Diagnostic Evaluation

1. Diagnostic Evaluation • UGI- pass clay colored stools after test • Lower GI • Gastric Acid stimulation test-experience flushed feeling when med is injected • Gastric PH • Laparoscopy • UGI Fiberoscopy/Esophagogastroduodenoscopy-

2. Cont. • With esophogogastroduodenoscopy- withhold food and fluids until gag reflux returns • Sigmoidoscopy – lye on left side with rt leg flexed

3. Cont. GI Tests • Pre-op bowel prep with GoLightly –purpose is to decrease post-op sepsis • Fiberoptic colonoscopy • Abdominal ultrasonography • Stool Test - False positive hematest may occur when taking Aspirin

4. Oral disorders • Salivary glands- parotitis • Cancer of the oral cavity –painless sore that has not healed • …xerostomia – dryness of the mouth • ….stomatitis- inflammation/breakdown of oral mucosa;side effect of chemotherapy • Nsg Interventions –promote preventive mouth care- medicate if bacterial/fungal infection • Promote adequate nutrition/hydration

5. Disorders of the esophagus • Mucus lined-muscular tube starts at base of pharynx ends 4cm below diaphragm.Two sphincters; upper and lower. Lower one, junction of stomach and esophagus allows for backward flow of stomach content. • Dysphagia: most common symptom . Many patho conditions responsible( including motility disorders –achalasia, diffuse spasm), GERD (gastroesophageal reflux is an inflammatory response- AKA Reflux Esophagitis), hiatal hernias, perforation,cancer,chemical burns.

6. Disorders of the Esophagus • Achalasia- absent peristalsis of distal esophagus • S&S= difficulty swallowing liquids and solids, regurgitate food to relieve pressure and to rid food that will not pass into stomach.Get pyrosis and chest pain • Dx-manometry to measure increase pressure • Tx= drink fluids with meals, eat slowly, ca channel blockers, nitrates, botulinum injection, surgery

7. Esophagus • Diffuse spasm-motor disorder-stressful situations get contractions of the esophagus • Clinical manifestations- dysphagia,chest pain • Dx- manometry and barium swallow shows area of spasm • Management:nitrates and sedatives to relieve pain,ca channel blockers to reduce spasms.small frequent feedings, soft diet,pneumatic dilation • GERD- (backflow of gastric or duodenal contents into esophagus. Have incompetant lower sphincter,pyloric stenosis or motility disorder.

8. Dumping Syndrome • The term Dumping syndrome refers to GI symptoms that occur in some after a GI surgery or vagotomy.Foods high in CHO and electrolytes empty rapidly in the jejunum.The hypertonic intestinal contents draw extracellular fluid from the circulating blood into the jejunum to dilute the high concentration of electrolytes and sugars. Early symptoms, weakness, diaphoresis, palpitations, diarrhea, cramping, get rapid increase in blood glucose, followed by increased insulin secretion, get reactive hypoglycemia

9. Cont. Dumping Syndrome • Vasomotor symptoms occur 90 minutes after eating (headache, diaphoresis, dizziness, pallor. • Tx- semirecumbant position during mealtime, after meal lye down 30 min to delay gastric emptying, fluids discouraged with meals.CHO intake should be low, glucose avoided.

10. GERD • S&S= pyrosis, indigestion, regurgitation,odynophagia, dysphagia- mimic heart attack • Dx- endoscopy or barium swallow • TX-avoid factors that cause irritation and decrease lower esophageal pressure. Low-fat, high fiber diet , avoid carbonated beverages, caffeine, tobacco, don’t eat/drink 2 hrs before sleep, , avoid tight clothes, normal wt, elavate HOB, meds

11. Cont. GERD • H2 blockers, antacids, gastric acid pump inhibitors, prokinetic agents, which accelerate gastric emptying ,Urecholine, Reglan, surgery (fundoplication) • Hiatal Hernia – Normally the opening in the diaphragm encircles the esophagus tightly and the stomach is in the abd.With HH the opening in which the diaphragm through which the esophagus passes becomes enlarged and the stomach tends to move up into the thorax. Axial or sliding Hernia-

12. HIATAL HERNIA • Axial Hernia get difficulty in swallowing, heart burn because GE junction is displaced upward toward thorax. • S&S= heartburn, indigestion or no symptoms.C/o include obstruction, hemorrhage, and strangulation • Dx- barium swallow, fluoroscopy • TX- frequent small feedings. Don’t recline for 1 hr after eating,elevate HOB, surgery, para-esophageal hernia may require emergency surgery.

13. Diverticulum • An outpouching of the sbmucosa or mucosa that protrudes through a weak portion of the musculature. • Tx – dysphagia, fullness in the neck, regurgitation of undigested food, gurgling noises after eating. The pouch becomes full of food or fluid and halitosis occurs • Dx- barium swallow. Avoid esophagoscopy because of perforation.

14. TPN • Management_ surgical removal of diverticulum. • For all patients with surgical intervention – TPN is ideal because it keeps nutritional balance and unlike a NG tube cannot cause aspiration • TPN- start slowly to avoid hypertonic fluid intake, assess site for infection. Weigh daily, I&O, assess lab values.C/O include sepsis, air embolism, displaced cath, pneumothorax, fluid overload, hyper and hypoglycemia

15. Gastritis • Inflammation of the gastric mucosa; acute or chronic • NSAIDs. ASA,ETOH intake, food irritation or contamination, ingestion of strong alkali or acid may cause mucosa to perforate causing scarring and pyloric obstruction. • Chronic gastritis cause by ulcers or bacteria H-Pylori

16. Gastritis • S&S – Acute (abd discomfort, headache, nausea, vomiting, some are asymptomatic) • Chronic(may have vit B12 deficiency, anorexia, heartburn after eating, halitosis, nausea and vomiting) Dx= UGI x-ray, H-pylori test Tx – repairing itself in about two days. Avoid irritant causes, neutralize the offending agent (antacids)NG tube,analgesics,sedatives IV fluids,gastric resection may be necessary due to pyloric obstruction, antibiotics,Vit B

17. Peptic Ulcer • Hollowed out area formed in the mucosal wall of the stomach, the pylorus, the duodenum or the esophagus.A peptic ulcer I referred as a gastric, duodenal, or esophageal or as peptic ulcer disease.Erosion of the mucosal or muscle layers or through the muscle to the peritoneum. More common in the duodenum. Zollinger-Ellison syndrome have extreme gastric acidity, peptic ulcers,gastrin secreting tumors of the pancreas is a

18. Type of peptic ulcer- Stress ulcers are different because they are ulcerations of the mucosa that occur in the gastro- duodenal area.H-Pylori are in 70% of gastric ulcers and 95% with duodenal ulcers.Treated with antibiotics.Have increase hydrochloric acid production. Ingestion of milk, ETIOH, carbonated drinks, smoking increase acid.

19. Peptic Ulcer • Familial tendency is a predisposing factor, Type O more susceptible to Peptic Ulcers. NSAIDS use, ETOH, excessive smoking. Stress ulcers may occur in those exposed to stressful situations ( burns, shock,sepsis, post op esophageal ulcers occur as a result of the backward flow of hydrochloric acid (GERD)

20. Peptic Ulcers • S&S=last a few days – months. Disappear and may reappear.C/O of dull, gnawing pain or burning in midepigastrium or in the back.Pain relieved by eating because it neutralizes the acid once food or alkali is gone pain reoccurs. Sharp localized tenderness with light palpation. Some relief with pressure on epigastrium.Pyrosis,abd distention, vomiting, constipation, diarrhea, or bleeding. • Dx- Endoscopy,stools for occult,pain relieved by food or arising suggest ulcer.

21. Peptic Ulcer • Tx- remission can occur, goal treat H_Pylori and/or mange gastric acidity. Life style changes, meds and surgery are part of the plan. • Meds- Antibiotics, H2 antagonists, proton pump inhibitors, cytoprotective agents, antacids (pg 863), smoking cessation, rest and decrease stress, dietary modifications

22. Surgical Intervention • Surgical management- those ulcers that do not heal after 12-16 weeks, hemorrhage, perforation, or obstruction or ZES not responding to meds. Vagaotomy, Billiroth I or II.Prophylactic use of H2 antagonist.If bleeding assess if fresh or coffee ground.Gastritis and hemorrhage from peptic ulcer are two most common causes of UGI bleed.The site of bleeding is usually distal portion of the duodenum, see hematemesis or melena.Assess for shock, treat blood loss, NG to suction/lavage, assess labs,PH gastric secretions,adm O2, IV’s

23. Perforation • If bleeding,transendoscopic coagulation by laser, heat probe, medication, a sclerosing agent or combo ot therapies can halt the bleeding. • Perforation is the erosion of the ulcer through the gastric serosa into the peritoneal cavity- EMERGENCY surgery. Penetration is the erosion of the gastric serosa into the pancreas, biliary tract or gasto-hepatic omentum. S&S- back and epigastric pain, not relieved by past med use.

24. Perforation cont… • S&S= sudden and severe abd pain, referred to the shoulder, especially to the rt side because of the phrenic nerve in the diaphragm, vomiting and collapse, rigid abd, hypotension and tachycardia.EMERGENCY surgery. Chemical peritonitisdevelops 2 hrs after perferation is followed by bacterial peritonitis, the perforation must be closed ASAP.Post-op = NG tube to suction, assess lytes and fluid balance, assess for peritonitis, Antibiotics.

25. Monitoring for Pyloric Obstruction • It is a narrowing of the opening between the stomach and duodenum. • Area distal to pyloric shincter becomes scarred from spasm or edema. Have N/V, constipation, fullness, wt. Loss, anorexia. Insert NG to decompress the stomach.Assess how much is aspirated from the NG, a residual of more than 200 is strongly suggestive of an obstruction.Managing the fluids and decompressing the bowel may help if not surgery (vagotomy and antrectomy)

26. Total Parenteral Nutrition- amino acid-dextrose /lipids • Negative Nitrogen Balance • TPN qualifiers: • Types of TPN • Central line method • Percutaneous cath: • PIC,Tunneled central catheters- Hickman broviac,groshong

27. Gastritis • Inflammation of the gastric mucosa: • Overuse of ASA,NSAIDS, etoh, bile reflux,ulcers, helicobacter pylori • Clinical manifestations: • Medical management: • Nursing management:

28. Peptic Ulcer • Excavation of the mucosal wall of the stomach • Location: gastric, duodenal, esophageal • Zollinger-Ellison Syndrome: • Clinical manifestations:sharp abd pain if perforated ulcer occurs • Medical management • Nursing management

29. Intestinal and Rectal Disorders • Watery stools associated with small bowel disease and loose, semisolid stools with disorders of the colon. Voluminous, grasy stools are assoc. with intestinal malabsorption, and the presence of mucus and pus in the stools suggest inflammatory enteritis or colitis.Oil droplets on the toilet water are diagnostic of pancreatic disorders.

30. stool • Dx = routine stool exam as well as stool for infectious or parasitic organisms, bacterial toxins, blood fat. Endoscopy or barium enema may assist with identifying the cause of diarrhea. • Keep accurate record of I&), bedrest , foods low in bulk, Antidiarrheal meds (Lomotil) • Fecal Incontinence- may result from trauma, stroke, dementia, diabetes, loss of muscle tone,fecal impaction

31. Stool • Dx- rectal exam,endoscopic-sigmoidoscopy ( to R/O fissures, tumors..) • Tx – treat the cause, bowel training, surgery includes sphincter repair, fecal diversion.

32. Irritable Bowel Syndrome • More common in women than in men. • Assoc. with hereditary, psychological stress, • diet high in rich and irritating foods, ETOH • Functional disorder of intestinal motility,neurologic regulating system may affect peristaltic waves to certain specific segments of the intestine and the intensity of propelling fecal matter.No inflammation of intestine or cellular changes.

33. Cont. • S&S – constipation/diarrhea or both, pain,bloating, and abd. Distention.Abd. Pain precipitated by eating and relieved by defecation. • Dx- stool studies, barium enema, colonoscopy-may revealspasm,mucus stimulation in the intestine. • Tx- relieve pain,control diarrhea, constipation,reduce stress.Well balanced high fiber diet, antidepressants,anticholinergic and Ca • Channel blockers to reduce spasms.

34. Malabsorption Conditions • Inability of the digestive system to absorb one or more nutrients-cho,fats,proteins. • Mucosal disorders –Chrohn’s disease • Post-op malabsorption (after gastric or intestinal resection) • Disorders that cause it of specific nutrients(disaccharidase deficiency leading to lactose intolerance

35. Cont.. • S&S- diarrhea or frequent,loose,bulky,foul-smelling stools with increased fat content often grayish. Abd distention,,flatus, weakness,wt loss. • DX- lactose tolerance test,fecal fat analysis • Tx- nutritional supplements, monitor fluid and electrolytes,antibiotics

36. Acute Inflammatory Intestinal Disorders • Lower Gi prone to acute inflammation caused by bacterial, fungal and bacterial infection, two causes-appendicitis and diverticulitis. Can lead to peritonitis –inflammation within the abd. • Appendicitis- rt lower abd, emergency surgery-low grade fever Rt quad. Pain,nausea,rebound tenderness,Rovsing’s sign, if ruptured, pain diffused.Never give a cathartic if suspect appendicitis- cause perforation of inflamed appen.

37. Appendicitis -diverticulitis • S&S- CBC, elevated WBC leukocyte count goes up,neutrophils go up • Tx- surgery (appendectomy), pain management, IV fluids • Diverticulitis- -food and bacteria are retained in the diverticulum produce infection and inflammation – impedes drainage and lead to perforation or abcess formation. 95% occur in sigmoid. Low dietary fiber intake could be a factor.

38. S&S-chronic constipation, bowel irregularity (sudden diarrhea), abrupt onset of crampy pain in left lower quadrant, low grade fever., large bowel may narrow with fibroptic strictures, leading to cramps, narrow stools, increased constipation.If untreatred leads to septicemia. • DX- barium enema shows narrowing of colon and thickened muscle layers.Lab test –elevated Sed rate and WBC.C/O – peritonitis,bleeding, abscess.

39. Peritonitis get symptoms of hard,rigid,board like abd, loss of bowel sounds,shock • TX- initially clear diet until inflammation leaves – high fiber, low fat helps increase stool volume, antibiotrics, bulk-forming laxative.Acute phase- NPO, IV fluids, NG to suction(distention or vomiting),Demerol not MS (causes increase intraluminal pressure) for pain,antispasmodica,stool softeners.

40. Diverticulitis • If perforation occurs- surgery(resection, end-to-end anastamosis, or double barrel colostomy.Treat peritonitis (antibiotics, fluid and electrolytes, colloids, isotonic IV fluids,analgesics

41. Inflammatory Bowel Disease • Regional enteritis (Crohn’s disease) and ulcerative colitis • Environmental factors such as food additives, tobacco, pesticides, radiation can trigger attack. • Crohn’s Disease –most common area is distal ileum and colon.Chronic inflammation extends through all layers of bowel wall from the intestinal mucosa. Fistulas, fissures and abscesses form as inflammation spreads into peritoneum.RLQ pain

42. Cont. Crohn’s • Hyperactive bowel sounds due to increase peristalsis.The lesions or ulcers are separated by normal tissue, advanced stages see granulomas and cobblestone appearance, bowel becomes thickened and fibrotic and intestinal lumen narrows. • S&S- insidious onset,abd pain unrelieved by defecation, crampy abd pains occur after a meal, WT LOSS, ANEMIA.

43. The ulcers in the membranes of the intestine get weeping, swollen intestine that continually empties an irritating discharge into the colon- causing chronic diarrhea and nutritional defecits. Can lead to perforation,get intraabdominal and anal abcesses.Fever leukocytosis. Abcesses and fissures are common.Someget periods of remission.

44. Cont. Crohns • Dx- proctosigmoidoscopic, stool for occult and staetorrhea. Barium study of the UGI shows “string sign” of the terminal ileum,, indicating stricture of the intestine, see ulcerations abcess, cobblestone appearance and fissures/fistulas.CBC and WBCAlbumin and Sed rates.

45. Cont. Crohns • C/O – fistula(between small bowel and skin(fluid accumulation and infection) Riskfor colon cancer. • ULCERATIVE COLITIS- recurrent ulcerative and inflammatory disease of the mucosal layer of the colon and rectum. • Patho: multiple ulcerations of the superficial mucosa of the colon,shedding of colonic epithelium,bleeding as a result of ulcerations.Lesions are continuous.Starts in rectum-bowel narrows,shortens and thickens.

46. Ulcerative colitis • S&S- exacerbations and remissions. ,bloody stools,diarrhea, abd pain,, cramping, feeling urgent need to defecate, pass 10 –20 stools /day.Hypocalcemia and anemia develop, rebound tenderness in RLQ • DX- stool pos for blood, low HCT<HGB,Alb,electrolyte imbalance,wbcs

47. Barium enema shows mucosal irregularities, shortening of the colon, dilatation of bowel loops.Cathartics are not to be given when prepping for bowel studies, may exacerbate the condition.Test can cause perforation. • C/O of UC ares toxic megacolon (ulcers go to muscularis –inhibiting the ability to contract get colonic distention – must respond to IV fluids, corticosteroids, antibiotics or surgery is necessary because of colonic perforation)Ileostomy is performed

48. Management of Ulcerative Colitis (UC) • For crohns and UC – oral fluids, low residue, high caloric diet with vitamin and iron supplement, Foods that cause diarrhea are avoided, cold foods and smoking are avoided. TPN may be necessary. • Pharm- sedatives, antidiarrheal,antiperistalsis meds(to rest bowel)sulfonamides to reduce inflammation

49. Cont. • Antibiotics, corticosteroids (assess for long term side effects (htn, fluid retention cataracts), immunosuppressants • Surgical Management- Strictureplasty(blocked section of bowel is widened, leaving bowel intact. Surgical removal of 50% of bowel cam be tolerated and the lesion can be resected and the remaining portions of the bowel are anastamosed

50. Cont. surgical • Total colectomy- excision of colon with ileostomy • Segmental colectomy- removal of segment of colon with anastamosis of the remaining colon. • subtotal colectomy- joing of ilieum and rectum • Total colectomy with continent ileostomy(formation of internal pouch) • Total colectomy with ileoanal anastamosis (formation of pouch with anal sphincter intact)