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o bj e c t i ve S After studying this chapter, the learner should be able to:

1 Explain' e fun ·ons of the mouth, esophagus, stomach, gallbladder, biliary ductal system, ex-
ocrine panaeas, and intestines.
Discuss e physiological changes that occur in the gastrointestinal system in response to aging.
Rela e e s bie ·'e and objective data components of the nursing assessment of the gastroin-
testinal sys em.
Differemia e various data that may be obtained from the diagnostic tests used for problems of the
gasuoin estinal uact.
Explain the nursing responsibilities associated with common diagnostic tests used for problems of
the gasuointestinal tract.

The gasuointestinal (GI) system, also termed the digestive sys- the GI system can perform the function of the teeth in their
tem and alimentary canal, consists of the GI tract and its acces- absence.
sory organs. ts primary function is to convert ingested nutri- The lubrication of food is accomplished by the action of
ents and uids into a form that can be used by the ceils of the the watery and mucous secretions of the salivary, parotid, sub-
body. This oal is accomplished through the processes of inges- lingual, and submandibular glands of the mouth. Saliva also
tion, digestion, and absorption. The second major function of contains ptyalin (amylase), which hydrolyzes starch to mal-
the GI system is the storage and final excretion of the solid waste tose. Small amounts of saliva, which contain 19A antibodies to
produets of digestion. Proper functioning of the GI system is es- many normal environmental microorganisms, are produced
sential to the maintenance of proper nutrition and health. continually to keep the tissues of the mouth moist and dean.
After chewing and moistening are completed, the muscular
ANATOMY ANO PHYSIOLOGY tongue pushes the food bolus back to the pharynx to initiate
swallowing (deglutition).
The upper portion of the GI tract consists of those structures
that aid in the ingestion and digestion of food. They indude ESOPHAGUS
the mouth, esophagus, stomach, and duodenum, plus the re- The esophagus begins at the lower end of the pharynx. It is a
lated organs of the biliary system and exocrine pancreas. The hoilow, muscular tube 10 inches (25 cm) in length that lies be-
lower GI traet consists of the small and large intestines, the hind the trachea, passes through the thorax, and connects the
reetum, and the anus. The structures of the GI system are il- mouth and stomach. The upper third is composed of skeletal
lustrated in Figure 38-1. The GI system is primarily composed muscle, and the lower two thirds are smooth muscle. Both
of a hoilow, muscular tube approximately 9 m (30 feet) in ends of the esophagus are protected by sphincters that help
length that stretches from the mouth to the anus. prevent the reflux of gastric contents. Both sphincters are
Although the tube is located within the body, it is really an normally closed, except during the act of swailowing.
extension of the external environment. The walls of the GI The primary function of the esophagus is to move the food
tract successfully prevent most harmful agents from entering bolus by peristalsis from the pharynx to the stomach. No en-
the body. The walls also prevent the escape of essential body zymes are secreted by the esophagus, and only mechanical di-
fluids and materials. The composition of the walls is predom- gestion takes place. The secretion of mucus assists in the
inantly smooth musde; however, the mouth and upper esoph- movement of the food bolus and protects the walls of the
agus, along with a portion of the rectum and anus, consist of esophagus from abrasion by partially digested food.
voluntary musde. Swallowing is a complex physiological mechanism that
must be accomplished without compromising respiration.
MOUTH It consists of three phases: (1) the voluntary phase, in which
The mouth is made up of the lips, cheeks, tongue, hard and the tongue forces the bolus of food into the pharynx; (2) the
soft palates, teeth, and salivary glands (Figure 38-2). These involuntary pharyngeal phase, in which the food moves into
structures begin the digestive process by mechanically break- the upper esophagus; and (3) the esophageal phase, during
ing down and lubricating the food. Because digestive enzymes which food moves from the pharynx down into the stomach.
can function only on the exposed surfaces of food particles, The esophageal musdes are activated by the glossopharyngeal
the teeth begin the breakdown of food. No other portion of and vagal nerves, which create rhythmic peristaltic waves that

1235
- 1236 unit viii ALTERATIONS IN DIGESTION AND ELlMINATION

Upper lip

Tongue
Parotid
Pharynx
gland
Hard palate

Larynx 50ft palate

Palatine Uvula
fossa

Liver
(Ieft lobe)

Stomach
Diaphrogm
Spleen

Sublingual gland Submandibulor gland

figo 38-2 The structures of the mouth.


Ascending colon

Cecum
ate protein digestion. This highly acidic pH also serves as a pro-
Appendix Sigmoid
colon teetive barrier, destroying most ingested microorgansims. Gas-
Rectum tric acid secretion is under the control of parasympathetic stim-
Anus
ulation via the vagus, as is the secretion of gastrin and histamine.
Gastrin is a hormone secreted from endocrine cellsin the gastric
figo 38-1 The organs of the gastrointestinal system
and related structures. glands of the stomach in response to vagal stimulation and me-
chanical distention of the stomach. The secretion of histamine
2 (HJ also increases gastric acid secretion. Approximately 2.0 to
propel the food toward the stomach. Food is prevented from 2.5 L of gastric secretions are produced each day.
passing into the trachea by the closing of the epiglottis and the The gastric mucosa is covered by a thick mucous gellayer
opening of the esophagus. produced by the densely packed epithelial cells of the mucosa.
The mucous layer is almost completely impermeable to hy-
STOMACH drogen ions. The mucosal epithelial cells also secrete bicar-
The stomach is roughly J shaped and lies in the upper ab- bonate, which acts as a buffer and helps neutralize the acidic
domen to the left of midline. It is positioned to the left of the secretions. The combined aetions of these two mechanisms
liver, to the right of the spleen, and posterior to both organs. are so effective that, although the gastric secretions have a pH
It is a muscular pouch whose shape changes with its contents. of less than 2, the intraluminal pH of the mucosa is main-
Its three major regions are the fundus, body, and antrum. The tained at about 7.'9
cardiac sphincter protects the opening from the esophagus, Gastric emptying is controlled by both hormonal and auto-
and the pyloric sphineter protects the exit to the duodenum. nomic nervous system activity.Parasympathetic stimulation by
The ruga e, or longitudinal folds, of the stomach enable it to the vagus nerve increases both peristalsis and secretion. Sympa-
quadruple in size and increase from a resting volume of 50 ml thetic stimulation inhibits them. The peristaltic contractions of
to a capacity of approximately 1500 ml for food digestion the stomach propel the chyme toward the antrum and occur at
without major changes in pressure. The stomach has an outer a frequency of about three to tive contractions per minute. The
serous layer and three layers of smooth muscle. The outermost pylorus eloses during antral contraction, and larger food parti-
layer of smooth musele is longitudinal, the middle layer is cir- eles are propelled back toward the body of the stomach for fur-
cular, and the inner layer is oblique (Figure 38-3). The rugae ther mixing. Gastric contents are emptied into the duodenum
are found on the inner mucosallayer. between peristaltic contractions. Although the pylorus is not a
The stomach primarily serves as a reservoir but also has di- true anatomical sphincter, it does help prevent the backflow of
gestive and secretory functions. Food is stored in the stomach duodenal contents and bile salts into the stomach.13
until partial1y digested. The fundus contains chief cells, which
secrete digestive enzymes, and parietal cells,which secrete wa- GALLBLADDER ANO BILlARY
ter, hydrochloric acid (HCl), and the intrinsic factor that is es- DUCTAL SYSTEM
sential for the absorption of vitamin B,2• The HCl is responsi- The gallbladder is a pear-shaped organ that lies on the inferior
ble for the highly acidic medium of the stomach (pH of surface of the liver. It is composed of serous, muscular, and
0.9 to 1.5), which is needed to activate the enzymes that initi- mucous coats and has a usual capacity of 50 ml, although it

L
Assessment of the GastrointestinaJ. Biliary, and Exocrine Pancreatic Systems chapter38 1237

Lower esophageal
sphincter

----- Fundus

Gastroesophageal opening

Serosa
Longitudinal muscle layer}
If Circular muscle layer Muscularis

Duodenol
y Oblique muscle layer
bulb

Antrum Rugae

figo 38-3 The stomach.

can increase in size under normal conditions. Innervation of PANCREAS


the gallbIadder is from the parasympathetic and sympathetic The pancreas is an elongated, flattened organ located in the
nervous system. The cystic duct connects the gallbIadder with posterior abdomen, with its head Iying within the curve of the
the remaining structures of the ductal system-the hepatic duodenum and its tail resting against the spIeen. The pancreas
ducts and common bile duct. has both exocrine and endocrine functions. The exocrine
The major function of the gallbladder is to store and con- functions are carried out by the acini cells and duct system,
centrate bile. Bile,which is formed in the liver,is excreted into and the endocrine functions are carried out by isIets of
the hepatic ducts, which unite to form the common bile duct. Langerhans cells (Figure 38-4). Exocrine functions will be dis-
It passes behind the pancreas, is joined by the pancreatic duct, cussed in this chapter. The endocrine functions have been pre-
and empties into the duodenum. The sphincter of Oddi viously discussed in Chapter 35.
regulates the flow of bile into the duodenum. A second The pancreas is divided into three parts, which are com-
sphincter is Iocated above the junction with the pancreatic posed of Iobules. The lobules are formed from groups of se-
duct and controls the flow of bile in the common bile dueto cretory cells termed acini, which drain into a ductal system
When this sphincter is closed, bile moves back into the gall- that ultirnately reaches the main pancreatic duct of Wirsung.
bIadder, where it is concentrated fivefold to tenfold. Because This major duct extends the entire Iength of the gland. At the
bile can be released direct1yinto the duodenum from the liver, head of the pancreas the ductal secretions enter the duode-
the gallbIadder is not essential to life. Bilesalts facilitate fat di- num thIOugh the ampulla of Vater. The sphincter of Oddi
gestion by emulsifying fats for action by intestinal lipases controls its opening.
and facilitate the absorption of fats, fat-soluble vitamins, and AppIOximately 2 L of pancreatic secretions are produced
cholesterol. daily. The ductal epithelium produces a balanced electrolyte
The release of bile from the gallbladder or liver is con- secretion, and the acini secrete digestive enzymes in an inac-
tIOlled by cholecystokinin (CCK). Approximately 600 to tive precursor state. The pancreatic secretions contain prote-
800 ml of bile is pIOduced daily.The CCK is released from the olytic enzymes, which break down pIOtein; pancreatic amy-
walls of the duodenal intestinal mucosa when lipids, amino Iase, which breaks down starch; and lipase, which hydrolyzes
acids, and hydrogen ions enter the duodenum from the stom- fat into glycerol and fatty acids. The pancreatic acini also
achoIt travels by the bIood to the galIbIadder and causes con- produce an enzyme inhibitor that prevents the activation of
traction of the galIbIadder's smooth musculature and relax- the secretions until they reach the duodenum. The produc-
ation of the sphincter at the end of the common bile duct tion of the pancreatic secretions is controlled by the action
(the sphincter of Oddi), so that bile can be emptied into the of the parasympathetic nervous system, gastrin, and hor-
duodenum. mones released from the duo denum during digestion.
Most of the bile salts are reabsorbed from the intestine into
the enterohepatic circulation and returned to the liver, where INTESTINES
they can be recircuIated. The system is so efficient that only The small intestine is about 2.5 cm (1 inch) wide and 6 m
15% to 25% of the bile salt pool needs to be replaced by the (20 feet) long and fills most of the abdomen. It consists of
liver each day. three parts-the duodenum, which connects to the stomach;
, 238 unit viii ALTERATIONS IN DIGESTION AND ELlMINATION

Accessory
pancrealic Pancrealic duct
A dud (dud of Wirsung)

Duodenum
Lesser
duodenal
papilla
Hepalo'
pancrealic
ampulla
Sphincter
ofOddi
Grealer
duodenal

r
apilla
(o Valer) plicae
circulares

Head of
pancreas

To
duodenum Vein Acini cells
To bloodslream (secrele enzymes)

fig.38-4 A, The pancreatic ductal system. B, Note both the endocrine and exocrine glan-
dular cells of the pancreas.

the jejunum, or midclle portion; and the ileum, which con- bile and pancreatic secretions to enter the intestine. Mucus-
nects to the large intestine (see Figure 38-1). producing glands are concentrated where gastric contents are
The large intestine is about 6 cm (2.5 inches) wide and emptied and digestive secretions enter the duodenum. The
1.5 m (5 feet) longo It also consists of three parts-the mucus helps protect the duodenum from the acids in the gas-
cecum, which connects to the small intestine; the colon; and tric chyme and the actions of the digestive enzymes.
the rectum. The ileocecal valve prevents backward flow of Digestion begins in the mouth and stomach, but it takes
fecal contents from the large intestine to the small intestine. place primarily in the small intestine. The intestinal mucosa is
The vermiform appendix, which has no known function, is impermeable to most large molecules, so proteins, fats, and
an appendage close to the ileocecal valve. The colon is sub- complex carbohydrates must be broken down into small par-
divided into four sections-the ascending, transverse, de- ticles before they can be absorbed. The intestinal mucosa also
scending, and sigmoid colons. The points at which the colon secretes surface enzymes that aid in digestion and about 2 L
changes direction are named for adjacent organs-the liver per day of serous fluid that acts as a diluting agent to facilitate
(hepatic flexure) and the spleen (splenic flexure). The rec- absorption.
tum is 17 to 20 cm (7 to 8 inches) long, ending in the 2 to Carbohydrate digestion, which begins in the mouth, is
3 cm anal canal. The opening of the anus is controlled by completed in the small intestine as disaccharides are broken
a smooth muscle internaI sphincter and a striated muscle down into monosaccharides (glucose, fructose, and galactose)
external sphincter. by the action of intestinal enzymes and pancreatic amylase.
Table 38-1 summarizes the major digestive enzymes. The Protein digestion, which begins in the stomach, is completed
actions and stimuli for secretion of the major gastrointestinal as polypeptides are broken down into peptides and amino
hormones are presented in Table 38-2. acids by the action of pancreatic trypsin. Fat digestion is ac-
complished by emulsification into small droplets by the action
Small Intestine of bile and pancreatic lipase. The droplets are then further
The primary functions of the small intestine are the digestion broken down into glycerol and fatty acids. The release of di-
of food and the absorption of nutrients. This process occurs gestive secretions is stimulated by the hormones secretin and
primarily in the jejunum and ileum. The duodenum contains cholecystokinin (CCK) (also called pancreozymin), as well as
the opening for the bile and pancreatic ducts, which allow by the action of the parasympathetic nervous system.
1$6$!:"
Assessment of the

Digestive Enzymes
Gastrointestinal, Biliary, and Exocrine Pancreatic Systems chapter 38 1239
I
I
I

SOURCE ACTION
MOUTH
Pytalin (salivary amylase) Breaks starch into maltose (polysaccharides to disaccharides)

STOMACH
Gastric pepsin Breaks protein into polypeptides

Gastric lipase Digests butterfat

PANCREAS
Pancreatic amylase Breaks starch into maltose (polysaccharides to disaccharides)
Trypsin Splits polypeptide chains
Pancreatic lipase Splits emulsified fat into monoglycerides

SMALL INTESTINE
Maltase Breaks maltose into glucose
Dextrinase Breaks alpha-limit dextrin to glucose
Lactase Breaks lactose into galactose and glucose
Sucrase Breaks sucrose into glucose and fructose
Enterokinase Activates trypsin
Peptidases Splits polypeptides into amino acids
Intestinal lipase Splits neutral fats into glycerol and fatty acids

1$6$!:') Major Gastrointestinal Hormones

HORMONE ACTlON STlMULUS FOR SECRETlON


Gastrin Stimulates secretion of gastric acid and pepsino- Secreted from antrum of stomach and duodenum in
gen; increases gastric blood flow; stimulates response to vagai stimulation, epinephrine, solu-
gastric smooth muscle contraction and motility tions of calei um saits, and alcohol; inhibited by an
antral stomach pH of less than 2.5
Secretin Stimulates secretion of bicarbonate-containing Secreted by duodenum in response to low pH chyme
solution by the pancreas and liver; inhibits gas- (Iess than 3.0) entering the duodenum
tric acid secretion and motility
Cholecystokinin Stimulates the contraction of the gallbladder Secreted in duodenum and jejunum in response to
and the secretion of pancreatic enzymes; slows the presence of fatty and amino acids
gastric emptying
Enterogastrone Inhibits gastric secretion and motility; relaxes Secreted in duodenum in response to the presence
sphincter of Oddi of partially digested proteins and fats

The inner mucosal surface of the small intestine is cov- testine. Slow contractions move the chyme back and forth in
ered with millions of villi, which are the functional units for small segments of the intestine (l to 4 em). This movement
absorption. Each villus is equipped with a blind-end lymph mixes the chyme and facilitates digestion and absorption. Seg-
vessel (lacteal) in its center, which is surrounded by capillar- mental peristaltic movements increase after meals. The
ies, venules, and arterioles (Figure 38-5). These structures propulsive peristaltic movements involve intestinal segments
bring blood to the surface of the intestine and provide a of 10 to 20 cm in length.19 Contraction occurs in the proximal
network for absorption into the portal blood or lymphatic segment, with relaxation in the distal segmento Chyme ad-
system.13 Ninety percent of absorption occurs within the vances slowly and normally takes 3 to 10 hours to move
small intestine by either active transport or diffusion. Active from the stomach to the colono Parasympathetic stimulation,
transport requires a metabolic energy expenditure and is primarily through branches of the vagus nerve, increases
used to absorb amino acids, monosaccharides, sodium, and peristaltic activity. Sympathetic stimulation is primarily
calcium. Fatty acids and water diffuse passively, primarily inhibitory.
into the lymphatics.
The contents of the small intestine (chyme) are propelled Large Intestina
toward the anus by regular peristaltic movements. Both seg- Minimal chemical digestion takes place in the large intestine.
mental and propulsive movements occur. The segmental It functions primarily to absorb water and electrolytes from
movements involve primarily the circular muscles of the in- the chyme and store the food waste (feces) until defecation.
-
I , 240 uni1: viii ALTERATIONS IN OIGESTION ANO ELlMINATION

nizant of the changes and incorporate appropriate modifica-


tions when planning care for the elderly population. Addi-
Epilhelium
ofvillus
tionally, problems associated with other chronic illnesses such
as diabetes require careful consideration because they are usu-
ally more important than the effects of aging itself.
Venule
In the mouth, teeth darken and may loosen or fracture, and
the gums recede. Salivary gland output decreases, which
Lacteal
causes mouth dryness and increased susceptibility to infection
and tissue breakdown. Aging causes decreased motility and
strength of peristalsis in the esophagus, but these changes ap-
Arteriole . Copillory pear to have minimal significance in healthy persons. Some
• deterioration in the lower esophageal sphincter may increase
the frequency of esophageal refluxoI
Gastric motility and emptying diminish slightlybut progres-
sivelywith age, and gastric acid secretion also decreasessteadily
afier age 50. AcWorhydria (absence of free HCI) is relatively
common. These changes can produce minor problems in diges-
tion but are usually asymptomatic. Chronic gastritis is common
in elderlypersons, but the condition is usually the result of bac-
terial colonization by Helicobader pylori and not aging.2
figo 38-5 The intestinal villus. Note the circulatory No significant changes in biliary system morphology are
vessels surrounding the lacteal. which drains into associated with aging. However, the composition of the bile
the Iymphatic system.
becomes increasingly lithogenic (likely to produce calculi),
possibly related to an increase in biliary cholesterol; therefore
Reabsorption occurs predominandy in the right or ascending the incidence of gallstones increases with each deeade.'
colonoThe colon can absorb 6 to 8 times more fluid than is de- The pancreas exhibits ductal hyperplasia and fibrosis with
livered to it daily, and only approximately 100 ml of fluid is aging, but these changes are not necessarily associated with al-
left in the colon to be mixed with the fecal residue. tered functioning. The output of pancreatic secretions steadily
The large number of microorganisms found in the large in- declines afier age 40, but related problems with absorption
testine further break down the residual proteins that were not have not been documented.
digested or absorbed in the small intestine. The breakdown of Aging-related changes in small intestinal function are im-
amino acids produces ammonia, which is converted to urea by portant and can lead to poor nutrition even with adequate in-
the liver. These intestinal bacteria also play a vital role in the take. Nutrient absorption is impaired, particularly the absorp-
synthesis of vitamin K and some of the B vitamins. The only tion of carbohydrates. Absorption of water-soluble vitamins
significant secretion of the colon is mucus, which protects the remains intact, but the absorption of vitamin D is defective in
walls and helps the fecal matter adhere into a mass. many elderly persons, and the active transport of calcium is
Approximately 450 ml of chyme reaches the cecum each also impaired. Decreased production of secretory IgA can lead
day. The transit time in the large bowel is slow, taking about to an increase in the frequency and severity of infections.4
12 hours to reach the rectum. The fecal contents in the colon Chronic constipation is one of the most common com-
are pushed forward by mass movements that occur only a few plaints in elderly persons. Yet,the segmental mass movements
times each day. These mass movements are stimulated by gas- and contractions of the large intestine have been found to be
trocolic reflexes initiated when food enters the duodenum unchanged as long as the individual remains physically active.
from the stomach, especially afier the first meal of the day. The incidence ofboth diverticula and polyps in the colon rises
The rectum is well innervated with sensory fibers. with age. There is a decrease in elasticity in the rectum and a
Parasympathetic fibers are responsible for the contraction of steady decrease in the rectal volume, which can result in
the rectum and relaxation of the internal sphincter of the sphincter failure. However, the sensation of rectal fullness re-
anus. The defecation reflex occurs when feces enter the rec- mains intact, and most problems with bowel incontinence in
tum. Afferent impulses are transmitted to the sacral segments elderly persons are not attributable to the effects of aging.'
of the spinal cord; subsequendy, reflex impulses are transmit-
ted back to the sigmoid and rectum, initiating relaxation of
SUB..JECTIVE DATA
the internal anal sphincter.
A thorough health history is necessary to adequately assess the
PHYSIOLOGICAL CHANGES WITH AGING health status of persons with potential dysfunction of the GI
Gastrointestinal complaints are extremely common in elderly system.
persons. Distinct changes occur in the GI system with aging,
although these changes are incompletely understood. Al- PATIENT/FAMILV HISTORY
though most of the aging-related changes do not interfere The nurse asks the patient about previous GI problems, hospi-
with normal functioning, it is important for nurses to be cog- talizations, and surgeries. This includes past and current med-
Assessment of the Gastrointestinal. Biliary, and Exocrine Pancreatic Systems cha,ner38 1241

Liver

Heart
Penetrating
duodenal
ulcer
Biliary colic
Cholecystitis, Cholecystitis
pancreatitis,
duodenal ulcer
Pancreatitis,
Appendicitis renal colic

Colon pain Rectallesions


Ureteral
colic

fig.38-6 Common sites of referred pain. Note that the pain's location may not be directly
over or even near the site of the organ.

ication use, both over-the-counter and prescribed. The use of in response to those stressors. Open-ended questions are most
antacids and laxatives is particu1arly important. The nurse in- effective for exploring beliefs and feelings about food.
quires about the presence of GI problems in the nuclear or ex- Complete nutritional assessment includes an evaluation of
tended farnily,including cancer and disorders such as inflam- the patient's use of sugar and salt substitutes, coffee, alcohol,
matory bowel disease,which have a docurnented hereditary link. and tobacco (both chewing and smoking). The presence of
dentures is an essential consideration because dentures may
DIET ANO NUTRITION significantly influence food selection and chewing.
The adequacy of the diet, in terms of both quality and quan-
tity, can be quickly estimated through comparison of the diet ABDOMINAL PAIN
with recommended food intake pattems. The nutritional as- Although pain is not an early or cornrnon manifestation of GI
sessment has particular significance in GI disorders, because disease,it is frequentlythe reason individuals seek medical atten-
it may reveal changes in eating pattems that are characteris- tion. The nurse assessesits onset, duration, character, location,
tic of specific illnesses or disorders. The nutritional assess- and relationship to meals,stressfulevents, or activity.Pain may be
ment includes an exploration of usual eating pattems and any experienced anywhere along the length of the GI tract in a spe-
changes that may be the result of illness or specific syrnptoms. cificlocalizedpattem, a generalnonspecific pattem, or referred to
The assessment explores changes in appetite, food preferences another somatic or skeletalregion that shares the same nerve in-
and intolerances, food allergies, planned and unplanned nervation8 (Figure 38-6). Abdominal pain may be continuous,
changes in weight, adherence to special or therapeutic diets, episodic, or associatedwith eating. The pain sensation is thought
and the use of dietary or vitamin supplements. A 24-hour di- to arise from the distention or sudden contraction of a hollow
etary recall may be a useful tool to approximate caloric and viscus; therefore local stretching or traction on pain-sensitive
specific nutrient intake and analyze the overall adequacy of structures will elicit the pain stimulus. The painful area may
the diet. Syrnptoms related to food intake should also be care- demonstrate local muscle guarding, which serves as a protective
fu1lyassessed. Changes in appetite and the presence of such mechanism as the overlyingmuscles contract. The pain associ-
syrnptoms as dysphagia, nausea, and discomfort are carefully ated with pancreatic or biliary dysfunction is usualiy severe.
explored. Abdominal pain or discomfort may be reported as heart-
Lifestyle,economic, and cultural factors affecting nutrition bum, indigestion, or stomachache and requires further clari-
are also assessed. Food has multiple social and emotional val- fication. The pain may interfere with chewing or swallowing
ues for individuals that are distinct from its role in nutrition. food. Specific foods, such as those that are spicy, very hot, or
Financial resources, access to food preparation and storage fa- very cold; alcohol; or smoking may initiate or aggravate the
cilities,and religious or social beliefs mayali influence both the pain. Abdominal pain may have been self-treated with a vari-
quality and quantity of the diet. Lifestyle factors can have a di- ety of over-the-counter preparations.
rect or indirect effect on GI function. Gastrointestinal syrnp- The term indigestion is commonly used by patients to de-
toms commonly develop in response to life stressors or worsen scribe heartburn (usually the result of reflux), uncomfortable
'242 unit viii ALTERATIONS IN OIGESTION ANO ELlMINATION

fullness or distention after meals, ar the excessiveproduction may result from erosion of the mucosa, leading to perforation
of flatus (gas). The nurse clarifies the patient's use of the term of the muscle wali or rupture of a blood vessel.
and the nature of the symptom.
Abdominal pain is commonly associated with other symp- OBJECTIVE DATA
toms that the nurse explores. Difficulties in swaliowing (dys-
phagia) may accompany disorders of the esophagus. Nausea Information gained from the physical assessment helps the
and vomiting are commonly associated with GI problems, and nurse establish the patient's needs and develop an appropriate
the nurse assesses far onset, frequency, duration, patterns of plan of care. The history and physical exarnination by the
occurrence, relationship to meals, quantity, and description of physician or nurse practitioner should be used when available
the emesis. Emesis may contain blood. "Coffee-ground" eme- to avoid unnecessary duplication.
sis may indicate old bleeding in the stomach. The presence of
bile produces a green color and has a bitter taste. MOUTH
Assessment of the mouth provides data indicating the patient's
FATIGUE ANO WEAKNESS ability to salivate, masticate, and swallow.A tongue blade and
Persons with GI system problems often complain of fatigue or penlight are needed, and gloves should be worn for ali exami-
weakness. Inadequate nutrient intake, abnarmal fluid and nations of the mouth. In certain situations, a mask and eye
electrolyte status, and increased metabolic demands may ali shield may also be appropriate. The lips are observed for sym-
contribute to the problem. It is important for the nurse to care- metry, color, moisture, swelling, cracks, or lesions. If asymme-
fully consider other problems that may be contributing to the try is noted, the ability to masticate and swallow is assessed.
symptoms, ineluding cardiac, respiratory, renal, and other The lips are normally reddish in color and are good indica-
metabolic disorders. These complaints may be present in a tors of paliar or cyanosis. Dryness may indicate dehydration.
wide variety of situatiollS,but their careful assessment is essen- Swelling is usually the result of an inflammatory response.
tial for planning an overali approach to care. Resolution of Cracks or fissures can occur with overdryness, exposure to
these problems usually takes time. Fatigue and weakness may cold, poorly fitting dentures, or a riboflavin deficiency.When
also contribute to weight loss, particularly when associated cracks occur in the corners of the mouth they are referred to
with persistent anorexia, nausea, vomiting, or abdominal pain. as angular stomatitis.
Lesions on the lips may be benign or malignant. A com-
ELlMINATION PATTERNS monly encountered benign lesion is herpes simplex (cold sore,
Patterns of bowel elimination vary significantly among fever blister), which is caused by a virus and can create enough
healthy individuals, and these patterns are commonly altered discomfort to limit mastication. The enamel surface of the
by GI system disarders. The nurse assesses the individual's teeth should be white but will darken with surface stains (tea,
usual elimination pattern and explores any changes that have coffee, tobacco). Commonly found abnormalities of the teeth
occurred. The use of laxatives, suppositories, or other prod- inelude caries, loose or broken teeth, and absence of some or
ucts to support bowel elirnination is carefully assessed. ali teeth. The gums-or gingivae-are normaliy pink, attach
Changes in the normal pattern of bowel elimination may to the teeth, and fill the interdental surfaces. If the person is
represent a physiological alteration, a pathological condi· partially or completely edentulous (without teeth), the gingi-
tion, ar simply a change in normal diet and activity patterns. vae are examined for areas of redness caused by improperly
Constipation-defined as the presence of smali, hard stools fitting dentures, partial plates, or implants. The person is then
that are passed with difficulty at infrequent intervals-is a elas- asked to insert the dentures to assess correct fit and comfort
sic example. It may be a temporary response to inactivity and for adequate mastication. Recession of the gum line is not un-
a diet change or a sign of bowel obstruction. Diarrhea and common in older individuals.
stools containing mucus, pus, and possibly undigested food The buccal mucosa is light pink, although patchy pigmen-
may indicate enteritis or invasion by a parasite. Partial ob- tation is seen in dark-skinned individuals. The mucosa is ex-
struction of the descending colon may produce smali, ribbon- amined for moisture, white spots or patches, debris, areas of
shaped stools, whereas no stool is passed if obstruction is com- bleeding, or ulcers resulting from ill-fitting dentures or braces.
plete. Constipation may also result from the administration of Dryness and debris may indicate dehydration. White, curdy
narcotics that slow peristalsis, and diarrhea can be the result of patches-which are removable with some effort-may be
surgical interventions that remove significant bowel segments. caused by candidiasis (thrush). White, nonremovable patches
Vvhen fat absorption is abnormal, steatorrhea (bulky, foul- (leukoplakia); white plaques within red patches; or red, gran-
smeliing, fatty stools) may occur. Ifbiliary obstruction is pres- ular patches may be premalignant lesions and should be re-
ent, the patient may give a history of elay-colored (grayish) ported to the physician. A round or oval white ulcer sur-
stools. Bright red blood in the stool indicates lower GI bleed- rounded by an area of redness is indicative of an aphthous
ing. Blood from the upper GI tract is changed by digestive se- ulcer (canker sore). (See Chapter 39.)
cretions, and the stool appears black and stid ..y (tarry). Some- When the tongue is depressed with a tongue blade and the
times the presence of blood in the GI tract acts as a powerful person says "Ah;' the soft palate is observed for symmetry and
cathartic and may produce abrupt, severe diarrhea. Blood in the effectivefunctioning of cranial nerve X (necessary for effec-
the stool (melena) may be a recent or a chronic symptom and tive swaliowing). The uvula, soft palate, tonsils, and posterior
Assessment of the Gastrointestinal, Biliary, and Exocrine Pancreatic Systems chapfer 38 1243

pharynx are observed for signs of inflammation. Tongue mo- small pillow under the head can help the patient relax the ab-
bility and function are essential to mastication, taste, and swal- dominal muscles and make palpation easier. Good lighting
lowing. :-;rormally,there is no limitation to movement in any di- should be available.
rection, but the tongue will deviate to the paralyzed side with
paralysis of the twelfth cranial nerve (hypoglossal). A thin, Inspection
white coating and presence of large papillae on the dorsum of The skin of the abdomen is inspected for color, texture, scars,
the tongue are normal findings, A thick coating indicates poor rashes, lesions, symmetry, contour, and visible peristalsis. The
oral hygiene, and a smooth, red surface suggests a nutritional abdomen is normally flat but will be rounded in an obese per-
deficiency.The ventral surface is exarnined for leukoplakia, ul- son and may appear scaphoid in the thin or emaciated person.
ceration, or nodules, any of which may indicate malignancy. The integrity and turgor of the skin are reliable indicators of
Any distinctive odor of the breath is noted. A foul odor total body hydration.
may occur afier the ingestion of certain foods, with poor hy- Abdominal distention may be caused by air or fluid in the GI
giene or oral infections, and with some metabolic dysfunc- tract or fluid in the peritoneal space (ascites). Air may coliect
tions such as diabetic ketoacidosis, liver disease, and bowel ob- from swallowingor from gas produced by bacterial action in the
struction. ~ormally the mandible will slide forward and down boweL Decreased peristalsis prevents the accumulated air from
without difficulty, and a "cracking" sound is audible when the moving through the GI tract. Fluid may also accumulate from
mouth is opened widely. The interior of the mouth should decreased peristalsis and be a symptom of partial or complete
also be carefully exarnined with a gloved finger to check for bowel obstruction. Ascites usually results from increased portal
areas of tendemess, ulcers, and lumps. hypertension secondary to liver or heart disease.
Measurement of abdominal girth provides a baseline for
ABDOMEN the evaluation of any increase or decrease in size related to dis-
Examination of the abdomen determines the presence or ab- tention. A measuring tape is placed around the abdomen at
sence of (1) tendemess, (2) organ enlargement, (3) masses, (4) the level of the umbilicus or 2.5 cm below, and the reading is
spasm or rigidity of the abdominal muscles, and (5) fluid or taken, It is important to lightly mark the site for measurement
air in the abdominal cavity. Physical examination of the ab- on the patient's skin with a waterproof pen so that ali subse-
domen is performed in the following order: inspection, aus- quent measurements are taken at the same leveI for accurate
cultation, percussion, and palpation, Auscultation is per- evaluation.
formed before percussion and palpation, because the latter Inspection will incorporate assessment for the presence of
two may alter the frequency and intensity of bowel sounds. jaundice, which is a common symptom in biliary tract or liver
The surface of the abdomen may be described anatomi- disease. A slight aortic pulsation may be present in the epigas-
cally in either four quadrants or nine regions (Figure 38-7). tric area, but peristalsis is normally not visible. A summary of
The patient should be in a supine position and as relaxed as common findings from abdominal inspection is included in
possible. Bending the patient's knees slightly and placing a Table 38-3.

fig.38-7 Regions of the abdomen. Left, The abdomen divided into four quadrants. Right,
The abdomen divided into nine topographical regions: 1, Epigastrium; 2, umbilical;
3, suprapubic; 4, right hypochondrium; 5, right lumbar or flank; 6, right inguinal or iliac;
7, left hypochondrium; 8, left lumbar or flank; 9, left inguinal or iliac.
1244 unit viii ALTERATIONS IN OIGESTION ANO ELlMINATION

nBm
__
Common Findings
fTom Abdominal Inspection
l!m!!'I!D
__
Common Findings
fTOmAbdominal Auscultation

FINDING INTERPRETATION
.
~ FINDING INTERPRETATION

Scars or striae May be result of pregnancy, obe- Absence of sounds in Peritonitis, paralytic ileus,
sity, ascites, tumors, edema, sur- 5 minutes pneumonia, and hypokalemia
gical procedures, or healed Repeated, high- Increased peristalsis heard in
burned areas pitched sounds oc- gastroenteritis, early pyloric
Engorged veins May be caused by obstruction of curring at frequent obstruction, early intestinal
vena cava or portal vein and cir- intervals obstruction, and diarrhea
culation from abdomen Bruit Presence of abnormal sounds
Skin color Observe for evidence of jaundice (turbulence of blood f10w
or inflammation (redness) through partially occluded or
Visible peristalsis May be caused by pyloric or in- diseased aorta or renal ~
testinal obstruction; normally artery) •
peristalsis not visible except for Hum and friction rub Heard over liver and splenic ~
slow waves in thin persons areas, indicating an increased
Visible pulsations Normally slight pulsation of aorta, venous blood f1ow, possibly
visible in epigastric region related to peritoneal inflam-
Visible masses and Observe for hernias, distention of mation
altered contou r ascites, and obesity; instructing
patient to cough may bring out
hernia "bulge" or elicit pain or Abnormalities may include either extreme. A virtual ab-
discomfort in the abdomen;
senee of normal sounds oceurs when bowel motility is inhib-
marked concavity may be caused '
by malnutrition ited by inflarnrnation or paralytie ileus. Exaggerated peristalsis
Spider angioma Appear on upper portion of body produees waves of loud, gurgling sounds called borborygmi,
and blanch with pressure; com- which may result from infection or obstruction. Bowel sounds
monly result from liver disease are auseultated by placing the diaphragm of the stethoscope
lightly against the abdomen and listening to all quadrants sys-
tematically. It may take 5 full minutes to determine that bowel
sounds are completely absent, but the absence of any bowel
_. : Anatomical Location of Organs sounds in 2 minutes clearly indieates a problem.lO Sounds that
within Each Abdominal Quadrant oeeur at a rate of about one per minute are hypoaetive. The
bell of the stethoscope may be used to auscultate for vascular
RIGHTUPPER LEFTUPPER sounds, sueh as bruits over the aorta and renal and iliae arter-
QUADRAm (RUQ) QUADRAm (LUQ)
ies.ll These sounds are not normally present. Box 38-1 out-
Liver
Gallbladder
Duodenum
Stomach
Spleen
Left kidney
! !ines the loeation of the organs within the quadrants of the
abdomen. A summary of common findings from auscultation
Right kidney Pancreas is found in Table 38-4. Optimal areas for auseultation of vas-
Hepatic flexure of colon Splenic flexure of colon cular sounds are illustrated in Figure 38-8.

RIGHTLOWER LEFTLOWER Percussion


QUADRAm (RLQ) QUADRANT (LLQ)
Percussion of the abdomen is used primarily to confirm the
Cecum Sigmoid colon
size of various organs and to determine the presence of exees-
Appendix Left ovary and tube
Right ovary and tube sive amounts of fluid or air. Normally, percussion over the ab-
domen is tympanie beca use of the presence of a small amount
of swallowed air within the GI tract. A dull or flat pereussion
note is found over a solid strueture. Dull sounds normally
Auscultation oceur over the liver and spleen or a bladder filled with urine.
Auseultation is used primarily to determine the presence Abnormal pereussion findings oeeur beeause of the presenee
or absenee of peristalsis. In the normal abdomen, boweI of ascites or abnormal masses. Aseites classieally produces a
sounds eaused by fluid and air movement ean always be heard. shifting dullness, whieh is caused by fluid movement to de-
Their intensity and frequency depend mainly on the phase of pendent areas. lnterpreting the sounds of abdominal pereus-
digestion. Most intestinal sounds oceur at a rate of 5 to 34 per sion may be diffieult in obese individuaIs.
minute (although some may not be audible for up to 5 min- The four quadrants are pereussed beginning with the tho-
utes) and are high pitched and gurgling in quality. A normal rax and moving downward systematieally. The degree of tym-
peristaltie wave produees audible sounds of air and fluid pany, from soft to pronouneed, is reeorded. Tympanie sounds
movement through the intestine. The sounds are the loudest should be heard beginning at the ninth interspaee in the lefi
to the right and below the umbilieusY upper quadrant of the abdomen.
Assessment of the Gastrointestinal, Biliary, and Exocrine Pancreatic Systems chapf:er38 1245

1'1

I
~ - -A Aorta

RighI renal Left renal


artery artery

RighI iliae Left iliae


artery

L
artery

RighI femoral ~ Left femoral


artery artery

figo 38-8 Sites for auscultation of vascular sounds


in the abdomen.

Palpa1:ion
Palpation is of value in determining the outlines of the ab-
dominal organs, determining the presence and characteristics
of any abdominal masses, and identifying the presence of di-
rect tenderness, guarding, rebound tenderness, and muscular
rigidity. In the presence of gallbladder disease, normal palpa-
tion of the liver elicits sharp pain and a positive inspiratory ar-
rest (Murphy's sign). The acute onset of pain causes the patient
to stop inspiration abruptly, midway through the breath.16 figo 38-9 Palpating for rebound tenderness.
Abnormal findings from palpation may indude (1) direct
tenderness over an organ capsule, (2) rebound tenderness
(Blumberg's sign), (3) muscular rigidity, or (4) masses that may or rectal prolapse. Internal hemorrhoids may appear when the
be felt if they are large enough or dose enough to the surface. patient bears down.
Distinction should be made between a distended abdomen that Variations in assessment findings in elderly persons are
is fum to the touch and one that is soft to the touch. summarized in the Gerontological Assessment Box. These are
Light palpation is used to elicit tenderness and cutaneous not abnormal findings and are common in this population.
hypersensitivity. The nurse uses the pads of the fingertips,
with the fingers together, and presses gently, depressing the DIAGNOSTIC TESTS
abdominal wall about 1 em. Ali quadrants are palpated using
smooth movements.6 Many of the examinations and tests performed for diagnosis
Deep palpab.-on is used to delineate organs and masses and of problems of the GI system are both time consuming and
should be performed only by properly trained persons because unpleasant. Several of the tests are intrusive procedures that
improper technique can result in injury. The nurse again uses are uncornfortable and embarrassing for the patient, which
the palmar surface of the fingers but presses more deeply using results in added stress for the patient. Representatives from
-a single- or two-handed technique. Rebound tenderness is the radiology departrnent or laboratory may assume respon-
tested by pressing slowly but fumly over the painful site. The sibility for instructing patients about diagnostic tests, because
fingers are then quickly withdrawn. Acute pain on withdrawal the tests will usually be performed on an outpatient basis.
reflects peritoneal inflammation (positive Blumberg's sign).9 Most institutions also have prepared literature for the patient
This maneuver (illustrated in Figure 38-9) can be extremely and family. It remains the nurse's responsibility to meet the
painful and should never be performed unnecessarily. educational and psychological needs of the patient by an-
swering questions concerning the test procedure, rationale
RECTUM for its use, and specific test preparation in a caring manner.
The normal perineal and perianal skin r~sembles the skin on Diagnostic tests are sequenced to make the most effective use
the remainder of the body with no breaks in integrity. Abnor- of time and equipment. The nurse ensures that the patient is
mal findings may include pruritus ani, coccygeal or pilonidal prepared physically and mentally to avoid the preventable
sinus tract openings, fistulas, fissures, external hemorrhoids, repetition of time-consuming and expensive tests.
•----------------------------------------------- ...••
1246 unit viii ALTERATIONS IN DIGESTION AND ELlMINATION

outlines the passageways of the GI tract for viewing by fluo-


ger-ontoJogi:ca~ss eS.srYle
nt roscopy or x-ray fi.lms.
Nursing responsibilities commonly involve eleansing of the
Peristalsis may be more easily observed beca use the
abdominal musculature is thinner and has less tone.
GI tract with enemas and laxatives. It is important for the
On inspection there are usually increased deposits of nurse to monitor the patient's fluid and electrolyte status be-
subcutaneous fat on the abdomen beca use the ratio cause extensive bowel eleansing may cause significant fluid
of fat to water increases with aging . losses, particularly in elderly persons. The nurse should pro-
• Palpation of abdominal organs is often easier because vide psychological support to the pati~t because the proce-
the abdominal wall is softer and thinner. The liver and
dures can be intrusive and uncomfortable. The nurse must
kidneys are most often palpable in the absence of obe-
also address educational needs of the patient, such as an ex-
sity.
Older adults often verbalize less pain than younger planation of the procedure, rationale for use, and procedural
adults when experiencing an acute abdomen. steps, which will assist in reducing anxiety.
Week-Iong diaries of dietary intake should be obtained
because food patterns may vary during the course of Upper Gas1:rointestinal Series
the month based on monthly income. An upper GI series involves visualization of the esophagus,
Common disorders in elders include gastritis and gall-
stomach, duodenum, and upper jejunum through the use of a
stones.
contrast medium. It is a fluoroscopic x-ray test that permits
the examination of the structure, position, peristaltic activity,
and motility of the organs. It can assist in the detection of tu-
LABORATORV TESTS mors, ulceration, inflammation, abnormal anatomy, or mal-
Numerous tests may be used as part of the evaluation of GI, position.
biliary, and exocrine pancreas function. Major blood and The procedure involves swallowing the contrast medium
urine tests that may be ordered are summarized in Table 38-5. (usually barium), which is prepared in a milk shake formo Al-
though it is flavored, the barium is unpleasant tasting and
STOOL EXAMINATION may cause vomiting. It is administered cold. The barium out-
5tool specimens are collected primarily for culture, determi- lines the structures as it flows by gravity through the esoph-
nation of fat content, and examination for the presence of ova, agus and stomach into the intestinal loops. Films are taken
parasites, and fresh or occult blood. 5tools to be analyzed for at intervals during the test, and the entire test takes about
the presence of bacteria (Salmonella, Shigella, and Staphylo- 45 minutes. The procedure may also be termed a barium
coccus aureus), ova, and parasites require that a fresh, warm swallow if only the function of the esophagus is to be evalu-
specimen be received in the laboratory and may necessitate ated. This shortened procedure takes about 15 minutes. If the
special collection procedures. small bowel is the primary focus of the test, it may be termed
Fecal urobilinogen is responsible for the brown color of the a small bowel series. The procedure is essentially the same, al-
stoo1. Biliary obstruction may cause decreased arnounts to be though it takes longer.
present and turns the stoollight or elay colored. These speci- No special preparation is necessary before a GI series; how-
mens should also be sent promptly to the laboratory beca use ever, the patient maintains nothing-by-mouth ( PO) status
urobilinogen breaks down rapidly. Table 38-6 identifies other for at least 6 hours before the testo After an upper GI series, the
fecal color changes that may occur. patient is prescribed a laxative to hasten elirnination of the
Detection of occult blood in the stool is useful in identify- barium; barium that remains in the colon may become hard
ing bleeding in the GI tract. Occult blood may be identified by and difficult to expel, leading to fecal impaction. The stool
one of three tests-guaiac (Hemoccult), benzidine, or ortho- should return to the normal color (barium is white) after the
toluidine (Occultest). The guaiac test is the least sensitive test barium is expelled.
and is often used to determine whether additional study is in-
dicated. It does not require any special preparation. Meat, Barium Enema
poultry, or fish can cause a false-positive test, and vitamin C in A barium enema elearly outlines most of the large intestine
quantities of greater than 500 mg per day may cause a false- through the use of a contrast medium. It is used to detect
negative test; therefore these substances must be omitted from colon polyps, tumors, and chronic inflammatory bowel dis-
the diet for 3 days before testing with benzidine or orthotolu- ease. If both an upper GI series and a barium enema are to be
idine. Determination of fecal fat may be done as part of a performed, the barium enema is done first, before barium
workup for malabsorption. Elevations in fecal fat will be pre- from the upper GI series reaches the colono
sent with biliary or pancreatic obstructions and many intesti- The procedure involves the instillation of barium through
nal malabsorption disorders. a rectal tube with an inflatable balloon to hold the barium in
the colono The patient is then placed in various positions
RADIOLOGICAL TESTS while the radiologist observes on a monitor as the barium
Visualization of the GI tract may be performed by barium flows through the colono The procedure takes about 30 min-
swallow, upper GI series, or barium enema. Barium is a ra- utes, and the instillation and retention of the barium cause the
diopaque substance that, when ingested or given by enema, patient considerable embarrassment and discomfort.
Assessment of the Gastrointestinal, Biliary, and Exocrine Pancreatic Systems chapter38 1247

bSdit:ii
',"N»
-
Major
f?! g
GI, Biliar'/- and Exocrine Pancreas Blood and Urine Tests
iQW1fm:;:.••.
Z'Z"0 $';9: -~m;.,ik4tf-;t;:t-,.,;";;tt!>I§i*M;gs::;s@-,t4}'A}4WC;; m:;:::;;":*=w«*~##*g· ;:g-jt:$# *;'§,. 'P;·qg:e::··,,·:;§g;;l1,.
BLOOD TEST RANGE OF NORMAL VALUES DESCRIPTlON AND PURPOSE í!l
Stomach gastrin <200 pg/ml (200 ng/L) Gastrin is a gastric hormone that is a powerful stimulus for gas-
tric acid secretion. Elevated leveis are found in those with per-

I
nicious anemia and Zollinger-Ellison syndrome.
.1 Helicobacter pylori None Helicobacter pylori detected in serum is a highly sensitive but

I
less specific indicator of an active infection; H. pylori infection
predisposes to peptic ulcer disease.

BIUARY SYSTEM
1 Total bilirubin 0.1 to 1.0 mg/dl Billrubln IS excreted In the bile. Obstruction in the biliary tract
contributes primarily to a rise in conjugated (direct) values.
• Conjugated (direct) 0.1-0.3 mg/dl
.~ Unconjugated (indirect) 0.1-0.8 mg/dl
Alkaline phosphatase 30-85 ImU/ml Alkaline phosphatase is found in many tissues with high con-
centrations in bone, liver, and biliary tract epithelium. Ob·
structive biliary tract disease and carcinoma may cause sig-
nificant elevations.

PANCREAS
Amylase 80-150 Somogyi units Amylase is secreted normally by the acinar cells of the pan-
creas. Damage to these cells or obstruction of the pancreatic
duct causes the enzyme to be absorbed into the blood in sig-
nificant quantities. It is a sensitive yet nonspecific test for pan-
creatic disease.
Lipase 0-110 units/L Lipase is a pancreatic enzyme normally secreted into the duo-
denum. It appears in the blood when damage occurs to the
acinar cells. It is a specific test for pancreatic disease.
Calcium 9.0-11.5 mg/dl Calcium leveis may be low in cases of severe pancreatitis or
steatorrhea, because calcium soaps are formed from the se-
questration of calcium by fat necrosis.

INTESTINE
Total protein (albumin/ Total protein: 6-8 g/dl Although primarily a reflection of liver function, serum protein
globulin) Albumin: 3.2-4.5 g/dl levei is also a measure of nutrition. Malnourished patients
Globulin: 2.3-3.4 g/dl have greatly decreased leveis of blood protein.
D-xylose absorption test Blood leveis of 25-40 mg/dl D-xylose is a monosaccharide that is easily absorbed by the
2 hr after ingestion normal intestine but not metabolized by the body. It does not
require biliary or pancreatic function. D-xylose is administered
orally and assists in the diagnosis of malabsorption.
Lactose tolerance test Rise in blood glucose levei An oral dose of lactose is administered. In the absence of in-
of >20 mg/dl testinal lactase, the lactose is neither broken down nor ab- I
sorbed and plasma glucose leveis do not rise. The test assists
in the diagnosis of lactose intolerance.
Carcinoembryonic antigen <5 ng/ml CEA is a protein normally present in fetal gut tissue. It is typi-
(CEA) cally elevated in persons with colorectal tumors. Although not
useful as a screening tool, it is useful in determining progno-
sis and response to therapy.

URINE
-.5-hydroxyi ndoleacetic 2-9 mg/2 hr Carcinoid tumors are serotonin secreting and are derived from
• acid (5-HIAA) neuroectoderm tissue-e.g., the appendix and intestine.
These neurohormones are metabolized to 5-HIAA by the liver
and excreted in the urine.
Urine bilirubin None Bilirubin is not normally excreted in the urine. Biliary stricture,
inflammation, or stones may cause its presence.
Urobilinogen 24-hr collection: 0.2-1.2 units A sensitive test for hepatic or biliary disease. Decreased lev-
24-hr collection: 0.05-2.5 mg eis are seen in those with biliary obstruction and pancreatic
cancer.
t! Urine amylase 10-80 amylase units/hr A rise in levei usually mimics the rise in serum amylase. The '1
levei remains elevated for 7-10 days, however, which allows
for retrospective diagnosis.
~~ t •• i ~~,r;l!kp' i -if*,~6,a::wa.:&:fR!I;Çi * '.UM'. f esa _IH &it
1248 uni1: viii ALTERATIONS IN OIGESTION ANO ELlMINATION

I#iB.!:!' Interpretation of Feces Colar can be used with the CT scan to better visualize the biliary
tract or to accentuate differences in tissue density of the pan-
COLOR INTERPRETATION creas. The test is comparable to ultrasonography in effective-
. White Barium ness. It is used less often because of its significantly higher cost
Gray, tan (clay) Lack of bile, biliary obstruction and moderate radiation exposure for the patient. It is ex-
Red Lower gastrointestinal bleeding, food tremely useful with obese individuals, however, because in-
intake (e.g., beets)
creased tissue density limits the effectiveness of ultrasound
Black
Tarry Upper GI bleeding
transmission.'2
Dry Rapid peristalsis with bile present The patient should maintain NPO status for 8 to 12 hours
Green Rapid peristalsis with bile present before the testo If contrast medium is to be used, the patient
should be assessed for allergies to iodine, seafood, or contrast
NOTE: Stool color may also vary in response to food intake and artificial col· medium. Barium studies, if necessary, should be done at least
ors in foods.
4 days before CT scan or after the scan, because the barium
can interfere with test results. There are no special after-
care considerations. The patient may resume pretest diet and
Preparation for a barium enema involves thorough cleans- activity.
ing of the bowel by laxatives, enemas, or both. Thorough
preparation is essential because retained fecal material ob- Radionuclide Imaging
scures the normal bowel anatomy. The patient may be asked Gastrointestinal scintigraphy may be used to localize the site
to restrict dairy products and follow a liquid diet for 24 hours of GI bleeding. Endoscopy provides excellent visualization of
before the testoThe patient typically maintains PO status for gastric or esophageal bleeding, but other areas of the GI
at least 8 hours before the testoLaxatives are administered after tract are much more difficult to visualize and pinpoint. An
the test with some barium preparations to facilitate the re- intravenous injection of 99mTcsulfur colloid is administered.
moval of the barium. The stools may be wrute tinged for sev- Pooling of the radionuclide will occur at the bleeding site/
eral days. Inpatients are closely monitored for complications No pretest preparation is required, and no discomfort is ex-
after the test, such as perforation of the bowel. Outpatients are perienced. Patients in unstable condition may not be candi-
instructed to report the development of abdominal pain and dates for this test if they are unable to traveI safely to the
to monitor carefully for constipation. nuclear medicine department for the 30 minutes required
for the testo
Ultrasonography
Ultrasonography involves the use of high-frequency sound Cholecystography
waves that are transmitted into the abdomen and create Oral cholecystography involves the radiographical exam-
echoes that vary with tissue density. The echoes bounce back ination of the gallbladder after the administration of a con-
to a transducer and are electronically converted into pictorial trast medium. A normal liver will remove radiopaque
images of the organs. This reveals organ size, shape, and posi- drugs-such as iodoalphionic acid (Priodax), iopanoic acid
tion and is extremely useful in diagnosing cysts, tumors, and (Telepaque), and iodipamide methylglucamine (Cholografin
stones. Ultrasonography has gradually become the procedure Meglurnine)-from the bloodstream and store and con-
of choice for diagnosing gallbladder disease because it does centrate them in the gallbladder. The dye-filled gallbladder
not expose the patient to radiation. The procedure is both shows on x-ray examination as adense shadow. If no shadow
painless and safe. is seen, this indicates a nonfunctioning gallbladder. Stones,
Patient preparation is straightforward. The patient main- wruch are not radiopaque, show as dark patches on the filmo
tains NPO status for 8 to 12 hours before the test, because Visualization of the gallbladder depends on absorption of
gas in the bowel may interfere with the results. If the gall- the dye through the intestinal tract, isolation of the medium
bladder is the focus of the test, the patient is instructed to by the liver, and a free passageway from the liver to the
eat a low-fat meal the evening before the test so that bile will gallbladder.
accumulate in the gallbladder, thereby enhancing visualiza- Ultrasonography has gradually replaced this once com-
tion. The patient resumes a normal diet and activity after monly used test in the diagnosis of gallbladder disease. Chole-
the testo cystography is primarily used today when the ultrasound pic-
ture is inconclusive.
Computed Tomography Patient preparation involves instruction to eat a fat-free
Computed tomography (CT) can also be used to assess pa- meal the evening before the test and to avoid all additional in-
tients with gallbladder, biliary ductal system, or pancreatic take except water until the test is completed. The patient is
problems. It is helpful in identifying problems similar to those carefully assessed for allergies to contrast dyes, seafood, or io-
described for ultrasonography. Multiple x-rays are passed dine. The radiopaque substance (usually iopanoic acid) is ad-
through the abdomen. A computer reconstructs the data into ministered orally 2 to 3 hours after the evening meal. The dose
two-dimensional images on a television screen. Still pho- is based on body weight, and the tablets are administered one
tographs can also be taken of the images. Contrast medium at a time at 5- to 10-minute intervals with several swallows of
Assessment of the Gastrointestinal, Biliary, and Exocrine Pancreatic Systems chapter38 1249

water after each pill. Side effects of the iodine- based tablets sistent choking or gagging during the procedure. After re-
may include abdominal cramping, vomiting, or diarrhea. The moval of the tubes, a mild sore throat is common.
patient then maintains ~O status until the testo A high-fat
food or drink may be adrninistered during the procedure to Manometry
stimulate emptying of the gallbladder. No specific care is indi- This test is used to measure the pressure in the lower
cated after the testo esophageal sphincter and record the duration and sequence of
peristaltic movements within the esophagus. Readings are
Cholangiography taken at various levelsin the esophagus with the patient at rest
Cholangiography involves the x-ray examination ofbile ducts and during swallowing. Baseline sphincter pressure is nor-
to demonstra te the presence of stones, strictures, or tumors. mally about 20 mm Hg. The test is used primarily to diagnose
The radiopaque substance may be administered intravenously esophageal reflux, but the graphic record of muscular activity
or injected directly into the common bile duct with a needle during swallowing may also help document the presence of
or catheter at the time of surgery. After surgery on the com- achalasia or esophageal spasm.12
mon bile duct, a radiopaque drug such as iodipamide methyl-
glucamine instilled through a drainage tube such as the T tube pH monitoring
to determine the patency of the duct before the tube is re- This test evaluates the competency of the lower esophageal
moved (T tube cholangiography). This dye also may be in- sphincter (LES) by obtaining a single measurement of the
jected through the skin and abdominal wall directly into a bile esophageal pH. An electrode is placed above the LES and at-
duct within the main substance of the liver (percutaneous tached to a manometry catheter. Normally, the esophagus
transhepatic cholangiography). The technique is useful in vi- maintains a pH of more than 6. Serial measurements may be
sualizing the location and extent of a pathological process, obtained by maintaining the electrode for a 24-hour period.
such as obstructive jaundice. It permits decompression of the The probe must be inserted transnasaUy and connected to a
liver for improved function. The procedure helps the surgeon recording box similar to a Holter monitor that is worn abou!
identify the location of pathological processes before surgery, the waist. The patient can then be monitored at home while
or it may indicate that surgery is not necessary. Complications eating a normal diet. Twenty-four-hour pH monitoring is the
from the test are rare, but include bile leakage leading to bile most sensitive and specific diagnostic test for the presence of
peritonitis or bleeding caused by accidental rupture of a blood abnormal acid refluxo
vessel.
The patient maintains NPO status for about 8 hours before Esophageal clearance test
the testoThe injection of the contrast medium may cause tem- In conjunction with the previous two tests, esophageal
porary pain or a feeling of pressure or epigastric fulIness. The clearance tests evaluate the function of both the upper and
patient is carefully monitored for bleeding or adverse reac- lower esophageal sphincters along with the body of the esoph-
tions to the dye. Vital signs are monitored, and the patient agus in response to swallowing foods or fluids. Normally,
typically rests in bed for about 6 hours after the test, lying on esophageal function allows for the complete clearance of acid
the right side as much as possible. The needle insertion site is material from the esophagus in less than 10 swallows. Read-
carefully monitored for signs of bleeding or infection. ings are recorded from the catheter tip to determine the rate
and efticiency of acid clearance.
SPECIAL TESTS
Esophageal Function Tests Acid perfusion test (Bernstein test)
Several diagnostic tests may be used to evaluate the function- Confusion surrounding the origin of heartburn symptoms
ing of the esophagus and aid in the diagnosis of esophageal re- is often resolved with the Bernstein test, which attempts to re-
flux or motility problems. These tests can be performed by produce the pain. Small quantities ofHCI are instilled into the
having the patient swallow two or three tiny tubes that are at- distal esophagus by nasogastric tube. The test is positive if the
tached to an external transducer. Once the tubes are located in acid produces pain. Saline is instilled to rinse out the acid, and
the stomach, they are slowly pulled back into the distal esoph- an antacid may be administered to relieve the pain.
agus at varying levels. Lower esophageal sphincter pressure,
swallowing activity, pH, and effectiveness of clearance can all Tests of Gastric Function
be measured in about 30 to 45 minutes. However, 24-hour pH Gastric analysis (basal gastric secretion
monitoring may be performed because it is considered the and gastric acid stimulation tests)
gold standard for the accurate diagnosis of esophageal refluxo Examination of the fasting contents of the stomach may be
No special preparation is required for these tests. It is im- used in establishing a diagnosis of gastric disease. The purpose
portant to provide the following instructions to the patient: is to quantify gastric acidity in the fasting and stimulated
(1) remain PO for 8 hours before thêprocedure(s); (2) avoid states. Abnormal secretion may be related to ulcers, malig-
alcohol and smoking the day before; and (3) medications such nancy, pernicious anemia, or Zollinger-Ellison syndrome. A
as antacids, H2-receptor antagonists, cholinergics, and anti- nasogastric tube is inserted, and gastric contents are aspirated.
cholinergics should not be taken before the test(s). Sedation is Gastric contents may then be aspirated every 15 minutes for
not required but may be used if the patient experiences per- 90 minutes.
----------------------------------------------,.
1250 unit viii ALTERATIONS IN OIGESTION ANO ELlMINATION

The patient is instructed to restrict food, fluid, and smok- bon dioxide, which can be collected and measured. The pa-
ing for 8 to 12 hours before the testoThe flow of gastric acid is tient exhales into a balloon or other receptacle, and the carbon
then stimulated by betazole hydrochloride, histamine phos- dioxide is measured with a scintillation counter. The sample
phate, or pentagastrin given subcutaneously. The person may can be collected 20 minutes after the solution is ingested. The
experience side effects of the medication, including flushing, test has minimal risks associated with radioactivity and is es-
feeling of warmth, slight headache, or itching. Epinephrine timated to be 97% sensitive for H. pylori and 100% specific.
is given to counteract the effects of histamine if sensitiv- Teaching is the essential component of patient preparation.
ity occurs. No specific aftercare is needed.

Tube/ess gastric analysis Biopsy


(Diagnex blue test) Upper gastrointestinal biopsy
Tubeless gastric analysis may be used for detection of gas- A biopsy of the oral cavity or tongue may be done on any
tric achlorhydria. The test will indicate the presence or ab- lesion or ulcerated area that requires a differential diagnosis.
sence of free hydrochloric acid but cannot be used to deter- This procedure is usually performed with a local anesthetic.
mine the amount of free hydrochloric acid, if any is present. After the biopsy, the biopsy site is assessed for bIeeding. Biopsy
For a tubeless gastric analysis, a gastric stimulant such as caf- of the stomach is typically performed during fiberoptic
feine is given. One hour Iater, a cation exchange resin contain- endoscopy.
ing azure A is given orally with water on an empty stomach. If
there is free hydrochloric acid in the stomach on the intro- Intestinal biopsy
duction of this resin, a substance will be released in the stom- Biopsy of the small or large bowel may also be performed
ach that will be absorbed from the small intestine and ex- during the course of endoscopic examination to allow tissue
creted by the kidneys within 2 hours. Absence of detectable analysis oflesions, polyps, or masses. A knife blade or snare is
amounts of blue dye in the urine indicates that free hy- typically used to obtain the tissue sample. The procedure is
drochloric acid probably was not secreted. not usually painful, although a feeling of pressure may be ex-
perienced. Bleeding from the site of the biopsy is uncommon.
Schilling test If bleeding does occur, the patient is instructed to report this
The Schilling test evaluates vitamin B12absorption. In the to the physician and to curtail physical activity until examined
normal GI traet, vitamin B12combines with the intrinsic fac- by a physician.
tor that is produced by the parietal cells in the gastric mucosa
and is absorbed in the distal portion of the ileum. Pernicious Endoscopy
anemia will develop if intrinsic factor is lacking or malab- Endoscopy allows for direct visualization of portions of the
sorption exists. This is relevant in patients who have had the GI tract by means of a long, flexible, fiberoptic scope (Fig-
terminal ileum removed for diseases such as Crohn's disease. ure 38-10). Images are provided through an eyepiece or onto
The test can identify problems of absorption. a video screen. The remote control tip moves in four direc-
The patient is administered an oral preparation of radioac- tions. Endoscopy may be used for direct inspection, biopsy,
tive vitamin B'2' followed by an intramuscular injection of and removal of polyps and stones.14 Additionally, bleeding
nonradioactive vitamin B'2to saturate the tissue-binding sites. may be controlled through laser or photocoagulation or the
Urinary B12levelsare measured after urine collection for 24 to injection of sclerosing agents. The upper GI tract may be vi-
48 hours. With normal absorption of vitamin B12,the ileum sualized as far as the duodenum by insertion of a fiberscope
absorbs more vitamin B12 than the body needs and excretes through the mouth. A fiberscope inserted through the rectum
the excess into the urine. With impaired absorption of vita-
min Bl2>little or no vitamin B'2 is excreted into the urine. In-
trinsic factor preparations may also be administered to differ-
entiate intestinal problems from pernicious anemia.
The person is instructed to maintain NPO status for 8 to
12 hours before the test, except for water. Laxatives should not
be used during the duration of the test, but no specific after-
care is indicated.

Urea breath test


Testing for H. pylori is technically difficult and eÀ-pensive.
The urea breath test (UBT) is based on the principIe that the
H. pylori organism is able to produce large amounts of urease,
a surface enzyme that catalyzes the urea in gastric secretions
into bicarbonate and ammonia. Patients are administered
an oral solution of carbon isotope-Iabeled urea in water. If
H. pylori is present in the stomach the urea is metabolized.
The labeled bicarbonate is excreted in the form of labeled car- figo 38-10 Flexible colon fiberscopes.

Assessment of the Gastrointestinal. Biliary. and Exocrine Pancreatic Systems chapt"er38 1251

is used for visualization of the reeturn (proctoscopy), sigmoid visibility,the patient should be told that a feeling of pressure or
colon (sigmoidoscopy), or the entire colon (colocoscopy). fullness willlikely be experienced. The entire test lasts about
Today, most endoscopic procedures are performed on an 15 to 30 minutes, unless additional treatments are planned.
ambulatory basis, even with the elderly.Oral fiberscope inser- Afier the procedure the patient is monitored carefully for
tion is uncomfortable and may precipitate gagging or choking signs of dyspnea, pain, bleeding, or acute dysphagia.Vital signs
despite the use of topical anesthetic sprays or gargles. Premed- are taken every 30 minutes for 3 to 4 hours, and no oral food
ication with an IV sedative such as midazolam (Versed) or di- or fluids are administered until the nurse determines that the
azepam (Valium) or an analgesicsuch as meperidine (Demerol) gag reflex is fully intacto Throat lozenges or saline gargles may
is used. Thus the patient is conscious but sedated; amnesia is of- be used to relieve sore throat after the testoComplications are
ten experienced when high doses of these drugs are used. rare but include aspiration, perforation, and bleeding.

Esophagogastroduodenoscopy Endoscopic retrograde


Upper GI endoscopy may be limited to the esophagus cholangiopancreatography
(esophagoscopy), stomach (gastroscopy), or duodenum (duo- Endoscopic retro grade cholangiopancreatography (ERCP)
denoscopy), or it may involve examination of the entire region also involves the oral insertion of an endoscope, but this de-
(esophagogastroduodenoscopy [EGD]) (Figure 38-11). It is vice has a side-viewing tip and a cannula that can be maneu-
particularly useful for identifying the source of upper GI vered into the ampulla of Vater (Figure 38-12). Dye may be
bleeding and for differentiating gastric malignancies from injected to outline the pancreatic and biliary ducts. The pro-
benign ulcers, and gastric ulcers from duodenal ulcers. Other cedure may be combined with papillotomy to enlarge the
uses include visualization of esophageal strictures, varices, tu- sphincter and release gallstones.18 Glucagon may be adminis-
mors, achalasia, and hiatal hernias; and surgical rem oval of tered to minimize spasm in the duodenum and sphincter.
gastric polyps. Care after the procedure is similar to that previously de-
Preparation for an EGD involves instructing the patient to scribed following an EGD. The patient is monitored carefully
maintain NPO status for 8 hours before the testoBecause air is for signs of abdominal pain, nausea, and vomiting, which
typically introduced as the endoscope is advanced to improve might indicate the development of pancreatitis.

Colonoscopy
Fiberoptic colonoscopy allows the examination of the en-
tire colon in most patients. It may be used to evaluate benign
and malignant growths, remove polyps, take biopsy speci-
mens, and localize sites of bleeding. The colonoscope is 105 to
Eyepiece 185 cm (42 to 72 inches) longo
Thorough bowel preparation is essential before the test,
which is especially difficult for the elderly. The patient may

Observalion
por!

Papilla
of Valer

figo 38-11 Fiberoptic endoscopy of the stomach. figo 38-12 Endoscopic retrograde cholangiopancre-
atography (ERCP).
1252 unit viii ALTERATIONS IN OIGESTION ANO ELlMINATION

receive a 2- to 3-day preparation involving a clear liquid diet, • Subjective data for GI assessment include patient/family
strong laxatives, and an enema the day of the testo A l-day history; diet and nutrition; presence of abdominal pain,
anorexia, or vomiting; fatigue and weakness; and elimina-
preparation with an oral osmotic solution has become stan-
tion patterns.
dard because it reduces overall electrolyte loss. A gallon of • Objective data include assessment ofthe mouth, abdomen,
polyethylene glycol (Colyte) solution is administered rapidly and rectum.
(8 ounces every 15 minutes) and induces a profuse watery di- • The abdomen is divided into either four quadrants ar nine
arrhea within 30 to 60 minutes, which lasts about 4 hoursY regions for assessment. Auscultation precedes percussion
The patient is then NPO for about 8 hours before the testo and palpation, because the assessment activities may alter
The procedure lasts for 20 to 60 minutes. Air is introduced the frequency and intensity of bowel sounds.
as the colonoscope is inserted to increase visualization of the
OIAGNOSTIC TESTS
mucosa. The air commonly causes abdominal cramping.
Afterward, the nurse assumes responsibility for carefully • Laboratory tests include analysis of stool and urine and a
variety of blood tests.
monitoring the patient and ensuring full recovery from seda-
• Major radiological tests include barium contrast studies
tion. Any changes in vital signs or development of severe of the entire GI tract, endoscopic examinations of the
abdominal pain, rectal bleeding, or fever should be immedi· upper and lower GI tract, ultrasonography, and chole-
ately reported to the physician. Additionally, arrangements cystography.
for transportation home are important because the patient • Endoscopy and ultrasonography are the mainstays of di-
should not drive. agnosis in GI system disease.
Sigmoidoscopy may be performed rather than colonos-
copy. This procedure allows for visualization of the anus,
References
rectum, and distal sigmoid colono Approximately 75% of ali
polyps and tumors of the large intestine can be visualized with 1. Altman DE: Changes in gastrointestinal, pancreatic, biliary and he-
patic function with aging, Gastroenterol Clin North Am 19(2):227,
a flexible sigmoidoscope. Pretest preparation instructions
1990.
vary widely. The patient may be instructed to prepare with a
2. Barker LR, Burton JR, Zieve PD: Principies of ambulatory medicine,
2-day clear liquid diet and pretest fasting. Fleet enemas may be Baltimore, 1995, Williams & Wilkins.
ordered, or a cleansing enema may be preferred. The knee- 3. Bel! rE, Dixon L, Sehy YA: Physical assessment: the breast and the
chest position and a strong urge to defecate that is produced pulmonary, cardiovascular, gastrointestinal, and genitourinary sys-
by the larger-diameter sigmoidoscope make this both an un- tems. In Chenitz WC, Stone JT, Salisbury SA, editors: Clinicai geran-
comfortable and unpopular procedure for patients. Sedation tological nursing, Philadelphia, 1991, WB Saunders.
4. Esberger KK: Guide to gastrointestinal problems of elders, Geriatr
is not usually employed.7 Aftercare involves monitoring for
Nurs 12(2):74, 1991.
distention, increased tenderness, and bleeding. The patient
5. Hogstel MO: Gastrointestinal system. In Clinicai manual of geranto-
may initially pass large amounts of flatus from the instillation logical nursing, St Louis, 1992, Mosby.
of air during the procedure. Slight rectal bleeding may occur 6. Holmgren C: Abdominal assessment, RN 55(3):28, 1992.
if biopsies have been taken. 7. nlustrated guide to diagnostic tests, Springhouse, Pa, 1994, Spring-
house.
8. Jarvis C: Physical examination and health assessment, Philadelphia,

iliiP-HK ;I!Ii!J:ai!LIi1L: •.• , 1996, WB Saunders.


9. Lindsey M: Abdominal assessment, Orthop Nurs 8(4):34,1989.
ANATOMY ANO PHYSIOLOGY 10. McConnell E: Auscultating bowel sounds, Nursing 20(6):76,1990.
• Functions of the GI tract include the following: salivation 11. O'Toole M: Advanced assessment of the abdomen and gastrointesti-
and mastication in the mouth, swallowing in the esopha- nal problems, Nurs Clin North Am 25(4):771, 1990.
gus, digestion in the stomach and small intestines, and ab- 12. Pagana KD, Pagana TJ: Mosby's diagnostic and laboratory test refer-
sorption in the large intestine. ence, ed 2, St Louis, 1997, Mosby.
• Carbohydrate digestion begins in the mouth and continues 13. Porth CM: Pathophysiology: concepts of altered health states, ed 4,
in the small intestine with the action of pancreatic and in- Philadelphia, 1996, JB Lippincott.
testinal enzymes. 14. Renkes J: GI endoscopy-managing the full scope of care, Nursing
• Protein digestion begins in the stomach and continues in 23(6):50,1993.
the small intestine with the action of pancreatic and in- 15. Sleisenger MH, Fordtran JS: Gastrointestinal disease, ed 4, Philadel-
testinal enzymes. phia, 1989, WB Saunders.
• Fat digestion takes place primarily in the small intestine 16. Stone R: Acute abdominal pain, Nurse Pract 21(12):19,1996.
with the action of the pancreatic enzymes and bile salts. 17. Thompson JM, Wilson SP: Health assessment for nursing practice,
St Louis, 1996, Mosby.
ASSESSMENT 18. Wilkinson M: Nursing implications after endoscopic cholangiopan-
• Changes in the GI system that occur with aging usually do creatography, Gastraenteral Nurs 13(2):105, 1990.
not interfere with normal functioning, unless chronic ill- 19. Yamada T et ai: Textbook of gastroenteralogy, Philadelphia, 1992,
nesses are present. JB Lippincott.