Test iv study guide

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NUR 201 Reference Book - Ignatavicius, D. (2013). Medical-surgical nursing: Patient-centered collaborative care (7th ed.). St. Louis, MO: Elsevier Saunders.

Gastrointestinal System Test IV Study Guide Jennifer Cook Website: https://nursessity.wordpress.com/

2015

Test IV Study Guide Gastrointestinal System 

GI Tract Functions – secretion, digestion, absorption, motility, and elimination. o During Digestion  Stomach – secretes hydrochloric acid  Liver – secretes bile  Accessory Organs – digestive enzymes are released aiding in food breakdown. Oral Cavity (mouth) – includes the buccal mucosa, lips, tongue, hard palate, soft palate, teeth, and salivary glands. o Saliva – contains mucin and an enzyme called salivary amylase (also known as ptyalin), which begins the breakdown of carbohydrates. Esophagus – primary function is to move food and fluids from the pharynx to the stomach. o Upper Sphincter (UES) – closes @ rest to prevent air from entering esophagus during respiration. Upper end of the esophagus. o Lower Sphincter (LES) – closes @ rest to prevent reflux. Located just above the gastroesophageal (GE) junction. GERD develops if it does not work properly. o Endoscopy – direct visualization of the GI tract using a flexible fiberoptic endoscope. o Esophagogastroduodenoscopy (EGD) – visual examination of the esophagus, stomach, and duodenum.  Flexible tube is passed down the esophagus while he or she is under moderate sedation such as Versed, Fentanyl, or Propofol. Atropine may be administered to dry secretions.  NPO until the gag reflex returns (usually in 1 to 2 hours).  Used w/Biopsy for Definitive DX of Gastric Cancer Stomach – located in the midline and LUQ of the abdomen w/4 anatomic regions. o Cardia – narrow portion of the stomach that is below the GE junction. o Fundus – the area nearest to the cardia. o Body or Corpus – main area of the stomach. o Antrium (Pylorus) – distal (lower) portion of the stomach and is separated from the duodenum by the pyloric sphincter. Both ends of the stomach are guarded by sphincters (cardiac and pyloric). o Parietal Cells – line the wall of the stomach and secrete hydrochloric acid. Also produce Intrinsic Factor. o Intrinsic Factor – secreted in the stomach. Important to absorption of Vitamin B12. Absence of the Intrinsic Factor causes Pernicious Anemia. Assess for

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development of atrophic glossitis secondary to Vitamin B12 deficiency. In atrophic glossitis, the tongue takes on a shiny, smooth, and “beefy” appearance. Cullen’s Sign – Bruising (ecchymosis) around the umbilicus. Indicates abdominal bleeding. Blumberg Sign – Rebound tenderness. Pain felt on release of abdomen. Borborygmus - ↑ bowel sounds, especially loud, gurgling sounds, result from ↑ motility of the bowel. Indication of Gastroenteritis and Mechanical Obstruction. Bowel Sounds – normally high-pitched, irregular gurgles q 5 to 15 seconds. Diminished after abdominal surgery or in the patient w/peritonitis or paralytic ileus.  Peristalsis Assessment – best, most reliable method for assessing the return of peristalsis after abdominal surgery is to ask the patient if he or she has passed flatus within the past 8 hours or a stool within the past 12 to 24 hrs. Bruits – Swooshing sounds over the abdominal aorta, the renal arteries, and the iliac arteries. If heard over the aorta, it usually indicates the presence of an aneurysm. If heard, do not percuss or palpate the abdomen. Notify the HCP of findings. Dyspepsia – indigestion or heartburn. PQRST  P – Precipitating or Palliative: What brings it on? What makes it better?  Q – Quality or Quantity: How does it look, feel, sound? How intense is it?  R – Region or Radiation: Where is it? Does it spread anywhere?  S – Severity Scale  T – Timing: onset, duration, frequency Physical Assessment Position – empty bladder, lie in a supine position w/knees bent, keeping arms at the sides to prevent tensing of the abdominal muscles. Order: RUQ, LUQ, LLQ, RLQ. Psychosocial Assessment – focuses on how the GI health problem affects the patient’s life and lifestyle. Two Primary Oncofetal Antigens – CA19-9 and CEA are evaluated to DX cancer, monitor the success of cancer therapy, and assess for the recurrence of cancer in the GI tract. CBC – aids in the DX of anemia and infection. GI bleeding is the most frequent cause of anemia. It is associated w/GI cancer, PUD, and IBD. Plain Film X-Ray – Normally the 1st x-ray study done to DX a GI problem. Upper GI Radiographic Series – an x-ray visualization from the mouth to the duodenojejunal junction. Esophagus (barium swallow).  Withhold foods and liquids for 8 hours before the test.  Drink plenty of fluids to eliminate the barium.

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 Stools may be chalky white for 24 to 72 hours as barium is excreted. Barium Enema Examination (Lower GI Series) – x-ray of the large intestine. Percutaneous Transhepatic Cholangiography (PTC) – x-ray of the biliary duct system using an iodinated dye instilled via a percutaneous needle inserted through the liver into the intrahepatic ducts. CT (Computed Tomography) provides a noninvasive cross-sectional x-ray view that can detect tissue densities and abnormalities in the abdomen, including the liver, pancreas, spleen, and biliary tract.  NPO for at least 4 hours before the test if a contrast medium is to be used. Colonoscopy – endoscopic examination of the entire large bowel.  Clear liquid diet the day before the scheduled colonoscopy.  NPO (except water) 4 to 6 hours before the procedure.  Avoid ASA, Anticoagulants, and Antiplatelet drugs for several days before the procedure.  Patient drinks and oral liquid preparation for cleaning of the bowel the night before the exam and may repeat that procedure the morning of.  Placed on left side w/knees drawn up while the endoscope is placed into the rectum and moved to the cecum.  Atropine sulfate is kept available in case of bradycardia resulting from vasovagal response.  Observe for signs of perforation (causes severe pain) and hemorrhage, such as a rapid drop in B/P.  Reassure the patient that a feeling of fullness, cramping, and passage of flatus are expected for several hours after the test.  Fluids are permitted after the patient passes flatus to indicate that peristalsis has returned.  Avoid driving for 12 hours after the procedure because of the effects of sedation. Gastric Cancer  Infection w/H. Pylori is the largest risk factor for gastric cancer because it carries they cytotoxin-assoicated antigen. A CagA gene.  Gastric surgery seems to ↑ the risk for gastric cancer because of the eventual development of atrophic gastritis, which results in changes to the mucosa. Patients with Barrett’s Esophagus from prolonged or severe gastroesophageal reflux disease (GERD) have an ↑ risk for cancer in the cardia (at the point where the stomach connects to the esophagus).  In patient’s w/advanced disease, anemia is evidenced by low H & H values. Early Symptoms Advanced Symptoms Indigestion N&V Abdominal discomfort initially Obstructive symptoms

relieved w/antacids Feeling of fullness Epigastric, back, or retrosternal pain

Iron deficiency anemia

Palpable epigastric mass Enlarged lymph nodes, etc. Weakness & Fatigue Progressive Weight Loss Signs of Distant Metastasis: Virchow’s nodes, Blurner’s Shelf Sister Mary Joseph nodes, Krukenberg’s tumor  Surgical resection by removing the tumor is the preferred method for treating gastric cancer. o Dumping Syndrome – Occur after eating as a result of rapid emptying of food contents into the small intestine, which shifts fluid into the gut causing abdominal distention.  Early manifestations – within 30 minutes of eating. Symptoms include: vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.  Late manifestations – 90 minutes to 3 hours after eating, is caused by a release of an excessive amount of insulin.  Diet - ↓ amount of food taken at one time and eliminate liquids ingested w/meals. ↑ protein, ↑ fat, low to moderate carbohydrate diet. Low roughage, No milk, sweets, or sugars.  Alkaline reflux gastrophathy (bile reflux gastropathy) – complication of gastric surgery in which the pylorus is bypassed or removed.  Delayed Gastric Emptying – often present after gastric surgery and usually resolves within 1 week.  Afferent Loop Syndrome – may occur when the duodenal loop is partially obstructed after radical surgery. Pancreatic and biliary secretions fill the intestinal loop, which becomes distended. o Bowel Elimination Patterns – Diarrhea (IBS-D), Constipation (IBS-C), Alternating Diarrhea and Constipation (IBS-A), or a Mix of Diarrhea and Constipation (IBS-M). Pancreas – lies behind the stomach. Divided into portions known as the head, the body, and the tail. o Two major cellular bodies:  Exocrine – 80% of the organ. Consists of cells that secrete enzymes needed for digestion of carbohydrates, fats, and proteins (trypsin, chymotrypsin, amylase, and lipase).  Endocrine – made up of the islets of Langerhans, w/Alpha cells producing glucagon and beta cells producing insulin.

Liver – largest organ in the body (other than skin). Secretes bile, essential for breakdown of fat. o Performs more than 400 functions in 3 major categories: storage, protection, and metabolism. It mainly stores minerals and vitamins such as iron, magnesium, and the fat-soluble vitamins A, D, E, and K. o Protective Function – involves phagocytic Kupffer cells, which are part of the body’s reticuloendothelial system. o Jaundice – yellowing of skin caused by bilirubin pigments. o Ammonia Level – may be measured to evaluate hepatic function. Gallbladder – pear-shaped, bulbous sac that is located underneath the liver. Collects, concentrates, and Stores the bile that has come from the liver. o Cholecystectomy – surgical removal of the gallbladder.  Laparoscopic Cholecystectomy – minimally invasive surgery (MIS), is currently the “gold standard” and is performed far more often than the traditional open approach. Often called a “lap chole.” Same-day surgery.  Traditional Cholecystectomy – abdominal laparotomy. Patient’s usually have biliary obstruction. If bile duct explored, a T-tube is put in place. Priority after T-tube removed, avoid raising drainage system above the site of insertion to prevent backup of bile into the surgical area and causing infection. o Cholecystitis – inflammation of the gallbladder.  Acute Colecystitis – Calculous and Acalculous  Calculous – chemical irritation and inflammation result from gallstones (cholelithiasis). o Peritonitis – infection of the peritoneum can result if a gallbladder perforation is large.  Acalculous – inflammation occurring without gallstones. Typically associated w/biliary stasis caused by any condition that affects the regular filling or emptying of the gallbladder. o Most Cases Occur With – severe trauma or burns, longterm TPN, multi-system organ failure, major surgery, hypovolemia.  Chronic Cholecystitis – results when repeated episodes of cystic duct obstruction cause chronic inflammation.  Gallbladder becomes fibrotic and contracted.  Pancreatitis and cholangitis (bile duct inflammation) occur as chronic complications of cholecystitis.  Jaundice occurs.  Symptoms – vague upper abdominal pain or discomfort that can radiate to the right shoulder, pain triggered by high-fat or high-volume meal,

anorexia, N & V, dyspepsia (indigestion), eructation (belching), flatulence, feeling of abdominal fullness, rebound tenderness (Blumberg’s sign), fever, jaundice, clay-colored stools, dark urine, steatorrhea.  Seen more frequently in obese patients  A familial or genetic tendency appears to play a role in the development of cholelithiasis.  Women’s Health – Remember the 4 F’s  Female, Forty, Fat, Fertile  Labs – WBC ↑, LDH may be ↑, AST may be ↑  Best DX Test – Ultrasonography of the RUQ  Drugs of Choice – Opioid Analgesia, such as Morphine or Dilaudid. NOT Demerol (can cause seizures). o Cholecystokinin Pancreozymin (CPP-PZ) - a polypeptide hormone secreted in the small intestine that stimulates gallbladder contraction and secretion of pancreatic enzymes. o Cholecystojejunostomy - surgical formation of a passage between the gallbladder and the jejunum. o Choledocholithiasis – presence of at least one gallstone in the common bile duct. Gallstones within the gallbladder and obstructing the common bile and cystic ducts. o Choledochostomy - surgical incision of the common bile duct usually to effect drainage for gallstones. o Oral Dissolution Therapy - A method of dissolving cholesterol gallstones. Cancer of the Gallbladder – Primary cancer of the gallbladder is rare, but is more common in women than men. Also more common in American Indians o Symptoms – anorexia, weight loss, N & V, Abdominal bloating, fever, general malaise, jaundice (in advanced disease), liver and spleen enlargement, severe abdominal pain (in advanced disease). o Prognosis – poor d/t usually being DX late in the disease process because of lack of specific symptoms. Small Intestine – longest, most convoluted portion of the digestive tract. o 3 Regions:  Duodenum – 1st 12 inches  Jejunum – 8 foot portion of the small intestine that follows the sphincter of Oddi.  Ileum – the last 8 to 12 feet o 3 Main Functions:  Movement (mixing and peristalsis), Digestion, and Absorption. o Small Bowel Capsule Endoscopy (enteroscopy) – provides a view of the small intestine.

Fast (water only) for 8 to 10 hours before the test and be NPO for the 1st 2 hours of the testing. o Surgery – obstruction is the most common reason for surgery. Large Intestine – extends about 5 to 6 feet in length from the ileocecal valve to the anus. Extends upward from the cecum as the colon. o The colon consists of 4 divisions:  Ascending, transverse, descending, and sigmoid. The sigmoid colon empties into the rectum. o Functions are:  Movement, Absorption, and Elimination o Sigmoidoscopy – Proctosigmoidoscopy, often referred to as sigmoidoscopy, is an endoscopic exam of the rectum and sigmoid colon using a flexible scope.  Clear Liquid diet for at least 24 hours before the test. o Colorectal Cancer – Colorectal refers to the colon and rectum, which together make up the large intestine, also known as the large bowel.  Most CRC’s are adenocarcinomas. Certain oncogenes alter colonic mucosa cell division.  Major Risk Factors - ↑ 50 years, genetic predisposition, personal or family HX of cancer and/or diseases that predispose to cancer such as familial adenomatous polyposis (FAP), Crohn’s disease, and ulcerative colitis.  It is the 3rd Most Common cause of cancer death in the U.S.  Colonoscopy – the definitive test for the DX of colorectal cancer.  Screening Recommendations @ Age 50  FOBT and Sigmoidoscopy – q 5 years  Double-Contrast Barium Enema – q 5 years  Colonoscopy – Q 10 years  Diet - ↓ fat, refined carbohydrates, and low-fiber foods.  Most Common Signs and Symptoms – rectal bleeding, anemia, and a change in stool consistency or shape. Gross blood is not usually detected w/tumors of the right side of the colon but is common (but not massive) with tumors of the left side of the colon and the rectum. Patient may report gas pains, cramping, or incomplete evacuation.  Hematochezia – the passage of red blood via the rectum. Tumors in the Rectosigmoid Colon associated with this. Straining to pass stools, and narrowing of stools.  Partial Bowel Obstruction – visible peristaltic waves accompanied by high-pitched or “tinkling” bowel sounds.  Complete Bowel Obstruction – total absence of bowel sounds.  Labs 

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H & H ↓ - d/t intermittent bleeding from tumor. Carcinoembryonic Antigen (CEA) (Normal value is ↓ 5 ng/mL or 5 mcg/L (SI Units) – an oncofetal antigen, ↑ in many people with CRC. Staging  Stage I – Tumor invades up to muscle layer  Stage II – Tumor invades up to other organs or perforates peritoneum  Stage III – Any level of tumor invasion and up to 4 regional lymph nodes  Stage IV – Any level of tumor invasion; many lymph nodes affected with distant metastases. Radiation TX – palliative measure that can control pain, hemorrhage, bowel obstruction, or metastasis to lung in advanced disease. Adjuvant Chemotherapy – Drugs cannot discriminate between cancer and healthy cells. Therefore common side effects are diarrhea, mucositis, leukopenia, mouth ulcers, and peripheral neuropathy. Surgical Removal of Tumor w/Margins Free of Disease – best method of ensuring removal of CRC. Colon Resection – removal of the tumor and regional lymph nodes w/reanastomosis (reattachment). Colectomy – colon removal w/colostomy (temp or permanent) or ileostomy/ileoanal pull-through and Abdominoperineal (AP) Resection (performed when rectal tumors are present). Colostomy – the surgical creation of an opening of the colon onto the surface of the abdomen.  Ascending Colostomy – done for right-sided tumors.  Transverse (double-barrel) Colostomy – often used in such emergencies as intestinal obstruction or perforation because it can be created quickly. There are two stomas – proximal (drains feces) and distal (drains mucus).  Descending Colostomy – done for left-sided tumors.  Sigmoid Colostomy – done for rectal tumors.  Should start functioning in 2 to 4 days postop.  Stool is liquid immediately postop, but becomes more solid, depending on where in the colon the stoma was placed.  AP Resection – Jackson-Pratt drains are place in the wound or through stab wounds near the wound.  Complete healing of the perineal wound may take 6 to 8 months.  Rectal pain and itching may occasionally occur after healing.

 Interventions may include Benzocaine and Sitz Baths.  Ileostomy – a procedure in which a loop of the ileum is placed through the abdominal wall (stoma) for drainage of fecal material into a pouching system worn on the abdomen.  Loop Stoma (surgical opening) – made by bringing a loop of colon to the skin surface, severing and everting the anterior wall, and suturing it to the abdominal wall.  Double-Barrel Stoma – Least common. Created by dividing the bowel and bringing both the proximal and distal portions to the abdominal surface to create two stomas. The proximal stoma (closest to the patient’s head) is the functioning stoma and eliminates stool. The distal stoma (farthest from the head) is considered nonfunctioning, although it may secrete some mucus.  Priority after Stoma Surgery – get a pouch in place. Intestinal Obstruction – can be partial or complete; mechanical or nonmechanical. o 65 and ↑ - diverticulitis, tumors, and fecal impaction are the most common causes. o Report to Physician ASAP – A temp higher than 100 with or without guarding and tenderness, and a sustained elevation in pulse could indicate a strangulated obstruction or peritonitis. A fever, tachycardia, hypotension, increasing abdominal pain, abdominal rigidity, or change in color of skin overlying the abdomen. o No definitive Labs to DX – but if strangulation occurs, there may be leukocytosis (↑ WBC’s) o Mechanical Obstruction – the bowel is physically blocked by problems outside the intestine (ex. Adhesions), in the bowel wall.  Symptoms – causes more intermittent colicky abdominal pain than seen with small bowel obstruction.  Other Causes  Benign or malignant tumor  Complications of Appendicitis  Hernias  Fecal Impactions  Strictures d/t Crohn’s disease or radiation  Intussusception – telescoping of segment of the intestine within itself. Bowel telescoping.  Volvulus – Bowel twisting of the intestine  Assessment – Auscultate for proximal high-pitched bowel sounds (borborygmi), which are associated with cramping early in the obstructive process as the intestine tries to push the mechanical obstruction forward.

o Nonmechanical Obstruction (Paralytic ileus or Adynamic ileus) – does not involve a physical obstruction in or outside the intestine.  Symptoms – pain described as a constant, diffuse discomfort.  Cause – most commonly from handling of the intestines during abdominal surgery. o NG Tubes – most patients have with an obstruction. o Flatus – if flatus has returned, peristalsis has returned. o Hypovolemia – (reduced circulatory blood volume) and electrolyte imbalances typically occur. Ranges from mild to extreme (hypovolemic shock). If severe, can lead to renal insufficiency or death. o Metabolic Alkalosis – an obstruction high in the small intestine causes a loss of gastric hydrochloride, which leads to this. o Metabolic Acidosis – obstruction at the end of the small intestine and lower in the intestinal tract causes loss of alkaline fluids, which leads to this. o Peritonitis – risk is ↑, if closed-loop obstruction (blockage in two different areas) or a strangulated obstruction (obstruction with compromised blood flow). Should withhold Opioid Analgesics as to mask symptoms. Should explain to the family and patient the reason for this. o Patient Position – position of comfort with frequent position changes to promote increased peristalsis. o Exploratory Laparotomy – a surgical opening of the abdominal cavity to investigate the cause of obstruction. In a conventional open surgical approach, the surgeon enters the abdominal cavity, and explores for obstruction and its cause. o KNOW Differences Below: Small-Bowel Obstruction Abdominal discomfort or pain possibly accompanied by visible peristaltic waves in upper and middle abdomen. Upper or epigastric abdominal distention Nausea and early, profuse vomiting (may contain fecal material) Obstipation Severe fluid and electrolyte imbalances. Metabolic Alkalosis 

Large-Bowel Obstruction

Intermittent lower abdominal cramping. Lower abdominal distention. Minimal or no vomiting. Obstipation or ribbon-like stools No major fluid and electrolyte imbalances. Metabolic Acidosis (not always present)

Polyps – intestinal tract are small growths covered with mucosa and attached to the surface of the intestine. Although most are benign, they are significant because some have the potential to become malignant.

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o Pedunculated – such as tubular adenomas, stalk-like, thin stems attaches them to the intestinal wall. o Sessile – such as villous adenomas, broad based. Hemorrhoids – unnaturally swollen or distended veins in the anorectal region. o Internal – cannot be seen on inspection of perineal area; lie above the anal sphincter. o External – lie below the anal sphincter and can be seen on inspection of anal region. Malabsorption – syndrome associated with a variety of disorders and intestinal surgical procedures, which interferes with the ability to absorb nutrients. o Causes Include  Bile Salt Deficiencies – can lead to malabsorption of fats and fat-soluble vitamins.  Enzyme Deficiencies – pancreatic enzymes are necessary for absorption of Vitamin đ??ľ12.  Presence of Bacteria  Disruption of mucosal lining of small intestine.  Celiac sprue – thought to be d/t a genetic immune hypersensitivity response to gluten or its breakdown products or to result from the accumulation of gluten in the diet with peptidase deficiency.  Tropical Sprue – caused by an infectious agent that has not been identified but thought to be bacterial. TX w/antibiotics.  Altered lymphatic and vascular circulation.  Decrease in gastric or intestinal surface area. o Symptoms  Chronic Diarrhea is a classic symptom  Steatorrhea – fatty stools. o Diet  Low-fat diet for patients who have gallbladder disease, severe steatorrhea, or cystic fibrosis.  After a total gastrectomy, a high-protein, high-calorie diet, and small, frequent meals are recommended. Appendicitis – acute inflammation of the vermiform appendix that occurs most often among young adults. It occurs when the lumen of the appendix is obstructed, leading to infection as bacteria invade the wall of the appendix. o Most common cause of RLQ pain o Gangrene can occur within 24 to 36 hours, is life threatening, and is one of the most common indications for emergency surgery. o Perforation results in Peritonitis w/a temperature of greater than 101 and a rise in pulse rate.

o As inflammation and infection progress, the pain becomes more severe and steady and shifts to the RLQ between the anterior iliac crest and the umbilicus. This area is referred to as McBurney’s Point. o Abdominal pain that increases w/cough or movement and is relieved by bending the right hip or the knees suggests perforation and peritonitis. o NPO to prepare for surgery and avoid making inflammation worse. o Laparoscopy – a minimally invasive surgical procedure w/one or more small incisions near the umbilicus through which a small endoscope is placed. o Natural Orifice Transluminal Endoscopic Surgery (NOTES) – transvaginal endoscopic appendectomy. Not used much if any anymore. o Laparotomy – open surgical approach with a larger abdominal incision for complicated or atypical appendicitis or peritonitis. o Peritonitis – life-threatening, acute inflammation of the visceral/parietal peritoneum and endothelial lining of the abdominal cavity.  Most often caused by contamination of the peritoneal cavity by bacteria or chemicals.  Common Bacteria – E-Coli, Streptococcus, Staph, Pneumococcus, and Gonococcus.  Fluid Shift – can cause Hypovolemia  Peristalsis slows or stops  Lumen becomes distended with gas and fluid which can eventually lead to septicemia (bacterial invasion of the blood).  Respiratory problems can also occur d/t increased abdominal pressure.  Symptoms  Rigid, boardlike abdomen, abdominal pain, distended abdomen, N & V, anorexia, diminished bowel sounds, inability to pass flatus or feces, rebound tenderness in abdomen, high fever, tachycardia, dehydration from high fever, decreased urine output, hiccups, possible compromise in respiratory status. Cardinal signs are abdominal pain and tenderness. 

Differential Features of Ulcerative Colitis and Crohn’s Disease Feature Ulcerative Colitis Crohn’s Disease Most often in the terminal Begins in the rectum and ileum, with patchy proceeds in a continuous involvement through all manner toward the cecum. layers of the bowel. Location Unknown Unknown Etiology 15-25 yr and 55-65 yr 15-40 yr Peak Incidence at age 10-20 liquid, bloody stools 5-6 soft, loose stools per per day day, non-bloody Number of stools

Complications Need for Surgery 

Hemorrhage; nutritional deficiencies Infrequent

Fistulas (common); nutritional deficiencies Frequent

Complications of Ulcerative Colitis and Crohn’s Disease o Hemorrhage/Perforation, Abscess formation, Toxic megacolon, Malabsorption, Nonmechanical bowel obstruction, Fistulas, Colorectal cancer, Extra intestinal complications, Osteoporosis Ulcerative Colitis – creates widespread inflammation of mainly the rectum and rectosigmoid colon. Periodic remissions and exacerbations. o Intestinal mucosa becomes hyperemic (has increased blood flow), edematous, and reddened. o Lining can bleed and small erosions or ulcers occur. o Abscesses can form in these ulcerative areas and result in tissue necrosis (cell death). o Symptoms  Stool typically contains blood and mucus. Patients report Tenesmus (an unpleasant and urgent sensation to defecate), and lower abdominal colicky pain relieved with defecation.  Malaise, anorexia, anemia, dehydration, fever, and weight loss are common. o Severity Severity Stool Frequency S&S <4 stools/day with/without Asymptomatic; Lab blood WNL Mild Minimal symptoms; mild abdominal pain, mild intermittent nausea, possible ↑ C>4 stools/day reactive protein or with/without blood ESR ↑ Moderate Fever, tachycardia, anemia, abdominal pain, ↑ C-reactive >6 bloody stools/day protein and/or ESR ↑ Severe Increasing symptoms, anemia may require transfusion, colonic >10 bloody stools/day distention on x-ray Fulminant o Colonoscopy is the most definitive test for DX of UC. o Drug TX – Includes 5-ASA medications like Sulfasalazine (Azulfidine), Mesalamine

o Ileostomy – a procedure in which a loop of the ileum is placed through the abdominal wall (stoma) for drainage of fecal material into a pouching system worn on the abdomen. o Total Proctocolectomy w/a Permanent Ileostomy – Total proctocolectomy w/permanent ileostomy is done for patients who are not candidates or do not want the ileo-anal pouch. The procedure involves the removal of the colon, rectum, and anus w/surgical closure of the anus. Crohn’s Disease – an inflammatory disease of the small intestine (most often), the colon, or both. o Strictures and deep ulcerations (cobblestone appearance) also occur, which put the patient at risk for developing bowel fistulas. o Severe malabsorption is more common in patient w/CD. Patient’s with CD can become very malnourished and debilitated. o Types of Fistulas that are complications of CD  External Enterocutaneous – between skin and intestine  Enteroenteric – between intestine and intestine o Made worse by bacterial infection and inflammation. o Anemia is common d/t slow bleeding and poor nutrition. o Decreased albumin levels. o If severe diarrhea or fistula is present, the patient may have electrolyte losses, particularly potassium and magnesium. Diverticular Disease o Diverticula – pouchlike herniations of the mucosa through the muscular wall of any portion of the gut, but most commonly in the colon. Usually occur in the sigmoid colon. Unless inflammation present, causes few problems. o Diverticulitis – the inflammation of one or more diverticula.  May have abdominal pain, most often localized to the LLQ. It is intermittent at 1st , but becomes progressively steady.  Can result in rupture of the diverticulum w/peritonitis, pelvic abscess, bowel obstruction, fistula, persistent fever or pain, or uncontrolled bleeding. Surgeon performs emergency surgery if peritonitis, bowel obstruction, or pelvic abscess present. o Diverticulosis – the presence of many abnormal pouchlike herniations (diverticula) in the wall of the intestine.  Usually has NO symptoms. o Diverticulum - an abnormal sac or pouch formed at a weak point in the intestinal wall. o Broad-Spectrum antibiotics like Flagyl are used o Avoid laxatives and enemas o Refrain from lifting, straining

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Restrict to low fiber or clear liquids based on symptoms. If more severe symptoms, NPO. Anal Disorders o Anorectal Abscess – localized area of induration and pus caused by inflammation of the soft tissue near the rectum or anus. Most often the result of obstruction of the ducts of glands in the anorectal region. Feces, foreign bodies or trauma can be the cause of the obstruction and stasis. o Anal Fissure – tear in the anal lining, which can be very painful.  Acute anal fissure – superficial and usually resolves on its own or heals quickly w/conservative TX.  Chronic fissure – recur, and surgical TX may be needed.  Anal Fistula – an abnormal tract leading from the anal canal to the perianal skin. Caused by obstruction of anal glands.  Symptoms – pruritus (itching), purulent discharge, and tenderness or pain that is worsened by bowel movements.  Fistulotomy – surgeon opens the tissue over the tract and scrapes the base. The incision site then heals by secondary intention (inside out).  Pilonidal Cyst – lesion of the sacral area that often has a sinus track extending into deeper tissue structures. Gastrointestinal Changes Associated w/Aging o Stomach - ↓ hydrochloric acid levels lead to ↓ absorption of iron and vitamin đ??ľ12 and to proliferation of bacteria. Encourage bland foods high in vitamins and iron. o Large Intestine - ↓ sensation to defecate. Leads to constipation and impactions. Encourage a high-fiber diet, ↑ fluids, and ↑ activity. o Pancreas - ↓ lipase level results in ↓ fat absorption and digestion. Steatorrhea, or excess fat in the feces, occurs because of ↓ fat digestion. Encourage small, frequent feedings. Assess for diarrhea. o Liver - ↓ enzyme activity depresses drug metabolism, which leads to accumulation of drugs – possibly to toxic levels. Assess for adverse effects of drugs. Cirrhosis – extensive irreversible scarring of the liver, usually caused by a chronic reaction to hepatic inflammation and necrosis. o Most Common Cause in U.S. – Hepatitis C (leading cause), alcoholism, and biliary obstruction. o Most Common Cause Worldwide – Hepatitis B and Hepatitis D are the leading causes. o Characterized by – fibrotic (scarred) bands of connective tissue that change the liver’s normal makeup.

o Diet – high-carbohydrate, moderate-fat, and high protein foods. o Early Disease – liver is usually enlarged, firm, and hard. o Later Disease – as pathologic process continues, the liver shrinks in size, resulting in decreased liver function. o Common Types  Postnecrotic Cirrhosis – caused by viral hepatitis [especially hepatitis C] and certain drugs or other toxins.  Laennec’s – alcoholic cirrhosis (caused by chronic alcoholism)  Biliary cirrhosis (also called cholestatic) – caused by chronic biliary obstruction or autoimmune disease. o Complications  Compensated Cirrhosis – liver is scarred but can still perform essential functions without causing major symptoms.  Decompensated Cirrhosis – liver function is impaired with obvious manifestations of liver failure.  Portal hypertension – a persistent increase in pressure within the portal vein greater than 5 mm Hg, is a major complication of cirrhosis. May also have Portal Hypertensive Gastropathy.  Splenomegaly (spleen enlargement) – blood flow backs into the spleen.  Destroys platelets causing thrombocytopenia (low serum platelet count).  Thrombocytopenia is often the 1st clinical sign that a patient has liver dysfunction.  Ascites – the collection of free fluid within the peritoneal cavity caused by increased hydrostatic pressure from portal HTN.  Patients with Cirrhosis and Ascites may develop acute spontaneous bacterial peritonitis (SBP).  Abdominal Girth Measurement – patient lies flat while the nurse pulls a tape measure around the largest diameter (usually over the umbilicus) of the abdomen. Mark the abdominal skin and flanks to ensure the same tape measure placement on subsequent readings. Taking daily weights; however, is the most reliable indicator of fluid retention.  Esophageal Varices – occurs when fragile, thin-walled esophageal veins become distended and tortuous from increased pressure.  Bleeding esophageal varices is a life-threatening medical emergency. Severe blood loss may occur, resulting in shock from hypovolemia.  Balloon Tamponade - a procedure in which a balloon is inflated within the esophagus or stomach, to apply pressure on bleeding

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blood vessels, compress the vessels, and stop the bleeding. It is used in the treatment of bleeding veins in the esophagus (esophageal varices) and stomach.  Variceal Banding - a doctor uses an endoscope to place an elastic ring that looks like a rubber band around an enlarged vein. May be instituted to prevent variceal bleeding.  Sclerotherapy – the injection of a sclerosing agent via a catheter, usually in an endoscopic procedure, to stop variceal bleeding. Priority Nursing Intervention for End Stage Disease – Manage N & V d/t possibility of developing Esophageal Varices (bleeding = emergency). Biliary Obstruction – production of bile in the liver is decreased. Prevents the absorption of fat-soluble vitamins (ex. Vitamin K). Hepatic encephalopathy (portal-systemic encephalopathy) – complex, cognitive syndrome that results from liver failure and cirrhosis.  Symptoms – Early: sleep disturbance, mood disturbance, mental status changes, and speech problems early. Late: neurological symptoms include altered LOC, impaired thinking processes, and neuromuscular problems. o Fetor Hepaticus – the distinctive breath odor of chronic liver disease and hepatic encephalopathy and is characterized by a fruity or musty odor. Happens in stage IV below. o Asterixis – a course tremor characterized by rapid, nonrhythmic extensions and flexions in the wrists and fingers. Happens in stage II and III below.  4 Stages of Development o Stage I: Prodromal – Personality changes, behavior changes (agitation, belligerence), emotional lability (euphoria, depression), impaired thinking, inability to concentrate, fatigue, drowsiness, slurred or slowed speech, sleep pattern disturbances. o Stage II: Impending – Continuing mental changes, mental confusion, disorientation, asterixis (hand flapping) o Stage III: Stuporous – progressive deterioration, marked mental confusion, stuporous, drowsy but arousable, abnormal ECG, muscle twitching, hyperreflexia, asterixis. o Stage IV: Comatose – unresponsiveness, leads to death, unarousable, obtunded, usually no response to painful stimulus, no asterixis, + Babinski’s sign, muscle rigidity, fetor hepaticus, seizures.

Hepatorenal Syndrome (HRS) – indicates a poor prognosis for the patient with liver failure.  Symptoms – Sudden ↓ in urine flow (<500 mL/24 hr) (oliguria), ↑ blood urea nitrogen (BUN) and creatinine levels w/abnormally ↓ urine sodium excretion, ↑ urine osmolarity. o Labs – Elevated AST (Norm. 8 – 48 U/L), ALT (Norm. 7 – 55 U/L), LDH (Norm. 122 – 222 U/L), Bilirubin (Norm. 0.1-1.0 mg/dL), Ammonia (Norm. 3.2 - 4.5 g/dl), Serum Protein can be elevated or decreased. Hepatitis – inflammation of the liver cells. o Fulminant Hepatic Liver Failure - acute liver failure (ALF) is defined as the rapid development of acute liver injury with severe impairment of the synthetic function and hepatic encephalopathy in a patient without obvious, previous liver disease. o Symptoms – Abdominal pain (RUQ), Changes in skin or sclera, Arthralgia (joint pain) or myalgia (muscle pain), Diarrhea/constipation, changes in color of urine or stool, fever, lethargy, malaise, N & V, pruritus (itching) o Chronic Hepatitis – usually occurs as a result of Hepatitis B or Hepatitis C. o Diet – high in carbohydrates and calories with moderate amounts of fat and protein after nausea and anorexia subside. Small frequent meals. o Drugs – use sparingly d/t liver needing to rest. o Hepatitis A – Hardy virus that can survive on human hands.  Resistant to detergents and acids but is destroyed by chlorine (bleach) and extremely high temperatures.  Usually has mild course similar to that of a typical flu-like infection and often goes unrecognized.  Spread by fecal-oral route by fecal contamination. Person to Person contact or by consuming contaminated food or water. o Hepatitis B  Spread by (blood) unprotected sex, sharing needles, needles sticks, blood transfusions, maternal-fetal route. Carriers can infect, even if not symptomatic.  Symptoms – anorexia, N & V, Fever, Fatigue, RUQ pain, Dark urine w/Light stool, Join pain, Jaundice. o Hepatitis C  Spread blood to blood.  Hepatitis C – Induced cirrhosis - is the leading indication for liver transplantation in the U.S.  Elisa Test – most common test used to DX o Hepatitis D o Hepatitis E

Causes a water-borne infection associated w/epidemics in the Indian subcontinent, Asia, Africa, Middle East, Mexico, and Central and South America.  Fecal contamination of food and water. Cancer of the Liver o May be primary tumors (hepatocellular carcinoma) starting in the liver, or they may be metastatic cancers that spread from another organ to the liver. o Vietnamese men, Black and Hispanic populations have twice the rate of the disease as Euro-Americans. o Symptoms – most are without symptoms. Late: weight loss, anorexia, and weakness. o Elevated serum alpha-fetoprotein (AFP) (a tumor marker for cancers of the liver, testis, and ovary) and increased alkaline phosphatase are also common. o Interventions  Surgical resection and liver transplantation offer the only treatments for long-term survival. Unfortunately, most patients are not candidates for surgical removal because their tumors are unresectable.  Hepatic Artery Embolization- causes cell death by blocking blood supply to the tumor in the liver. It is performed under moderate sedation. Catheter threaded through the femoral artery to inject small particles into the hepatic artery.  Common Ablation – includes radiofrequency ablation (RFA), percutaneous ethanol injection, and cryotherapy. RFA uses energy waves to heat cancer cells and kill them. Ethanol injected directly into the tumor to destroy tumor cells. Cryotherapy uses liquid nitrogen to freeze and destroy liver tumors.  Cryoablation – similar to RFA (radiofrequency ablation), but the radiologist uses an extremely cold gas through a probe into the tumor.  Liver Transplantation – has become a common procedure worldwide. It is the most effective TX for an increasing number of patients w/acute and chronic liver diseases.  Orthotopic Liver Transplantation - refers to a procedure in which a failed liver is removed from the patient's body and a healthy donor liver is transplanted into the same location. The procedure is the most common method used to transplant livers.  United Network of Organ Sharing (UNOS) – Nationwide program where donor livers are distributed and based on regional considerations and patient acuity. Candidates w/ the highest acuity receive highest priority.

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Most Common Complications – Acute graft Rejection and Infection. o Watch For – tachycardia, fever, RUQ or Flank pain, diminished bile drainage, change in bile color, increased jaundice, abdominal distention and guarding, N & V, claycolored stools, changes in urine output, etc. Azotorrhea - excessive discharge of nitrogenous substances in the feces or urine. Budd-Chiari Syndrome - a condition caused by occlusion of the hepatic veins that drain the liver. It presents with the classical triad of abdominal pain, ascites, and liver enlargement. Constructional Apraxia - characterized by an inability or difficulty to build, assemble, or draw objects. Endoscopic Retrograde Cholangiopancreatography (ERCP) – includes visual and radiographic examination of the liver, gallbladder, bile ducts, and pancreas to identify the cause and location of obstruction. Hernia – weakness or defect in the abdominal muscle wall through which a segment of the bowel or other abdominal structure protrudes. o Indirect Inguinal Hernia – a sac formed from the peritoneum that contains a portion of the intestine or omentum. o Direct Inguinal Hernia – in contrast, pass through a weak point in the abdominal wall. o Femoral Hernia – protrude through the femoral ring. Pulls the peritoneum and often the urinary bladder into the sac. o Umbilical Hernia – congenital or acquired. Congenital umbilical hernias appear in infancy. Acquired umbilical hernias directly result from increased intraabdominal pressure. Most commonly seen in obese people. o Incisional, or Ventral Hernias – occur at the site of a previous surgical incision. Result from inadequate healing of the incision. Caused by postoperative wound infections, inadequate nutrition, and obesity. o Strangulated Hernia – when the blood supply to the herniated segment of the bowel is cut off by pressure from the hernia ring (band of muscle around the hernia). If a hernia is strangulated, there is obstruction of the bowel loop.  Signs of Strangulation – abdominal distention, nausea, vomiting, pain, fever, and tachycardia. o Assessment  Reducible Hernia – assess patient’s abdomen in lying and then again when standing. If the hernia is reducible, it may disappear when the patient is lying flat.  Never forcibly reduce a hernia. The maneuver could cause strangulated intestine to rupture.

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Absent Bowel Sounds – may indicate obstruction and strangulation, which is a medical emergency. o Interventions  Truss – a pad made w/firm material. It is applied only after the physician has reduced the hernia if it is not incarcerated. The patient then usually applies the truss upon awakening. Must assess the skin daily under the truss.  Most Hernias are Inguinal. Surgical repair is the TX of choice.  Minimally Invasive Inguinal Hernia Repair (MIIHR) (Herniorrhaphy) – through a laparoscope and is surgery of choice.  Hernioplasty – surgeon reinforces the weakened outside abdominal muscle was with a mesh patch.  Avoid coughing. Encourage deep breathing and ambulation. Inflammatory Bowel Disease - involves chronic inflammation of all or part of your digestive tract. IBD primarily includes ulcerative colitis and Crohn's disease. Both usually involve severe diarrhea, pain, fatigue and weight loss. Irritable Bowel Syndrome – functional GI disorder characterized by chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating. o Most common concerns of patients w/IBS is pain in the LLQ of the abdomen. o Patients often report belching, gas, anorexia, and bloating. o Routine lab values are normal. o May have a Hydrogen Breath test.  NPO (may have water) for at least 12 hours before the hydrogen breath test. o Diet – avoid caffeine, alcohol, egg, wheat products, beverages that contain sorbitol or fructose, and other gastric irritants.  Dietary Fiber and bulk help produce bulky, soft stools and establish regular bowel habits. 30 to 40 g of fiber each day. o Overactive bladder medication can be used (not FDA approved) – Enablex and Toviaz are examples. o Peppermint oil and Probiotics can also be used. Laparoscopic Lithotripsy – “Lithotripsy”: use of sound, laser, or dry shock wave energy to break a kidney stone into small fragments; also called “extracorporeal shock wave lithotripsy.” Melena – blood in the stool, with the appearance of black tarry stools. Pancreatitis - inflammation in the pancreas. o Amylase – (Normal Value: 25 – 125 units/L) an enzyme, found chiefly in saliva and pancreatic fluid that converts starch and glycogen into simple sugars. ↑ within 12 to 24 hrs. and remain elevated for 2 to 3 days in patient w/Pancreatitis. Persistent ↑ may be an indicator of pancreatic abscess or pseudocyst.

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o Lipase – (Normal Value: 0 – 110 units/L) a pancreatic enzyme that catalyzes the breakdown of fats to fatty acids and glycerol or other alcohols. This also helps determine the presence of acute pancreatitis. Serum levels may ↑ later and remain ↑ for up to 2 weeks. Secretin - a hormone released into the bloodstream by the duodenum (especially in response to acidity) to stimulate secretion by the liver and pancreas. Steatorrhea – fatty stools. Trypsin - a digestive enzyme that breaks down proteins in the small intestine. It is secreted by the pancreas in an inactive form, trypsinogen. Xenograft – tissue transplanted (grafted) from another species; for example, a heart valve transplanted from a pig to a human. Zollinger-Ellison Syndrome – rare disease that is manifested by upper gastrointestinal tract ulceration, increased gastric acid secretion, and one or more duodenal or pancreatic tumors, called a gastrinoma. o Early Course of the disease: symptoms are similar to those of PUD. o No H. Pylori. o Drugs of Choice: PPI’s like Prevacid, Prilosec. Reduce gastric acid and heal the ulcers. o Radical Pancreaticoduodenectomy (Whipple Procedure) can be performed in some patients. o Aggressive Disease – can be treated w/chemotherapeutic agents like 5fluorouracil, doxorubicin, and streptozocin to reduce tumor size and control symptoms before surgery.

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