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Gastrointestinal Disorders

Capstone Presentation by Kaye Balicanta, Lauren Goodman, Jillian Haley, and Damon Josephsen
by

Kaye Balicanta

on 27 June 2013

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Transcript of Gastrointestinal Disorders

Garcia-Rodriguez, L. A., Lin, K. J., Hernandez-Diaz, S., & Johanssan, S. (2011). Risk of upper gastrointestinal bleeding with low-dose Acetylsalicylic Acid alone and in combination with Clopidogrel and other medications. Circulation, 123, 1108-1115. doi:10.1161/CIRCULATIONAHA.110.973008

Purpose: The aims of this study were to examine the risk of UGIB among users of low-dose ASA and clopidogrel (either alone
or in combination) and to assess the effects of concomitant
administration of other gastrotoxic medications on this risk of UGIB in the general population.

Method: Obtained data from The Health Improvement Network (THIN), which is a UK database. Individuals were 40-84 y/o and had already established a primary care provider for the past 2 years (ability to acquire prescription data for the past year). Pts. who already had a diagnosis of cancer, esophageal varices, Mallory-Weiss disease, alcohol abuse, liver disease, or coagulopathy before the start date were excluded from the source population.

Conclusion: Use of low-dose ASA is associated with an almost 2-fold increase in the risk of UGIB compared with
nonuse. This risk is increased further in individuals taking low-dose ASA along with clopidogrel, oral anticoagulants, non-steroidal anti-inflammatory drugs, or high-dose oral corticosteroids.
Objectives
What is the root to that Gastrointestinal Disorder?!
Discuss the following topics:
Gastrointestinal Bleeding
Irritable Bowel Syndrome
Hiatal Hernia
Pancreatitis
Ulcerative Colitis
Chron's Disease
Gastrointestinal Bleeding
Irritable Bowel Syndrome (IBS)
Hiatal Hernia
Crohn's Disease
Crohn’s Disease and Ulcerative Colitis
References
Its cause is idiopathic
One of the most common GI conditions
Approximately 12% of adults in the US report IBS symptoms
It accounts for 3.5 million doctor’s visits and remains of the the leading causes of work absenteeism
More common in women than men(Brunner, & Smeltzer, 2010)
What is it?
Heredity
Anxiety, depression, stress
Diet high in fat
B6 deficiency (article) there are associations between symptoms and the intake of specific food groups & nutrients in people with IBS
Stimulating or irritating foods such as alcohol and caffeine
Smoking
(Brunner, Ligaardena, 2011)
Predisposing factors associated with IBS
Functional disorder of intestinal motility
Change in motility may be r/t neuroendocrine dysregulation—changes in serotonin (signals motility).
Changes in motility may also result from infections, vascular or metabolic disturbances
Peristaltic waves are affected at specific segments of the intestine and the intensity in which fecal matter is propelled forward
(Brunner, & Smeltzer, 2010)
IBS Pathophysiology
Symptoms range in their intensity—it can go from mild and infrequent, to severe and continuous
Primary symptom is alteration in bowel patters; constipation, diarrhea or a combination of both!
Pain, bloating, cramping, and abdominal distention (gotta-go feeling)
Eating sometimes causes the abdominal pain and is relieved by defecation
What are the s/s?
Recurrent abdominal pain or discomfort for at least 3 days a month in the past 3 months that include 2 or more of the following;

Improvement with defecation
Onset associated with change in stool frequency
Onset associated with change in appearance of stool
(Brunner, & Smeltzer, 2010)
Assessment of IBS
Requires rests that confirm the absence of structural or other disorders
Stool studies; contrast, x-ray, and proctoscopy may be performed to rule out other colon diseases
Barium enema and colonoscopy (reveal spasm, distention or mucous accumulation in intestine).
Manometry and electromyography used to study intraluminal pressure changes generated by spasticity
(Brunner, & Smeltzer, 2010)
Diagnosis
Goal is to relieve abdominal pain, control episodes of diarrhea or constipation, and reduce stress
Restriction of fast acting irritants such as beans, caffeine, corn, wheat, diary, fried foods, alcohol and spicy foods
High fiber diet to control diarrhea and constipation
(Brunner, & Smeltzer, 2010)
Treatment of IBS
Exercise to reduce anxiety and increase GI motility
Hydrophilic colloids, and antidiarrheal agents (loperamide) to control urgency
Antidepressants (may effect serotonin levels slow intestinal motility improving diarrhea and abd discomfort)
Anticholinergics or antispasmodics (propantheline) to decrease smooth muscle spasm, cramping and constipation
(Brunner, & Smeltzer, 2010)
Treatment cont..
Probiotics to decrease abd gas and bloating
CAM therapies such as artichoke leaf abstract, peppermint oil, caraway oil.
Acupuncture? (article)
- more effective than pharmacological therapy. 84% of patients in the acupuncture group had improvement in symptom severity compared to 63% of patients in the pharmacological treatment group
(PubMed.gov, 2012)
Treatment cont…
Good dietary habits (avoid foods that trigger a flare up)
Keeping a food diary for 1-2 weeks to identify those triggers
Eat slowly and at regular times
Increase fluid intake but avoid drinking with meals as this results in adb distention
Avoid alcohol and smoking
Stress management (yoga, meditation)
(Brunner, & Smeltzer, 2010)
Patient Teaching of IBS
Occurs when the opening of the diaphragm that the esophagus passes through, becomes enlarged and part of the upper stomach moves into the lower portion of the thorax
- Occurs more often in women than men
- Two types: sliding and paraesophageal
(Brunner, & Smeltzer, 2010)
What is it?
Sliding- occurs when the upper stomach and gastroesphogeal junction are displaced and slide in and out of the thorax
Paraesophogeal - occurs when one all or part of the stomach pushes through the diaphragm beside the esophagus (Type is determined by extent of herniation)
Sliding (Type I), Paraesophageal Hernias
50% are asymptomatic

Sliding hernia, the pt may complain of heart burn, dysphagia, and regurgitation

Paraesophageal- pt may feel a sense of fullness or chest pain after eating. Reflux does not usually occur because the gastroesophageal sphincter is intact

X-rays, barium swallow, and fluoroscopy is used to diagnose it
(Brunner, & Smeltzer, 2010)
How do I know if I have one?
Frequent, small feedings that can easily pass through esophagus
Do not recline for 1 hour after eating
Elevate HOB 10-15 degrees
surgery is indicated in 15% of these cases-paraesophageal hernias may require emergency surgery to correct twisting of the stomach
(Brunner, & Smeltzer, 2010)
Patient Teaching for Hiatal Hernia
A nurse is teaching a patient just diagnosed with irritable bowel syndrome ways to reduce an exacerbation. The patient demonstrates a need for further teaching when he states;
A: “I will drink tea instead of coffee”
B: “I will avoid the Outback’s bloomin’ onion appetizer”
C. “I started wearing a nicotine patch”
D: “I stopped having my night cap beverages”
Question Time!
A: “I will drink tea instead of coffee”

Tea still contains caffeine, the patient should avoid anything caffeinated to prevent a flare up
Answer
50 y/o Mr. Bowel comes into the “we fix colon problems” clinic. During the interview with the nurse, he reveals he’s recently lost his job, has had reoccurring bouts of anxiety, and drowns his sorrows in Captain and Cokes. Which of these factors predisposes Mr. Bowel of developing IBS?

A: none he should just suck it up
B: anxiety, bi-polar, alcohol intake
C: Depression, anxiety, age
D: alcohol intake, anxiety, depression
Question Time!
D: alcohol intake, anxiety, depression

Predisposing factors of developing IBS include; stress, anxiety, depression, heredity, alcohol intake, caffeine, and smoking
Answer
A patient has recently been diagnosed with IBS. Which intervention should the nurse teach the client to reduce symptoms?

A: Instruct the pt to avoid drinking fluids with meals
B: Explain the need to decrease intake of flatus-forming foods
C: Teach the pt how to perform perianal care
D: Encourage pt to see a psychologist

Question Time!
A: Instruct the pt to avoid drinking fluids with meals

This will prevent abdominal distention which causes symptoms of IBS. Gas forming food will prevent symptoms of IBD, not IBS. Perianal care will not prevent IBS. IBS does have a psychological factor, but, interventions should be taught first
Answer
A Pt. diagnosed with a hiatal hernia has been scheduled for a laparoscopic Nissen fundoplication (fundus of stomach is wrapped around lower end of the esophagus). Which statement indicates that the nurse’s teaching has been effective?

A: “I will have 3 or 4 small incisions”
B: “I will be able to go home the same day of surgery”
C: “I will not have any pain because it is laparoscopic”
D: “I can return to work 1 day after my surgery”
Question Time!
A: “I will have 3 or 4 small incisions”

-with this type of procedure, there are 4-5 incisions that allow for the passage of equipment to visualize the abdominal organs and perform the surgery. Some remain in the hospital for more than one day so the statement is false. There is not a surgery that isn’t painful. Pt should wait at least 1 week before returning to work as this is still considered surgery
Answer
To prevent gastroesophageal reflux in a male pt with hiatal hernia, the nurse should teach which discharge instruction?

A. “Lie down after meals to promote digestion.”
B. “Avoid coffee and alcoholic beverages.”
C. “Take antacids with meals.”
D. “Limit fluid intake with meals.”
Question Time!
B. “Avoid coffee and alcoholic beverages.”

Prevent reflux of stomach acid into the esophagus, the nurse should advise the pt to avoid foods & beverages that increase stomach acid, such as coffee and alcohol. The nurse should also teach the client to avoid lying down after meals, which aggravates reflux, and to take antacids after eating. There isn’t a need to restrict fluids with meals as long as they aren’t gastric irritants.
Answer
Answer and Rationale - Gastrointestinal Diseases NCLEX Review Questions Part 2 - RNpedia.com. (n.d.). Retrieved fromhttp://www.rnpedia.com/home/exams/nclex-exam/gastrointestinal-diseases-nclex-review-questions-part-2/answer-and-rationale

Brunner, L. S., & Smeltzer, S. C. (2010). Brunner & Suddarth's textbook of medical-surgical nursing. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

Colgrove, K. C., & Callicoatt, J. (2007). Med-surg success: A course review applying critical thinking to test taking. Philadelphia, PA: F.A. Davis.

Crohn’s Disease. (2011, January 18). Retrieved June 15, 2013 from http://digestive.niddk.nih.gov/ddiseases/pubs/crohns/#what.

Garcia-Rodriguez, L. A., Lin, K. J., Hernandez-Diaz, S., & Johanssan, S. (2011). Risk of upper gastrointestinal bleeding with low-dose Acetylsalicylic Acid alone and in combination with Clopidogrel and other medications. Circulation, 123, 1108-1115. doi:10.1161/CIRCULATIONAHA.110.973008

Gorstein, F., & Rubin, E. (2005). Rubin's pathology: Clinicopathologic foundations of medicine. Philadelphia, Pa. [u.a.: Lippincott Williams & Wilkins.

Ligaardena, S. C. (2011). Low intake of vitamin B6 is associated with irritable bowel syndrome symptoms. Nutrition Research. Retrieved from www.sciencedirect.com

Lippincott Williams & Wilkins, & Anatomical Chart Co (2006). Atlas of pathophysiology. Philadelphia: Lippincott Williams & Wilkins.

Longstreth, George F. (2012, October 29). Crohn’s Disease. Retrieved June 17, 2013 from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001295/

Mayo Clinic Staff. (2011, August 9). Crohn’s disease. Retrieved June 15, 2013 from http://www.mayoclinic.com/health/crohns-disease/DS00104.

McCance, K. L., & Huether, S. E. (2002). Pathophysiology: The biologic basis for disease in adults & children. St. Louis: Mosby.

PubMed.gov (2012, May 16). Acupuncture for treatment of irri... [Cochrane Database Syst Rev. 2012] - PubMed - NCBI. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22592702

Rubin, E., & Farber, J. L. (1999). Pathology. Philadelphia: Lippincott-Raven.

Pathophysiology of GI Bleeding
Cancer of the colon, small intestine, or stomach
Intestinal polyps (a pre-cancerous condition)
Abnormal blood vessels in the lining of the intestines (angiodysplasias)
Bleeding diverticulum, or diverticulosis
Crohn's disease or ulcerative colitis
Esophageal varices
Esophagitis
Gastric (stomach) ulcer
Intussusception (bowel telescoped on itself)
Mallory-Weiss tear
Meckel's diverticulum
Radiation injury to the bowel
Causes of
GI Bleeding
Case Study
Question Time!
A client is suspected of having a slow gastrointestinal bleed. The nurse should evaluate the client for which of the following?
a) Nausea.
b) Increased pulse.
c) Tarry stools.
d) Abdominal cramps.
Answer
C) Black, tarry stools indicate the presence of a slow upper gastrointestinal bleed. The longer the blood is in the system, the darker it becomes as the hemoglobin is broken down and iron is released. Vital sign changes, such as an increased pulse, are not evident with slow gastrointestinal bleeds. Nausea and abdominal cramps can occur but are not definitive signs of gastrointestinal bleeding.
Question Time!
A client has massive bleeding from esophageal varices. In what order should the nurse and care team provide care for this client?
a) Control hemorrhaging
b) Relieve the client’s anxiety
c) Replace fluids
d) Maintain a patent airway
Answer
D, A, C, B) The goal that has the highest priority when a client has a massive bleed from esophageal varices is to maintain a patent airway. The nurse should position the client to prevent aspiration and assess respirations and oxygen saturation. The nurse should then assist the health care provider in controlling the hemorrhage by using esophageal balloon tamponade. Octreotide (Sandostatin) may be administered to reduce portal pressure. The third priority is to restore circulating blood volume with blood and I.V. fluids. Esophageal bleeding is an anxiety-provoking event for the client and, although life-saving measures are the priority, the nurse and health care team should explain procedures to the client and provide reassurance as needed.
Question Time!
A client is admitted with upper GI bleeding. The nurse promotes hemodynamic stability by:
a) Encouraging oral fluid intake
b) Monitoring central venous pressure (CVP)
c) Monitoring laboratory test results and vital signs
d) Giving blood, electrolyte, and fluid replacement.
Answer
D) stabilize a client with acute bleeding, normal saline solution or lactated Ringer's solution is given until blood pressure rises and urine output returns to 30ml/hr. A CVP line is inserted to monitor circulatory volume. When shock is severe, plasma expanders are given until typed and crossmatched blood is available. Oral fluid intake is contraindicated with upper GI bleeding. Monitoring vital signs and laboratory values enables the nurse to evaluate the results of treatment, but these measures don't facilitate hemodynamic stabilization.
Crohn’s disease is a disease that causes inflammation, or swelling, and irritation of any part of the digestive tract, also called the gastrointestinal (GI) tract.
The most commonly affected part is found at the end of the small intestine, the ileum.
The GI tract consists of hollow organs that are joined in a long twisted tube that runs from the mouth to the anus.
What is Crohn’s Disease?
The movement of muscles in the GI tract (peristalsis), along with the release of hormones and enzymes, allows for the digestion of food.
When a patient has Crohn’s disease, inflammation extends deep into the lining of the GI tract. This can cause pain to the patient, and at the same time make the intestines empty frequently, thus causing diarrhea.
Chronic inflammation can cause scar tissue to form inside the GI tract. When this happens it can cause a stricture, which is a narrowing of the passageway. When this happens, it becomes harder for food to pass through the intestines and can cause pain and cramping.
What is Crohn’s disease, cont.
Crohn’s disease is an inflammatory bowel disease (IBD) the general name for diseases that cause inflammation and irritation in the intestines.
Crohn’s disease can be difficult to diagnose because its symptoms are similar to other intestinal disorders, such as ulcerative colitis and other IBDs, and irritable bowel syndrome.
For example, ulcerative colitis and Crohn’s disease both cause abdominal pain and diarrhea.
Crohn's Disease Cont…..
Age. Crohn's disease can occur at any age, but you're likely to develop the condition when you're young. Most people who develop Crohn's disease are diagnosed before they're 30 years old.
Ethnicity. Although whites have the highest risk of the disease, it can affect any ethnic group. If you're of Eastern European (Ashkenazi) Jewish descent, your risk is even higher.
Family history. You're at higher risk if you have a close relative, such as a parent, sibling or child, with the disease. As many as 1 in 5 people with Crohn's disease has a family member with the disease.
Risk Factors
The cause of Crohn’s is still not known, however researchers think its cause is an abnormal reaction in the bodies immune system.
Normally, the immune system protects people from infection by identifying and destroying bacteria, viruses, or other potentially harmful foreign substances. Researchers believe that in Crohn’s disease the immune system attacks bacteria, foods, and other substances that are actually harmless or beneficial.
When this happens, white blood cells accumulate in the lining of the intestines, producing chronic inflammation, which leads to ulcers, or sores, and injury to the intestines

What causes Crohn’s disease?
Researchers have found that high levels of a protein produced by the immune system, called tumor necrosis factor (TNF), are present in people with Crohn’s disease.
However, researchers do not know whether increased levels of TNF and abnormal functioning of the immune system are causes or results of Crohn’s disease.
Research shows that the inflammation seen in the GI tract of people with Crohn’s disease involves several factors: the genes the person has inherited, the person’s immune system, and the environment.
Causes, con’t…
S/S of Crohn’s disease can vary from being mild to severe. When the disease is active and not in remission these are some of the s/s that a patient may experience:
Diarrhea. The inflammation that occurs in Crohn's disease causes cells in the affected areas of your intestine to secrete large amounts of water and salt. Because the colon can't completely absorb this excess fluid, you develop diarrhea. Intensified intestinal cramping also can contribute to loose stools. Diarrhea is a common problem for people with Crohn's.
Blood in your stool. Food moving through your digestive tract may cause inflamed tissue to bleed, or your bowel may also bleed on its own. You might notice bright red blood in the toilet bowl or darker blood mixed with your stool. You can also have bleeding you don't see (occult blood).
Signs and Symptoms
Abdominal pain and cramping. Inflammation and ulceration may cause the walls of portions of your bowel to swell and eventually thicken with scar tissue. This affects the normal movement of contents through your digestive tract and may lead to pain and cramping. Mild Crohn's disease usually causes slight to moderate intestinal discomfort, but in more-serious cases, the pain may be severe and include nausea and vomiting.
Ulcers. Crohn's disease can cause small sores on the surface of the intestine that eventually become large ulcers that penetrate deep into — and sometimes through — the intestinal walls. You may also have ulcers in your mouth similar to canker sores.
Reduced appetite and weight loss. Abdominal pain and cramping and the inflammatory reaction in the wall of your bowel can affect both your appetite and your ability to digest and absorb food.
S/S con’t…
People with severe Crohn's disease may also experience:
Fever
Fatigue
Arthritis
Eye inflammation
Mouth sores
Skin disorders
Inflammation of the liver or bile ducts
Delayed growth or sexual development, in children
S/S con’t.
Blood tests can be used to look for anemia caused by bleeding. Blood tests may also uncover a high white blood cell count, which is a sign of inflammation or infection somewhere in the body.
Stool tests are commonly done to rule out other causes of GI diseases, such as infection. Stool tests can also show if there is bleeding in the intestines.
Flexible sigmoidoscopy and colonoscopy. These tests are used to help diagnose Crohn’s disease and determine how much of the GI tract is affected. Colonoscopy is the most commonly used test to specifically diagnose Crohn’s disease. Colonoscopy is used to view the ileum, rectum, and the entire colon, while flexible sigmoidoscopy is used to view just the lower colon and rectum.
How is it Diagnosed?
Computerized tomography (CT) scan. CT scans use a combination of x rays and computer technology to create three-dimensional (3-D) images. For a CT scan, the person may be given a solution to drink and an injection of a special dye, called contrast medium.
Upper GI series. An upper GI series may be done to look at the small intestine. No eating or drinking is allowed for 8 hours before the procedure, if possible. During the procedure, the person will stand or sit in front of an x-ray machine and drink barium, a chalky liquid. Barium coats the small intestine, making signs of Crohn’s disease show up more clearly on x rays. A person may experience bloating and nausea for a short time after the test
Lower GI series. A lower GI series may be done to look at the large intestine.
Diagnosed, cont
Anal fissure. This is a crack, or cleft, in the anus or in the skin around the anus where infections can occur. It's often associated with painful bowel movements. This may lead to a perianal fistula. Malnutrition. Diarrhea, abdominal pain and cramping may make it difficult for you to eat or for your intestine to absorb enough nutrients to keep you nourished. Additionally, anemia is common in people with Crohn's disease.
Colon cancer. Having Crohn's disease that affects your colon increases your risk of colon cancer.
Other health problems. In addition to inflammation and ulcers in the digestive tract, Crohn's disease can cause problems in other parts of the body, such as arthritis, inflammation of the eyes or skin, clubbing of the fingernails, kidney stones, gallstones and, occasionally, inflammation of the bile ducts. People with long-standing Crohn's disease also may develop osteoporosis, a condition that causes weak, brittle bones.
Complications cont.
Anti-inflammatory drugs
Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease. They include:
Sulfasalazine (Azulfidine). Although this drug isn't always effective for treating Crohn's disease, it may be of some help for Crohn's that affects the colon. It has a number of side effects, including nausea, vomiting, heartburn and headache.
Mesalamine (Asacol, Rowasa). This medication is less likely to cause side effects than sulfasalazine, but possible side effects include nausea, vomiting, heartburn, diarrhea and headache. You take it in tablet form or use it rectally in the form of an enema or suppository, depending on which part of your colon is affected. This medication is generally ineffective for disease involving the small intestine.
Corticosteroids. Corticosteroids can help reduce inflammation anywhere in your body, but they have numerous side effects, including a puffy face, excessive facial hair, night sweats, insomnia and hyperactivity. More-serious side effects include high blood pressure, diabetes, osteoporosis, bone fractures, cataracts, glaucoma and an increased susceptibility to infections. Long-term use of corticosteroids in children can lead to stunted growth.
Treatments
Immune system suppressors
These drugs also reduce inflammation, but they target your immune system rather than directly treating inflammation. By suppressing the immune response, inflammation is also reduced.
Azathioprine (Imuran) and mercaptopurine (Purinethol). These are the most widely used immunosuppressants for treatment of inflammatory bowel disease.
Infliximab (Remicade). This drug is for adults and children with moderate to severe Crohn's disease. It may be used soon after diagnosis, particularly if your doctor suspects that you're likely to have more severe Crohn's disease or if you have a fistula.
Treatments cont.
Antibiotics
Antibiotics can reduce the amount of drainage and sometimes heal fistulas and abscesses in people with Crohn's disease.
Metronidazole (Flagyl). Once the most commonly used antibiotic for Crohn's disease, metronidazole can cause serious side effects, including numbness and tingling in your hands and feet and, occasionally, muscle pain or weakness.
Ciprofloxacin (Cipro). This drug, which improves symptoms in some people with Crohn's disease, is now generally preferred to metronidazole.
Other medications that you can take include anti-diarrhea, pain medications, laxatives, and iron supplements.
Treatments cont:

If diet and lifestyle changes, drug therapy or other treatments don't relieve your signs and symptoms, your doctor may recommend surgery.
During surgery, your surgeon removes a damaged portion of your digestive tract and then reconnects the healthy sections. In addition, surgery may also be used to close fistulas and drain abscesses. A common procedure for Crohn's is strictureplasty, which widens a segment of the intestine that has become too narrow.
The benefits of surgery for Crohn's are usually temporary. The disease often recurs, frequently near the reconnected tissue or elsewhere in the digestive tract. Up to 3 of 4 people with Crohn's disease eventually need some type of surgery. Many will also need a second procedure or more. The best approach is to follow surgery with medication to minimize the risk of recurrence.
Surgery
These are some things that can help control your symptoms and increase the time between flair-ups.
Limit dairy products. Like many people with inflammatory bowel disease, you may find that problems, such as diarrhea, abdominal pain and gas, improve when you limit or eliminate dairy products.
Try low-fat foods. If you have Crohn's disease of the small intestine, you may not be able to digest or absorb fat normally. Instead, fat passes through your intestine, making your diarrhea worse.
Avoid problem foods. Eliminate any other foods that seem to make your signs and symptoms worse. These may include "gassy" foods such as beans, cabbage and broccoli, raw fruit juices and fruits, spicy food, popcorn, alcohol, and foods and drinks that contain caffeine, such as chocolate and soda.
Eat small meals. You may find you feel better eating five or six small meals a day rather than two or three larger ones.
Drink plenty of liquids. Try to drink plenty of fluids daily. Water is best. Alcohol and beverages that contain caffeine stimulate your intestines and can make diarrhea worse, while carbonated drinks frequently produce gas.
Lifestyle and Home Remedies
Presentations of GI Bleeding
Acute Bleeding
Hematemesis: bloody vomitus; either fresh, bright red blood or dark, grainy, digested blood with "coffee grounds" appearance
Melena: black, sticky, tarry, foul-smelling stools caused by digestion of blood in the gastrointestinal tract
Hematochezia: fresh, red blood passed from the rectum

Occult Bleeding
Trace amounts of blood in normal-appearing stools or gastric secretions; detectable only with a guaiac test
Pancreatitis
Pancreatitis is a rare disease in which the pancreas becomes inflamed. Pancreatic damage occurs when the digestive enzymes (lipase, protease, and amylase) are activated in the pancreas rather then passing into the small intestines and begin attacking the pancreas, causing damage to the organ.
(http://my.clevelandclinic.org)
Pathophysiology
Acute Pancreatitis: It arises as a sudden inflammation that occurs over a short period of time and lasts only several days. It may resolve on its own.

VS.

Chronic Pancreatitis: Is characterized by progressive destruction of the pancreas. Attacks re-occur for more than 6 months that cause scarring and damage to the pancreas that make it susceptible to infection and further inflammation. It often goes undetected until 80%-90% of the tissue is destroyed. It is usually non-resolving.
(UptoDate.com, 2012)
Acute vs. Chronic
The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious beliefs. She becomes upset when the physician persists in asking her about her alcohol intake. The nurse should explain that the reason for these questions is that:

A. There is a strong link between alcohol use and acute pancreatitis.
B. Alcohol intake can interfere with the tests used to diagnose pancreatitis.
C. Alcoholism is a major health problem, and all clients are questioned about alcohol intake.
D. The physician must obtain the pertinent facts, regardless of religious beliefs.
Question Time!
A. There is a strong link between alcohol use and acute pancreatitis.

Alcoholism is a major cause of acute pancreatitis in the United States. Because some clients are reluctant to discuss alcohol use, staff may inquire about it in several ways.
(Billings & Hensel, 2013)
Answer
60-75% of all cases are caused by gallstones or alcohol abuse.

Hereditary- Can be caused by a family history of hypertriglyceridemia and hereditary pancreatitis.

Certain medications

Cystic fibrosis or mutations of the cystic fibrosis gene. (Chronic)

Blockage of the pancreatic duct (from trauma, tumors, etc.)

Pancreatic cancer

Other diseases, such as lupus (Chronic)

Unexplained- About 20% patients with acute pancreatitis have no underlying cause.

(Uptodate.com, 2012)
Risk Factors
Acute Pancreatitis:
- Sudden, constant pain in the upper abdomen. The pain may wrap around the upper body and involve the back in a band-like pattern.

- In people with gallstone pancreatitis, gallbladder pain may occur before pancreatic pain. Gallbladder pain (billiary colic) occurs in the right upper quadrant, extending to the back and right shoulder. The pain gradually increases in intensity and often follows a meal.

- Tenderness and swallon abdomen

- Nausea & Vomiting

- In patients with alcoholic pancreatitis the symptoms often occur 1-3 days after an alcohol binge.
(Uptodate.com, 2012)
Signs and Symptoms

Chronic Pancreatitis:

- Long-standing pain in the middle of the abdomen that often spreads to the back. However, about 20% of patients do not have any pain at all.

- Nausea and Vomiting

- Indegestion


- Difficulty digesting fats in foods.
Losing weight without trying
Loose, oily, foul-smelling stools (steatorrhea)
Vitamin and nutrient deficiencies
- These symptoms usually do not develop until the pancreas has lost about 90% of its function.
(Uptodate.com, 2012)
Signs and Symptoms
Diabetes: The pancreas can lose its ability to produce enough insulin.

Breathing problems: May cause changes in your body that affect your lung function, causing the level of oxygen in your blood to fall to dangerously low levels.

Infection: May make your pancreas vulnerable to bacteria and infection.

Kidney failure: Acute pancreatitis may cause kidney failure, which may be treated with dialysis if the kidney failure is severe and persistent.
(UptoDate.com, 2012)
Complications
Malnutrition: Both acute and chronic pancreatitis can cause your pancreas to produce fewer of the enzymes that are needed to break down and process nutrients from the food you eat. This can lead to malnutrition, diarrhea and weight loss, even though you may be eating the same foods or the same amount of food.

Pancreatic cancer: Long-standing inflammation in your pancreas caused by chronic pancreatitis is a risk factor for developing pancreatic cancer

Pseudocyst: Acute pancreatitis can cause fluid and debris to collect in cyst-like pockets in your pancreas. A large pseudocyst that ruptures can cause complications such as internal bleeding and infection.

Severe acute pancreatitis may cause dehydration and low blood pressure. If bleeding occurs in the pancreas, shock and even death may follow.
(UptoDate.com, 2012)
Complications Con’t:
A client with acute pancreatitis has a blood pressure of 88/40, heart rate of 128 bpm, respirations of 28/min, and Grey Turner’s sign. What action should the nurse perform first?

A. Assess the urine output
B. Place an intravenous line
C. Position of the left side
D. Insert a nasogastric tube
Question Time!
B. Place an intravenous line

Grey Turner’s sign is a bluish discoloration on the flank area caused by retroperitoneal bleeding. The vital signs are showing hemodynamic instability. IV access should be obtained to provide immediate volume replacement.
(Billings & Hensel, 2013)
Answer
The Diagnosis is based on:
- A history of abdominal pain
- The presence of known risk factors
- Elevated lipase, protease, and amylase levels
Levels are elevated within 24 hours of the onset of symptoms
White blood cell count is usually elevated

Hypocalcemia is present and correlates with the severity of pancreatitis.
(Brunner & Suddarth’s, 2010)
Assessment & Diagnosis
X-ray studies of the abdomen and chest may be obtained to differentiate pancreatitis from other disorders that can cause similar symptoms.

Ultrasound and contrast-enhanced CT scans are used to identify an increase in the diameter of the pancreas and to detect pancreatic cysts, abscesses, or pseudocysts.

Hematocrit and hemoglobin levels are used to monitor the patient for bleeding.

ERCP is the most useful study in the diagnosis of chronic pancreatitis. It provides details about the anatomy of the pancreas and the pancreatic and biliary duct. It is also helpful in obtaining tissue for analysis and differentiating pancreatitis from other conditions, such as carcinoma
(Brunner & Suddarth’s, 2010)
Assessment & Diagnosis Con't
ERCP
Acute Pancreatitis:

- Management is directed towards relieving symptoms and preventing or treating complications.

- All oral intake is withheld to inhibit stimulation of the pancreas and secretion of digestive enzymes.

- Parenteral nutrition plays an important role inpatients with severe acute pancreatitis lasting more then 48-72 hours. Research shows positive outcomes with use of enteral feedings.

- Adequate administration of analgesics is essential to provide sufficient pain relief.
(Brunner & Suddarth’s, 2010)
Medical Management
Acute Pancreatitis:

- Correction of fluid, blood loss, and low albumin levels is necessary to maintain fluid volume and prevent renal failure.

- Placement of biliary drains and stents in the pancreatic duct through endoscopy.

- Aggressive respiratory care is indicated because of high risk of elevation of the diaphragm, pulmonary infiltrates and effusion, and atelectasis.
Close monitoring of arterial blood gases
Humidified oxygen
Mechanical ventilation

- Postacute Management:
Antacids
Oral feedings that are low in fat and protein are gradually initiated
Caffeine and alcohol are eliminated from the diet
(Brunner & Suddarth’s, 2010)
Medical Managemen con't
Chronic Pancreatitis:

- Treatment is directed toward preventing and managing acute attacks, relieving pain and discomfort, and managing exocrine and endocrine insufficiency.

- Pain Management: Opioids are often avoided. nonprescription pain medications usually control pain, such as NSAIDS.

- Surgery may be indicated to:
Relieve persistent abdominal pain and discomfort
Restore drainage of pancreatic secretions
Reduce the frequency of acute attacks
(Brunner & Suddarth’s, 2010)
Medical Management
Chronic Pancreatitis:

- Common Surgeries:

Whipple Resection: The head of the pancreas, a portion of the bile duct, the gallbladder and the duodenum is removed. Occasionally a portion of the stomach may also be removed. After removal of these structures the remaining pancreas, bile duct the intestine is sutured back into the intestine to direct the gastrointestinal secretions back into the gut.
(Brunner & Suddarth’s, 2010)
Medical Management con't
Common Surgeries:

Cholecystectomy: Is performed if pancreatitis develops as a result of gallbladder disease.

Pancreaticojejunostomy (Roux-en-Y): Joins the pancreatic duct to the jejunum.






(Brunner & Suddarth’s, 2010)
Medical Management con't
The nurse should monitor the client with acute pancreatitis for which of the following complications?

A Heart Failure
B Doudenal ulcer
C. Cirrhosis
D Pneumonia
Question Time!
D. Pneumonia

The client with acute pancreatitis is prone to complications associated with the respiratory system. Pneumonia, atelectasis, and pleural effusion are examples of respiratory complications that can develop as a result of pancreatic enzyme exudate. Pancreatitis does not cause heart failure, ulcer formation, or cirrhosis.
(Billings & Hensel, 2013)
Answer
Histamine-2 antagonists such as Tagamet and Zantac may be prescribed to decrease pancreatic activity by inhibiting secretion of gastric acid.

Proton Pump inhibitors such as Protonix may be used for patients who do not have tolerate H2 antagonists.

Opioids (acute) such as Fentanyl or Dilaudid

Nonprescription pain meds (Chronic) such as Ibuprofen

Antibiotics are used if an infection is present

Insulin may be required if hyperglycemia occurs

If an episode of pancreatitis occurred during treatment with thiazide diuretics, corticosteroids, or oral contraceptives, these medications are discontinued.
(Brunner & Suddarth’s, 2010)
Pharmacology
Relieve pain and discomfort

Improve breathing pattern

Improve nutritional status

Maintain skin integrity

(Brunner & Suddarth’s, 2010)
Nursing Management
When providing care for a client hospitalized with acute pancreatitis who has acute abdominal pain, which of the following nursing interventions would be most appropriate for this client? Select all that apply.

A. Placing the client in a side-lying position.

B. Administering morphine sulfate for pain as needed.

C. Maintaining the client on a high-calorie, high protein diet.

D. Monitoring the client’s respiratory status.

E. Obtaining daily weights.
Question Time!
A, D, E

The client with acute pancreatitis usually experiences acute abdominal pain. Placing the client in a side-lying position relieves the tension on the abdominal areas and promotes comfort. A semi-Fowler’s position is also appropriate. The nurse should also monitor the client’s respiratory status because clients are prone to develop respiratory complications. Daily weights are obtained to monitor the client’s nutritional and fluid volume status. While the client will likely need opioid analgesics to treat pain, morphine sulfate is not appropriate as it stimulates spasm of the sphincter of Oddi, thus increasing the client’s discomfort. During the acute phase of the illness while the client is experiencing pain, the pancreas is rested by withholding food and drink. When the diet is reintroduced, it is high-carb, low-fat, bland diet.
(Billings & Hensel, 2013)
Answer
Gastrointestinal Tract
Specific Signs & Symptoms
Peptic Ulcer
- epigastric or right upper quadrant pain
Esophageal ulcer
- odynophagia
- gastroesophageal reflux
- dysphagia
Mallory-Weiss tear
- emesis
- retching
- coughing prior to hematemesis
Variceal hemorrhage
- jaundice
- weakness
- fatigue, anorexia
- abdominal distention
Malignancy
- dysphagia
- early satiety
- involuntary weight loss
- cachexia
Assessments/Interventions
Provide oxygenation via nasal cannula
Assess Pts. for signs of hypovolemia, orthostatic hypotension, increase in heart rate (20 bpm when moving from a recumbent position to a standing position), supine hypotension (indicates blood volume loss of at least 40%)
Examine their stool color
Assess Pt. for abdominal pain
Establish 2 large bore IV lines (16 gauge or larger)
Obtain a type and screen
Obtain hemoglobin concentrations, platelet counts, coagulation studies (Prothrombin time with INR), liver enzymes (AST, ALT), albumin, BUN and creatinine levels
** Keep Pt. NPO! **
Medical Interventions
Lower endoscopy (aka colonoscopy) or upper endoscopy
Angiography
Nasogastric lavage
Bolus Infusions of isotonic crystalloids
- 0.9% NSS or LR
Blood transfusions are given when the HGB is <7 g/dL

Pharmocologic Tx
Acid Suppressors such as PPI
- Protonix
- Nexium
- Prevacid
Somatostatin and its analongs
- Stilamin
- Sandostation
Antibiotics
The client diagnosed with Crohn’s disease is crying and telling the nurse, “I can’t take it anymore. I never know when I will get sick and end up in the hospital.” Which statement would be the nurses best response?
A. I understand how frustrating this must be for you
B. You must keep thinking about the good things in life
C. I can see you are very upset. Ill sit down and we can talk.
D. Are you thinking about doing anything like committing suicide?
Question Time!
C: The client is crying and is expressing feelings of powerlessness; therefore the nurse should allow the client to talk.
Answer
The client diagnosed with Crohn’s disease, also know as regional enteritis. Which statement by the client would support this diagnosis?
A. My pain goes away when I have a bowel movement
B. I have bright red blood in my stool all the time
C. I have episodes of diarrhea and constipation
D. My abdomen is hard and rigid and I have a fever
Question Time!
The ileum is the most common site for Crohn’s (regional enteritis) and causes right lower quadrant pain that is relieved by defecation.
Answer
The nurse is speaking to a support group for clients with Crohn’s disease. What information would be most important for the nurse to discuss with the clients?
A. Discuss coping skills that assist with adaptations to lifestyle modifications
B. Teach about drug administration, dosages, and scheduled times
C. Teach dietary changes necessary to control symptoms
D. Explain the care of the colostomy and necessary equipment
Question Time!
The client is diagnosed with acute exacerbation of Crohn’s disease. Which assessment data would warrant immediate attention?
A. White blood cell is 10.0
B. Serum amylase is 100units/dL
C. Potassium 3.1 mEq/L
D. Blood glucose 138 mg/dL
Question Time!
The objectives for support groups are to help members cope with chronic diseases and help manage symptom control.
Answer
Potassium level is low as a result of excessive diarrhea and puts the client at risk for cardiac arrhythmias.
Answer
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