the intestinal obstruction - CAUSES: 1. Intussusception 2. Volvulus 3. Hernia
-

Crampy, colicky pain Blood & mucus without fecal matter & flatus Vomiting (fecal vomiting) Abdominal distention Signs of dehydration

Abdominal x-ray Abdominal UTZ Lab studies (electrolyte level, CBC)

DECOMPRESSION use of NGT IV therapy Antibiotic

Repairing hernia Dividing the adhesion

Maintaining the function of NGT Assess & measure NGT output Assess F&E imbalance If pts condition doesnt improve, the nurse prepare the pt for surgery

Results in accumulation of intestinal contents, fluids & gas proximal to the obstruction Leads to severe distention & perforation Dehydration occurs more slowly Intestinal strangulation & necrosis if blood supply is cut-off

*Symptoms progress slowly Constipation Abdominal distention Crampy low abdominal pain Fecal vomiting

Abdominal x-ray (flat & upright) Abdominal UTZ

COLONOSCOPY - to untwist & decompress the bowel CECOSTOMY- surgical opening in the cecum Rectal tube to decompress area lower in the bowel

SURGICAL RESECTION remove the obstructing lesion Temporary or permanent colostomy ILEOANAL ANASTOMOSIS

Administer IV fluids & meds as prescribed Prepare the pt for surgery General abdominal wound care & postop care after surgery

Surgical creation of a pouch of small intestine that can serve as internal receptacle for fecal discharge. A nipple valve is constructed at the outlet.

Select suitable time for irrigation Irrigation should be performed at the same time each day. Before the procedure, the pt will sit on the chair in front of the toilet or the toilet itself.

Hang 500-1500ml ml irrigating solution (lukewarm tap water) 18-20 above the stoma. The dressing on pouch is removed Allow pt to participate to learn to perform it unassisted.

DIVERTICULUM saclike outpouching of the lining of the bowel that extends to a defect in the muscle layer DIVERTICULOSIS multiple diverticula are present without inflammation or symptoms

DIVERTICULITIS infection & inflammation in diverticula

- Food & bacteri retained in diverticulum

- leads to perforation or abscess

Bowel irregularity Intervals of diarrhea Crampy pain in LLQ Low-grade fever Nausea Anorexia Abdominal distention

CT Scan procedure of choice - reveals abscess Abdominal X-ray Barium enema (diverticulosis) Colonoscopy Lab tests (CBC, ESR)

Peritonitis Abscess formation Bleeding Shock

Bedrest Analgesic Antispasmodic

Diet : - clear liquid until inflammation subsides; then a high-fiber low-fat is recommended Antibiotics 7 to 10 days Bulk-forming laxative (e.g Metamucil) IV fluids

ONE-STAGE RESECTION - Inflamed area is removed & a primary end-to-end anastomosis is completed MULTIPLE STAGED PROCEDURE - For complications such as obstruction or perforation

ASSESSMENT Assess the pain Review dietary habits Ask about Hx of constipation, tenesmus, distention Auscultation & palpation Stool inspection VS

NURSING DIAGNOSIS - Constipation r/t narrowing of the colon from thickened segment & stricture - Acute pain r/t inflammation & infection

Fluid intake of 2L/day High fiber diet Exercise program Set time for defecation Stool softeners & oil retention enema as prescribed

Analgesics & antispasmodics as prescribed Records the intensity, duration & location of pain

Also known as GLUTEN ENTEROPATHY or TROPICAL SPRUE Intolerance to GLUTEN CHON component of wheat, barley, rye & oats Accumulation of glutamine (amino acid) toxic to intestinal mucosa

Acute diarrhea Anorexia Abdominal pain & distention Muscle wasting (buttocks & extremities) Vomiting Anemia Irritability

Precipitated by infection, fasting & ingestion of gluten Lead to electrolyte imbalance, rapid dehydration & severe acidosis Causes profuse watery diarrhea & vomiting

Gluten-free diet Substitute corn & rice as grain sources Mineral & vitamin supplements (A,D,E,K) Read food labels carefully

Inability to tolerate lactose as a result of absence or deficiency of lactase

Symptoms occurring after ingestion of milk products Abdominal distention Crampy, abdominal pain Diarrhea Excessive flatus

Eliminate the offending dairy product or administer enzyme replacement. In infants, soy-based formula can be a substitute. Provide calcium & Vit. D supplement Encourage consumption of hard cheese, cottage cheese or yogurt instead of drinking milk

Dilated portions of veins in the anal canal. 50% of people age 50 yrs

Shearing of mucosa during defecation Increased pressure due to pregnancy

1. 2.

INTERNAL HEMORRHOIDS above the internal sphincter EXTERNAL HEMORRHOIDS outside the external sphincter

Itching & pain (anus) Bright red bleeding w/ defecation

Rectal exam Stool exam

High-residue diet Good personal hygiene Avoid excessive straining during defecation Increase fluid intake

Warm compress Sitz bath Analgesic ointment & suppositories (Faktu) Bedrest

Infrared photocoagulation Bipolar diathermy Laser therapy Injecting sclerosing solution

RUBBER-BAND LIGATION PROCEDURE Hemorrhoid is visualized thru anoscope, a rubber band is slipped over the hemorrhoid Distal tissues becomes necrotic & slough off

CRYOSURGICAL HEMORRHOIDECTOMY - Freezing the hemorrhoid for sufficient time to cause nercrosis HEMORRHOIDECTOMY - Surgical excision of hemorrhoid - Rectal sphincter is dilated & hemorrhoid is removed with a clamp & cautery and excised.