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GI Disorders Lecture

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Leslie Wagner

on 4 March 2016

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Transcript of GI Disorders Lecture

GI Disorders
Leslie Wagner, MS-RN
NURS 303

Pharynx
Tongue
Esophagus
Pancreas
Stomach
Pancreatic Duct
Liver
Gallbladder
Duodenum
Common Bile
Duct

Transverse Colon
Ascending Colon
Descending Colon
Cecum
Appendix
Rectum
Anus
Ileum
Oral Cavity
Routine Tests: Stool Examination
Stool culture
Stool for ova and parasites
Stool for occult blood
Routine Tests: X-Rays
Does not show abdominal organs
Help detect and evaluate kidney stones or tumors
Abnormal gas collection
Routine Tests: CT Scan
Cross section taken every 1/4 inch
Tumors, obstructions, foreign objects
Done with or without contrast
Routine Tests:
Barium Studies
Barium swallow
Upper GI series
Lower GI series
Barium enema
Permits study of large intestine
Dx: inflammatory disorders, colorectal cancer, polyps, diverticula, structural changes
Uncomfortable
Nursing Care: Preparatory
NPO after midnight
Low residue diet 2-3 days prior
Clear liquids day before
Bowel prep
Barium enema before UGI if both ordered
Post Procedure
Constipation
Stool color
Complications
Routine Tests: Endoscopy
Allows for visualization of body cavity
Tube is lighted, flexible, and able to pass instruments through it
Biopsy, polyps, foreign body removal, and cauterization
Consent required
Routine Tests: EGD and ERCP
Esophogogastroduodenoscopy
Esophagus, stomach, beginning of duodenum
Endoscopic Retrograde Cholangiopancreatography
Opening of liver, gall bladder, and pancreas
Patient Care
Pre-Procedure
NPOx8 hours
Sedative given
During Procedure
Anesthetize throat
Instructed to swallow tube
Post-Procedure
Bedrest
NPO
Complications
Routine Tests: Colonoscopy
Endoscopic exam of entire large bowel
Prep:
Liquid diet
NPO
Golytely
Procedure:
Versed
Left side position
Atropine
Fill colon with air for visualization
Post Procedure:
Bedrest
Vital signs
Safety
Bowel sounds
Flatus
Complications:
Perforation
Monitor for bleeding
Routine Tests: Sigmoidoscopy and Proctoscopy
Visual exam of the sigmoid colon, lower rectum, and anal muscosa
Prep:
Liquid diet
NPO
Laxatives/enemas
Procedure:
Left side or knee chest
Bear down
30 minutes
Complications:
Same as colonoscopy
Routine Tests: Gastric Analysis
Analyzes stomach's secretion of HCL acid and pepsin
Prep:
No smoking
No gum
No food
NGT placed
Routine Tests: Gastric Analysis
Basal gastric secretion: Amount of HCL secretion between meals
Gastric acid simulation: Follow up if small amounts are collected in BGS
Procedure: Samples are drawn from an NGT
Decreased Levels: suggestive of gastric carcinoma
Increased Levels: suggestive of gastric or duodenal ulcers
Routine Tests: Ultrasoundography
High frequency waves passed through body and the echoes created vary with tissue density
Prep:
NPO x12 hours, may have water
Full bladder
Procedure:
Gel applied to the end of transducer and placed on abdomen
Moved back and forth until images obtained
Hiatal Hernia
Causes:
Muscle weakness in esophageal hiatus
Age
Congenital weakness
Trauma
Surgery
Strong association to GERD
Hiatal Hernia
Symptoms:
Many asyptomatic
Reflux eventually results due to exposure of the espophageal sphincter
Diagnostics:
EGD or barium swallow
Hiatal Hernia
Meds: PPIs and anatacids
Surgery:
Open or conventional fundoplication
Laproscopic Nissen Fundoplication (LNF)
Hiatal Hernia
Fundas wrapped around esophagus 360 degrees
Done laparoscopically
3-4 puncture wounds
Hiatal Hernia: Post Op
Diet
Meds
No driving x1 week
Activity
Incision care
Monitor and report s/s infection, N/V,uncontrolled pain
GERD: Gastroesophageal Reflux Disease
Progression:
Periodic GERD is normal
Frequent GERD breaks down mucosal barrier and initiates inflammatory response
Chronic inlammation leads to capillary bleeding
Over time fibrotic tissues form and impairs swallowing and narrows esophagus
GERD
Causes:
Inappropriate LES relaxation
Pressure of LES lowered by:
Chocolate
Coffee
Tea
Nicotine
CCBs
NSAIDs
Obesity
Pregnancy
Alcohol
OJ
Tomato based foods
GERD
Symptoms:
Heartburn
Acid regurgitation
Waterbrash
Frequent belching
Dysphagia
GERD
Severe Symptoms:
Pain after every meal x20+ minutes
Cough and asthma symptoms from getting into endotracheal tree
Wheezing
GERD
Diagnostics:
EGD
Barium swallow
24 hour pH monitoring
GERD
Treatment:
Medication
Lifestyle changes
Weight loss
Loose clothing
Sleep
Avoid irritating foods
Avoid tobacco
No heavy lifting, bending over
4-6 small meals, no bedtime snacks
Stay up 1-2 hours after eating
Bedtime modifications
Esophageal Cancer
Risk Factors:
Over expression and mutation of tumor suppressor genes
Over expression of a protein that promotes cell division and growth (genetically linked)
Tobacco use: 2-6X more likely
Alcohol intake: shots
GERD: normal epithelium replaced
Esophageal Cancer
Symptoms:
Dysphagia: related to tumors
Odynophagia: cold liquid intolerance
Severe, persistent pain
Esophageal Cancer
Treament: Non-Surgical
Nursing care when eating and after
Elevate HOB 30 degrees
Monitor for aspiration
Jejunostomy or gastrostomy tubes
XRT and chemo
Esophageal Cancer
Treatment: Surgical
Minimally invasive esophagectomy
Lower esophagus and gastric fundus are removed laparscopically
Open esophagectomy
Stomach made into esophagus
Colon Interposition
Section of colon made into esophagus
Esophageal Cancer
Post Op Care:
Respiratory Support
#1 priority for first 24 hours
Chest tubes: expected
Ventilator: expected
High fowlers position
Esophageal Cancer
Post Op Care:
CV complications
Lymph node dissection can lead to FVE
Wound Management
Leaks can occur
Splint incision
Assess fever, fluid accumulation, inflammation
Cine-esophagram study: swallowing study before oral fluids started
Esophageal Cancer
Post Op Care:
NGT: Expected post op
No repositioning
May irrigate with saline: WITH PERMISSION
If NGT doesn't unclog with irrigation, call MD
Drainage: serosanguinous, then greenish yellow
Continued blood indicates suture line bleed
Gastritis
Acute:
Resolves in a few days
Caused by H. pylori, NSAIDs, caffeine, alcohol, and steroids
Chronic:
Patchy, diffuse inflammation
Parietal cells that produce needed acid begin to atrophy
Leads to pernicious anemia
Gastritis
Treatment:
Medications
Antibiotics
H2 Receptor Blockers
Anticholinergics
Antacids
Mucosal Barrier Sealant
Prostaglandin Analog
B12
Diet
Caffeine
High acidic content
Spicy foods
Lifestyle Changes
No tobacco
No alcohol
Peptic Ulcer Disease: Gastric and Duodenal
Breakdown of GI tract mucosa related to:
Infection by H. Pylori
Releases damaging enzyme
NSAID administration
Inhibits production of prostaglandin which maintains normal mucosa
Other: smoking, ETOH, ASA, genetics
Location of ulcer is often determined by symptoms
Peptic Ulcer Disease
Personality Profile
Type A, stressed, perfectionist
Stress (physical and emotional) increases cortisol release
Cortisol blocks prostaglandin
Prostaglandin protects mucosa
Peptic Ulcer Disease
Disease Progression: Ulcer Development
Damage to mucosa permits further erosion of abdominal wall
Erosion leads to histamine release and stimulate acid secretion
Mucosal capillary damage causes perforation, hemorrhage, peritonitis, and shock
Peptic Ulcer Disease
Disease Progression: Perforation
Sudden abdominal pain
"Board like abdomen"
Knee chest position
Stool
BUN elevation related to GI bleeding
Peptic Ulcer Disease
Disease Progression: Vomiting
Vomiting blood=emergency
Iced saline lavage via NGT
2 large bore IV sites
Blood products
Normal saline
Peptic Ulcer Disease
Special Precautions: Esophageal Varices
Liver disease leads to varices
Clotting factors are decreased
Veins distend, clot and scar continuous
Creates varicose veins around esophagus
Medical emergency if patient with liver disease is having stools with blood in them
Difficult to treat
Peptic Ulcer Disease
Treatment
Medications: Same as GERD
Avoid caffeine, milk, ETOH, coffee and tobacco
3 normal meals
No bedtime snacks
No ASA or NSAIDs
Surgical Procedures
Vagotomy:
Cuts vagus nerve
Destroys vagal interaction of stomach which decreases acid production
Antrectomy:
Mucosa of antrum produces gastrin
Gastrin stimulates HCL acid and pepsin production
Antrum in removed surgically
Surgical Procedures
Gastrectomy:
Can also be done to remove benign or malignant tumors
Surgical excision of stomach
Total=entire stomach removed
Esophagus sutured to duodenum or jejunum
Surgical Intervention: Partial/Subtotal Resection
Billroth I:
Removal of distal portion of stomach; stomach anastamosed to duodenum
Gastrin source removed: acid secreting parietal cells
Billroth II:
Proximal remnant of stomach anastamosed to proximal duodenum
Treatment for duodenal and gastric ulcers
Duodenal stump preserved to allow bile flow to the jejunum
Gastrectomy: Pre Op Prep
Fluid and electrolytes given as needed to make up for underlying disease deficiencies
Diet: liquid for 24 hours prior and then NPO after midnight
TPN: may be used dependent on how badly the disease has progressed prior to surgery
Skin prep
Gastrectomy: Post OP
IVF because patient will be NPO until BS return
NGT: removes secretions and prevents vomiting
May irrigate (with permission)if clogged, no repositioning
Diet
Start with sips of warm fluids
6 small, bland meals
120ml fluid between
Ambulation: as tolerated and ordered by MD
Gastrectomy Complications: Dumping Syndrome
Result of large portion of stomach and pyloric sphincter removal
Stomach loses control over amounts of gastric chyme entering small intestines after surgery
The gastric chyme bolus that occurs as a result causes a decrease in plasma volume
This creates a fluid shift that distends the bowel lumen and stimulates intestinal motility
Dumping Syndrome: Symptoms
Sweating
Tachycardia
Dizziness
Stomach cramps
Borborgymi
Urge to defecate
Symptoms occur 30 minutes to 3 hours after eating
Dumping Syndrome Management
Decrease amounts of food
High protein, high fat, low carb
No liquids with meals
Lie down after eating
Bending, stooping, lying on right side
Sedatives or antispasmotics
Diverticular Disease
Increased lumen pressure of the bowel forces herniation through weak areas of the wall
Out pouchings of mucosa form through muscular wall of intestine
Sigmoid colon most common site
Incidence: increases with age from 35; low fiber diets
Diverticular Disease Terminology
Diverticulum: one outpouching
Diverticula: more than one outpouching
Diverticulosis: presence of diverticulum without inflammation
Diverticulitis: presence of inflammation of diverticulum or diverticula
Diverticular Disease: Symptoms
Asymptomatic except with flare up
Crampy
Lower left quadrant pain
Low grade fever
N/V
Diverticular Disease: Diagnostics
History and symptoms
Sigmoidoscopy/colonoscopy
Ultrasound or CT
Barium enema
Diverticular Disease: Treatment and Management
Treatment:
Bedrest
Antibiotics
No response to this treatment=IVF/antibiotics, NGT, colon resection
Management:
Diverticulosis: high fiber diet, bulk forming laxatives, stool softners. Avoid nuts, popcorn, seeds
Diverticulitis: liquids only with active infection, no food or laxatives, force fluids, prevent constipation, IV antibiotics
Inflammatory Bowel Disease
Cause unknown; hereditary disposition
Associated with allergies
Autoimmune component and stress
Smoking
IBD general term for conditions characterized by bowel inflammation
IDB: Crohn's vs. Ulcerative Colitis
Nature of inflammation
Location in GI tract
Pattern of distribution
Degree of mucosal penetration
Diagnostics and treatment are the same for both
Appendicitis
Inflammation of the appendix
Caused by fecaliths that block the lumen
Blockage leads to bacteria and infection in the wall of the appendix
Appendicitis: Symptoms
RLQ pain at McBurneys point
Rebound tenderness
Low grade fever
Increased WBCs
N/V
Anorexia
Appendicitis
Diagnostics
US
CBC
Symptoms
Precautions prior to surgery:
No laxatives or enema
No heat, ice instead
Wait for analgesics
Keep NPO
Appendicitis
Complications
Gangrene: 24-36 hours after appendicitis begins
Perforation: may develop in first 24 hours but more likely after 48
Appendicitis
Treatment:
Appendectomy
Emergent related to risk of rupture and peritonitis
Peritonitis
Peritonitis
Local or internalized inflammation of peritoneum
Fluid can shift into abdomen (ascites)
Causes shock from volume depletion
Peritonitis Causes
Perforation
External penetrating wound
Gangrenous GB
Ascending infection from genital tract
Post Op infection
Peritonitis
Symptoms
Abdominal pain, tenderness
Rigid/board like abdomen
Guarding
Parlaytic ileus: absent BS and distention
Fever, increased WBC
N/V
FVD or shock
Peritonitis
Treatment
NGT
IV antibiotics
IVFs
Strict I&O
Assessment: LOC, VS, respiratory
Drains and incision care
Gallbladder Disease: Cholecystitis
Acute infection of the gallbladder
Types:
Calculous cholecystitis
Acalculous cholecystitis
Causes:
Gallstones
Surgery
Trauma
Cholecystitis: Symptoms
Pain
Fullness
Tenderness
Rigidity
Nausea/vomiting
Fever
Leukocytosis
Elevated liver enzymes
Cholelithiasis
Acute or chronic
Imbalance of cholesterol, bile salts, and calcium
Precipitation occurs
Risk factors: 5 F's
Fair skin
Fat
Forty
Female
Fertile
Cholelithiasis: Symptoms
Pain
Jaundice
Steatorrhea
Vitamin deficiency
Dark amber urine
Pruritis
Dietary Considerations
Low fat, high carb and protein
Non gas forming veggies
Foods to avoid:
Whole milk
Doughnuts
Avocados
Sausage
Cheese
Nuts
Butter
Alcohol
Non-Surgical Stone Removal
Dissolution of stones
Instrumental removal
Extracorporeal Shock Wave Lithotripsy
Repeat shock waves through water to fragment stones
Multiple sessions
No incision
Outpatient
Return to work in 48 hours
Extracorpeal Shock Wave Lithotripsy
Procedure
Place patient in prone position
Spinal, general, or epidural anesthesia with high wave shock
No anesthetic if low wave
Wave timed with heart beat
Side Effects
Petechiae
Gross hematuria
Bile duct obstruction
Surgical Approaches
Pre Op
Cxray, EKG, Xray of GB
LFTs and clotting studies
Teach TC and techniques
No deep breathing
Laproscopic Cholecystectomy
3-4 puncture sites created in abdomen
Scope inserted through puncture sites in abdomen
Gas used to visualize GB
Viewed on screen to identify and remove
Laproscopic and open consents signed in case surgeon is unable to complete laparascopically
Laproscopic Cholecystectomy
Post Op: Expected
Short recovery: DC in about 24 hours
People typically have abdominal (incisional) pain under control in a day
Less side effects: such as ileus
Low grade temp (99.6 or less r/t dehydration)
Shoulder Pain: gas gets trapped under diaphragm, will go away in a few days
Post Op: Unexpected
N/V
Previous abdominal pain
If these occur, think about perforation and have patient evaluated
Cholecystectomy with T-Tube
Major abdominal surgery
Considered the conventional cholecystectomy and was done frequently before laproscopcally
Incision
Long recovery
Drains/T-Tubes:
Placed to maintain common bile duct flow while swelling goes down
Record amount and color
Insertion site
Less than 500mls in 24 hours
Hang below abdominal level
Complications
Invasive Liver Studies
Potential complications
Consent
Conscious sedation
Percutaneous Liver Biopsy
Needle aspiration of liver cells through skin
Instructed to exhale and hold while needle inserted through lower ribs
Pre Procedure:
Labs
Post Procedure:
Bleeding
Monitor for shock
Invasive Liver Studies
Arteriography
Visualizes circulation in liver
Dye injected through catheter inserted through femoral artery and threaded to hepatic artery
Post Procedure:
Apply pressure to site
VS q15 minutes
Monitor for bleeding
Pulses
Invasive Liver Studies
Angiography
Visualizes hepatic circulation through hepatic vein
Accessed through vena cava
Laparoscopy
Direct visualization of organs
Gas involved
Consent required
Paracentesis
Removal of abdominal fluid
For diagnostic or excessive fluid removal
Done when fluid recurs and increases pressure on diaphragm
Pre Procedure:
Void immediately before
Weigh and measure
During:
High fowlers or sitting on side of bed
Post Procedure:
Monitor hypovolemic shock
Observe for perforation (Bowel: bleeding, shock, peritonitis. Bladder: rigid abdomen with little to no output
This pretty much sums up GI...should we all just leave now?
Barium Swallow
Allows examination of esophagus and pharynx
Detects: strictures, hiatal hernias, tumors, ulcers
X-Rays are taken as patient swallows the barium
Upper GI Series
UGI Series
Follows passage of barium
Observes from the esophagus to stomach
Diagnosis for
Cancer
Gastritis
Gastric and duodenal ulcers
Lower GI Series
UGI with SBF
Upper GI series with Small Bowel Follow Through
Follows passage of barium through small intestines
Diagnosis: malabsorption syndromes, obstruction, bleeding, inflammation
Barium Enema
Gastric VS. Duodenal
Gastric:
Pain: intermittent and runs from epigastrium to back
Onset: 30-60 min after eating
Effect of food: worsens
Other: may have vomiting
Duodenal:
Pain: intermittent but only in the epigastrium
Onset: 2-3 hours after meal
Effect of food: temporarily improves
Other: pain often at night
Pathophysiology
Normal response is inflammatory reaction to bacteria to wall off localized area
If walling off fails, inflammation spreads and contamination becomes massive
Body shunts extra blood to area and fluid is shifted from the ECF into peritoneal cavity
This causes hypovolemic shock and ascites
Ulcerative Colitis: Symptoms
Diarrhea
May occur nocturnally
Blood and mucous in stool
5-30 stools per day
LLQ cramping, relieved by defecation
Weight loss
No fever
Anemia
Severe disease may involve other systems:
Uveitis
Arthritis
Crohn's Disease: Symptoms
Manifestations vary among patients due to the diversity of involvement
Persistent diarrhea that may be semi-formed
Stools don't typically contain mucous or blood
RLQ pain relieved by defecation
RLQ mass often present
Fever, fatigue, malaise, weight loss, anemia
Mucosa appears as cobblestone
UC and Crohn's Diagnostics
Sigmoidoscopy
Colonoscopy
Upper GI series
Lower x-ray series
Stool for occult blood
Also tested to rule out infectious causes
CBC
C-reactive protein: elevated related to inflammation
UC and Crohn's: Treatment
Medications
Anti-inflammatory drugs
Azulfidine: antibiotic and anti-inflammatory combination
Mesalamine
Corticosteroids
May be administered locally (per recturm) for UC
Remicade
Anti-diarrheals
Ulcerative Colitis and Crohn's: Diet
Dependent on each patient's case
Eliminating milk and milk products may benefit
Increased fiber may slow diarrhea (bulk effect)
Contraindicated in patients with strictures
Crohns: all food may be withheld for a period of time to promote bowel rest during acute exacerbation
TPN could be started
Ulcerative Colitis and Crohn's: Surgical Intervention
Bowel obstruction in Crohn's may lead to resection
Colectomy: UC
Ostomy
If patient returns with NGT after colon surgery, we may readjust and irrigate if no drainage
Small Bowel Obstruction: Patho
Failure of the intestinal contents to move through the bowel lumen
May affect large or small bowel
SBO is most commonly affected
Types of obstruction
Mechanical
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