2. OBJECTIVES
Review anatomy and physiology of the GI tract
Review gastrointestinal intubation and nutrition
• TPN, enteral feedings
Describe the clinical manifestations and management of acute GI
disorders
Identify complications of acute GI disorders & the prevention
and management
3. ANATOMY AND PHYSIOLOGY
Alimentary canal:
Oropharyngeal cavity (anterior to spine, posterior to trachea)
Esophagus
Stomach
Small intestine (ABSORPTION)
Large intestine (ELIMINATION)
Accessory organs:
Pancreases
Liver
Gallbladder
4. Gastroesophageal Junction
• Inlet into stomach
• LUQ
• Stores food & produces digestive
enzymes
Stomach: HCl- acid secretion
• Cardia (main portion)
• Fundus
• Body
• Antrum
• Pylorus (inlet into small intestine)
5. GI Function
Functions of the GI system:
Digestion /absorption of nutrients
Elimination of waste products
Detoxification and elimination of bacteria,
viruses, chemical toxins, & drugs
***Swallowing is a conscious / voluntary process
6. SMALL INTESTINE:
Largest segment of GI tract
-Duodenum (proximal portion)
• Ampulla of Vater
-Jejunum (medial portion) where absorption begins
-Ileum (distal portion)
• Ileocecal valve
• Absorption of nutrients into blood stream thru intestinal wall
• Pancreas secretes enzymes for digestion
• Common bile duct
• ILEOCECAL VALVE: RLQ where bowel sounds are heard best
• Controls passage of digestive material into large intestine
7. LARGE INTESTINE:
Ascending
Transverse
Descending
Sigmoid
Rectum
Anus
Colonoscopy: sigmoid colon descending colon
-assessing for diverticulitis, bleeding, etc.
Reabsorption of water & electrolytes
Elimination of waste products
10. LIVER
More than 400 functions
Vascular functions
Blood storage & filtration
Secretory functions
Bile production
Bilirubin metabolism
Metabolic functions
Carbohydrate, fat & protein metabolism
Clotting factors liver disease = inc. bleeding
Detoxification
Vitamin & mineral storage
LFT: AST/ALT
11. Abdominal Arterial System
BLOOD SUPPLY TO GI TRACT:
• Superior mesenteric artery
• Inferior mesenteric artery
Branch off of thoracic & abdominal aorta
Gastric artery: supplies oxygen & nutrients
12. Portal Venous System
Superior Mesenteric
Inferior Mesenteric
Gastric
Splenic
Cystic
13. GENERAL ASSESSMENT
Health History:
Pain (major reason why pts seek health care)
Dyspepsia / indigestion (upper abdominal distress)
Belching, regurgitation, abdominal fullness
Intestinal Gas
N / V
Change in Bowel Habits / Stool Characteristics (clay-colored, greasy/fatty, etc)
Weight changes / Diet
Medications
Melena (upper GI bleed) / hematochezia
16. PHYSICAL ASSESSMENT
Causes of Decreased Bowel Sounds
Peritonitis
Gangrene
Reflux Ileus
Surgical Manipulation of Bowel
Late Bowel Obstruction
Causes of Increased Bowel Sounds
Early Pyloric or Intestinal Obstruction
Bleeding Ulcers/ Electrolyte Disturbances (blood is
irritating to the GI tract, wants to get rid of it = bloody
stools)
Bleeding Esophageal Varices
Diarrhea
Subsiding Ileus
17. PHYSICAL ASSESSMENT
Percussion
Detects fluid, gas or masses
Tympany: presence of gas
Dullness: presence of a mass, spleen, liver, kidneys
Palpation
Evaluate major organs
Tenderness / Rebound Tenderness (pain felt on release)
Rigidity / Guarding
18. DIAGNOSTICS—
Serum Laboratory Studies:
LFT
BMP / electrolytes
CBC
Magnesium
Phosphorus
Amylase
PT / pTT
CEA protein: not normally detected in blood… can indicate malignancy.
Stool Tests: Occult blood (turns blue presence of blood)
Imaging Studies: abdominal ultrasound (#1, noninvasive) / CT / MRI / PET
Endoscopic Procedures: DIRECT visualization
DNA Testing (BARRIER: insurance won’t pay for it)
19. ENDOSCOPIC PROCEDURES
Upper GastrointestinaI Fibroscopy/ Esophagogastroduodenoscopy (EGD)
• Fasting 8-12 hrs before
Endoscopic Retrograde Cholangiopancreatography (ERCP)
• Gallbladder studies
• FAT FREE DIET
Fiberoptic Colonoscopy
• Virtual Colonoscopy (swallow a pill with a camera in it... Eliminated in stool)
• Sigmoidoscopy
Endoscopy through an Ostomy
• Assess FX of stoma, presence of necrosis, tissue viability (how well it is doing)
20. INTERVENTIONS
Provide pre & post-procedure instruction
Reassurance
Alleviate anxiety
Report abnormal lab values
Assess for adequate hydration
21. INTERVENTIONS
Clear liquid diet or NPO after midnight
Bowel preps / Cleansing enemas
Allergies to Contrast (CT scans, allergies to shellfish or iodine)
Renal Protective Measures:
• Mucomyst, IV bicarb = help isolate free radicals & prevent complications
Conscious sedation – need anesthesia present
-Versed
-Propofol hypoTN
Post-procedure assessments / frequent vitals
22. GI INTUBATION
Decompression reduced N/V
Lavage put water in & pulling it back out…used for active bleeding
• Iced saline lavage for esophageal varices vasoconstriction and dec. bleeding
Diagnose GI Motility Disorders
Administer Medications and Feedings
Treat smaller obstructions:
• NGT/ OGT to decompress stomach
• Prevention of invasive surgery
Compression of Bleeding Sites
Aspiration of Gastric Contents
23. NASOGASTRIC / NASOENTERIC
TUBE FEEDINGS
Meet Nutritional Requirements enteral > parenteral
Low cost
Well Tolerated
Ease of Use
Preserve GI Integrity
Preserve Intestinal & Hepatic Metabolism
Maintain Fat Metabolism & Lipoprotein synthesis
Maintain Normal Insulin / Glucagon Ratios
24. NASOGASTRIC / NASOENTERIC TUBES
Nasogastric Tubes
• Levin (no air vent)
• Gastric or Salem Sump (air vent, low continuous wall suction)
• Sengstaken-Blakemore (SMALL diameter… crushed meds can clog up
tube)
***after administering crushed meds thru gastric tube… need to flush with a
decent amt of saline to PREVENT CLOGGING of the tube.
Nasoenteric Feeding Tubes
• Dobhoff
Gastrostomy
Jejunostomy
25. NGT NURSING INT:
Patient Preparation
Insertion of Gastric Tube: lean forward, give pt sips of water / swallowing.
Make sure lubricant is water souble to prevent aspiration!!! (ex: Vaseline is NOT
water soluble)
Confirm Placement: MUST HAVE AN XRAY
• Inject air, auscultate LUQ (stomach), should hear gurgling.
• Aspirate: are we getting gastric contents back?
Secure the Tube
Monitor Patient / Maintain Tube Function
Oral / Nasal Hygiene
Potential Complications: skin breakdown,
Removal of Gastric Tube: intentional vs accidental
26. Nasogastric Tube
DO NOT place a NGT in a pt with a
history of esophageal varices…
HIGH RISK OF BLEEDING
30. ACUTE GI BLEEDING
Upper GI Bleeding:
Peptic Ulcer Disease (PUD):
Duodenal Ulcers
Gastric Ulcers
Stress Ulcers
• Cushing’s Ulcers:) overstimulation of the vagal nerve (assoaicted with
severe head trauma, brain surgery)
• Curling’s Ulcers: sympathetic response that causes a dec. in mucosal blood
flow ischemia CAUSES: massive burns, shock, anoxia
Esophageal / Gastric Varices (hemorrhoids)
Mallory-Weiss Tear (usually resolves spontaneously)
• Longitudinal arterial hemorrhage
• Forceful episodes of retching / dry-heaving/ vomiting
• Seizures
• Alcoholism
31. Peptic Ulcer Disease (PUD)
Risk Factors:
Smoking / chewing tobacco
H. pylori bacteria
Medications
• NSAID’s
• ASA
• Steroids (administer PPI / antacids)
Alcohol
• Gnawing, burning pain in mid to upper
abdomen
• Between meals or at night
• Bloating
• N/V
• Heartburn
• Severe cases: melena, hematochezia,
coffee-ground emesis, weight loss
32. Types of Peptic Ulcers
Gastric ulcers: Form in the lining of the stomach
Duodenal ulcers: Form in the upper portion of small intestine
Symptoms of gastric and duodenal ulcers
similar, except for when pain occurs
Pain from a gastric ulcer:
• Occurs when food is still in the stomach,
SHORTLY AFTER EATING.
Pain from a duodenal ulcer:
• Occurs when the stomach is EMPTY…several
hours after eating
• Pain may improve after eating.
• Pain may wake you in the middle of the night.
35. Mallory-Weiss Tear
Arterial Hemorrhage
Longitudinal tear
Forceful retching / vomiting
Forceful coughing
Epileptic seizures
Long-term use of NSAID’s / ASA
Excessive alcohol intake
Assess on XRAY
Longitudinal tear = air enters space (can be seen on XRAY)
INT: usually heal on their own, may give PPIs or H2-blockers
36. Esophageal Varices
Portal hypertension distended vessels
Veins become distended & varices develop fragile and prone to rupture
Lower esophagus
Upper portion of stomach
Tend to bleed easily
Enlarged vessels in esophagus
Any chronic liver disease can cause esophageal varices
S&S of acute alcoholism
39. Symptoms
People with chronic liver disease and esophageal varices may have no symptoms
Small amount of bleeding: Dark or black streaks in the stools = Melena
Larger amounts of bleeding type & cross-match pts on admission
• Black, tarry stools
• Bloody stools
• Light-headedness
• Paleness
• Symptoms of chronic liver disease
• Vomiting
• Vomiting blood
• Dec Hgb/Hct
• May be hypotensive if bleeding is severe
TX: PRBCs
0.9% NS if hypotensive
45. MANAGEMENT of UPPER GI BLEEDING
Hemodynamic Stabilization
• Oxygen administration (dec. Hgb & Hct)
• IVF resuscitation
• Colloids
• Blood / Blood products
Gastric Lavage / decompression
• Only use orogastric tube if pt is intubated.
• Nasogastric tube used for A&O pts.
46. Definitive / Supportive Therapies:
Pharmacological Therapies
• Antacids (risk for alkalosis)
• Histamine Blockers
• Proton Pump Inhibitors (PPIs)
• Mucosal Barrier Enhancers especially in H. pylori (Prilosec)
• Antibiotics
MANAGEMENT of UPPER GI BLEEDING
47. Endoscopic Therapies to stop bleeding:
• Sclerotherapy: inject a caustic agent that clots.
• Clips / Band Ligation
• Thermal methods: cauterization
Surgical Therapies:
• Gastric Resections
• BILLROTH I: stomach joined to duodenum
• BILLROTH II: stomach joined to jejunum
• Done with a vagotomy to ↓ amt of stomach
acid production.
MANAGEMENT of UPPER GI BLEEDING
48. ACUTE GASTRIC PERFORATION
Abrupt onset of severe abdominal pain
Abdominal tenderness
Board-like abdomen
Absent bowel sounds
Leukocytosis r/t infection (gastric contents enter peritoneum)
Presence of free air in peritoneum on chest x-ray:
Hole in the stomach air enters peritoneum
Will see presence of air just below the diaphragm—air rises
Gastric decompression
Start on ABX
May require emergent surgery if free air doesn’t spontaneously resolve.
49. BOWEL OBSTRUCTION
Blockage prevents normal flow through intestinal tract
Can lead to ischemia & necrosis.
Mechanical Obstruction:
Intra-luminal pressure on intestinal wall
Intussusception: bowel telescopes on itself
Tumors
Hernias (incarcerated hernia—bowel closes off)
Volvulus
Strictures, adhesions, stenosis
Scar tissues
Functional Obstruction:
Musculature is unable to propel contents forward in the bowel.
Paralytic ileus
Crohns
Diabetes
Neurological disorders (Parkinsons)
Surgical manipulation of bowel
Amyloidosis: protein deposits on internal walls fibrosis
50. SMALL BOWEL OBSTRUCTION
Abdominal distention
↓ venous and arteriolar capillary pressure
Edema, congestion, necrosis to rupture/perforation
Peritonitis
Reflux vomiting
Metabolic Alkalosis
• Loss of Hydrogen, Chloride, and Potassium
Dehydration & Acidosis (if persistent)
• Loss of Sodium and Water
Hypovolemic Shock
51. LARGE BOWEL OBSTRUCTION
Accumulation of intestinal contents, gas & fluid proximal to (above) obstruction
Most common: Adenocarcinoma’s
Severe distention
Can cause a perforation
Dehydration occurs slower (not vomiting)
↑ intrathoracic pressure:
Intestinal strangulation & necrosis
Interrupted blood supply
TX: bowel resection with anastomosis
52. MANAGEMENT
SMALL BOWEL:
Decompression: Nasogastric tube
IVF resuscitation
Electrolyte repletion
Surgical Intervention: depends on cause, duration of obstruction, &
condition of intestine
LARGE BOWEL:
Decompression
IVF resuscitation
Electrolyte repletion
Colonoscopy: untwist affected portion of bowel/ decompress
Surgical Intervention: Cecostomy / Colostomy with stoma.
Colostomy can be reversed.
53. PERITONITIS
Inflammation of the peritoneum
Bacterial Infection
Leakage of abdominal contents into peritoneal cavity
Peritoneal fluid:
Turbid, cloudy
↑ protein, WBCS
Cellular debris & blood
Intestinal hypermotility (small intestine) paralytic ileus
Air & fluid accumulation in the bowel
Pain: Diffuse, Intense, Rebound tenderness
56. MANAGEMENT of PERITONITIS
IVF resuscitation
Electrolyte repletion
Analgesics / Antiemetics (Zofran)
Antibiotic Therapy
Surgical Intervention: Remove infected material & correct the cause
Post-op complications:
• Evisceration / Dehiscence
• first action: cover with saline-soaked sterile gauze, don’t want bowel to dry out)
• Staples with retention sutures, mesh placement to hold organs in place.
• Abscess formation
• Tx: surgical drains/JPs, start on broad-spectrum ABX, culture & sensitivity testing
WASHOUT with liters of fluid: done to prevent recurrent infection & remove as much
infected material out as possible.
57. PANCREATITIS
Inflammation of the Pancreas
Rapid progression
Can reoccur in the same pt.
Due to premature activation of pancreatic enzymes
These enzymes are very corrosive to organs/tissues.
Autodigestion of pancreas
Converts Trypsinogen to active form, trypsin
Most damaging pancreatic enzymes:
Phospholipase A
Digests phospholipids on cell membranes causes cell membrane destruction
Elastase
Digests elastic tissue of vessel walls
Results in hemorrhage & edema
58. ACUTE PANCREATITIS
Mild: Interstitial /Edematous
Areas of fat necrosis in & around pancreas
Resolves in 5-7 days
TX: NPO, pain control
Severe: Necrotizing (destruction of cell membrane)/ Hemorrhagic
(elastase destroys lining of vessels)
Extensive necrosis in & around pancreas
Pancreatic cellular necrosis
Hemorrhage within the pancreas
Associated with local & systemic complications infection/sepsis, MODS
65. SYSTEMIC COMPLICATIONS
Gastrointestinal
Gastrointestinal bleeding
Pancreatic pseudocyst
Pancreatic abscess
Renal
Azotemia
Oliguria
AKI due to hypoperfusion / ↓ CO
Metabolic
Hypocalcemia
Hyperglycemia
Hyperlipidemia
Metabolic acidosis
66. SUPPORTIVE THERAPY
Hemodynamic Stability:
IV Fluids (massive amts, assess for hemodilution, may need to give blood)
Inotropes
Electrolyte repletion
Blood transfusion
Antibiotic Therapy
Respiratory
Renal
Nutrition: enteral or parenteral, monitor total protein & albumin levels
Control Pain!
Opiates
Correct Underlying Cause
(lithotripsy for gallstones, cholecystectomy, gallbladder decompression)
67.
68. ACUTE LIVER FAILURE
Liver Failure:
Unable to perform its many functions
Results from necrosis or decreased blood supply to liver cells
Hepatitis
Inflammation of the liver
Cirrhosis
Chronic disease: liver tissue replaced by fibrotic tissue
Fatty liver disease
Liver cells replaced by fatty cells or tissue
69. LIVER FUNCTIONS
Very vascular organ
Secretory:
• Production / secretion of bile
• Conjugation of bilirubin:
• byproduct of Hgb degradation, enters blood stream bc bound to proteins
Metabolic:
• Metabolism: carbs, proteins, fats (NEED TO BE LIMITED IN LIVER FAILURE, esp. proteins)
• Synthesis: prothrombin, fibrinogen & factors VII, IX, and X (clotting factors)
• Detoxification: hormones, drugs (Tylenol, Dilantin, oral contraceptives, sulfonamides, psych meds.)
Storage:
• Blood
• Glucose
• Vitamins
• Fat
70. EVALUATION OF LIVER FUNCTION
Liver Enzymes
• ALT / SGPT
• AST / SGOT
• Alk Phos
Bilirubin (conjugated/unconjugated)
Coagulation (PT/PTT)
Serum Ammonia
Serum Albumin
71. ACUTE HEPATITIS
Inflammatory liver disease:
• Inflammation of hepatocytes
• Edema
• Interrupts normal blood supply
• Necrosis of healthy cells portal HTN / congestion of portal system
Viral
Liver injury / necrosis
Acute: lasts about 6 months
• Complete resolution of injured hepatic tissue.
• Rapid deterioration to liver failure and death.
72. ACUTE VIRAL HEPATITIS
Hepatitis A: Fecal-oral route
Contaminated food & water
Contaminated raw shellfish
Hepatitis B: Blood / body fluid contact precautions
Chronic infection: Hepatitis & cirrhosis
Contaminated needles / sexually transmitted (STDs)
Vaccine (2 doses)
Hepatitis C: Blood / blood products
Transfusions prior to 1992
IV drug abusers (contaminated needles)
Occupational exposure
Major cause: chronic hepatitis, cirrhosis & hepatocellular cancer
Major indication for liver transplant
73. Acute Hepatitis
Symptoms:
GI pain (RUQ)
Fever, chills
Jaundice (starts in sclera skin)
Severity of jaundice depends on
disease progression.
Caused by accumulation of bilirubin.
N/V
Fatigue
Management:
Rest
Nutritional support
Prevent spread of the virus
74. HEPATIC CIRRHOSIS
Liver enlargement
Portal hypertension
Ascites
Jaundice
Infection / Peritonitis which can lead to…
• Bacteremia
• Bacterial peritonitis
GI Varices r/t portal HTN vasodilates vessels
Edema
• Decreased plasma albumin / total protein
Vitamin Deficiencies & Anemia
Mental Deterioration (hepatic encephalopathy due to build up of
ammonia) TX: lactulose to get rid of ammonia
76. CLINICAL SIGNS & SYMPTOMS
Hepatic Failure
Vague
Weakness
Fatigue
Loss of appetite
Weight loss
Abdominal discomfort
Nausea / vomiting
Change in bowel habits
Clay colored stools, dark urine
Fulminant Hepatic Failure (severe)
Hyperexcitability & asterixis r/t
ammonia build up & hypocalcemia
Insomnia
Irritability
Decreased LOC / coma
Convulsions
Sudden onset high fever
Nausea / vomiting
Chills
Jaundice
77. COMPLICATIONS OF
HEPATIC FAILURE
Hepatic Encephalopathy
• Ammonia
• Nitrogenous wastes
• Asterixis
• Cerebral edema
Portal Hypertension
• Disruption of blood flow
• Dilation of vessels
Esophageal Varices
• Engorgement of esophageal veins
• Rupture: medical emergency
Ascites
• Fluid in abdominal cavity
• Decreased colloid osmotic pressure r/t dec. albumin
• Abdominal compartment syndrome ascites causes compression of abdominal organs.
78. Ascites Management
Medical management:
Bed rest
Sodium & fluid restriction
Diuretics
Paracentesis: complications—organ perforation, hypotension if too much fluid removed, F&E imbalance
• May not remove all the fluid to prevent complications.
• If pt becomes hypotensive…need to administer fluids!
Albumin
Nutritional support
Peritoneovenous shunt – long term management
• LeVeen shunt
• Denver shunt
79. Denver Shunt
• Used for chronic ascites management
• Has pump attached
• Recirculates volume / replete intravascular space
• Retains nutrients
• Inc renal blood flow
• Inc. CO
• Inc. u/o
• Eases WOB and enhances gas exchange
80. Ascites Management
Nursing Management:
Monitor volume status
I&O
Daily weights
Assess respiratory status
Supplemental O2
Assist with procedures to relieve pressure
Paracentesis, thoracentesis, chest tube placement
81. COMPLICATIONS OF
HEPATIC FAILURE
Hepatorenal Syndrome
• Renal failure in the absence of pathology
• Decreasing glomerular filtration rate (GFR)
• Reduced urine sodium
• Presence of azotemia
• Oliguria anuria
• High BUN/creatinine ratio
Sepsis / SIRS
Spontaneous Bacterial Peritonitis
Transposition of bacteria across cell membrane to ascitic fluid.
Mvmt of bacteria across cell membrane into peritoneum.
82. SUPPORTIVE THERAPY
Encephalopathy
• Correct underlying cause
• Control protein intake
• Lactulose / Neomycin / Metronidazole
• Intubation /mechanical ventilation
Hypoglycemia
• Monitor serum glucose
• IV replacement with dextrose.
Metabolic abnormalities
• Monitor serum electrolytes & repletion
• Acidosis: Bicarbonate administration if pH<7.
83. SUPPORTIVE THERAPY
Gastrointestinal Hemorrhage
FFP /platelets to replace clotting factors with Vitamin K
Vitamin K takes longer to work so need FFP as emergent measure.
Antacids / H2 Blockers (lowers hydrochloric acid)
Cerebral Edema
ICP monitoring
IV Mannitol
Barbiturate induced coma to lower metabolism(phenobarbital, esp. if ICP is elevated)
Elevate HOB 30 degrees
84. SUPPORTIVE THERAPY
Hepatorenal Syndrome
• Fluid resuscitation
• TIPS Procedure
• Inotropes
• Low-dose dopamine to increase renal blood flow
• 80% mortality unless they get a Liver Transplant
Spontaneous Bacterial Peritonitis
• Antibiotic therapy
• Third generation cephalosporin for 5-7 days, until
ascitic fluid cell count normal
