common disorders of the upper GI tract
GERD (gastroesophageal reflux disease)
PUD (peptic ulcer disease)
disorders of the lower GI tract
- IBD (inflammatory bowel disorder)
- IBS (irritable bowel syndrome)
- intestinal obstruction
- diverticular disease
disorders of the biliary tract
gall bladder disease
Gastroesophageal Reflux Disease (GERD)
reflux of gastric secretions into the esophagus
causes of GERD
- Relaxation of lower esophageal sphincter
- Pregnancy
-Delayed gastric emptying
- Acid hypersecretion
- Hiatal hernia
- Obesity
- Increased intra-abdominal pressure
complications related to GERD
- Esophageal or peptic stricture (scar tissue leading to swallowing problems)
- Barrett's esophagus (damage to cells (pre-cancerous growth)
- Dysphagia
- Hemorrhage
- Non-cardiac chest pain
-Pulmonary or ENT complications (can reflux into respiratory syst
expected outcomes for GERD patients
- Symptoms controlled
- No reflux related complications
- Able to comply with therapeutic regimen
- Satisfactory quality of life
symptom history of GERD
- Heartburn
- Regurgitation
- Dysphagia (indicative of stricture)
- Laryngitis (late respiratory signs)
- Chronic cough (late respiratory signs)
GERD diagnostic studies
- Diagnosis primarily based off patient symptoms (further diagnostics done if puzzling presentation or no reaction to treatment)
- Barium swallow (hiatal hernia)
- Esophagoscopy (Barrett's esophagus)
- pH monitoring studies
- Esophageal motility studies
-
GERD treatment
- Anti-secretory medications
- Metoclopramide (Reglan) (pro-mobility agent)
- Surgery (for severe symptoms)
types of anti-secretory medications
- H2 blockers and OTC H2 blockers (histamines, pepcid, zantac)
- proton pump inhibitors (decrease acid production; example: omeprazole)
symptom management/morbidity reduction teaching components
- Diet teaching
- Elevate HOB on 4 to 6 inch blocks
- Smoking cessation
- Avoid stooping, bending and tight fitting garments (increases intra-abdominal pressure)
- Don't lay down after eating
- Eat small meals
- Lose weight
- Avoid onions, chocolate, and
fundoplication
operation performed to correct gastroesophageal reflux; a surgical technique used to suture the fundus of the stomach around the esophagus to prevent reflux
approaches to fundoplication
laparoscopic, thoracic, high upper abdominal
postoperative care following fundoplication
- Care of the NG tube (nurse doesn't manipulate NG tube if misplaced or dislodged due to risk of damaging incision site; nurse can call doctor for orders to gently irrigate)
- Manage nausea
- Pain management
- Early ambulation
- Patient education (avoid r
pathophysiology of peptic ulcer disease (PUD)
erosion of the gastric mucosa resulting from digestive action of HCL acid and pepsin
two types of peptic ulcer disease (PUD)
(1) gastric and (2) duodenal (more common)
common cause of duodenal ulcers
95% to 100% prevalence of H Pylori infection in patients with duodenal ulcers
complications of peptic ulcer disease (PUD)
- hemorrhage (most common)
- perforation (most lethal)
- gastric outlet obstruction
these are all considered emergency situations
perforation
hole that completely penetrates a structure (bowel)
gastric outlet obstruction
an obstruction that prevents the normal emptying of stomach contents into the duodenum
assessment of pelvic ulcer disease
- symptom history (pain or blood in the stool)
- diagnostic tests (endoscopy, tests for H. Pylori, lab tests, and barium studies)
pre- and post-operative care for an endoscopy
pre-op care: prepare the OR, consent form, NPO
post-op care: patient will be sleepy, have a sore throat; patient may resume oral liquids and food after confirmed presence of swallow reflex
What values may we be looking at when conducting lab tests for peptic ulcer disease (PUD)?
- CBC
- blood loss
- occult blood in stool
What condition would be apparent when conducting a barium study for PUD?
gastric outlet obstruction
expected outcome for patient with peptic ulcer disease (PUD)
- Satisfactory pain relief
- Ability to adhere to therapeutic regimen
- Absence of complications
medication management for peptic ulcer disease (PUD)
- Antacids (raise pH of stomach content)
- H2 receptor antagonists (reduce acid production)
- Anticholinergic drugs: decrease cholinergic stimulation of gastric secretions (watch for side effects when sympathetic system takes drive; may see dry mouth, flu
lifestyle modifications for peptic ulcer disease (PUD)
- Dietary modifications (small, more frequent meals; constant food coating may be protective against acid; avoid irritating foods)
- Stress management (hyper-secretion of HCL with stress)
- Smoking cessation
management of acute exacerbation of peptic ulcer disease (PUD)
- NG suction
- Mouth care
- Monitor gastric secretions
- IV fluid replacement
- Monitor VS and hydration status (bleeding may present as decreased BP and tachycardia)
- Provide physical and emotional rest
- Pain control
S/S of hemorrhage r/t peptic ulcer disease (PUD)
- change in VS and amount and redness of aspirant
- may have decreased pain as blood buffers GI secretions
focus of care when hemorrhage r/t peptic ulcer disease (PUD)
immediate focus is to restore blood volume and stop spilling of gastric contents into peritoneum if perforation present
care for patient with hemorrhage r/t peptic ulcer disease (PUD)
NG, IV, albumin (blood expander), blood, Hemodynamic monitoring, Foley (fluid balance), broad spectrum antibiotics (especially when any sign of gastric content in the peritoneum), pain medication, possibly vasopressin (increases BP by vasoconstriction), s
S/S of perforation r/t peptic ulcer disease (PUD)
- sudden severe abdominal pain
- rigid board-like abdomen
- severe generalized abdominal and shoulder pain
- drawing up of knees
- shallow grunting respirations
- diminished or absent bowel sounds
care for patient with perforation r/t peptic ulcer disease (PUD)
Monitor VS closely, NG (suctioning), patient may be frightened, note allergies-antibiotic therapy will be started, prepare for surgery
presentation of gastric outlet obstruction r/t peptic ulcer disease (PUD)
Pylorus is narrowed by scar tissue, edema, inflammation, and pylorospasm
care for patient with gastric outlet obstruction r/t peptic ulcer disease (PUD)
NG tube (empty stomach), IV fluids, medication therapy, balloon dilations through endoscope, surgery to remove scar tissue as needed
surgical therapies for peptic ulcer disease (PUD)
- Billroth I
- Billroth II
- Vagotomy
- Pyloroplasty
Billroth I
an operation in which the pylorus is removed and the proximal stomach is anastomosed directly to the duodenum
Billroth II
an operation in which the greater curvature of the stomach is connected to the first part of the jejunum in end-to- side anastomosis
Vagotomy
The surgical dissection of branches of the vagus nerve to reduce acid secretion in the stomach
Pyloroplasty
Surgical repair of the pyloric sphincter
post-operative care following surgery to correct peptic ulcer disease (PUD)
-NG suction (BE CAREFUL OF INCISION; avoid plugging through order for light irrigation)
-Drainage changing from bright red to yellow green
- Physician must reposition or replace NG if needed
- Pain control
- IV fluid therapy
post-operative complications following surgery to correct peptic ulcer disease (PUD)
- dumping syndrome
- post-prandial hypoglycemia
- bile reflux gastritis
dumping syndrome
a condition whereby food moves too rapidly from the stomach into the small intestine; may see post-prandial hypoglycemia because rush of insulin is released to try to counteract bolus of chyme
S/S dumping syndrome
post eating weakness, sweating, palpitations, dizziness, abdominal cramps, borborygmi, urge to defecate
treatment for dumping syndrome
- usually self limiting
rest and reassurance
- best diet to decrease hyperosmolor composition and amount of chyme is 6 small dry feedings
- avoid fluid with meals
- low refined sugar
- low CHO
- moderate fat and PRO
-lay down after eating for 30 minutes (
post-prandial hypoglycemia
variant to dumping syndrome; bolus of high CHO fluid into small intestine results in excessive insulin secretion
S/S of post-prandial hypoglycemia
Secondary hypoglycemia 2 hours after eating, usual S/S
interventions for post-prandial hypoglycemia
treat hypoglycemia (increase blood sugar with carbs or glucagon), same diet interventions as dumping syndrome
bile reflux gastritis
a disabling postgastrectomy condition characterized by abdominal pain, bilious vomiting, and weight loss. The syndrome appears to be caused by free enterogastric reflux of bile and other proximal small bowel constituents
danger of bile reflux gastritis
can cause ulcer recurrence
treatment of bile reflux gastritis
treat with Questran (binds with bile salts) and antacids
two forms of inflammatory bowel disease (IBD)
1. Crohn's disease
2. Ulcerative colitis
common characteristics of inflammatory bowel disease
- Chronic illnesses with alternating periods of exacerbations and remissions
- Characterized by recurrent inflammation of the intestinal tract, diarrhea, and abdominal pain
- Extraintestinal manifestations common
Who is at high risk for inflammatory bowel disease (IBD)?
- Most commonly diagnosed in adolescents and young adults
- Highest rates among North Americans and Northern Europeans
- Etiology Unknown, many speculations
- Suspected genetic predisposition
disease distribution: Crohn's disease (CD) and ulcerative colitis (UC)
CD: disease can be anywhere in the GI tract; however, it is most commonly seen in distal small intestine
UC: disease limited to the colon (large intestine)
inflammation: Crohn's disease (CD) and ulcerative colitis (UC)
CD: skips lesions that affect all layers of the bowels
UC: travels from rectum upwards (mostly mucosa layer damaged)
In which IBD do we typically see more weight loss and malnutrition?
more common in Crohn's because the damaged small intestine is where nutrients are typically absorbed
carcinogenesis with IBD
increased risk of cancer in both Crohn's and ulcerative colitis
surgery: Crohn's disease (CD) and ulcerative colitis (UC)
CD: try not to perform surgery with Crohn's because it is a progressive condition in which it is important to maintain as much healthy bowel as possible (can't afford to be taking out portions of the bowel); if surgery performed, elevated risk of short bo
Strictures, fistula, and perianal disease: Crohn's disease (CD) and ulcerative colitis (UC)
CD: strictures more commonly seen because all layers of GI tract affected
UC: toxic megacolon
fistula
abnormal passageway between two organs or between an internal organ and the body surface
significance of fistula
- If infected fistula perforates into abdominal cavity, it may lead to sepsis
+ Immediate surgery may be necessary
+ May require temporary colostomy
Fistulous disease of ano-perineal area
+ drainage and stool may seep through fistula in between bowel movements
+ May lead to social isolation
+ May require temporary colostomy
toxic megacolon
complication in which the colon dilates and becomes atonic and vulnerable to perforation; seen more commonly with ulcerative colitis
extra-intestinal manifestations of inflammatory bowel disease (IBD)
- Mouth: Aphthous ulcers
- Musculoskeletal: Arthritis/arthralgias, Ankylosing Spondolytis (arthritis of the spine), Osteoporosis
- Liver: Primary Sclerosing Cholangitis
- Skin: Erythema Nodosum (red lumps on skin), Pyoderma Gangrenosum, Perianal lesions
-
episcleritis
looks like pink eye but not drainage; inflammation of the outermost layers of the sclera
pyoderma gangrenosum
deep ulcerative cutaneous condition, unknown etiology, poor wound healing; seen with inflammatory bowel disease
Does ulcerative colitis surgery resolve extra-intestinal manifestations of condition?
no
common nursing diagnoses for inflammatory bowel disease
- Pain
- Risk for impaired skin integrity (diarrhea, fistulas, colostomies, pyoderma gangrenosum)
- Body image disturbance (sick, weight loss, anal fistulas)
- Diarrhea
- Altered nutrition
- Risk for fluid volume deficit (diarrhea)
- Ineffective managemen
goal for treatment in the restoration phase
- Rest the bowel (NPO or elemental diet)
- Control the inflammation
- Combat infection
- Correct malnutrition
- Alleviate stress
- Symptom relief via drug therapy
- Consider surgery if conservative treatment fails
- Establishment of therapeutic, supportiv
function of medication management in the restoration phase of IBD
- Control inflammation
- Immunosupression
- Prevention and treatment of secondary infections
- Correct malnutrition
- Alleviate stress
- Rest the bowel
- Antidiarrheals
In what circumstance would we not give an antidiarrheal?
Contradicted in Crohn's Disease and toxic megacolon
function of cobalamin shots in Crohn's patients
shots given to Crohn's patients if vitamin B deficient due to impaired absorption
What types of drugs are used to control inflammation and suppress immune response?
- Aminosalicylates
- Corticosteroids
- Immune modulators
- Biological therapy
- Antimicrobials
function of aminosalicylates in IBD patients
To induce and/or maintain a remission in mild to moderate disease by controlling inflammation
types of aminosalicylates
1. With sulfapyridine (azulfadine): component that helps the medication travel to where it needs to be; however, it has side effects
2. Without sulfapyridine (mesalamine, olsalazine, balsalazide): newer agents
How are aminosalicylates delivered?
- Acts locally
- PO, suppository, enema forms
function of corticosteroids in IBD patients
used to induce a remission (given for short-term use)
types of corticosteroids given to IBD patients to induce a remission
- Oral Prednisone (need to take with calcium supplements)
- IV steroids (methylprednisolone)
- Budesonide (has high local activity if there is a growth concern)
function of immune modulators in IBD patients
to maintain remission after corticosteroids are administered (more of a long-term option) for severe disease
types of immune modulators used in IBD patients
- 6-mercaptoprine
- Azathioprine
- Methotrexate (not helpful for U.C.)
care management of IBD patient taking immune modulators
- Monitor blood counts (may cause bone marrow suppression)
- Increased risk of infection
- Encourage fluids (to protect kidneys)
- Not immediately effective
function of biological therapy for IBD patients
Used to induce and/or maintain remission in moderate to severe disease (used in combination with immune modulators); therapy is costly and puts patient at an increased risk for infection
What is it important to remember when administering biological therapy?
-Have to check for latent TB, hepatitis, and opportunistic cancer before administration
- Immunogenic: do not discontinue then restart (if you start and stop, the body may produce antibodies against therapy, causing a reaction if restarted)
What additional medications may be needed if disease in the terminal ilium?
Cobalamin
Cholestyramine
goals of nutritional management in IBD patients
Goals are (1) to provide adequate nutrition without exacerbating symptoms, (2) to correct and prevent malnutrition, (3) replace fluid and electrolyte losses, and (4) to prevent weight loss.
diet therapy for IBD patients
- Low in residue, roughage, and fat; high in calories and protein, with vitamin and iron supplements
- Milk and milk products may need to be excluded
- Elemental diet may be needed during acute exacerbations and can be used to assist in maintaining remiss
characteristics of a low residue diet
Avoid the following:
- Whole grains
- Raw and dried fruits
- Raw and cruciferous vegetables
- Nuts, seeds, beans and lentils
characteristics of elemental diet
high in calories and nutrients; lactose-free; it is usually composed of amino acids, fats, sugars, vitamins, and minerals
function of total parenteral nutrition in IBD patients
positive nitrogen balance while resting the bowels
surgery in Crohn's disease patients
- Crohn's disease is not cured by surgery
- Type of surgery depends on the affected areas and the condition of the client
- May require balloon dilation of strictures
function of surgery in ulcerative colitis patients
removal of the colon cures the GI manifestations of the disease
indications for surgery in ulcerative colitis patients
- Failure to respond to conservative treatment
- Frequent and debilitating exacerbations
- Massive bleeding, perforation, strictures
- Obstruction or precancerous changes
types of surgical procedures used to treat ulcerative colitis
- Total proctocolectomy with permanent ileostomy
- Total proctocolectomy with continent ileostomy (Koch's pouch)
- Total colectomy and ileal reservoir
Total proctocolectomy with permanent ileostomy
colostomy bag required
Total proctocolectomy with continent ileostomy (Koch's pouch)
maintain internal push that can be catheterized and drained; however, rarely used because of pouchitis and valve failure
Total colectomy and ileal reservoir
most common procedure for ulcerative colitis
two step procedure
(1) totally remove colon but keep the anus
(2) attach the ileum to the anus
preoperative care for ulcerative colitis patient
- Review information given by MD
- Arrange for visit/evaluation from WOC nurse
- Comprehensive preoperative assessment
- Collaborate with UOA (united ostomy association) for trained ostomate visit
Prescribed bowel prep (prophylactic antibiotics and NPO @
postoperative care of the patient with ileostomy
- Routine assessment and post-op care for patients having abdominal surgery
- Monitor for signs of hemorrhage, abdominal abscess, SBO, wound dehiscence, dehydration and electrolyte imbalance
- Stoma and skin care
- Addressing psychosocial needs
- Educatio
irritable bowel syndrome (IBS)
- Disorder of colon motility
- A symptom complex characterized by intermittent and recurrent abdominal pain associated with an alteration in bowel function (constipation or diarrhea)
-Typically triggers (bowels are super-sensitive to stimuli)
- Symptoms r
types of irritable bowel syndrome (IBS)
1. predominantly diarrhea
2. predominantly constipation
common triggers for IBS
chocolate
milk
caffeine
alcohol
stress
treatment for irritable bowel syndrome (IBS)
- Establish trusting relationship with client (make not feel judged)
- Encourage 20 grams of fiber per day
- Eliminate gas forming foods
- Use yogurt instead of milk products
- If anxiety stress management techniques (pharmacological assistance with stres
medications used for irritable bowel syndrome
Loperamide (Imodium): diarrhea predominant
Alosetron (Lotronex): diarrhea predominant
Lubiprostone (Amitiza): anti-constipation medication
Dicyclomine (Bentyl): anti-spasmodic drug
intestinal obstruction
- blockage of the intestines that prevents the forward movement of the contents
- partial or complete blockage of the small or large intestine caused by a physical obstruction
- commonly seen with inflammatory bowel disease
classifications of intestinal obstructions
partial (NPO; use of balloon to dilate bowel)
complete (surgery required)
causes of intestinal obstruction
mechanical (physical blockage, adhesions of scar tissue, hernias, cancer)
non-mechanical (paralytic ileus: absence of intestinal peristalsis; causes: surgery, acute appendicitis, electrolyte imbalance, vertebral compression fracture)
pathophysiology of intestinal obstructions
- Fluid gas and intestinal contents collect proximal to the obstruction
- Increased pressure leads to increased capillary permeability
- Extravasation of fluids and electrolytes into the peritoneal cavity
- Can lead to rupture of the bowel
- Incarceration
clinical manifestations of intestinal obstructions (dependent on type and location of obstruction)
- Nausea
- Vomiting (rapid onset if high in bowels)
- Pain (strong pain if bowel becomes ischemic)
- Abdominal distention
- Absence of flatus
- Obstipation
diagnostic studies for intestinal obstruction
- CT scan
- Abdominal x-rays (gas and fluid found; air in peritoneum means perforation of bowel)
- Barium enema (rare)
- Sigmoidoscopy/ colonoscopy
- Laboratory tests (CBC, lytes, BUN, Amylase, hemacult stool)
interventions for intestinal obstructions
- Decompression of the intestine and relief or removal of the obstruction
- Correction of fluid and electrolyte imbalances
- Promote comfort
complications of intestinal obstructions
Shock
Strangulation
Renal failure
In what population do you commonly see diverticular disease?
older adults
causes of diverticula
straining to have a bowel movement results in increased intra-abdominal pressure; weak spots in bowel causes out-pocket
clinical manifestations of diverticulosis
may not clinically present; could have LLQ pain
clinical manifestations of diverticulitis
inflammation and infection of the outpouching
complications of diverticular disease
- Perforation with peritonitis (sharp pain, board-like abdomen, no bowel sounds)
- Abscess and fistula formation
- Bowel or ureteral obstruction
- Bleeding
diagnostic studies of diverticular disease
- Stools for occult blood
- Barium enema
- Sigmoidoscopy
- Colonoscopy
- CBC
- UA
- Blood culture
care management diverticulosis
- High fiber diet
- Increased fluid
- Maintain ideal weight (decrease intra-abdominal pressure)
- Avoid increasing abdominal pressure (don't strain for bowel movement, tight fitting clothing, bending, vomiting)
care management of diverticulitis
- Goal is to allow bowel to rest and inflammation to subside, monitor for peritonitis
+ Bedrest
+ Antibiotic therapy
+ NPO
+ NG
+ Ongoing monitoring (dehydration, perforation, shock)
+ Surgery if indicated
common gallbladder pathologies
- Cholecystitis (inflammation of the gallbladder)
- Cholelithiasis (stones in the gallbladder)
- Choledocholithiasis (stones in common duct)
clinical manifestations of acute cholecystitis
- Mid epigastric or RUQ abdominal pain
- intense, sudden onset, may radiate to back and shoulder
- nausea and vomiting
- mild to moderate temperature elevation
- Murphy's Sign (when palpate abdomen, it causes respiratory arrest/gasping in)
- leukocytosis
clinical manifestations of cholelithiasis
Depends in whether stones are mobile (biliary colic) or whether biliary obstruction is present
clinical manifestations of biliary obstruction
- Biliary colic
- Jaundice
- Pruritis
- Fever and chills
- BMs loose and light in color
- Possible hepatomegaly
diagnosis of biliary obstruction
- Ultrasound of GB is gold standard
- CBC
- Blood cultures (high white cell count)
- Serum bilirubin (bile block)
- Amylase and lipase (pancreatic involvement)
- Alkaline phosphatase AST and ALT (bile block and liver damage)
Management of an Acute Biliary Attack
- Analgesics
- Antispasmotics/ Anticholinergics
- Antibiotics
- Maintenance of fluid and electrolyte balance
- Antiemetics
- May have an NG
- Cholestyramine if obstructive jaundice with severe itching (binds to bile salts)
surgical procedures for biliary obstructions or gallbladder diseases
- Laparoscopic cholecystectomy
- Open Chole (incision of the right upper quadrant under the rib cage; consult respiratory therapy because patient may be apprehensive to do deep breathing because of stitches)
- Transhepatic Biliary Catheter (used if obstru
post-operative care for a laparoscopic cholecystectomy
- Monitor for bleeding
Assess for shoulder pain (gas pain)
- Sims position (keeps air bubble away from diaphragm to reduce gas pain)
- Ambulate (relieves gas pain)
- Clear liquids
- Home same or next day
- Return to work one week
post-operative care for a open cholecystectomy
- Pain control
- Adequate ventilation (coughing or deep breathing)
- Advance diet based on bowel sounds (watch for post-op ileus)
- Penrose or JP, sterile dressing, protect skin
- T-Tube (if common duct explored)
- Avoid heavy lifting 4 to 6 weeks
- Disch
T-tube (open chole)
- Gravity drainage
- Monitor drainage and record amounts
- Skin/site care
- Monitor for complications
- Patient education for home care
chronic or home management following a cholecystectomy
- Low fat diet
- Fat soluble vitamin supplements
- Teach S/S obstruction: jaundice, clay colored stools, dark foamy urine, steatorrhea, fever, elevated WBCs
- If obstruction present watch for S/S bleeding due to decreased production of thrombin, bleeding