Anatomic and Physiologic Overview Organization of The Digestive System

• Organs of the digestive system are divided

Organs of digestive system form essentially:
into 2 main group : the gastrointestinal tract
• a long continuous tube open at both ends
(GI tract) and accessory structures .
• alimentary canal (gastrointestinal tract)
Mouth-pharynx-esophagus-stomach-small intestine-large • GI tract is a continuous tube extending
intestine through the ventral cavity from the mouth to
Attached to this tube are assorted accessory organs and the anus – it consists of the mouth , oral
structures that aid in the digestive processes cavity , oropharynx , esophagus , stomach ,
• salivary small intestine , large intestine , rectum , and
• glands anus
• teeth
• liver • Accessory structures include the teeth,
• gall bladder tongue (in oral cavity) , salivary glands , liver
• pancreas , gallbladder , and pancreas .
• mesenteries

Functions of the Digestive System

Ingestion
the oral cavity allows food to enter the digestive tract
and have mastication (chewing) occurs , and the
resulting food bolus is swallowed .

Digestion:
• Mechanical digestion
• Chemical digestion
Sympathetic and Parasympathetic
Mechanical digestion begins in the:
1. Mouth • Sympathetic nerves exert an inhibitory effect
2. Stomach on the GI tract, decreasing gastric secretion
and motility and causing the sphincters and
3. Small intestine
4. Large intestine blood vessels to constrict.

• Parasympathetic nerve stimulation causes

peristalsis and increases secretory activities.

Function of the Digestive System

Major functions of the GI tract include:

• Breakdown of food particles into the

molecular form for digestion

• Absorption into the bloodstream of small

nutrient molecules produced by digestion
 • Elimination of undigested unabsorbed foodstuffs contains taste buds to detect taste
and other waste products sensations(intrinsic) .
• Food particles are mixed with saliva during
mastication , resulting in a moist lump called bolus
for easier passage into or pharynx .

Teeth

• Adapted for mechanical digestion

(mastication) in the oral cavity .
• 20 deciduous or primary teeth before the
age of 6.
• By age 7, 32 permanent or secondary teeth
are developed & are divided into 4 types:
incisors (for cutting) , Canines (for tearing) ,
Premolars (for crushing), and Molars (for
grinding). these teeth follow the human
dental formula of 2-1-2-3.

Small Intestine Function

Muscular movement of the GI tract • Digestive enzymes secreted by the pancreas

include:
• Peristalsis wavelike movement that occurs from the • trypsin, which aids in digesting
oropharynx to the rectum , allowing GI tract to push protein
food particles toward the anus • amylase, which aids in digesting
• Mixing mixing motion in the oral cavity and stomach starch
that allows the GI tract to repeatedly break down food • lipase, which aids in digesting fats.
into smaller particles , using mechanical digestion . • These secretions drain into the pancreatic
duct, which empties into the common bile
• Segmentation regions of the small intestine contracting duct at the ampulla of Vater.
and relaxing independently , allowing the small • Bile, secreted by the liver and stored in the
intestine to digestive and absorb more efficiently gallbladder, aids in emulsifying ingested fats,
Mouth & Oral Cavity making them easier to digest and absorb.
• The sphincter of Oddi, found at the
• Food enters the GI tract by ingestion . confluence of the common bile duct and
• Food is broken down by mechanical digestion , duodenum, controls the flow of bile.
using mastication . • Intestinal secretions total approximately
• One chemical digestive process occur where • 1 L/day of pancreatic juice,
amylase enzyme in saliva breaks down • 0.5 L/day of bile, and
polysaccharide into disaccharides . • 3 L/day of secretions from the glands
• The tongue , made of skeletal muscle, of the small intestine.
manipulates the food during mastication . it also • Two types of contractions occur regularly in
the small intestine:
 • Segmentation contractions produce mixing waves that proximal portion of the right colon through the ileocecal
move the intestinal contents back and forth in a valve.
churning motion. • With each peristaltic wave of the small intestine,
• Intestinal peristalsis propels the contents of the small the valve opens briefly and permits some of the
intestine toward the colon contents to pass into the colon.
• Both movements are stimulated by the presence of • Bacteria, a major component of the contents of
chyme the large intestine, assist in completing the
breakdown of waste material, especially of
→ Carbohydrates are broken down into undigested or unabsorbed proteins and bile salts
disaccharides (e.g., sucrose, maltose, and
galactose) and monosaccharides (e.g., glucose, Two types of colonic secretions are added to the
fructose) residual material:
→ Glucose is the major carbohydrate that tissue • Electrolyte solution is chiefly a bicarbonate
cells use as fuel. solution that acts to neutralize the end
→ Proteins are a source of energy after they are products formed by the colonic bacterial
broken down into amino acids and peptides. action
→ Ingested fats become monoglycerides and fatty • Mucus protects the colonic mucosa from the
acid through emulsification, which makes them interluminal contents and provides adherence
smaller and easier to absorb. for the fecal mass.
→ Chyme stays in the small intestine for 3 to 6 • Slow, weak peristalsis moves the colonic
hours, allowing for continued breakdown and contents along the tract.
absorption of nutrients • This slow transport allows for efficient
reabsorption of water and electrolytes,
▪ Small, fingerlike projections called villi line the entire which is the major function of the colon.
intestine and function to produce digestive enzymes as • Intermittent strong peristaltic waves propel
well as to absorb nutrients. the contents for considerable distances.
▪ Absorption is the major function of the small intestine. • This generally occurs after another meal is
▪ Vitamins and minerals are absorbed essentially eaten, when intestine-stimulating hormones
unchanged. are released.
▪ Absorption begins in the jejunum and is accomplished by • The waste materials from a meal eventually
active transport and diffusion across the intestinal wall into reach and distend the rectum, usually in
the circulation. about 12 hours
▪ Nutrients are absorbed at specific locations in the small • As much as one fourth of the waste materials
intestine and duodenum, whereas fats, proteins, from a meal may still be in the rectum 3 days
carbohydrates, sodium, and chloride are absorbed in the after the meal was ingested.
jejunum.
▪ Vitamin B12 and bile salts are absorbed in the ileum Waste Products of Digestion
▪ Magnesium, phosphate, and potassium are absorbed
throughout the small intestine. • Feces consist of undigested foodstuffs,
inorganic materials, water, and bacteria.
Colonic Function • Fecal matter is about 75% fluid and 25%
solid material
• Within 4 hours after eating, residual waste material •
passes into the terminal ileum and slowly into the
• The composition is relatively unaffected by alterations Common Symptoms
in diet because a large portion of the fecal mass is of
nondietary origin, derived from the secretions of the ✓ Pain
GI tract. ✓ Dyspepsia
• The brown color of the feces results from the ✓ Intestinal Gas
breakdown of bile by the intestinal bacteria. ✓ Nausea and Vomiting
• Chemicals formed by intestinal bacteria are
responsible in large part for the fecal odor Change in Bowel Habits and Stool Characteristics
• Gases formed contain methane, hydrogen sulfide, and − Diarrhea,
ammonia, among others. − Constipation
• The GI tract normally contains approximately 150 mL The characteristics of the stool can vary greatly. Stool
of these gases, which are either absorbed into the is normally light to dark brown; however, specific
portal circulation and detoxified by the liver or disease processes and ingestion of certain foods and
expelled from the rectum as flatus. medications may change the appearance of stool

− Elimination of stool begins with distention of the

rectum, which initiates reflex contractions of the rectal
musculature and relaxes the normally closed internal
anal sphincter
− The internal sphincter is controlled by the autonomic
nervous system
− the external sphincter is under the conscious control
of the cerebral cortex.
− During defecation
▪ the external anal sphincter voluntarily
relaxes to allow colonic contents to be
expelled
▪ Normally, the external anal sphincter is If blood is shed in sufficient quantities into the upper
maintained in a state of tonic contraction GI tract, it produces a tarry-black color (melena),
− Defecation is seen to be a spinal reflex (involving the whereas blood entering the lower portion of the GI
parasympathetic nerve fibers) that can be inhibited tract or passing rapidly through it will appear bright or
voluntarily by keeping the external anal sphincter dark red.
closed
− Contracting the abdominal muscles (straining) Other common abnormalities in stool characteristics
facilitates emptying of the colon. The average described by the patient may include:
frequency of defecation in humans is once daily, but 1. Bulky, greasy, foamy stools that are foul in odor
this varies among people. and may or may not float

2. Light-gray or clay-colored stool, caused by a

decrease or absence of conjugated bilirubin

3. Stool with mucus threads or pus that may be

visible on gross inspection of the stool
 4. Small, dry, rock-hard masses occasionally streaked • Auscultation always precedes percussion and
with blood palpation, because they may alter sounds.
Auscultation is used to determine the character,
5. Loose, watery stool that may or may not be
location, and frequency of bowel sounds and to
streaked with blood
identify vascular sounds.
Physical Assessment
• Bowel sounds are assessed using the diaphragm
Abdominal Inspection, Auscultation, Percussion, and of the stethoscope for soft clicks and gurgling
Palpation sounds (Weber & Kelley, 2014).

1. Consistent use of one of these mapping methods Auscultation

results in a thorough evaluation of the abdomen
1. The frequency and character of the sounds are
and appropriate documentation.
usually heard as clicks and gurgles that occur
2. The four quadrant method involves the use of an irregularly and range from 5 to 30 per minute.
imaginary line drawn vertically from the sternum to 2. The terms normal (sounds heard about every 5
the pubis through the umbilicus and a horizontal to 20 seconds), hypoactive (one or two sounds
line drawn across the abdomen through the in 2 minutes), hyperactive (5 to 6 sounds heard
umbilicus. in less than 30 seconds), or absent (no sounds in
3 to 5 minutes) are frequently used in
3. Inspection is performed first, noting skin changes, documentation, but these assessments are
nodules, lesions, scarring, discolorations, highly subjective (Li, Wang, & Ma, 2012).
inflammation, bruising, or striae. 3. Using the bell of the stethoscope, any bruits in
4. Lesions are of particular importance, because GI the aortic, renal, iliac, and femoral arteries are
diseases often produce skin changes noted.
4. Friction rubs are high pitched and can be heard
5. The contour and symmetry of the abdomen are over the liver and spleen during respiration.
noted, and any localized bulging, distention, or 5. Borborygmi (“stomach growling”) is heard as a
peristaltic waves are identified. loud prolonged gurgle.
6. Expected contours of the anterior abdominal wall Percussion
can be described as flat, rounded, or scaphoid. 1. Percussion is used to assess the size and density of
the abdominal organs and to detect the presence
of air-filled, fluid-filled, or solid masses.
2. Percussion is used either independently or
concurrently with palpation because it can validate
palpation findings.
3. All quadrants are percussed for overall tympani
and dullness.
4. Tympani is the sound that results from the
presence of air in the stomach and small intestines;
dullness is heard over organs and solid masses.
5. The use of light palpation is appropriate for
identifying areas of tenderness or muscular
resistance, and deep palpation is used to identify
masses.
 PROCEDURES Esophageal manometry is used to detect motility
Endoscopic retrograde cholangiopancreatography disorders of the esophagus and the upper and
(ERCP) uses the endoscope in combination with x- lower esophageal sphincter.
rays to view the bile ducts, pancreatic ducts, and
• Also known as esophageal motility studies,
gallbladder.
these studies are very helpful in the
Fiberoptic Colonoscopy
diagnosis of achalasia (i.e., absence of
1. Colonoscopy is performed while the patient is
peristalsis), diffuse esophageal spasm,
lying on the left side with the legs drawn up
scleroderma, and other esophageal motor
toward the chest.
disorders.
2. Capsule colonoscopy is another option for
patients who cannot tolerate colonoscopy. Electrogastrography, an electrophysiologic
This minimally invasive test consists of an study, also may be performed to assess gastric
ingestible capsule with a two-sided camera motility disturbances and can be useful in
(similar to the PillCam ESO). detecting motor or nerve dysfunction in the
stomach.
Anoscopy, Proctoscopy, and Sigmoidoscopy
• Endoscopic examination of the anus, • Electrodes are placed over the abdomen,
rectum, and sigmoid and descending colon is and gastric electrical activity is recorded
used to evaluate chronic diarrhea, fecal for up to 24 hours.
incontinence, ischemic colitis, and lower GI • Patients may exhibit rapid, slow, or
hemorrhage and to observe for ulceration, irregular waveform activity.
fissures, abscesses, tumors, polyps, or other
pathologic processes. Defecography measures anorectal function and is
performed with very thick barium paste instilled
Endoscopy Through an Ostomy into the rectum.
• Endoscopy through an ostomy stoma is Fluoroscopy is used to assess the function of the
useful for visualizing a segment of the small rectum and anal sphincter while the patient
or large intestine and may be indicated to attempts to expel the barium.
evaluate the anastomosis for recurrent
disease, or to visualize and treat bleeding in • The test requires no preparation.
a segment of the bowel. • The nurse educates the patient about
Manometry and Electrophysiologic Studies what to expect during these procedures.

Manometry and electrophysiologic studies are Laparoscopy (Peritoneoscopy)

methods for evaluating patients with GI motility • also known as diagnostic laparoscopy, is a
disorders. surgical diagnostic procedure used to
• The manometry test measures changes in examine the organs inside the abdomen. It's
intraluminal pressures and the a low-risk, minimally invasive procedure that
coordination of muscle activity in the GI requires only small incisions.
tract with the pressures transmitted to a • uses an instrument called a laparoscope to
computer analyzer. look at the abdominal organs.
Gastrointestinal Intubation Other tubes:

GI intubation is the insertion of a flexible tube into Sengstaken–Blakemore and Minnesota tube
the stomach, or beyond the pylorus into the
• are used to treat bleeding esophageal varices
duodenum (the first section of the small intestine) or
the jejunum (the second section of the small Commonly used gastric tubes:
intestine). • Levin and Salem Sump tube
The tube may be inserted through Levin Tube
• the mouth • The Levin tube has a single lumen (channel within
a tube or catheter) and is made of plastic or rubber.
• the nose
• This tube is connected to low intermittent suction
• the abdominal wall.
(30 to 40 mmHg) to avoid erosion or tearing of the
The tubes are of various diameters (French [Fr] size) stomach lining, which can result from adherence of
and lengths, depending on their intended use. GI the tube’s lumen to the mucosa of the stomach.
intubation may be performed in order to: Salem Sump
Indication: • The Salem Sump tube is a radiopaque (easily seen
on x-ray), clear plastic, double-lumen gastric tube.
✓ Decompress the stomach and remove gas and
fluid • The inner, smaller lumen (known as the blue port)
✓ Lavage (flush with water or other fluids) the vents the larger suction-drainage tube to the
stomach and remove ingested toxins or other atmosphere by means of an opening at the distal
harmful materials end of the tube.
✓ Diagnose GI disorders Gastric and Enteric Tubes for Administration of Tube
✓ Administer tube feedings, fluids, and Feedings, Fluids, and Medications
medications
✓ Compress a bleeding site 1. Gastric or enteric (of or relating to the intestines)
feeding tubes are used for patients who have the
✓ Aspirate GI contents for analysis
ability to receive and process nutrition, fluids, and
Tube Types medications adequately by the gastric route.
2. Naso enteric tube (i.e., inserted through the nose
Gastric Tubes for into the stomach and beyond the pylorus into the
small intestine) or oroenteric tube (i.e., inserted
• Decompression,
from the mouth to the small intestine) for feeding
• Drainage, can be used.
3. Nasoduodenal tubes Enteric tubes placed in the
• Aspiration, and duodenum via the nares
4. Naso jejunal tubes those placed in the jejunum
• Lavage
(the portion of the small intestine distal to the
duodenum) via the nares.
 Definition of terms − jejunum: second portion of the small intestine, which
extends from the duodenum to the ileum
− aspiration: removal of substance by suction or the
inhalation of fluids or foods into the trachea and − lavage: flushing of the stomach with water or other
bronchial tree fluids with a gastric tube to clear it

− bolus feeding: a feeding given into the stomach in large − lumen: the channel within a tube or catheter
amounts and at designated intervals − nasoduodenal tube: tube inserted through the nose
− central venous access device (CVAD): a device designed into the proximal portion of the small intestine (i.e.,
and used for administration of sterile fluids, nutrition duodenum)
formulas, and medications into central veins − nasoenteric tube: tube inserted through the nose into
− cyclic feeding: periodic infusion of feedings given over the stomach and beyond the pylorus into the small
8 to 18 hours intestine

− decompression (gastric/intestinal): removal of gastric − nasogastric (NG) tube: tube inserted through the nose
or intestinal contents to prevent gas and fluid distention into the stomach

− dumping syndrome: physiologic response to rapid − nasojejunal tube: tube inserted through the nose into
emptying of gastric contents into the small intestine, the second portion of the small intestine (i.e., jejunum)
manifested by nausea, weakness, sweating, − orogastric tube: tube inserted through the mouth into
palpitations, syncope, and possibly diarrhea the stomach
− duodenum: the first part of the small intestine, which − osmolality: ionic concentration of fluid
arises from the pylorus of the stomach and extends to
the jejunum − parenteral nutrition (PN): method of supplying
nutrients to the bodyby an intravenous route
− enteral nutrition: nutritional formula feedings infused
through a tube directly into the gastrointestinal tract − percutaneous endoscopic gastrostomy (PEG): a
feeding tubeinserted endoscopically into the stomach
− enteric: of or relating to the intestines
− peripherally inserted central catheter (PICC): a device
− gastroparesis: partial paralysis of the stomach that inserted intoa peripheral vein and designed and used
results in decreased gastric motility and emptying for administration of sterilefluids, nutrition formulas,
− gastrostomy: surgical creation of an opening into the and medications into central veins
stomach for the purpose of administering fluids, − peristalsis: wavelike movement that occurs
nutrition formulas, and medications or for involuntarily in thealimentary canal
decompression and drainage of stomach contents
− radiopaque: can be easily localized on x-ray
− intravenous fat emulsion (IVFE or lipid): an oil-in-water
emulsion of oils, egg phospholipids, and glycerin; also − stoma: artificially created opening between a body
referred to as intravenous lipid emulsion cavity (e.g.,stomach or intestine) and the body surface

− intubation: the insertion or placement of a tube into a − stylet: a stiff wire placed in a catheter or other tube that
body structure or passageway allows the tubeto maintain its shape during insertion

− jejunostomy: surgical creation of an opening into the − total nutrient admixture (TNA): an admixture of lipid
jejunum for the purpose of administering fluids, emulsions,proteins, carbohydrates, electrolytes,
nutrition formulas, and medications vitamins, trace minerals, and water
 DISORDERS OF THE SALIVARY GLANDS − Sialadenitis
− Viral Infections (mumps)
1. The salivary glands consist of: the parotid glands, one
− Cysts
on each side of the face below the ear; the
− Benign Tumors
submandibular glands, located below the jawbone
− Malignant Tumors
2. The sublingual glands, in the floor of the mouth under − Sjogren’s Syndrome
the tongue; and the minor salivary glands in the lips, − Sialadenosis
buccal mucosa, and the lining of the mouth and throat. Parotitis
3. About 1500 mL of saliva is produced daily and • The most common inflammatory condition
swallowed. of the salivary glands.

4. The major functions of the salivary glands include • Inflammation of the parotid, may be due to
lubrication, protection against harmful bacteria, and mumps (epidemic parotitis), a
digestion. communicable disease caused by viral
infection and most commonly affecting
unvaccinated children.

SALIVARY GLANDS Medical management

1. 3 pairs of salivary glands called parotid , Maintaining adequate nutritional
submandibular , and sublingual gland secrete most of Fluid intake
the saliva in the oral cavity , using salivary ducts . Good oral hygiene,
Discontinuing medications that can diminish
2. Saliva helps moisten the food during mastication ,
salivation
dissolve the food in forming the bolus , and help
− Tranquilizers
cleanse the teeth.
− diuretic agents
3. Saliva consists of 99.5% water , the remaining 0.5% is • Antibiotic therapy is necessary for bacterial
dissolved substances including amylase enzyme (for parotitis, and analgesics may be prescribed to
chemically digesting carbohydrate ), bicarbonate ion control pain.
(HCO3 - ; maintains pH of saliva at 6.5-7.5) , and many • If antibiotic therapy is not effective, the gland may
electrolytes. need to be drained by a surgical procedure known
as parotidectomy.
SALIVARY GLANDS DISORDERS
• This procedure may be necessary to treat chronic
Common SGD include: parotitis.
• The patient is advised to have any necessary
− Sialolithiasis dental work performed prior to surgery
 Sialadenitis • Salivary calculi are formed mainly from calcium
phosphate.
• Inflammation of the salivary glands may be caused
by dehydration, radiation therapy, stress,
malnutrition, salivary gland calculi (stones;
sialolithiasis), or improper oral hygiene.

• commonly associated with infection by S. aureus

Assessment

• swollen and

• quite tender,

• the stone itself can be palpable, and

• its shadow may be seen on x-ray images.

Symptoms include
✓ pain, Management
✓ swelling, and
✓ purulent discharge • Calculus can be extracted fairly easily from
the duct in the mouth.
Management • Sometimes, enlargement of the ductal
• Antibiotics orifice permits the stone to pass
• Massage, spontaneously.
• hydration,
• warm compresses, and • Occasionally, lithotripsy, a procedure that
• Sialagogues uses shock waves to disintegrate the stone,
• Surgical drainage or excision of the gland and its may be used instead of surgical extraction for
duct are considered in cases of sialadenitis that are parotid stones and smaller submandibular
recurrent or refractory to antibiotics. stones.
Salivary Calculus (Sialolithiasis) Hiatal Hernia
• Sialolithiasis, or salivary calculi (stones), usually occur Hiatal Hernia, the opening in the diaphragm through
(in 80% to 90% of cases) in the submandibular gland. which the esophagus passes becomes enlarged, and
• Salivary gland ultrasonography or sialography (x-ray part of the upper stomach moves up into the lower
studies imaged after the injection of a radiopaque portion of the thorax
substance into the duct) may be required to
demonstrate obstruction of the duct.
 − More often in women than in men
− There are two main types of hiatal hernias:
• sliding
• paraesophageal − Type 4 hiatal hernia:This is the rarest type of
TWO MAIN TYPES OF HIATAL HERNIAS hiatal hernia. In this type, other organs
Sliding, or type I, hiatal hernia occurs when the besides the stomach, such as the spleen or
upper stomach and the gastroesophageal junction intestines, may also herniate through the
are displaced upward and slide in and out of the hiatus.
thorax

Clinical Manifestations

The patient with a sliding hernia may have

Paraesophageal hernia occurs when all or part of
the stomach pushes through the diaphragm beside • Pyrosis
the esophagus
• Regurgitation
There are three subtypes of paraesophageal hiatal
• Dysphagia
hernia:
• but many patients are
− Type 2 (or rolling) hiatal hernia: In this type, asymptomatic
the upper part of the stomach herniates
through the hiatus. The patient may present with vague
symptoms

• intermittent epigastric pain or

fullness after eating

Large hiatal hernias may lead to

• intolerance to food

• Nausea

• Vomiting
− Type 3 hiatal hernia: In this type, both the Sliding hiatal hernias are commonly
stomach and the lower esophagus herniate associated with GERD
through the hiatus.
Hemorrhage, obstruction, and strangulation
can occur with any type of hernia
Assessment and Diagnostic Procedure Surgical Management

Diagnosis is typically confirmed • Laparoscopic

• x-ray studies • transabdominal or transthoracic approach

• barium swallow Post-op management

• esophagogastroduodenoscopy (EGD) • diet slowly from liquids to solids,

which is the passage of a fiberoptic tube through the • managing nausea and vomiting
mouth and throat into the digestive tract for
• tracking nutritional intake
visualization of the esophagus, stomach, and small
intestine; esophageal manometry; or chest CT scan • monitoring weight.
SLIDING ESOPHAGEAL HERNIA • postoperative belching

• vomiting,

• gagging,

• abdominal distension, and

• epigastric chest pain

Perforation

Esophageal perforation is a surgical emergency. It

may result from iatrogenic causes, such as endoscopy
PARAESOPHAGEAL HERNIA
or intraoperative injury, or from spontaneous
perforation associated with forceful vomiting or
severe straining (Boerhaave syndrome), foreign-
body ingestion, trauma, and malignancy.

Clinical Manifestations

The patient has

• excruciating retrosternal pain

• followed by dysphagia
Management
• Infection
• frequent, small feedings
• Fever
• advised not to recline for 1 hour after eating
• Leukocytosis
• elevate the head of the bed on 4- to 8-inch (10-
• severe hypotension
to 20-cm) blocks
• mediastinal sepsis can occur with Boerhaave
• Surgical hernia repair is indicated in patients
syndrome
who are symptomatic
 • which may be accompanied by pneumothorax symptoms and/or mucosal injury to the
and subcutaneous emphysema esophagus.

Assessment and Diagnostic Findings • Excessive reflux may occur because of an

incompetent lower esophageal sphincter,
• X-ray studies,
pyloric stenosis, hiatal hernia, or a motility
• Fluoroscopy disorder

• barium swallow Incidence of GERD

• esophagram (a noninvasive test) • Aging

• Chest CT scan may be used to identify the • irritable bowel syndrome

site and scope of the injury
• Obstructive airway disorders (asthma,
Management COPD, cystic fibrosis)

Esophageal perforation requires immediate • Peptic ulcer disease, and

treatment. Treatment includes:
• Angina
• patient remain NPO (nothing by mouth)
GERD is associated with tobacco use, coffee
• beginning IV fluid therapy drinking, alcohol consumption, and gastric
infection with Helicobacter pylori.
• administering broad-spectrum antibiotics
(ampicillin-sulbactam [Unasyn], piperacillin-
tazobactam [Zosyn], or a carbapenem [e.g.,
imipenem{Primaxin}])

• antifungal therapy (if the patient is

immunosuppressed, has HIV infection, or
shows no improvement with antibiotics)

• supportive monitoring and care (intensive

care unit level-of-care often required)
evaluating and preparing the patient for Clinical Manifestations
surgery
• pyrosis (heartburn)
Surgical Procedure • dyspepsia (indigestion),
• regurgitation,
• Drainage, diversion, stent placement or
• dysphagia or
• Esophagostomy (removal of the esophagus) • odynophagia,
• hypersalivation, and
Gastroesophageal Reflux Disease
• esophagitis
• Gastroesophageal reflux disease (GERD) is a
fairly common disorder marked by backflow GERD can result in:
of gastric or duodenal contents into the • dental erosion,
esophagus that causes troublesome • ulcerations in the pharynx and esophagus,
• laryngeal damage,
 • esophageal strictures, • hypersalivation, and
• adenocarcinoma, and • esophagitis
• pulmonary complications Assessment and Diagnostic Procedure

• Esophageal lining that is red rather than

Assessment and Diagnostic Procedure
pink
• Endoscopy • EGD
• barium swallow • Biopsy
• Ambulatory 12- to 36-hour Esophageal pH Management
monitoring
• Monitoring varies depending on the extent
Management
of cell changes
• Educating the patient • Follow-up biopsies
• low-fat diet • Use of proton pump inhibitors (PPIs)
• avoid caffeine tobacco, beer, milk, foods
containing peppermint or spearmint, and
Pharmacologic Management of GERD
carbonated beverages
• avoid eating or drinking 2 hours before
bedtime
• maintain normal body weight
• avoid tight-fitting clothes
• Elevate the head of the bed by at least 30
degrees
Barrett Esophagus

Barrett Esophagus is a condition in which the

lining of the esophageal mucosa is altered.

Clinical Manifestations

• complains of symptoms of GERD

• heartburn.
• symptoms related to peptic ulcers or
esophageal stricture, or both
• pyrosis (heartburn)
• dyspepsia (indigestion),
• regurgitation,
• dysphagia or
• odynophagia,
 GASTRITIS CLINICAL MANIFESTATIONS

• Gastritis (inflammation of the gastric or ACUTE GASTRITIS - RAPID ONSET OF SYMPTOMS

stomach mucosa)
• epigastric pain or discomfort
• common GI problem
• dyspepsia (indigestion)
• affects women and men about equally and is
• Anorexia
more common in older adults
• Hiccups
• The nonerosive form of acute gastritis is most
• nausea and vomiting
often caused by an infection with Helicobacter
EROSIVE GASTRITIS MAY CAUSE BLEEDING
pylori (H. pylori)
• Acute gastritis •blood in vomit
• Chronic gastritis •melena (black, tarry stools)
•hematochezia (bright red, bloody
MOST OFTEN CAUSED OF ACUTE GASTRITIS
stools)
EROSIVE FORM CHRONIC GASTRITIS

•
aspirin and other nonsteroidal anti- • acute gastritis
inflammatory drugs (NSAIDs) (e.g., • pyrosis (a burning sensation in the
ibuprofen [Motrin]) stomach and esophagus that moves
• alcohol consumption up to the mouth; heartburn) after
• gastric radiation therapy eating
NONEROSIVE FORM • Belching
• a sour taste in the mouth
• Helicobacter pylori (H. pylori)
• early satiety,
• more severe form of acute gastritis
• anorexia, or
• ingestion of strong acid or alkali
• nausea and vomiting
• Scarring can occur - resulting in pyloric
Patients with chronic gastritis may not be able to
stenosis (narrowing or tightening) or
absorb vitamin B12 because of diminished
obstruction
production of intrinsic factor by the stomach’s
PATHOPHYSIOLOGY
parietal cells due to atrophy, which may lead to
1. disruption of the mucosal barrier that normally pernicious anemia
protects the stomach tissue from digestive juices
(e.g., hydrochloric acid [HCl] and pepsin).

2. Impaired mucosal barrier allows corrosive HCL,

pepsin, and other irritating agents (e.g., NSAIDs
and H. pylori) to come in contact with the gastric
mucosa, resulting in inflammation.

3. In chronic gastritis, persistent or repeated insults

lead to chronic inflammatory changes, and
eventually atrophy (or thinning) of the gastric
tissue
 ASSESSMENT AND DIAGNOSTIC FINDINGS HISTAMINE-2 RECEPTOR ANTAGONISTS (H2
BLOCKERS)
• Endoscopy
• Histologic examination of a tissue specimen • famotidine [Pepcid],
obtained by biopsy • ranitidine [Zantac]
• Complete blood count (cbc) – hemorrhage
or pernicious anemia PROTON PUMP INHIBITORS

• clarithromycin [Biaxin]
• omeprazole [Prilosec]
• rabeprazole [AcipHex]

Gastric outlet obstruction also called PYLORIC

OBSTRUCTION a narrowing of the pyloric orifice,
Endoscopic view of EROSIVE GASTRITIS (LEFT). which cannot be relieved by medical management
Damage from irritants (RIGHT) results in increased
intracellular pH, impaired enzyme function, CHRONIC GASTRITIS
disrupted cellular structures, ischemia, vascular •
modifying the patient’s diet
stasis, and tissue death.
•
promoting rest
MEDICAL MANAGEMENT •
reducing stress
Gastric mucosa is capable of repairing itself after an •
recommending avoidance of alcohol
episode of acute gastritis and NSAIDs
• Instructing the patient to refrain from • initiating medications that may
alcohol and food until symptoms subside include antacids, H2 blockers, or
• If the symptoms persist, intravenous (IV) proton pump inhibitors
fluids NURSING MANAGEMENT
Therapy is supportive REDUCING ANXIETY
• nasogastric (NG) intubation
• Antacids 1. nurse offers supportive therapy
• histamine-2 receptor antagonists 2. patient may be anxious because of pain and
(H2 blockers) planned treatment modalities
• proton pump inhibitors • nurse uses a calm approach to assess the
• IV fluids patient and to answer all questions as
completely as possible
− Fiberoptic endoscopy may be necessary PROMOTING OPTIMAL NUTRITION

ANTIBIOTICS 1. nurse offers supportive therapy

2. helps the patient manage the symptoms
• metronidazole [Flagyl] 3. nurse monitors fluid intake, output and serum
• amoxicillin [Amoxil] electrolyte
• clarithromycin [Biaxin] 4. nurse discourages the intake of caffeinated
• metronidazole and tetracycline beverages
5. nurse discourages the intake of caffeinated
beverages
6. Discouraging cigarette smoking
7. When appropriate, the nurse initiates and refers duodenum), in the duodenum or in the
the patient for alcohol counseling and smoking esophagus.
cessation programs. Erosion of a circumscribed area of mucosa is the
NURSING MANAGEMENT cause erosion may extend as deeply as the
muscle layers or through the muscle to the
PROMOTING FLUID BALANCE
peritoneum (thin membrane that lines the inside
− Daily fluid intake and output are monitored of the wall of the abdomen)
❑ Peptic ulcers are more likely to occur in the
− To detect early signs of dehydration duodenum than in the stomach
− Electrolyte values are assessed ❑ Esophageal ulcers occur as a result of the backward
flow of HCl from the stomach into the esophagus
− Nurse must always be alert to any indicators of (gastroesophageal reflux disease [GERD]).
hemorrhagic gastritis ❑ Use of NSAIDs such as ibuprofen and aspirin is also
a major risk factor for peptic ulcers.
• Hematemesis (vomiting of blood)
❑ There is no evidence that the ingestion of milk,
• Tachycardia caffeinated beverages, and spicy foods are
associated with the development of peptic ulcers
• Hypotension
❑ Familial tendency also may be a significant
− All stools should be examined predisposing factor. People with blood type O are
− Vital signs are monitored more susceptible to the development of peptic
RELIEVING PAIN ulcers than are those with blood type A, B, or AB.
❑ Peptic ulcer disease is also associated with
− Instructing the patient to avoid foods and Zollinger–Ellison.
beverages that may irritate the gastric mucosa − a rare condition in which benign or malignant
− Correct use of medications to relieve chronic tumors form in the pancreas and duodenum
gastritis that secrete excessive amounts of the
− Nurse must regularly assess the patient’s level of hormone gastrin
pain
DEEP PEPTIC ULCER ADAPTED FROM STRAYER PATHOPHYSIOLOGY
1. Gastroduodenal mucosa
2. Cannot withstand the digestive action of
gastric acid (hcl)
3. Erosion is caused by the increased
concentration or activity of acid–pepsin
4. Decreased resistance of the normally
protective mucosal barrier
PEPTIC ULCER DISEASE 5. Damaged mucosa cannot secrete enough
mucus to act as a barrier against normal
A peptic ulcer may be referred to as a gastric, digestive juices
duodenal, or esophageal ulcer, depending on its 6. Exposure of the mucosa to gastric acid (hcl),
location pepsin, and other irritating agents
Peptic ulcer is an excavation (hollowed-out area) • NSAIDs
that forms in the mucosa of the stomach, in the • H. pylori
pylorus (the opening between the stomach and 7. Leads to inflammation, injury, and
subsequent erosion of the mucosa
 CLINICAL MANIFESTATIONS ACID CONTROLLERS PROTON PUMP
(H2 BLOCKERS) INHIBITORS
• Many patients with peptic ulcers have no signs
1. H2 blockers block 1. PPIs block acid production
or symptoms
histamine 2, which is at the source, the proton
• Silent peptic ulcers most commonly occur in just one of several pump, making PPIs more
older adults and those taking aspirin and other acid-producing effective than H2 blockers
NSAIDs. stimuli in the at reducing acid
stomach. production.
− dull, gnawing pain
2. Decrease stomach 2. Decrease stomach acid >
− burning sensation in the mid-epigastrium or acid production for 8 24 hours
the back hours.
3. Relieves heartburn 3. Are recommended to
associated with acid treat frequent heartburn.
indigestion and sour
stomach, prevents
heartburn brought
on by eating or
drinking certain
foods and
beverages.
4. Begins working 4. Begins working 1 hour,
within 15 – 30 peak effect in 1-4 days.
minutes.
PEPTIC ULCER DISEASE 5. Provide relief for up 5. Provide relief for 24
DUODENAL (80%) to 12 hours. hours.
❑ Increased gastric secretion between meals, 6. Are available over 6. Are available over the
after meals, during night. the counter. counter.
❑ Twice as many parietal cells
❑ Pain 2-3 hours after meal PROTON PUMP H2 BLOCKERS
❑ Relieved by food INHIBITORS
❑ Peak age 35-45 years old 1. Retention 3 days 12 hours
❑ May cause weight gain Time
❑ Hemorrhage, perforation outlet obstruction 2. Onset of 1-3 hours < 1 hour
Effects
GASTRIC Parietal Enterochromaffin –
3. Cells
❑ Decreased gastric acid secretion Involved like cells
❑ 2/3 as many parietal cells 4. Affected H+/K+ ATPase Histamine Receptor
❑ Pain ½ -1 hour after meal Site
❑ Not relieve by food Diarrhea, Nausea, Sore Throat,
5. Side
❑ More likely to be malignant Headache, Abdominal Diarrhea, Nausea,
Effects
❑ Peak age 50-60 years old Pain Headache,
❑ May cause weight loss Weakness
❑ Hemorrhage perforation
6. Uses Ulcers, GERD, Mild Heartburn also known as Billroth II gastrectomy or
Esophagitis gastrojejunostomy, is a surgery that removes part of
the stomach (antrectomy) and reconnects the
remaining stomach directly to the jejunum (second
part of the small intestine), bypassing the duodenum
SMOKING CESSATION (first part).
• Decreases the secretion of bicarbonate
from the pancreas into the duodenum,
resulting in increased acidity of the
duodenum.
• delayed healing of peptic ulcers

DIETARY MODIFICATION
• to avoid oversecretion of acid and
hypermotility in the GI tract
• by avoiding extremes of temperature in
food and beverages and overstimulation
from the consumption of alcohol, coffee Indications
The Billroth II procedure is most commonly
SURGICAL MANAGEMENT performed for the following reasons:
VAGOTOMY with or without pyloroplasty
(transecting nerves that stimulate acid secretion and 1. Stomach cancer: Early stage stomach
opening the pylorus) cancer can be treated with a Billroth II
procedure.
2. Peptic ulcer disease: While less common
today due to the effectiveness of
medications, Billroth II can be a surgical
option for severe peptic ulcers that don't
respond to other treatments.
3. Zollinger-Ellison syndrome: This rare
condition causes the stomach to produce
too much acid. Billroth II surgery can help
reduce acid production.
ANTRECTOMY, which is removal of the pyloric There are two variations of the Billroth II
(antrum) portion of the stomach with anastomosis reconstruction, depending on the position of the
jejunal loop relative to the colon:
❑ Antecolic: The jejunal loop is placed in front
of the colon.
❑ Retrocolic: The jejunal loop is placed behind
the colon.

BILLROTH II PROCEDURE
 GASTRECTOMY The client who was diagnosed to have gastric cancer
the removal of part or all of the stomach. There are had undergone gastrectomy. Which of the following
three main types of gastrectomy: statements when made by the client indicates that
he understands the health teachings
1. PARTIAL GASTRECTOMY
This procedure removes only a portion of the a. I'll take vitamin K for life
stomach, usually the lower part (antrum). The b. I'll take vitamin B12 for life
remaining stomach is then reattached to the small c. I'll take vitamin C for life
intestine. d. I'll take vitamin B6 for life

2. SLEEVE GASTRECTOMY Nurse Ja9 is teaching a group of middle-aged men

This is a weight loss surgery that removes about 75% of about peptic ulcers. When discussing risk factors for
the stomach along the left side, creating a banana- peptic ulcers, the nurse should mention:
shaped sleeve. The remaining portion of the stomach is
a. a sedentary lifestyle and smoking.
then stapled closed.
b. a history of hemorrhoids and smoking.
3. TOTAL GASTRECTOMY c. alcohol abuse and a history of acute renal
This procedure removes the entire stomach. The failure.
esophagus (tube connecting the throat to the stomach) d. alcohol abuse and smoking.
is then directly connected to the small intestine.
An adult is admitted with a duodenal ulcer. On the
Q&A second day after admission, the client develops
For CJ Cool who is taking antacids, which instruction would severe, persistent pain radiating to the shoulder.
be included in the teaching plan? What action should the nurse take first?

a. Take the antacids with 8 oz of water." a. Notify the physician.

b. Avoid taking other medications within 2 hours b. Place client in a high-Fowler’s position to
of this one." decrease pressure on the gastric area and
c. Continue taking antacids even when pain shoulder.
subsides.“. c. Examine the client for board-like rigidity of
d. Weigh yourself daily when taking this the abdomen.
medication d. Administer ordered prn pain medication
The nurse is caring for a male client with a diagnosis of
A client diagnosed with gastric ulcer is for discharge.
chronic gastritis. The nurse monitors the client knowing
Which of the following should be included by the
that this client is at risk for which vitamin deficiency?
nurse in the health teachings regarding diet?
a. Vitamin A
a. you must eat bland diet
b. Vitamin B12
b. you can eat most foods as long as they
c. Vitamin C
don't bother your stomach
d. Vitamin E
c. you should refrain from eating fruits and
vegetables
d. you should eat low fiber diet
The client with a duodenal ulcer is ready for c. Irrigating the nasogastric tube
discharge. Which statement made by the client
d. Coughing and deep-breathing exercises
indicates a need for more teaching about his diet?
a. “It’s a good thing I gave up drinking alcohol After gastroscopy, an adaptation that indicates
last year.” major complication would be:
b. “I will have to drink lots of milk and cream
every day.” a. Nausea and vomiting
c. “I will stay away from cola drinks after I am b. Abdominal distention
discharged.” c. Increased GI motility
d. “Eating three nutritious meals and snacks d. Difficulty in swallowing
every day is okay.”
Which of the following should the nurse advise to a
Mr. Lex Luto ulcer perforates into the peritoneal client who had undergone partial gastrectomy?
cavity. To relieve the pain caused by perforation, Mr. a. drink fluid with meals
Lex Luto is most likely to: b. lie down after meals
a. lie on his left side c. increase fats in the diet
b. turn into his stomach d. assume upright position during and after
c. rigidly maintain the supine position meals
d. draw his knees up to his abdomen

Mrs. Beth Logan is placed on the bland diet and

receives medications to decrease gastric acidity.
Which medication reduces hydrochloride acid
secretion?
a. cimetidine (tagamet)
b. sucralfate (carafets)
c. aluminum hydroxide (amphogel)
d. aspirin

A male client with a peptic ulcer is scheduled for a

vagotomy and the client asks the nurse about the
purpose of this procedure. Which response by the
nurse best describes the purpose of a vagotomy?

a. Halts stress reactions

b. Heals the gastric mucosa
c. Reduces the stimulus to acid secretions
d. Decreases food absorption in the stomach

The nurse is caring for a female client following a

Billroth II procedure. Which postoperative order
should the nurse question and verify?

a. Leg exercises

b. Early ambulation
Constipation 2. Slow-transit constipation which is caused
by inherent disorders of the motor function
Constipation is defined as fewer than three bowel
of the colon (e.g., Hirschsprung disease),
movements weekly or bowel movements that are
and is characterized by infrequent bowel
hard, dry, small, or difficult to pass.
movements
People more likely to become constipated are
3. Defecatory disorders which are caused by
women
dysfunctional motor coordination between
• particularly pregnant women, the pelvic floor and anal sphincter. This can
• patients who recently had surgery, cause not only constipation but also fecal
• older adults, non-Caucasians, incontinence.
• and those of lower socioeconomic status
Clinical Manifestations
Constipation is a symptom and not a disease
• fewer than three bowel movements per
Constipation can be caused by certain medications week
• abdominal distention
Pathophysiology • pain and bloating
Interference with one of three major functions of • sensation of incomplete evacuation
the colon: • straining at stool
• mucosal transport (i.e., mucosal • elimination of small volume lumpy, hard, dry
secretions facilitate the movement of stools
colon contents)
Assessment and Diagnostic Procedure
• myoelectric activity (i.e., mixing of the
rectal mass and propulsive actions) • patient’s history
• processes of defecation (e.g., pelvic floor • physical examination
dysfunction). • possibly the results of a barium enema
The urge to defecate is stimulated normally by • Sigmoidoscopy
rectal distention that initiates a series of four • stool testing for occult blood
actions: • Anorectal manometry
• Defecography
• stimulation of the inhibitory rectoanal
reflex • colonic transit studies
• relaxation of the internal sphincter muscle • Pelvic floor magnetic resonance imaging
• relaxation of the external sphincter (MRI)
muscle and muscles in the pelvic region
Complications
• and increased intra-abdominal pressure.
• Increased arterial pressure
Interference with any of these processes can lead
to constipation. • fecal impaction

Three classes of constipation → fecal incontinence

→ hemorrhoids (dilated portions of
1. Functional constipation which involves
anal veins),
normal transit mechanisms of mucosal
→ fissures (normal or abnormal folds,
transport. This type of constipation is most
grooves, or cracks in body tissue)
common and can be successfully treated by
→ rectal prolapse, and megacolon
increasing intake of fiber and fluids
Medical Management Nursing Management
• Health education The nurse elicits information about:
• exercise, • onset and duration of constipation,
• bowel habit training • current and past elimination patterns
• increased fiber and fluid intake • the patient’s expectation of normal bowel
• judicious use of laxatives elimination
• Patients can be educated to sit on the toilet • lifestyle information
with legs supported and to utilize the • Past medical and surgical history
gastrocolic reflex • current medications
• Biofeedback • laxative and enema
• Enemas and rectal suppositories
 − Increase muscle strength through an exercise
regimen, increased ambulation, and
Diarrhea
abdominal muscle toning to help propel colon
Diarrhea is an increased frequency of bowel contents.
movements (more than 3 per day) with altered − Perform abdominal toning exercises, including
consistency (i.e., increased liquidity) of stool. contracting abdominal muscles 4 times daily
and leg-to-chest lifts 10–20 times each day.
It can be associated with
− Use the normal position (semisquatting) to
• Urgency maximize the use of abdominal muscles and
force of gravity.
• perianal discomfort
− Avoid overuse or long-term use of stimulant
• Incontinence laxatives.

• Nausea Pathophysiology
Any condition that causes increased intestinal 1. Acute and persistent diarrheas are classified as
secretions, decreased mucosal absorption, or either noninflammatory (large-volume) or
altered motility can produce diarrhea inflammatory (small-volume)
2. Enteric pathogens that are noninvasive (e.g., S.
Classification aureus, Giardia). They cause noninflammatory
1. Acute diarrhea is self-limiting, lasting 1 or 2 diarrhea, which is characterized by a large
days volume of loose, watery stools.
2. Persistent diarrhea typically lasts between 2
and 4 weeks Types of chronic diarrhea:
3. Chronic diarrhea persists for more than 4 • secretory
weeks and may return sporadically • osmotic,
• malabsorptive
Preventing Constipation • infectious, and
The nurse instructs the patient to: • exudative.
− Recognize the physiology of defecation and
the importance of responding to the urge to Clinical Manifestations
defecate. • abdominal cramps
− Understand the normal variations in patterns • Distention
of defecation. • borborygmus (i.e., a rumbling noise caused
− Establish a bowel routine, and be aware that by the movement of gas through the
having a regular time for defecation (e.g., best intestines)
time is after a meal) may aid in initiating the • Anorexia
reflex. • Thirst
− Ensure proper dietary habits, such as eating • Painful spasmodic contractions of the anus
high-residue, high-fiber foods (e.g., fruits, • tenesmus (i.e., ineffective, sometimes
vegetables); adding bran daily (must be painful straining with a strong urge)
introduced gradually); and increasing fluid
intake (unless contraindicated) to help Assessment
prevent constipation. • abdominal auscultation
• palpation for tenderness
 • Inspection of the abdomen, mucous Fecal Incontinence
membranes, and skin Fecal incontinence describes the recurrent
involuntary passage of stool from the rectum for at
Assessment and Diagnostic Procedure least 3 months
• complete blood cell count (CBC)
• serum chemistries Factors that influence this disorder include:
• Urinalysis • the ability of the rectum to sense and
• routine stool examination accommodate stool
• stool examinations • the amount and consistency of stool
• Endoscopy or barium enema • the integrity of the anal sphincters and
musculature,
Complications • rectal motility
Most common complication of diarrhea:
• dehydration Clinical Manifestations
• cardiac dysrhythmias • minor soiling
• metabolic acidosis • occasional urgency
• muscle weakness • loss of control or complete incontinence
• Paresthesia • poor control of flatus
• Hypotension • Diarrhea
• Anorexia • constipation.
• hypokalemia • incontinence
• drowsiness Passive incontinence
• irritant dermatitis Urge incontinence

Medical Management Assessment and Diagnostic Procedure

• Controlling symptoms • rectal examination
• preventing complications • endoscopic examination
• eliminating or treating the underlying • flexible sigmoidoscopy
disease. • Anorectal manometry
• infection control measures • Endosonography
• pelvic MRI scan
Medications • transit studies
• antibiotics agents
• anti-inflammatory agents Nursing Management
• antidiarrheal agents • health history
• diphenoxylate with atropine • previous surgical procedures
• chronic illnesses
Nursing Management • dietary patterns
• health history • bowel habits and problems
• patient’s medication therapy • current medication regimen
• medical and surgical history Stool charts (feces)
• dietary patterns and intake □ frequency
□ volume
□ consistency
Irritable Bowel Syndrome (IBS) Medical Management
Irritable bowel syndrome (IBS) is a chronic Lifestyle modification
functional disorder characterized by recurrent □ stress reduction
abdominal pain associated with disordered bowel □ adequate sleep,
movements, which may include diarrhea, □ exercise regimen
constipation, or both (Lacy et al., 2016; Skrastins & □ soluble fiber (diet)
Fletcher, 2016).
□ Women are affected more often than men Medications
□ IBS is typically diagnosed in adults younger • Antibiotic
than 45 years of age • Antidiarrheal agents - diarrhea and fecal
urgency.
Pathophysiology • Antispasmodic agents - pain
1. IBS results from a functional disorder of • Antidepressants - anxiety
intestinal motility
2. Neuroendocrine dysregulation Nursing Management
3. Especially changes in serotonin signaling, • bowel habit diary
infection, irritation, or a vascular or → bristol stool form scale
metabolic disturbance • good sleep habits
4. The peristaltic waves are affected at specific • good dietary habits
segments of the intestine and in the • encouraged to eat at regular times
intensity with which they propel the fecal • adequate fluid intake
matter forward. • avoid alcohol use and cigarette smoking
• relaxation techniques
Clinical Manifestations • cognitive-behavioral therapy
alteration in bowel patterns • yoga, and exercise
• constipation (classified as ibs-c),
• diarrhea (classified as ibs-d), DISORDERS OF MALABSORPTION
• combination of both (classified as ibs-m for Celiac Disease
“mixed”) Celiac disease is a disorder of malabsorption caused
• pain, by an autoimmune response to consumption of
• bloating products that contain the protein gluten.
• Gluten is most commonly found in wheat,
• abdominal distention
barley, rye, and other grains, malt, dextrin,
Assessment and Diagnostic Findings and brewer’s yeast.
• Abdominal pain related to defecation; • Women are afflicted twice as often as men
• Abdominal pain associated with a change in • Any age (genetically predisposed)
frequency of stool • more common among Caucasians
• Abdominal pain associated with a change in
Risk include those with
form/appearance of stool.
• Type 1 diabetes,
• Bristol Stool Form Scale
• Down syndrome
• CBC
• Turner syndrome
• C-reactive protein
• Calprotectin
Most common GI clinical manifestations: Non-GI signs and symptoms
• diarrhea • fatigue
• steatorrhea • general malaise
• abdominal pain • depression
• abdominal distention • hypothyroidism
• flatulence • migraine headaches
• weight loss • osteopenia
• anemia
• seizures
• paresthesia in the hands and feet
• a red shiny tongue
Assessment and Diagnostic Procedure
• serologic tests • Rebound tenderness
• endoscopic biopsy - confirmatory • Anorexia
• Nausea
Medical Management • Vomiting
• There are no drugs that induce remission • Diminished peristalsis
• A consult with a dietician may be advisable
• paralytic ileus
• patients who present with anemia may
• temperature of 37.8° to 38.3°C (100° to
require folate, cobalamin, or iron
101°F)
supplements
• increased pulse rate
• Patients with osteopenia may require
• hypotensive.
treatment for osteoporosis
Assessment and Diagnostic Procedure
Nursing Management
• white blood cell count is elevated
− patient and family education
• hemoglobin and hematocrit levels may be
• gluten-free diet
low if blood loss has occurred
• avoid other gluten products
• Serum electrolyte studies
ACUTE ABDOMEN/SURGICAL ABDOMEN • abdominal x-ray
• Abdominal ultrasound
Peritonitis • Computed tomography (CT)
Peritonitis is inflammation of the peritoneum, which • MRI
is the serous membrane lining the abdominal cavity
and covering the viscera. Medical Management
The most common bacteria implicated are: • Fluid, colloid, and electrolyte replacement
□ Escherichia coli and Klebsiella • isotonic solution
□ Proteus • Analgesic medications
□ Pseudomonas • Antiemetic agents
□ Streptococcus species. • Intestinal intubation and suction
• Oxygen therapy
Peritonitis can be categorized • Antibiotic therapy
• Primary peritonitis also called spontaneous
bacterial peritonitis (SBP) Nursing Management
• Secondary peritonitis □ intensive care is needed for the patient
• Tertiary peritonitis with septic shock.
□ increases fluid and food intake gradually.
Clinical Manifestations
Pain Signs indicating that peritonitis is subsiding
• constant, include:
• Localized • decrease in temperature and pulse rate,
Abdomen • softening of the abdomen,
• extremely tender and distended • return of peristaltic sounds,
Muscles • passing of flatus, and bowel movements
• Rigid
Appendicitis
• The appendix is a small, vermiform (i.e.,
wormlike) appendage
• 8 to 10 cm (3 to 4 inches) long
• attached to the cecum just below the
ileocecal valve
• most frequent cause of acute abdomen
• incidence is slightly higher among males

Pathophysiology
1. appendix becomes inflamed and edematous
2. becoming kinked or occluded by a fecalith Assessment and Diagnostic Procedure
(i.e., hardened mass of stool) • complete history and physical examination
3. lymphoid hyperplasia (secondary to • CBC - elevated WBC count and elevated
inflammation or infection) neutrophils
4. rarely, foreign bodies (e.g., fruit seeds) or • C-reactive protein levels – Elevated
tumors • CT scan
5. inflammatory process increases • laparoscopy
• intraluminal pressure
• causing edema and obstruction of Complications
the orifice • peritonitis,
• abscess formation
Clinical Manifestations • portal pylephlebitis
• Vague periumbilical pain (i.e., visceral pain • septic thrombosis
that is dull and poorly localized) • Perforation
• Anorexia
• Nausea Medical Management
• low-grade fever • prevent fluid and electrolyte imbalance
• Local tenderness (McBurney point) • prevent dehydration
• Rebound tenderness • Prevent sepsis
• Rovsing sign • IV fluids
• Constipation • Antibiotics
Appendix has ruptured • Appendectomy
• pain becomes consistent • Laparotomy or laparoscopy
• abdominal distention
• paralytic ileus Nursing Management
• preventing fluid volume deficit
• reducing anxiety
• preventing or treating surgical site infection
• preventing atelectasis
• maintaining skin integrity
• attaining optimal nutrition
 Patient for surgery Risk Factor
• high Fowler position • Low intake of dietary fiber
• IV infusion • Obesity
• antibiotic therapy • History of cigarette smoking
• administration of analgesic • Nonsteroidal anti-inflammatory drugs
• parenteral opioid (NSAIDs) and acetaminophen (Tylenol)
• Urine output is monitored • Positive family history
• encouraged to ambulate
Clinical Manifestations

Diverticular Disease • Chronic constipation sometimes precedes

the development of diverticulosis
□ Diverticulum is a saclike herniation of the lining of • bowel irregularity
the bowel that extends through a defect in the • Diarrhea
muscle layer. • Nausea
□ Diverticula may occur anywhere in the GI tract • anorexia,
• bloating or abdominal distention

Diverticulitis
• Mild to severe LLQ pain
• change in bowel habits
• Constipation
• Nausea
• Fever
• leukocytosis
□ Diverticulosis is defined by the presence of multiple
Complications
diverticula without inflammation or sympto ms
□ Prevalence increases with increasing age Acute complications of diverticulitis
• abscess formation
□ Diverticulosis is the most common pathologic
incidental finding on colonoscopy • Tenderness
• palpable mass
• Fever
• leukocytosis
• Bleeding
• peritonitis
Chronic complications of diverticulitis
• fistula formation
• colovesicular fistulas
• colovaginal fistulas

Assessment and Diagnostic Findings

• Colonoscopy
• CBC – elevated WBC
• Urinalysis
 • abdominal CT scan with contrast agent –
Confirmatory
• Abdominal x-rays

Medical Management
Uncomplicated diverticulitis or Hinchey Stage I
diverticulitis
• Diet - clear liquid diet- high-fiber - low-fat
diet
• Analgesic Medication
• Rest
• oral fluids
• antibiotics

Surgical Management Nursing Management

Hinchey Stage III or IV diverticulitis • fluid intake of 2 L/day
• Soft diet
• CT-guided percutaneous drainage
• increased fiber
• IV antibiotics • exercise program
• bulk laxatives - psyllium,
Two types of surgery

1. One-stage resection Intestinal Obstruction

Intestinal obstruction exists when blockage
2. Multiple-stage prevents the normal flow of intestinal contents
through the intestinal tract
Two types
1. Mechanical obstruction
2. Functional or paralytic obstruction
• Obstruction can be partial or complete.
• Most bowel obstructions occur in the small
intestine

Causes of small bowel obstruction

• Adhesions – most common
• tumors,
• Crohn’s disease
• hernias
Causes of large bowel obstruction
occur in Sigmoid colon
• Carcinoma
• Diverticulitis
• inflammatory bowel disorders
• fecal impaction
Clinical Manifestations NURSING MANAGEMENT
1. assessing and measuring the NG output
• crampy pain
2. assessing for fluid and electrolyte imbalance
• Vomiting
• signs of dehydration 3. monitoring nutritional status
• intense thirst, drowsiness, generalized ASSESSING FOR MANIFESTATIONS CONSISTENT
malaise, aching, and a parched tongue and WITH RESOLUTION
mucous membranes • return of normal bowel sounds,
• Distended abdomen • decreased abdominal distention,
• subjective improvement in abdominal pain
ASSESSMENT AND DIAGNOSTIC PROCEDURE and
The approach to small bowel obstruction focuses on: • tenderness, passage of flatus or stool
• confirming the diagnosis
• identifying the etiology Large Bowel Obstruction
• determining the likelihood of • large bowel obstruction
strangulation • accumulation of intestinal contents
• Abdominal x-ray and CT • fluid, and gas proximal to the obstruction
• Electrolyte studies and a CBC
• severe distention and perforation
MEDICAL MANAGEMENT Adenocarcinoid tumors account for the majority of
large bowel obstructions
➢ Decompression of the bowel through an NG
tube resting the bowel in this manner
Clinical Manifestation
Before surgery
• IV fluids • constipation may be the only symptom for
SURGICAL MANAGEMENT weeks
➢ Depends on the cause of the obstruction • Shape of the stool is altered - increasing in
➢ Most common causes of size
obstruction (hernia and • Blood loss in the stool may result in iron
adhesions) deficiency anemia
• Laparoscopy • weakness,
• Open laparotomy • weight loss
 • Anorexia INFLAMMATORY BOWEL DISEASE
• Distended abdomen
• crampy lower abdominal pain Inflammatory bowel disease (IBD) is a group of
• large bowel visibly outlined - abdominal chronic disorders:
wall • Crohn’s disease (i.e., regional
enteritis)
Assessment and Diagnostic Findings • Ulcerative colitis

Medical Management
• Restoration of intravascular volume
• correction of electrolyte abnormalities
• NG aspiration and decompression are
instituted immediately
• Colonoscopy - untwist and decompress the
bowel
• Cecostomy - provides an outlet for
releasing gas and a small amount of
drainage
• rectal tube – decompress
• metal colonic stent - palliative intervention
• colonic stent
• Temporary or Permanent colostomy
• Ileoanal anastomosis - removal of the
entire large bowel

Nursing Management
• monitor the patient for symptoms
• Provide emotional support and comfort
• IV fluids and electrolytes
• preoperative education
• routine postoperative nursing
✓ abdominal wound care.

Difference between SBO and LBO

Crohn’s Disease (Regional Enteritis) Clinical Manifestations
• prominent right lower quadrant abdominal
Crohn’s disease is characterized by periods of
pain
remission and exacerbation.
• diarrhea unrelieved by defecation
• subacute and chronic inflammation of the GI • formation of granulomas
tract wall that extends through all layers • crampy abdominal pain.
• abdominal tenderness and spasm
• can occur anywhere in the GI tract • weight loss, malnutrition, and secondary
• commonly occurs in the distal ileum and the anemia occur
ascending colon
Assessment and Diagnostic Findings
barium study - “string sign” x-ray image of
the terminal ileum
CT scan
• bowel wall thickening and mesenteric
edema, as well as obstructions, abscesses,
and fistulae
MRI
• identifying pelvic and perianal abscesses
and fistulae
Pathophysiology CBC
1. crypt inflammation and abscesses • hematocrit and hemoglobin levels -
2. develop into small, focal ulcers - initial decreased
lesions then deepen into longitudinal and • white blood cell count – elevated
transverse ulcers • erythrocyte sedimentation rate (ESR) -
3. creating a characteristic cobblestone elevated.
appearance to the affected bowel • Albumin and protein - decreased
4. Fistulas, fissures, and abscesses form as the
Complications
inflammation extends into the peritoneum
• intestinal obstruction
5. Granulomas can occur in lymph nodes, the
• stricture formation
peritoneum
• perianal disease
6. skip lesion is a wound or inflammation that
• fluid and electrolyte imbalances
is clearly patchy, "skipping" areas that
• Malnutrition
thereby are unharmed
• fistula and abscess formation
• enterocutaneous fistula – most common
fistula
• Abscesses
• colon cancer

Ulcerative Colitis

Ulcerative colitis is a chronic ulcerative and

inflammatory disease of the mucosal and
submucosal layers of the colon and rectum that is
 characterized by unpredictable periods of • skin lesions (e.g., erythema nodosum), eye
remission and exacerbation with bouts of lesions (e.g., uveitis), joint abnormalities
abdominal cramps and bloody or purulent (e.g., arthritis), and liver disease
diarrhea.

Inflammatory changes typically begin in the

rectum and progress proximally through the
colon.

Assessment and Diagnostic Findings

• Abdominal x-ray
• Colonoscopy - definitive screening test
• Biopsies - histologic characteristics
• CT scanning, MRI, and ultrasound studies -
abscesses and perirectal involvement
• laboratory test - low hematocrit and
Pathophysiology hemoglobin levels , elevated white blood
affects the superficial mucosa of the colon cell count, low albumin levels, electrolyte
• multiple ulcerations, imbalance
• diffuse inflammations, and • C-reactive protein – elevated
• desquamation or shedding of the colonic • antineutrophil cytoplasmic antibody levels
epithelium – Elevated
Ulcerations - Bleeding
• mucosa becomes edematous and inflamed Common intestinal organisms:
• muscular hypertrophy and fat deposits
• abscesses, fistulas, obstruction, and fissures • Entamoeba histolytica,
- uncommon • C. difficile and Campylobacter,
Clinical Manifestations • Salmonella,
• Diarrhea with passage of mucus, pus, or • Shigella, and
blood • Cryptospora species
• Left lower quadrant abdominal pain
Complications
• intermittent tenesmus
• toxic megacolon - colonic distention
• bleeding may be mild or severe, and pallor,
• Perforation
anemia, and fatigue
• Bleeding as a result of ulceration
• anorexia, weight loss, fever, vomiting, and
• vascular engorgement
dehydration, as well as cramping, tenesmus
• highly vascular granulation tissue
• Hypoalbuminemia, electrolyte imbalances,
• Symptoms
and anemia
 • fever, abdominal pain and distention,
vomiting, and fatigue
• colon cancer

Medical Management of Chronic Inflammatory

Bowel Disease
• reducing inflammation
• suppressing inappropriate immune
responses
• providing rest
• Improving quality of life
• preventing or minimizing complications
• Management depends on the disease
location, severity, and complications

Nutritional Therapy Polyps of the Colon and Rectum

• Oral fluids and a low-residue,
• high-protein, A polyp is a mass of tissue that protrudes into the
• high-calorie diet with supplemental vitamin lumen of the bowel. Polyps can occur anywhere in
therapy the intestinal tract and rectum.
• iron replacement − They can be classified as neoplastic or non-
• IV therapy neoplastic
• Cold foods and smoking are avoided • Adenocarcinomas
• Parenteral nutrition may be indicated • mucosal and hyperplastic

Pharmacologic Therapy Clinical manifestations

• Sedatives and antidiarrheal and • depend on the size of the polyp and the
antiperistaltic - minimize peristalsis amount of pressure it exerts on intestinal
• Aminosalicylates such as sulfasalazine tissue
(Azulfidine) - for mild or moderate • Rectal bleeding
inflammation • Lower abdominal pain
• Sulfa-free aminosalicylates - preventing
and treating recurrence of inflammation Diagnostic Procedure
• Antibiotics - metronidazole [Flagyl] – • digital rectal examination
complications • double-contrast barium enema studies
• Corticosteroids – prednisone - reduced or • Sigmoidoscopy
stopped, the symptoms of disease may • colonoscopy
return
DISORDERS OF THE ANORECTUM
• Immunomodulators - used to alter the
• Proctitis
immune response
• Anorectal Abscess
Surgical Management
• Anal Fistula
1. Total Colectomy With Ileostomy
• Anal Fissure
2. Restorative Proctocolectomy With Ileal
• Hemorrhoids
Pouch Anal Anastomosis
• Pilonidal Sinus or Cyst
3. Continent Ileostomy
 Anal Fistula
An anal fistula is a tiny, tubular, fibrous tract that
extends into the anal canal from an opening located
beside the anus in the perianal skin
• Fistulas usually result from an abscess.
• They may also develop from trauma,
fissures, or Crohn’s disease.
• Untreated fistulas may cause systemic
infection with related symptoms

Symptoms
• Purulent drainage or stool may leak
constantly
• passage of flatus or feces from the vagina or
bladder