GI Review

Nursing 21 GI Test January 1, 2013

Anatomy
      Oropharynx – Oral cavity Esophagus - tube that begins at the base of the pharynx, prevents reflux o LES – Lower esophageal sphincter Stomach Gastric secretions o HCL, Pepsin, Intrinsic factor –>absorbs B12 –>pernicious anemia Small Intestine – movement, digestion, absorption Large Intestine – Movement absorption Rectum anus o Organs that empty into the GI tract and aid digestion  Liver – stores mineral and vitamins detox, metabolism, produces bile, stores & releases glycogen, stores fatty acids & triglycerides  Gallbladder – concentrates & stores bile  Pancreas – Exocrine function – enzymes trypsin, chymotrypsin, amylase & lipase Endocrine function – islet of Langerhans produces insulin

Disorders of the Esophagus Gastro-Esophageal Reflux Disease GERD
  Chronic Heartburn, reflux Backflow of gastric contents into the esophagus, breakdown of the esophageal mucosa  Causing Esophagitis- Break down of the esophageal mucosa - acute symptoms of inflammation. o Iliac sphincter doesn’t close and allows acid from stomach to come back up Pathophysiology o Incompetent LES o Irritation of esophagus from gastric contents  Hyperemia - increase of blood flow to different tissues in the body  Erosion o Abnormal esophageal clearance o Delays in gastric emptying o Heals with Barrett’s Epithelium instead of squamous  More resistant to acid and support healing but are cancerous Incidence o 15-20% of population, mainly Caucasians  10% report daily symptoms, 44% monthly symptoms Etiology/Causes o Some correlation with hiatal hernia o Nighttime reflux – supine position decreases peristalsis o Large meals – delays stomach emptying times  Diet, nutrition, spicy foods, fatty foods, caffeine, no carbonated drinks – except ginger ale(is ok), chocolate, peppermint, nicotine  Can have herbal tea o Increased intra-abdominal pressure – tight clothes - belts, obesity – esp. abdominal obesity, bending over, pregnancy o Anticholinergic drugs, Ca Channel Blockers, Nitrates, estrogen & progesterone decrease LES pressure, Procardia o NG Tube – keeps cardiac sphincter open allow acid to reflux o Stress

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Nursing 21 GI Test January 1, 2013

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Assessment of GERD o History - co-morbid with diagnosed asthma-post nasal drip S/s o Heartburn - dyspepsia o Dysphagia, esophageal stricture (narrowing of esophagus), o Hoarseness-acid may spill into lungs causing aspiration o Odynophagia – painful swallowing o Regurgitation w/o nausea or belching o Pain  Sub sternal, retrosternal, burning, radiating to neck, jaw, back  20m – 2h worse after meal Dx o Barium swallow  Eval of esophagus, stomach, small intestine o Endoscopy o Endoscope o EGD –Esphagogastrodedunoscopy  Conscious sedation – Propfol, valium, versed  NPO from midnight, can’t drive 12h posttest, gag reflex takes awhile to return continue NPO, mild discomfort, belching  Signs of rupture or complication  Vomit blood – hematemesis, shoulder pain, tarry stool, fever assume fetal position to relieve pain  Direct visualization, biopsies o 24h pH monitoring Tx o o o o Small frequent meals, remain upright after eating, 1-2h, no meals 3h before bed, eat slowly Elevate HOB, avoid recumbent position Avoid acid foods, spicy foods, fatty foods, caffeine, no carbonated drinks – except ginger ale, chocolate, peppermint, nicotine. No tomatoes Meds to avoid - weaken the tone LES  Calcium Channel Blockers  Very Nice Drugs Alvin  Verapamil, Nifedipine, Diltiazem, Amlodipine  Theophylline  Anticholinergic - Bronchodilator that blocks the input from parasympathetic nervous system  Atrovent  Atropine Medications  Antacids –Elevates gastric pH  Maalox, Mylanta, Gaviscon-take with food (attaches to gastric contents)  S/E  Cause diarrhea, metabolic alkalosis  H2 (Histamine) Receptor Blockers – Decrease gastric acid secretion  Cimetidine (Tagamet) DON’ T TAKE WITH BETA BLOCKERS  Pepsid  Rantidine (Zantac)  Nizatidine (Axid) AVOID CITRUS JUICES  Proton-pump inhibitors PPI – reduce gastric secretions, relieves symptoms. Take with severe GERD. o DON’T CRUSH  Omeprazole (Prilosec)  Lansoprazole (Prevacid) – Give by itself or with apple juice  Esomeprazole (Nexium)- may cause insomnia take in the AM

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Nursing 21 GI Test January 1, 2013
  Pantoprazole

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Promotility Agents/Prokinetic Drugs – accelerates gastric emptying, increase LES. Empties stomach fast  Bethanechol (Urecholine)  Metoclopramide (Reglan) S/E  Hallucination, anxiety, ataxia – unsteady gait  Not used long term  Tardive dyskinesia- involuntary muscle movements

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Surgical  Laparoscopic procedure - To tighten LES  For pt who don’t respond to medicine  Open Surgical Procedure  Nissen fundoplication - Gastric fundus wrapped around lower esophagus to increase pressure  Minimal invasive surgery  Get them out of bed,  Complications o Should follow anti-reflux regiment, NG Tube o Bloating, pneumonia atelectasis, expand your lungs - splint, pain meds

Hiatal Hernia

Same Meds AS GERDS

Hiatal Hernia – Cardiac sphincter becomes enlarged allowing the stomach to pass into the thoracic cavity  Risk Factors – Increased age, congenital weakness, trauma, obesity Sliding /Esophageal Hernia – Esophagus & upper stomach slides in & out of thoracic cavity  S/s o Heartburn, regurgitation & dysphagia after eating, chest pain, belching. Pain worse after meals, put patient in supine position  Tx o Small frequent meals, elevate HOB, don’t lie down immediately post meals Rolling (Para esophageal) – All parts of the stomach pushes through diaphragm  S/s o Worse lying down, breathlessness after eating, feelings of suffocation, chest pain that mimics angina  Tx o Same as GERD o Small frequent meals, remain upright after eating, 1-2h, no meals 3h before bed, eat slowly o Elevate HOB, avoid recumbent position o Avoid acid foods, spicy foods, fatty foods, caffeine, no carbonated drinks – except ginger ale, chocolate, peppermint, nicotine o Meds to avoid - weaken the tone LES  Calcium Channel Blockers  Very Nice Drugs Alvin  Verapamil, Nifedipine, Diltiazem, Amlodipine  Theophylline  Anticholinergic - Bronchodilator that blocks the input from parasympathetic nervous system  Atrovent  Atropine o Medications  Antacids –Elevates gastric pH  Maalox, Mylanta, Gaviscon  S/e - Cause diarrhea, metabolic acidosis

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Nursing 21 GI Test January 1, 2013
 H2 (Histamine) Receptor Blockers – Decrease gastric acid secretion  Cimetidine (Tagamet) DON’ T TAKE WITH BETA BLOCKERS  Pepsid  Rantidine (Zantac)  Nizatidine (Axid) AVOID CITRUS JUICES Proton-pump inhibitors PPI – reduce gastric secretions, relieves symptoms o DON’T CRUSH  Omeprazole (Prilosec)  Lansoprazole (Prevacid)  Esomeprazole (Nexium)  Pantoprazole Promotility Agents/Prokinetic Drugs – accelerates gastric emptying, increase LES  Bethanechol (Urecholine)  Metoclopramide (Reglan) S/e Hallucination, anxiety, ataxia – unsteady gait. Not used long term

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Surgical  Laparoscopic procedure - To tighten LES  For pt who don’t respond to medicine  Open Surgical Procedure  Nissen fundoplication - Gastric fundus wrapped around lower esophagus to increase pressure  Minimal invasive surgery  Get them out of bed,  Complications o Should follow anti-reflux regiment, NG Tube Bloating, pneumonia atelectasis, expand your lungs - splint, pain Obstruction, strangulation & volvulus(twisting)

Gastritis

Gastritis - inflammation of the stomach lining Acute & Chronic  Refers to pattern of inflammation rather than specific time course  Chronic – increases with age  Acute M>F Chronic F>M  Increased risk – smokers & drinkers Assessment  History- high risk groups, family history, lifestyle, alcohol tobacco, caffeine,  Meds – ASA NSAIDS steroids S/s  Heartburn, epigastric pain, indigestion, N/V Dx  Esophagogastroduodenoscopy (EDG), gastric biopsy, H pylori (Best Way to Dx)  Upper GI Series Barium swallow  CBC  Serum vitamin B12 levels  Gastric analysis Acute Gastritis – inflammation of the gastric mucosa  Disruption of gastric mucosa allowing HCL & pepsin contact with gastric tissue leading to irritation  Gastric mucosa rapidly regenerates  Self limiting- Comes and goes Patho  Ingestion of corrosives – lye, draino

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Nursing 21 GI Test January 1, 2013
 Ingestion of irritants – ASA, NSAIDS, steroids, spicy food, excessive coffee, alcohol  Effects from cytoxic agents – chemo or radiation  Ingestion of infectious substance E coli, Salmonella, Staph S/s  May be asymptomatic at first but then rapid onset – anorexia, abd discomfort, belching, N/V, dyspepsia o More sever abd pain, hematemesis (bloody vomit), melena (black stool), gastric hemorrhage Tx  Goal – promote healing through diet & medication to relieve pain (non-steroidal antibiotic) & reduce stress  NPO & IVF prn  Progress diet as tolerated, avoid spicy foods & large meals, teach food safety Meds  Phenothiazines (Compazine) o Vomiting  Antacids o Buffers gastric acids & raises pH o Maalox, pepto bismal  H2 (Histamine) Receptor Blockers – Decrease gastric acid secretion o Cimetidine (Tagamet) DON’ T TAKE WITH BETA BLOCKERS o Pepsid o Rantidine (Zantac) o Nizatidine (Axid) AVOID CITRUS JUICES  Proton-pump inhibitors PPI – reduce gastric secretions, relieves symptoms o DON’T CRUSH o Omeprazole (Prilosec) o Lansoprazole (Prevacid) o Esomeprazole (Nexium) o Pantoprazole  Cytoprotective o Binds to ulcer site to form acid resistant mucosal barrier o Carafate-acts locally, pepto bismal

Chronic Gastritis

Chronic Gastritis – Progressive disorder beginning with superficial inflammation which eventually leads to atrophy of gastric tissues, change in cells. Types  Type A Autoimmune o Loss of HCL & pepsin secretion, develop pernicious anemia (B12 deficiency). Sever atropic glossitis ->painful, smooth, shiny, red tongue, tingling of hands & feet  Type B – chronic infection of mucosa o H. pylori (Dual antibiotic therapy) S/s  Vague or absent symptoms  Anorexia, belching, feeling of fullness, N/V, dyspepsia, intolerance to fatty or spicy foods, weight loss or fatigue  Vague epigastric heaviness not relieved by antacids Tx  Usually managed in community, no hospitalization  Bland small frequent meals, avoid foods that cause symptoms, dietary consult,  Teach – meds, smoking cessation, alcohol treatment Meds  Antacids  Anticholinergic – Compazine to stop vomiting/ Reglan  Type A – Vit B12  Type B – Dual antibiotic therapy

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Nursing 21 GI Test January 1, 2013
o o o Tetracycline, amoxicillin, clarithromycin PPI Bismuth Salts pepto bismal

Peptic Ulcer- H. Pylori

Peptic Ulcer - Break in the continuity of the esophageal gastric or duodenal mucosa. It occurs in any part of the GI tract that comes in contact with HCL acid or pepsin. Etiology –  10% of pop M>F, Gastric–age 55-70, Duodenal age-30-55, Stress-induced erosive-complication of life threatening condition  Curling’s ulcer with burns  Cushing ulcer after CNS damage Patho  H. Pylori – damages gastric epithelial cells-decreases gastric mucosa effectiveness 80% of the problem  Ulcerogenic Agents – ASA, NSAIDS – interrupts prostaglandin synthesis which maintains mucosa barrier of gastric mucosa. Alcohol, smoking, caffeine Assessment/History  High risk groups –Type A personalities, use of ulcerogenic agents/meds anyone on steroids  Past medical history – burns, arthritis, alcoholism  Heredity – blood type 0-35% more susceptible to duodenal ulcers  Family history Assessment/Physical  Abd distension  Bowel Sounds- hyperactive then may diminish  Epigastric tenderness- where the heart is  Stool many be guiac positive-hidden blood in stool  Orthostatic hypotension Assessment/PSY  Impact on lifestyle-work, family, social, leisure activities S/s Peptic Ulcer/ Gastric  Food increases pain …Pep up the pain!!!  Pain – aching, pressure, heaviness, gnawing, mid-left epigastric region or back

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Dx   

Pain with full stomach ½-1h post meal Vomiting hematemesis (vomiting blood) Bleeding – bright red to coffee grounds

CBC, Guiac test, Gastric acid analysis – to measure the amount of acid in the stomach, upper GI series, EDG, H. pylori testing S/s Duodenal Ulcer Perforate S/S: Emergency  Food relieves pain… Duo eat food down!!!  Pain in the right epigastric area & upper back  Patient in fetal position  Occurs 2-3h after meals and at night  Dysphagia  Appetite wnl  Bleeding  Vomit less then gastric  rupture  Bleeding – Melena (dark tarry stool)  More likely to perforate then gastric Upper GI Series  Barium (not used if bleeding) as contrast medium  Flouroscopic visualization of esophagus stomach and duodenum  Contraindicated with active bleeding or obstruction  Detects up to 90% of ulcers  NPO after midnight

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Nursing 21 GI Test January 1, 2013
      Bowel cleansing Must clean out barium with fluid or laxatives

EDG

1. 2. 3. 4.

Direct visualization of esophagus, gastric & duodenal mucosa& biopsy Conscious sedation Position on left side – facilitates drainage of secretions Post procedure o Check gag reflex, keep NPO, s/s of perforation-difficulty swallowing, bleeding and pain Goal - promote healing, relieve pain, reduce stress & prevent complications Tx  Monitor v/s, capillary refill, skin turgor- Monitor for bleeding  Avoid ulcerogenic medications  Reduce stress- Biofeedback, guided imagery, medication ad exercise.  Diet o 3 regular or small frequent feedings, avoid caffeine, fried foods, spicy foods, citrus, carbonated beverages, quite smoking – it inhibits secretion bicarbonate from pancreas to duodenum Meds  Antacids o Buffers gastric acids & raises pH-drink the right dose may cause alkalosis!! o Maalox, Gelusil  H2 (Histamine) Receptor Blockers – Decrease gastric acid secretion Pain relief o Cimetidine (Tagamet) DON’ T TAKE WITH BETA BLOCKERS Eliminate H. Pylori o Pepsid o Rantidine (Zantac) Heal ulcer o Nizatidine (Axid) AVOID CITRUS JUICES Prevent  Proton-pump inhibitors PPI – reduce gastric secretions, relieves symptoms reoccurrence o DON’T CRUSH o Omeprazole (Prilosec) o Lansoprazole (Prevacid) o Esomeprazole (Nexium) o Pantoprazole  Cytoprotective o Binds to ulcer site to form acid resistant mucosal barrier o Carafate-acts locally, pepto bismal Hemorrhage S/S: Cx

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Hemorrhage most common
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Fatigue, weakness, dizziness, change in LOC, increase in HR, RR, decreased BP Minimal – occult bleeding (not visible to naked eye) Massive shock- Fluid Volume Deficit  Oral – coffee ground to bright red blood  Rectal – black tarry stool o Pyloric obstruction o Bowel perforation – peritonitis – inflammation of the peritoneum o Ulcer perforation – peritonitis Peritonitis – inflammation of the peritoneum o Abd rigidity, board like, decreased BS, upper Quad pain,

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^HR ^RR Decr. BP

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Fever, N/V, hypotension, tachycardia, tachypnea,  Tx – O2, IVF, NGT, blood transfusions, emergency surgery if bleeding cannot be controlled Surgical Management o Vagotomy  Severs vagus nerve-to prevent HCL acid secretion  Tx of choice for high risk clients o Gastrectomy o

o Positive Kehr’s sign- rt shoulder pain

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Nursing 21 GI Test January 1, 2013
  Cx:     Diaphoresis Tachycardia Pallor lightheadedness BilrothI-removes portion of stomach & remaining portion anastomosed to duodenum Needs B12 replacement BilrothII-removes portion of stomach & anastomosed to jejunum-used more in duodenal ulcers

Dumping Syndrome
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Dumping syndrome-Rapid emptying of gastric contents which move to small intestines & cause distention

Occurs after gastrectomy/gastric bypass
High CHO stimulates fullness because of osmolality H2O moves from intravascular space to intestine-intestinal fullness Starts 30min after meals Weakness Palpitation Diaphoresis/ pallor Dizziness Cramping Diarrhea Small frequent feeding High protein, high fat, low carb Delay gastric emptying

Tx

o Eliminate fluids with meals o Lie down after meals for at least 30 mins o Eat/rest in semi-recumbent position (side lying)

Disorders of the Intestines Irritable Bowel Syndrome

Irritable Bowel Syndrome-disorder of intestinal motility, Spastic bowel, functional colitis  Non-inflammatory  Most common digestive disorder of western society  W>M  Etiology o Heredity, psychological, stress, diet rich, irritating foods alcohol  IBS Risk Factors o Coffee, gastric stimulants, diverticular disease, lactose intolerance  Assessment o History S/s o Altered bowel habits – constipation, diarrhea, combination of both o Bloating – abdominal distention-fecal impaction o Pain often in LLQ – relieved by defecation, colicky, spasms, dull or continuous

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Nursing 21 GI Test January 1, 2013
Dx o o o o Meds o o o Diet o o Stool studies-occult blood, ova & parasites, culture Sigmoid/colonoscopy Barium edema Small bowel series- NPO after midnight Bulk forming laxatives- Metamucil w/ glass of water Anticholinergics- Bentyl Antidiarrheal – Lomotil is a narcotic

Increase fiber- adds bulk and water to stool often reducing diarrhea & constipation
Limit gas forming & fried foods

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o Regular meals, chew food slowly o Eliminate caffeine o Walk to increase peristalsis Stress mgmt. Home care – teach complications fecal impact/bowel obstruction

Increase fluid intake 8-10 glasses

Diverticulitis

Diverticulitis-is a common digestive disease particularly found in the large intestine. Diverticulitis develops from diverticulosis – comes with age, which involves the formation of pouches (diverticula) on the outside of the colon. Diverticulitis results if one of these diverticula becomes inflamed/infected.  Most common pathology of colon in the US  Rare in cultures with high fiber diet  Can be acute attack or prolonged infection Patho  Mucosa & submucosal layers of colon herniates through muscular wall due to increased pressure within bowel lumen  Outpouchings form & collect undigested food & bacteria (hard mass) – irritation  Hard mass may interfere with blood supply-can lead to microscopic of extensive perforation

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Nursing 21 GI Test January 1, 2013
Assessment  S/s     Dx Cx Tx   History – Risk factors –

constipation history for several years

Acute – irregular bowel habits o Constipation/diarrhea LLQ crampy pain, palpable mass Low grade fever below 100 N/V X-Ray, CT, sigmoid/colonoscopy, Ba edema, CBC, Stool for guiac Peritonitis, abscess formation, fistula formation, hemorrhage, bowel obstruction

 V/S, temp over 101 & elevated WBC need hospitalization  NPO initially and bed rest  IVF, possible TPN  NGT  Broad spectrum antibiotics, Cipro, Flagyl, Mefoxin  Analgesics for pain  Antispasmodics  Stool softeners- not a laxative or enema  Diet progresses as symptoms resolve, liquid, soft low fiber(acute stage),  High fiber diet with full recovery  Diet modifications decrease risk of complications  Avoid seeds  Avoid straining, bending lifting  Assess for Cx -> peritonitis, abscess formation Tx Surgical  Usually indicated for pt with generalized peritonitis or abscesses that does not respond to tx  Bowel resection  Hartman procedure with temporary colostomy

Inflammatory Bowel Disease

Inflammatory Bowel Disease-A combination of chronic diseases, similar but distinct pathology & treatments, effect people of all ages, but particularly younger populations Chronic disease with exacerbations, incidence greater in the upper socioeconomic groups, incidence among Jewish pop is 3x greater, more common in Caucasians and women, runs in families Crohn’s Disease  Occur anywhere in the GI tract but mostly terminal ileum  Chronic inflammation through out the entire bowel wall  Skips segments of bowel & area of the intestine appears healthy

 Cobblestone appearance
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Chronic inflammation causes the bowel wall to ulcerate and for fistulas abscesses

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Nursing 21 GI Test January 1, 2013

S/s       Steatorrhea – fatty black stool Diarrhea 5-6x’s a day, may contain blood (usually brown/ yellow) Pain – RLQ relieved by defecation, palpable RLQ mass Fever, fatigue, malaise, weight loss, anemia Serious nutritional deficiencies Patient looks sick

 Pain-crampy, increase after meals

Ulcerative Colitis  Diffuse inflammation of intestinal mucosa with ulceration & abscess formation  Begins in the rectum, proceeds toward to cecum  Bowel – moth-eaten appearance  Large bowel shortens & narrows  Remission & exacerbations- gets worse Cx  Hemorrhage  Colon perforation – rare leads to peritonitis – 15% mortality S/S  Bloody diarrhea – more the 10-20x’s a day  Pain in LLQ, crampy pain relieved by defecation  Fatigue, anorexia weakness  Rebound tenderness – peritonitis Psy Assessment  Understanding of the illness, Social support& Family support, Lifestyle impact o Effect of pain & diarrhea on sleep & social habits Dx  Barium Enema- give laxative after  Sigmoid colonoscopy- get consent and do a time out  CAT scans  Stool examination  CBC/ESR (detects inflammation)  Chemistry-albumin, electrolytes  Serum vitamin levels- lose nutrients from diarrhea Meds  Corticosteroids o Control and decrease inflammation, prednisone, Solu-conrtef-IV  Antidiarrheal agents- Too much can cause toxic megacolon o Imodium  Antimicrobial o inhibits prostaglandin production in bowel o anti-inflammatoru

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Nursing 21 GI Test January 1, 2013
Sulfasalazine (Azulfidine) – Calms bacteria, give with meal and full glass of water, don’t crush, may cause RASH  Sulfonaurea  Asacol Immunosuppressive agents o Imuran- last resort when nothing else will work. Puts patient at risk for infection. o

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Diet Acute phase  NPO, I&O, Daily weights, TPN/PPN, enteral feedings, elemental formulas (Ensure) Non-Acute Phase  Individualized diet – low residue (food that don’t digest well) , low fiber diet  Eliminate o Alcohol, fried & flavored cheeses, tough flavored meats, raw or whole cooked veggies, whole grains, rich pastries and gravies, dried fruit, seeds, nuts, olives, popcorn, spices, vinegar Care of PT with TPN ( to completely rest the bowel)/PPN  Change dressing daily- sterile technique  Change IV tubing daily  Monitor glucose (hyperglycemia)  Monitor fluid overload Surgical MGMT  Total colectomy – removal of the colon (severe cases)  Total colectomy –with an ileal pouch and anastomosis o Tx choice for extensive ulcerative colitis o Colon & rectum removed, ileal pouch to anus o Temporary ileostomy for 2-3 months  Ileostomy – ostomy made to ileum o Colon, rectum, & anus removed o Anal canal closed  Kock’s ileostomy o Intra- abd reservoir (lower abdomen) o Nipple reservoir o Catheter inserted into pouch to drain stool Post-op MGMT  Ileostomy o Assess stoma pink/red o Skin care o Empty pouch 1/3 full – prevent leaking o Advise drainage dark green liquid (12-72 hrs.)thickens to yellow brown o Report rash, purulent or ulcerated areas, bulging around stoma o Adequate fluid intake  Kock’s Ileostomy o No external pouch needed o Teach sensation of fullness of internal pouch o Minimal skin problems o No leakage of stool o Malfunction of nipple valve

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Nursing 21 GI Test January 1, 2013 Small Bowel obstruction
Abd discomfort and pain possibly accompanied by peristaltic waves in upper to mid Abd Upper and epigastric abd distention/ pain Nausea and early profuse vomiting / vomit feces Obstipation Sever fluid and electrolyte imbalances Metabolic alkalosis  Administer IV Fluids

Large Bowel obstruction
Intermittent lower abdominal cramping Lower abd distention Minimal or no vomiting may contain fecal matter Obstipation or ribbon like stool No major fluid or electrolyte imbalances Metabolic acidosis

Pancreatitis

Pancreatitis – inflammation of the pancreas, triggered by injury to the pancreatic duct, may be auto immune->auto-digestion of pancreas by its own enzymes  Very common in middle aged males – from drug abuse and binge drinking  Women – biliary disease  Doesn’t have to fatal  Can be caused by gall stones, or ERCP of gallbladder- irritate pancreas Risk Factors  Drug abuse, fatty diet, genes, ERCP S/s Pain  Can start as mild non-specific abd pain o Epi-gastric, ULQ  Becomes intense  Radiates to back, left flank, left shoulder  Begins 12-24h after alcohol use  Relieved if in fetal position, bending forward, sitting upright  N/V Assessment  Jaundice  Epigastric tenderness  Abd distension  Fever, change in LOC  Retro-peritoneal bleeding

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Positive Turner’s sign
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Bluish discoloration of left flank Bluish discoloration peri-umbilical

Positive Cullen sign

Cx            Paralytic ilias – decreased or absent BS Abd tenderness with rigidity and guarding – AKA peritonitis Full distended abdomen – ascities Changes in v/s – tachycardia, tachypnea, hypotension, dyspnea Sever circulatory complications – assess hemodynamic status ->frequently take v/s Hypovolemic shock Listen for lung sounds Pleural effusion Hypocalcemia (lipolysis) o s/s- hypotension, bradycardia, tetany muscle spasm, laryngospasm/stridor , increased DTR & BS, diarrhea, Trousseau & Chovstek sign Alcohol abuse – DT’s- Delirium Tremors- alcohol withdrawal Labs

Changes in v/s – tachycardia, tachypnea, hypotension, dyspnea

Dx

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Nursing 21 GI Test January 1, 2013
Amylase (25-125)– increased (3x), 1sr 12-24h after symptoms appear, elevated for a few days o Lipase (<200) – increased, know it’s pancreatitis  Hypocalcemia o s/s- hypotension, bradycardia, tetany muscle spasm, laryngospasm/stridor , increased DTR & BS, diarrhea, Trousseau & Chovstek sign  Abnormal liver function tests  Elevated WBC’s, glucose, bilirubin  Abnormal CRX  Cat scan  Endoscopic Retrograde Cholangiopancreatography (ERCP)- examines – liver, gallbladder, bile ducts, pancreas for an obstruction or stone Nursing Dx  Acute Pain  F&E imbalance  Imbalanced nutrition – less then body requirement- weight loss  Deficient fluid volume- Decr UO, hypervolemia, kidney failure  Pain mgmt. o Demerol, not morphine o Position – whatever feels most comfortable – fetal Tx  F&E replacement – NPO initially – correct fluid imbalance, restore all electrolytes  Elevated glucose – insulin  ICU if necessary  Watch for respiratory complications  NG tube Meds  Zantac  PPI’s  Secretin  Antacid  Anti-cholinergic o Bentyl  Ca chloride, calcitonin Diet  NPO  TPN  Then small frequent feedings o Low fat, high carb, high protein, no caffeine, nutritional supplements  NO ALCOHOL o

Chronic Pancreatitis
Chronic pancreatitis – pancreas starts to degenerate from repeated alcohol abuse, chronic obstruction of common bile duct  remissions & exacerbations  Men more then women  Lose exocrine and endocrine function o Mal-absorption of fats and proteins, weight loss, muscle loss, starvation edema, DM s/s  Burning recurrent pain, LUQ radiating to back  Jaundice  Abd tenderness and distension, ascites  Frequent foul smelling, pale, bulky, frothy BM  Strateria – mal-absorption of fat, clay colored stool with dark urine

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Nursing 21 GI Test January 1, 2013
  Dx  Same as pancreatitis Nursing Dx  Same as pancreatitis  Ineffective breathing patterns  Activity intolerance Non-Surgical Tx Pain  Demerol  Torifol  No morphine  Opioids, narcotics  Glucose – insulin  Exocrine – pancreatic enzymes, pancrea-lipase->lipan-creatinine, take with meals Diet  TPN  When cleared to eat o High calorie, carb, protein, low fat Surgical Tx  Choly  Pancreatic transplant Weight loss, elevated glucose, polyuria, polydipsia, Pulmonary Cx o Pleural effusion, pneumonia, ARDS

Peritonitis

Peritonitis – acute inflammation of the peritoneum, peritoneal cavity contaminated with bacteria, toxin enter the blood stream s/s  Pt complaining abd pain – localized or general  It is – inflammation = Fever  Tachycardia  Elderly – change in LOC  Diminished BS, rigid-> board-like abd,  Guarding – they don’t want you to touch them  Abd distension Dx  WBC’s over 20,000, nigh neutrophil count  Air and fluid in the cavity Tx  ABC, O2, IV fluid, antibiotic  Avoid lifting for 6 weeks  Daily weight, strict I&O  NG tube, pain mgmt.  Tx fever o Sweating, change sheets, chills Tx Surgical  Exploratory Laporatomy  Antibiotics do the trick if caught on time Teaching  Antibiotics  Call the Dr. o Swelling, redness, warmth, bleeding at incision site, fever over 101, abd pain, no lifting for 6 wks. Unusual and foul smelling drainage.

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Cirrhosis- blood cant go through the liver

Cirrhosis – chronic degenerative diease of the liver. Alternation in structure and function of the liver, becomes enlarged, inflamed, degenerates, fibrotic tissue develops, interferes with blood flow through the liver Collateral circulation – allows blood to bypass an obstruction.  Trying to maintain normal blood flow, new veins, very fragile, can’t handle full blood volume Risk Factors  Can occur at any age, more males then females, more common in African Americans and Hispanics, genetic Etiology  Not understood Laneck’s cirrhosis  Alcohol abuse  Will develop fatty liver after a period of heavy drinking Cx  Portal hypertension – increase in pressure within the portal venous system ->veins become congested in the o Esophagus, rectum, abd o Pressure pushes the fluid out and contributes to ascities o Mostly irreversible o Not recognized until client has Esophageal varices hemorrhage  Usually occurs after vomiting  Pt has hematemesis- bloody stool o Portal hypertension, cirrhosis and meatemesis  Esophageal varices- Life threatening o Most dangerous consequence of portal hypertension o Collateral vessels rupture easily from coughing, sneezing, vomiting Valsalva (give stool softener- Colace)  Rupture can be sudden without pain -> medical emergency  Goal of Tx – control bleeding, prevent hypovolemic shock,  Priority – Airway  Med- Inderal/ Cogard ( Lower BP and HR)  Acities o Big heavy belly, look 12 month preggers, dyspnea, hypoxia, hepatomegaly, spenomegaly o Nursing Dx  EFV – presence of excess fluid in peritoneal cavity, caused by increased hydrostatic pressure from portal hypertension  Decrease serum albumin  Plasma shifts from vasculature to peritoneal area  Watch for dependent edema o Tx  Strict I&O (restrict fluid)  Diet – high calorie, protein and vitamin, low sodium,  Measure abd girth  Mg is low in alcoholics o Meds  Diuretics - Spirolactone, aldactone- can cause hyponatremia and hypokalemia  Increase urine output  K sparing  Antacid if needed  Riopan Paracentesis Surgical Mgmt  TIPSS  Trans-jugular intra-hepatic portal system shunt o Surgical shunting of blood from the portal system to venous system – to reduce portal pressure o Cx – bilateral crackles, hemorrhage

o o

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Nursing 21 GI Test January 1, 2013
 Portal Systemic Encephalopathy PES o Hepactic coma, gradual or sudden alteration in LOC- Neuro!!!!! o Ammonia is the most common cause  Increased serum ammonia  Liver can no longer detoxify  Med- give Lactulose promotes excretion of ammonia in stool. 2-3 BM/ day. Not watery. o Tx  Decreased ammonia levels  Diet therapy – restrict or eliminate protein, simple carb, TPN  Meds  Meomycin sulfate ->broad spectrum antibiotic ->decreases ammonia production  Vassopressin o Surgical Tx  Shunt the blood, porto-cable shunt, spleno-renal shunt  Balloon tamponade- passed through nose into stomach to apply pressure to bleeding site End-stage liver disease o Hepatic failure, hepato-renal syndrome, very poor prognosis, kidney’s involved o Decreased Urine Output o Elevated – BUN, creatinine, ammonia, bilirubin o Pt has jaundice



Tx Vague symptoms o Flu-like syndrome, non-specific GI, fatigue, anorexia, weight loss, Indigestion, change in bowel function o N/V, abd discomfort ->RUQ Assessment  Jaundice, Icterus – jaundice of the eyes  Pruritis – itching, ecchymosis on body, petachiae  Palmar erythema – redness of the palms  Vascular lesions – spider angioma on nose  Dependent edema  Asterixis – abnormal muscle tremor in the hands, tongue and feet  (+) Babinski Amenorrhea- no menstral for women  Gynomastea- man boobs  Fector hepaticus- fruity breath Dx  ER usually before admission  LABS – CBC, H&H, electrolytes, BUN, Na, K  Liver function test – AST, ALT, LDH o All would be elevated o Protein and albumin are decreased  PT/INR – Increased, monitor for Cx  Thrombocytopenia- first sign of liver dysfunction ( low platelet count) 

Biliary Disorders

Anything with lethiasis is a stone Chololethiasis – Gall stones Cholocystitis – acute or chronic inflammation of gall-bladder  Caused by obstruction of bile flow from Stricture, gall stones, edema, tumor Chololidocosiasis – stones in the bile duct Cholangitis – inflammation of the bile duct Prevalence  Overweight sedentary lifestyle

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Nursing 21 GI Test January 1, 2013
 Caucasions  Women more then men  Whites  Lots of it in white overweight middle aged women Risk Factors  Increased age  Diabetes Type I, cholesterol lowering drugs (statin)  Cirrhosis  Obesity, sedentary lifestyle, genetics  Pt with pancreatitis  TPN for more than 1 month S/s  Id high risk groups  Past medical history 4 F’s  Family history • Fair  Nutritional history o What foods do they not tolerate • Fat Pain • Forty  Biliary cholic – it comes and goes, can’t lie flat • Fertile  Patient is extremely uncomfortable  URQ – upper midline o Radiates to scapula o Builds and peaks, rising gradually  If peritoneum involved o Guarding and ridgity  N/V  Dyspepsia, heartburn, belching, eruption gas  Elderly – change in LOC  Jaundice b/c common duct is obstructed Chronic Choly  refuse surgery, increase in serum bilirubin  jaundice  light clay colored or tan stool  Steatorrhea – stool floats, altered fat absorbtion  Urine is dark amber from the bile  Dehydration  Fever Dx  Liver function test – bilirubin  Elevated WBC  Ultrasound – best for cholycustitis  Endoscopic retrograde ERCP – can get to the pancreas Tx non surgical  Rest, diet o Low fat, small frequent meals, avoid foods that cause gas, alcohol, fried prepared foods o NG tube – to decompress the stomach (low suction)  Pain o Demerol, mepardine  Morphine is contra indicated because it causes spasms of sphincter of Odii o Sub-lingual Nitro  Reduces cholic, relaxes smoth muscles o Reglan for nausea o Tygan for vomiting- antienemic Drug of choice: Dilaudid o Anti-spasmatic  Domitol & Bentyl  o Anti-biotic  Ampicillin & Gentomycin

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

F&E o o o

NPO IV Maintain urine output of 30 ml/h TPN, FVE watch glucose

Tx surgical  Laparoscopic surgery – explore the common bile duct, remove stones, install T tube in common bile duct o Allow for adequate bile drainage during duct healing o Should be free of kinks o Not connected to suction o Green/ yellow o Don’t irrigate o <400 ml/day o May be blood tinged o Should have drainage for the 1st 24h (1 day- 6 weeks) o Assess tube for pain or leakage into peritoneal cavity  Record TACO starts bloody q8h then green brown  Cx of Cholecystectomy- Respiratory o Pneumonia, o Atelectasis (collapsed lung) – If not breathing deep use incentive spirometer  Interventions – position q2h, cough and deep breath, elevate HOB, get them walking  Laparoscopic Choly o Same day surgery, very common, 4-5 small incisions, blow up the belly with Co2 endoscope, OOB ASAP  Shockwave Lithotripsy o Select clients fewer the 4 stones smaller then 3cm o Conscious sedation, shockwaves to reduce stones o Pt in water send shockwaves takes about an hour o Cx-Ecchymosis in area of shockwaves o Gross hematuria – goes away in 24h Post-Op  Check dressing and T tube  Reposition 2qh, strict I&O  Diet low fat!  Encourage coughing and deep breathing- incentive spirometer  Low wall suction NG tube  Check bowel sounds  TEDs or SED’s  Assess for pain, discharge teaching low fat diet  Older Adult may be confused!

Hepatitis

Hepatitis – widespread inflammation of liver cells, liver enlarged and congested ->hepatomegaly Type A  Contaminated water, foreign travel, shellfish o Caught in infected water or handled y someone infected  Oral fecal route  Usually not life threatening  Flu-like symptoms o Irritable, muscle aches, N/V, diarrhea, Tx  Immunoglobulin – before 2wks exposure  Encourage rest periods, disposable dishes Type B  Skin and mucus membranes  Sexual contact, sharing needles, needle sticks, hemodialysis  Incubation period 6-24 wks

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s/s   Meds   Type C  s/s          Fatigue, anorexia, low-grade fever, RUQ tender, Enlarged liver, clay colored stool, bark urine, jaundice Interferon Anti-viral - Epivir Skin mucus membrane, blood plasma, STD, maternal fetal route, razor, nail clippers Very similar to A much more sever Leading cause of cirrhosis – hepatocellular cancer Liver transplant o Little piece can regenerate whole new liver Fatigue, anorexia, low-grade fever, RUQ tender, Enlarged liver, clay colored stool, bark urine, jaundice Liver enzymes Liver biopsy Bleeding, v/s Pulse Ox and cap refill

Tx

Diet

 Hi carb and cal- ensure  Moderate fat and protein, maintain good nutrition  Small F.F Meds  Tygan  Dramamine for nausea  No Compazine –hemo toxic Teaching  Avoid OTC drugs, Tylenol  No drinking  SFF, rest  Avoid sex until negative  If you have puritis – keep nails short and wash with water  Prevention is key!

Paralytic Ileus  Stress reaction  24-48 hrs  Intestines stop working  Pt may have gas  Ambulate post op  Decreased peristalsis  Hypokalemia  Decreased or no BS

Jaundice: • Liver • Gallbladder • Pancreas

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