Management of conditions affecting GI and accessory organs of digestion

Afroz Lakhani, RN,BScN

Quick Review of GI A&P
 "alimentary canal"
 all organs through which food passes (mouth to anus)
 Accessory Structures
1. assist in digestion
2. includes teeth, salivary glands, liver, gall bladder, pancreas

 Layers of GI Tract
 Esophagus
 Passage about 10 inches long, lined with a mucous membrane.
 Function is to complete the act of swallowing.
 The involuntary movement of material down the esophagus is carried out by the process known as peristalsis, which is the wavelike action produced by contraction of the muscular wall. This is the method by which food is moved throughout the alimentary canal.

 Stomach
• four major secretory cells:
• chief cells: pepsinogen activation by low pH to form pepsin , is a protease for protein digestion
• parietal cells : HCl secretion enhanced by histamine via H2 receptors
Tagamet blocks H2 histamine receptors to inhibit HCl secretion
intrinsic factor binds to and allows B12 absorption in intestines
• G-cell : secretes gastrin hormone
activates gastric juice secretion & gastric smooth muscle “churning” , activates gastroileal reflex which moves chyme from ileum to colon
• mucus cell :protective role of mucus against acids and digestive enzymes
• pyloric sphincter regulates entry into the duodenum
• chyme is liquified digested material

 Small Intestine
• 22 ft long
• divided into three continuous parts: duodenum, jejunum, and ileum.
• Most of the absorption of food takes place in the small intestine, villi
• receives digestive juices from three accessory organs of digestion: the pancreas, liver, and gallbladder

 Large intestine
• 5 ft long
• Cecum, appendix , ascending, transverse, descending colon , sigmoid colon, rectum
• The main function is the recovery of water and electrolytes from the mass of undigested food it receives from the small intestine. As this mass passes through the colon, water is absorbed and returned to the tissues. Waste materials, or feces, become more solid as they are pushed along by peristaltic movements.
• Constipation is caused by delay in movement of intestinal contents and removal of too much water from them.
• Diarrhea results when movement of the intestinal contents is so rapid that not enough water is removed

 Diagnostic Procedures

• Upper GI studies (barium swallow)
 Examination of the upper GI tract under fluoroscopy after patient drinks barium sulfate.
 Pre : NPO midnight
 Post: Instruct for increased oral fluids to help pass the barium.
 Monitor stools for passage of barium. Stools should appear chalky white in color.


Lower GI tract study (barium enema)
 Fluoroscopic and radiographic examination of large intestine after rectal instillation of barium sulfate
 Pre: low residue diet 1 or 2 days prior,
clear liquid and laxative evening before,
NPO midnight, cleansing enema morning of test.
 Post: Increase oral fluids to pass barium, mild laxative, monitor stools, report absence of bowel movement more than 2 days.

Gastric analysis:
 Aspirate gastric contents thru NG tube for the analysis of acidity, appearance, volume.
4 Upper GI fiberoscopy: ( EGD)
5 Anoscopy, proctoscopy, and sigmoidoscopy:
6 Fiberoptic colonoscopy:
7 Cholecystography: to detect gall stones, and assess ability to fill, concentrate , contract and empty.
 Pre: no allergies to iodine or seafood, NPO, anaphylactic shock symptoms.
 Post: dysuria is common cause contrast agent excreted in urine, fatty meal to pass contrast agent.

8 Paracentesis: Transabdominal removal of fluid from the peritoneal cavity.
 Pre: Consent, void prior procedure, measure ab girth, wt, upright or fowler’s position.
 Post: v/s, dry sterile dressing and monitor bleeding, ab girth, look for hematuria, hypovolemia.

9 Liver biopsy:
 Pre:consent, must ck prothombin time, partial thromboplastin time, platelet.
 Post: site bleeding, peritonitis, bedrest, place patient on the rt side with a pillow under the coastal margin to decrease the risk of hemorrhage, avoid coughing, straining, no heavy weights for one week.

 Assessment
 Dietary History:
 The number of meals ate per day.
 Meal times.
 Food restrictions or special diets followed.
 Changes in appetite. Increased? Decreased? No appetite?
 What foods, if any, have been eliminated from the diet? Why? What foods are not well tolerated?
 Alterations in taste.
 Medications used. Dosage and frequency.
 Assessment contd…
 Bowel pattern history: Frequency of bowel movements. Use of laxatives and/or enemas. Changes in bowel habits. Stool Description (color, consistency, any blood)
 any complaints??
Nausea. Frequency? Duration? Associated with meals? Relieved by?
 Vomiting. Frequency? Character of emesis? Relieved by?
 Heartburn/indigestion. Frequency? Duration? Associated with specific foods? Relieved by?
 Gas (belching and flatus). Frequency? Associated with specific foods? Relieved by?
 Pain. Location? Frequency? Duration? Character of the pain?
 Weight loss. How much? In what time period?
 Assessment
 Inspect skin for color, abnormalities, contour, abdomen for distention.
 Auscultate bowel sounds, normal 5-30/min or every 5-15 secs in all quadrants.
 Listen at least 5 minutes in each quadrant to be certain for any absence.

 Stool test
 Stool samples can be examined on the ward and in the laboratory to determine the presence of substances that aid in diagnosis. For example:
 color, consistency, and amount of stool. The presence of unseen blood (occult)
 In the laboratory, tests can be performed to determine the presence of fat, urobilinogen, ova, parasites, bacteria, and other substances.
 Small, dry, hard stools may indicate constipation or fecal impaction.
 Diarrhea may indicate fecal impaction or fecal mass, or it may be the result of a disease process (such as colitis or diverticulitis) or a bacterial infection (such as dysentery)..
 Black, tarry stools may be the result of upper GI bleeding, iron supplements, or diet selection (eating black licorice, for example).
 Reddish colored stools may be the result of bleeding in the lower GI tract or diet selection (eating carrots or beets).
 Gastroesophageal Reflux (GER)
 Back flow of gastric and duodenal contents into the esophagus.
 Cx: incompetent lower esophageal sphincter, pyloric stenosis or motility disorder. May mimic heart attack.
 Pathophysiology Gastritis
 In gastritis, the gastric mucous membrane becomes edematous
 and hyperemic (congested with fluid and blood) and undergoes
 superficial erosion . It secretes a scanty amount of gastric juice, containing very little acid but much mucus. Superficial ulceration may occur and can lead to hemorrhage.
 Gastritis
 Stomach or gastric mucosa inflammation.
 Acute: Contaminated food, irritating (spicy), over use of aspirin, excess alcohol
 Abdominal discomfort, headache, anorexia, n/v, hicupping
 Chronic: benign or malignant ulcers or H pylori, medications, caused by autoimmune diseases, smoking or reflux.
 Anorexia, heartburn, belching, vit B12 def, sour taste
 PUD
 An ulceration in the mucosal wall of the stomach, pylorus, duodenum or esophagus.
 Gastric and duodenal are common
 Predisposing factors: Stress, smoking, use of steroids, NSAIDs, alcohol, gastritis, family hx, infection with H-pylori.
 Complication: hemorrhage, perforation, pyloric obstruction.
 Assessment: Gnawing, sharp pain LT of midepigastric 1 0r 2 hrs after eating.
 Implementation: v/s, signs of bleeding, Meds




Pathophysiology Irritable Bowel Syndrome IBS results from a functional disorder of intestinal motility.
 The change in motility may be related to the neurologic regulatory system, infection or irritation, or a vascular or metabolic disturbance.
 The peristaltic waves are affected at specific segments of the intestine and in the intensity with which they propel the fecal matter forward. There is no evidence of inflammation or tissue changes in the intestinal mucosa.
 IBS contd…
S/S:
 constipation, diarrhea, or a combination of both. Pain, bloating, and abdominal distention often accompany
 The abdominal pain is sometimes precipitated by eating and is frequently relieved by defecation.
 Mngt: aimed at relieving abdominal pain, controlling the diarrhea or constipation, and reducing stress.
 Restriction and then gradual reintroduction of foods that are possibly
 irritating may help determine what types of food are acting as irritants
 (eg, beans, caffeinated products, fried foods, alcohol, spicy
 foods).
 A healthy, high-fiber diet to help control the diarrhea and constipation.
 Exercise to reducing anxiety and increasing intestinal motility.

 APPENDICITIS Pathophysiology
 The appendix becomes inflamed and edematous as a result of either becoming kinked or occluded by a fecalith (ie, hardened mass of stool), tumor, or foreign body.
 The inflammatory process increases intraluminal pressure, initiating a progressively severe, generalized or upper abdominal pain that becomes localized in the right lower quadrant of the abdomen within a few hours.
 Eventually, the inflamed appendix fills with pus.
 Appendectomy (ie, surgical removal of the appendix) is performed as soon as possible to decrease the risk of perforation.

 Nursing Management:
 Goals : relieving pain, preventing fluid volume deficit, reducing anxiety, eliminating infection , disruption of the GI tract, maintaining skin integrity, and attaining optimal nutrition.
 The nurse prepares the patient for surgery, which includes an
 intravenous infusion to replace fluid loss and antibiotic therapy to prevent infection.
 An enema is not administered because it can lead to perforation.
 After surgery, the nurse places the patient in a semi-Fowler
 position. This position reduces the tension on the incision and abdominal organs, helping to reduce pain.
 An opioid, morphine sulfate, is prescribed to relieve pain.
 When tolerated oral fluids are administered.
 Any patient who was dehydrated before surgery receives intravenous fluids.
 Food is provided as desired and tolerated on the day of surgery.

COLOSTOMY:
 A colostomy is a surgically created, artificial opening (stoma) into the colon through the abdomen. It may be temporary or permanent.
 A temporary colostomy is normally made for diversion of fecal material. Fecal diversion is utilized in order to rest a portion of the colon following intestinal surgery, in preparation for further surgery, or in cases of severe inflammatory disease (such as diverticulitis).
 A permanent colostomy serves as an artificial anus for the remainder of the patient's life. This procedure is done in conjunction with the removal of the lower bowel and rectum. Although there is no sphincter muscle control at the stoma, bowel movements may be controlled by a daily routine that encompasses diet, physical activity, and colostomy irrigation. Consistency of the bowel movements generally depends upon the location of the colostomy, but can be manipulated by the patient's choice of diet.

Colostomy Irrigation
Irrigation should be done at the same time each day in order to establish regularity of bowel evacuation. Unless contraindicated or otherwise ordered by the physician, it is best to establish a routine of daily irrigation in accordance with the patient's former bowel habits. For example, if the patient has always moved his bowels after breakfast, establish the irrigation routine for that time, rather than some other arbitrary schedule.

Ileostomy:
An ileostomy is a surgically created, artificial opening (stoma) into the small bowel (ileus) through the abdomen. The stoma is located low on the abdomen (lower quadrants.) Most ileostomies are performed because of inflammatory bowel disease.
 An ileostomy may be temporary or permanent. If temporary, the bowel is left intact. In a permanent ileostomy, the colon is removed.
 Unlike a colostomy, an ileostomy cannot be regulated. The fecal contents of the ileum are fluid, and drain continuously. For this reason, an ileostomy patient must always wear an appliance.

Dietary considerations (ileostomy)
 Most physicians do not recommend dietary restrictions once the patient has recovered from surgery and is released from the hospital. However, foods that cause discomfort, gas, or diarrhea should be omitted.
 Hard to digest foods should be avoided if they cause discomfort. Examples are celery, popcorn, berries, and high-fiber foods.
 Odor-causing foods include cabbage, onions, fish, and eggs. These foods should be tested individually to determine if they can be tolerated.
 Spinach, parsley, yogurt, and buttermilk act as deodorizers on the intestinal tract.
 All foods ingested will normally pass through the ileostomy within 4-6 hours.