COMPREHENSIVE NOTES OF THE TOPIC COVERED FOR 4TH EXAM

Metabolic and Gastrointestinal, Liver Alterations

OVERVIEW

The GI tract, also called the alimentary canal

It consists of:

 Mouth  Small and large intestines

 Esophagus  Rectum
 Stomach

The salivary glands, liver, gallbladder, and pancreas secrete substances into this tract to form the GI system.

Main functions of the GI tract:

 the digestion of food to adequately meet the body's NUTRITION needs

 the ELIMINATION of waste resulting from digestion.

GI tract is susceptible to many health problems, including:

 Structural or mechanical alterations  Inflammation or autoimmune disease

 Impaired motility  Cancer
 Infection

STRUCTURE

The lumen, or inner wall, of the GI tract consists of four layers:

 Mucosa
- the innermost layer, includes a thin layer of smooth muscle and specialized exocrine
gland cells.
 Submucosa
- which is made up of connective tissue. It surrounded the Mucosa.
 Muscularis
- is composed of both circular and longitudinal smooth muscles, which work to keep
contents moving through the tract.
 Serosa
- it is the outermost layer and it is composed of connective tissue.

FUNCTION

The functions of the GI tract include:

 Secretion  Motility
 Digestion  Elimination
 Absorption

- Food and fluids are ingested, swallowed, and propelled along the lumen of the GI tract to the anus for
elimination.
- The smooth muscles contract to move food from the mouth to the anus.
- Before food can be absorbed, it must be broken down to a liquid, called chyme.

Digestion

- is the mechanical and chemical process in which complex foodstuffs are broken down into simpler
forms that can be used by the body.
- during digestion, the stomach secretes hydrochloric acid, the liver secretes bile, and digestive
enzymes are released from accessory organs, aiding in food breakdown.
 - after the digestive process is complete, absorption takes place.

Absorption

- is carried out as the nutrients produced by digestion move from the lumen of the GI tract into the
body's circulatory system for uptake by individual cells.

GASTROINTESTINAL CHANGES ASSOCIATED WITH AGING

 Physiologic changes occur in the GI system as people age, especially after 65 years of age.
 Changes in digestion and ELIMINATION that can affect NUTRITION are common

PATIENT HISTORY

- The purpose of the health history is to determine the events related to the current health problem.
- Focus questions about changes in appetite, weight, and stool.
- Determine the patient's pain experience.
 Collect data about the patient's age, gender, and culture can be helpful in assessing who is likely to have
particular GI system disorders.
 Older adults are more at risk for stomach cancer than are younger adults.
 Younger adults are more at risk for inflammatory bowel disease (IBD).
 Colon cancer is becoming more common among young people who are obese.

NUTRITION HISTORY

- A nutrition history is important when assessing GI system function.

- Many conditions manifest themselves as a result of alterations in intake and absorption of nutrients.
- The purpose of a nutrition assessment is to gather information about how well the patient's needs are
being met.
 Inquire about any special diet and whether there are any known food allergies.
 Ask the patient to describe the usual foods that are eaten daily and the times that meals are taken.

Health problems can also affect nutrition:

 Anorexia (loss of appetite for food)
 Dysphagia (difficulty or pain with swallowing)
 Nausea, vomiting, or dyspepsia (indigestion or heartburn)

Family History and Genetic Risk

- Ask about a family history of GI disorders.

- Some GI health problems have a genetic predisposition.

Current Health Problems

- Ask about the location, quality, quantity, and timing of each symptom (onset, duration), and factors that
may aggravate or alleviate it.
- Because GI signs and symptoms are often vague and difficult for the patient to describe, it is important to
obtain a chronologic account of the current problem, symptoms, and any treatments taken.
- If a patient has kept a diary of dates, symptoms, and treatments used, this can be helpful to establish
patterns.

Pain is a common concern of patients with GI tract disorders. Abdominal pain is often vague and difficult to
evaluate. The mnemonic PQRST may be helpful in organizing the current problem assessment:

P: Precipitating or palliative

Q: Quality or quantity
 R: Region or radiation

S: Severity scale

T: Timing

PHYSICAL ASSESSMENT

 Right upper quadrant (RUQ)

- Most of the liver
- Gallbladder
- Duodenum
- Head of the pancreas
- Hepatic flexure of the colon
- Part of the ascending and transverse colon
 Left upper quadrant (LUQ)
- Left lobe of the liver
- Stomach
- Spleen
- Body and tail of the pancreas
- Splenic flexure of the colon
- Part of the transverse and descending colon
 Left lower quadrant (LLQ)
- Part of the descending colon
- Sigmoid colon
- Left ureter
- Left ovary and fallopian tube
- Left spermatic cord
 Right lower quadrant (RLQ)
- Cecum
- Appendix
- Right ureter
- Right ovary and fallopian tube
- Right spermatic cord

The abdomen is assessed by using the four techniques of examination:

 Inspection
- Observe the shape of the abdomen by observing its contour and symmetry. The contour of
the abdomen can be rounded, flat, concave, or distended.
 Auscultation
- Auscultation of the abdomen is performed with the diaphragm of the stethoscope, because
bowel sounds are usually high pitched. Place the stethoscope lightly on the abdominal wall
while listening for bowel sounds in all four quadrants.
 Percussion
- The liver and spleen can be percussed. An enlarged liver is called hepatomegaly. Dullness
heard in the left anterior axillary line indicates enlargement of the spleen (splenomegaly).
Mild-tomoderate splenomegaly can be detected before the spleen becomes palpable.
 Palpation
- To determine the size and location of abdominal organs and to assess for the presence of
masses or tenderness. Palpation of the abdomen consists of two types: light and deep. Deep
palpation is used to further determine the size and shape of abdominal organs and masses.

PSYCHOSOCIAL ASSESSMENT

 Focuses on how the GI health problem affects the patient's life and lifestyle.
 The interview focus is on whether usual activities have been interrupted or disturbed, including
employment.
  Question the patient about recent stressful events.
 Emotional stress has been associated with the development or exacerbation (flare-up) of irritable
bowel syndrome (IBS) and other GI disorders.

DIAGNOSTIC ASSESSMENT

Laboratory Assessment

 Complete Blood Count (CBC)

 Urine Tests
 Stool Tests

Imaging Assessment

 Endoscopy
- is direct visualization of the GI tract using a flexible fiberoptic endoscope. It is
commonly requested to evaluate bleeding, ulceration, inflammation, tumors, and
cancer of the esophagus, stomach, biliary system, or bowel.
 Esophagogastroduodenoscopy (EGD)
- is a visual examination of the esophagus, stomach, and duodenum. This procedure
has largely replaced upper GI series testing.
 Endoscopic Retrograde Cholangiopancreatography (ERCP)
- includes visual and radiographic examination of the liver, gallbladder, bile ducts,
and pancreas to identify the cause and location of obstruction.
 Small Bowel Capsule Endoscopy or enteroscopy
- provides a view of the small intestine. It is used to evaluate and locate the source
of GI bleeding.
 Colonoscopy
- is an endoscopic examination of the entire large bowel. It is considered the gold
standard test for detecting colon cancer. It can also evaluate the cause of chronic
diarrhea or locate the source of GI bleeding.
 Virtual Colonoscopy
- is a noninvasive imaging procedure to obtain multi-dimensional views of the entire
colon is the CT colonography, most popularly known as the virtual colonoscopy.
 Sigmoidoscopy or Proctosigmoidoscopy
- is an endoscopic examination of the rectum and sigmoid colon using a flexible
scope. The purpose of this test is to screen for colon cancer, investigate the source
of GI bleeding, or diagnose or monitor inflammatory bowel disease.
 Ultrasonography (US)
- is a technique in which high-frequency, inaudible vibratory sound waves are
passed through the body via a transducer.
 Endoscopic ultrasonography (EUS)
- provides images of the GI wall and high-resolution images of the digestive organs.
This procedure is useful in diagnosing the presence of lymph node tumors;
mucosal tumors; and tumors of the pancreas, stomach, and rectum.
 Liver-Spleen Scan
- uses IV injection of a radioactive material that is taken up primarily by the liver and
secondarily by the spleen. The scan evaluates the liver and spleen for tumors or
abscesses, organ size and location, and blood flow

GI Bleeding

 Minimal bleeding from ulcers is manifested by occult blood in a dark, “tarry” stool (melena).
 The digestion of blood within the duodenum and small intestine may result in this black stool.
 Melena may occur in patients with gastric ulcers but is more common in those with duodenal ulcers.
 Pyloric (gastric outlet) obstruction (blockage) occurs in a small percentage of patients and is
manifested by vomiting caused by stasis and gastric dilation.
 Obstruction occurs at the pylorus (the gastric outlet) and is caused by scarring, edema, inflammation,
or a combination of these factors.

Symptoms of obstruction include:

 - abdominal bloating
- nausea
- vomiting.
 When vomiting persists, the patient may have hypochloremic (metabolic) alkalosis from loss of large
quantities of acid gastric juice (hydrogen and chloride ions) in the vomitus.
 Hypokalemia may also result from the vomiting or metabolic alkalosis.

 Peptic ulcer disease is caused most often by bacterial infection with H. pylori and NSAIDs.
 Gastric ulcer pain often occurs in the upper epigastrium with localization to the left of the midline and is
aggravated by food.
 Duodenal ulcer pain is usually located to the right of or below the epigastrium. The pain associated with a
duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the patient at night

 To assess for fluid volume deficit that occurs from bleeding, take orthostatic blood pressure
and monitor for signs and symptoms of dehydration.
 Also assess for dizziness, especially when the patient is upright, because this is a symptom of
fluid volume deficit.
 Older adults often experience dizziness when they get out of bed and are at risk for falls.
 GI bleeding may be tested using a nuclear medicine scan. No special preparation is required for this scan.
 A second scan may be done 1 to 2 days after the bleeding is treated to determine if the interventions
were effective.

The primary purposes of drug therapy in the treatment of PUD are:

1. provide pain relief

2. eliminate H. pylori infection
3. heal ulcerations
4. prevent recurrence

A common drug regimen for H. pylori infection is PPI–triple therapy, which includes a proton pump inhibitor
(PPI) such as lansoprazole (Prevacid) plus two antibiotics such as metronidazole (Flagyl, Novonidazol) and
tetracycline (AlaTet, Panmycin, Nu-Tetra) or clarithromycin (Biaxin, Biaxin XL) and amoxicillin (Amoxil,
Amoxi) for 10 to 14 days.

ABDOMINAL COMPARTMENT SYNDROME

 Abdominal compartment syndrome is defined as end-organ dysfunction caused by intra-abdominal

hypertension (IAH).

Clinical manifestations of abdominal compartment syndrome include:

 decreased cardiac output

 decreased tidal volumes
 increased peak pulmonary pressures
 decreased urine output
 hypoxia

 IAH is defined as an IAP greater than or equal to 12 mm Hg (normal 5 to 7 mm Hg).

 IAH may be graded as follows:
 IAH grade I (12 to 15 mm Hg)
 IAH grade II (16 to 20 mm Hg)
 IAH grade III (21 to 25 mm Hg)
 IAH grade IV (greater than 25 mm Hg)

LIVER FAILURE
 Acute liver failure (ALF) is a life-threatening condition characterized by severe and sudden liver cell
dysfunction, coagulopathy, and hepatic encephalopathy.
 Medical management focuses on treatment of elevated ammonia levels and control of
complications such as bleeding, metabolic disturbances, and cerebral edema.
  Nursing actions include protecting the patient from injury and maintaining surveillance for
complications

The causes of ALF include:

 Infections  Hypoperfusion
 Medications  metabolic disorders
 Toxins  surgery

 ALF develops over 1 to 3 weeks, followed by the development of hepatic encephalopathy within 8
weeks, in a patient with a previously healthy liver.
 The interval between the failure of the liver and the onset of hepatic encephalopathy usually is less
than 2 weeks.
 The underlying cause is massive necrosis of the hepatocytes.

Types of Surgery

 Esophagectomy
- is usually performed for cancer of the distal esophagus and gastroesophageal junction.
 Pancreaticoduodenectomy
- the pancreatic head, the duodenum, part of the jejunum, the common bile duct, the
gallbladder, and part of the stomach are removed.
 Bariatric Surgery
- refers to surgical procedures of the GI tract that are performed to induce weight loss.

ACUTE PANCREATITIS

 Acute pancreatitis can be caused by gallstones and alcoholism, and it can result in autodigestion of
the pancreas.
 Medical management focuses on fluid management, nutrition support, and control of systemic and
local complications.
 Nursing actions include providing comfort and emotional support and maintaining surveillance for
complications

Diagnostic Procedures

 Abdominal ultrasonography
 Computed tomography scan
 Magnetic resonance imaging
 Endoscopic retrograde cholangiopancreatography
 Abdominal radiographs (flat plate and upright or decubitus)
 Chest radiographs (posteroanterior and lateral)

Complications of Acute Pancreatitis

Respiratory

 Early hypoxemia  Pulmonary infiltration

 Pleural effusion  Acute respiratory distress syndrome
 Atelectasis  Mediastinal abscess

Cardiovascular

 Hypotension and shock  ST-T changes

 Pericardial effusion

Renal

 Acute tubular necrosis  Renal artery or vein thrombosis

 Oliguria
Hematologic

 Disseminated intravascular coagulation  Hyperfibrinogenemia

 Thrombocytosis

Endocrine

 Hypocalcemia  Hyperglycemia
 Hypertriglyceridemia

Neurologic

 Fat emboli  Encephalopathy and coma

 Psychosis

Ophthalmic

 Purtscher retinopathy (sudden blindness)

Dermatologic

 Subcutaneous fat necrosis

Gastrointestinal or Hepatic

 Intraabdominal hypertension/abdominal compartment syndrome

 Hepatic dysfunction  Duodenal obstruction

 Obstructive jaundice  Pancreatic
 Stress ulceration  Bowel infarction
 Erosive gastritis  Massive intraperitoneal bleed
 Paralytic ileus  Perforation

DIABETIC KETOACIDOSIS
 DKA is a life-threatening complication of diabetes mellitus.
 Individuals with type 1 diabetes who are dependent on insulin are typically affected.

The diagnostic criteria for DKA are:

 Blood glucose greater than 250 mg/dL

 pH less than 7.3
 Serum bicarbonate less than 18 mEq/L
 Moderate or severe ketonemia or ketonuria
- It is categorized as mild, moderate, or severe – assessed by blood pH, bicarbonate, ketones and by the
presence of altered mental status.
- Ketoacidosis occurs when free fatty acids are metabolized into ketones: Acetoacetate, β-hydroxybutyrate,
and acetone are the three ketone bodies that are produced.
- Diagnosis of DKA is based on the combination of presenting symptoms, patient history, medical history
(type 1 diabetes), precipitating factors (if known), and results of serum glucose and urine ketone testing.

HYPERGLYCEMIA
 increases plasma osmolality, and the blood becomes hyperosmolar.
 Cellular dehydration occurs as the hyperosmolar extracellular fluid draws the more dilute intracellular
and interstitial fluid into the vascular space in an attempt to return the plasma osmolality to normal.
 Catecholamine output stimulates further glycogenolysis, lipoly

HYPERGLYCEMIC HYPEROSMOLAR STATE

 is a potentially lethal complication of type 2 diabetes.

 Ketosis is absent or mild.
  Inability to replace fluids lost through diuresis leads to profound dehydration and changes in level of
consciousness.

The diagnostic criteria for HHS are:

 Blood glucose greater than 600 mg/dL

 Arterial pH greater than 7.3
 Serum bicarbonate greater than 18 mEq/L
 Serum osmolality greater than 320 mOsm/kg H2O (320 mmol/kg)
 Absent or mild ketonuria
- Most patients with this level of metabolic disruption experience visual changes, mental status changes, and
potentially hypovolemic shock.
- High risk: older adults with type 2 diabetes & CV conditions.
- HHS has a slow, subtle onset and develops over several days.
- Initially, the symptoms may be nonspecific and may be ignored or attributed to the patient’s concurrent
disease processes.

MEDICAL/SURGICAL MANAGEMENT

i. Volume restoration
 Fluid replacement is provided in the initial phase of treatment to prevent circulatory
collapse.
 Patients who are able to drink are given voluminous amounts of fluid orally to balance
output.
 For patients who are unable to take sufficient fluids orally, hypotonic IV solutions are
infused and carefully monitored to restore the hemodynamic balance.

ii. Nasogastric Suction Tubes

 Remove fluid regurgitated into the stomach, prevent accumulation of swallowed air, may
partially decompress the bowel, and reduce the patient’s risk for aspiration.
 It can also be used for collecting specimens, assessing the presence of blood, and
administering tube feedings.
 Nursing management focuses on preventing complications common to this therapy, such as
ulceration and necrosis of the nares, esophageal reflux, esophagitis, esophageal erosion and
stricture, gastric erosion, and dry mouth and parotitis from mouth breathing.
iii. Esophagogastric Balloon
 A procedure in which a balloon is inflated within the esophagus and stomach to apply
pressure on bleeding blood vessels, compress the vessels, and stop the bleeding.
 Used in the treatment of bleeding veins in the esophagus (esophageal varices) and stomach.
iv. Tamponade Tube Billroth I and II
 Billroth I, more formally Billroth's operation I, is an operation in which the pylorus is removed
and the distal stomach is anastomosed directly to the duodenum.
 The Billroth II always follows resection of the lower part of the stomach (antrum).
v. Transjugular Intrahepatic Portosystemic Shunt
 Is an angiographic interventional procedure for decreasing portal hypertension.
 TIPS is advocated for:
1. Patients with portal hypertension who are also experiencing active
bleeding or have poor liver reserve
2. Transplant recipients
3. Patients with other operative risks
 The TIPS procedure is usually performed by a gastroenterologist, vascular surgeon, or
interventional radiologist.
 Cannulation is achieved through the internal jugular vein, and an angiographic catheter is
advanced into the middle or right hepatic vein.
 The midhepatic vein is then catheterized, and a new route is created connecting the portal
and hepatic veins using a needle and guide wire with a dilating balloon.
 A polytetrafluoroethylene-coated stent is then placed in the liver parenchyma to maintain
that connection
vi. Liver Transplantation
  Must be considered for any patient who has irreversible acute or chronic liver disease that is
progressive and for which there is no therapy of established efficacy.
 Diseases of the liver may be categorized as chronic, vascular, fulminant or subfulminant,
inborn errors of metabolism, and hepatic malignancies.
 The decision to offer liver transplantation to any patient must be based on evaluation
criteria, which vary among institutions and which are modified as advances in technical
ability, immunosuppression, and perioperative management continue.
vii. Reverse Hydration
 Reverse hydration is severely mineral deficient and has an acidic pH.
 As with distilled water, it does not supply the body with needed trace minerals, and it may
have a mild chelating effect.
viii. Reverse Ketoacidosis
 One of the first things that will be done to treat your diabetic ketoacidosis is to replace fluids.
 This can be in the hospital, a doctor’s office, or home.
ix. Electrolyte replacement
 Increasing the circulating levels of insulin with therapeutic doses of IV insulin promotes the
rapid return of potassium and phosphorus into the cell.
 Many hospitals have potassium replacement algorithms that are used to treat hypokalemia.
 Serum phosphate levels are carefully monitored, and phosphate is replaced if the level is
lower than 1.0 mg/dL.
x. Rapid Hydration
 The "Rapid Hydration Protocol" greatly reduced duration of hydration without adverse
effects.
 Rapid hydration decreased the time needed for hydration and the number of nurses involved
in the first day of chemotherapy, and contributed to having chemotherapy begin earlier. 

PHARMACOLOGICAL MANAGEMENT

Complementary and Alternative Therapy

Ginger
- Ginger has been used as a cooking spice as well as an herbal medicine throughout history,
and has been commonly used to treat morning sickness, motion sickness, colic, gas, upset
stomachs and nausea. 
Bitter fruit (Ampalaya)

- The leaves and fruit - used as vegetables - are excellent sources of Vit B, iron, calcium, and
phosphorus. It has twice the amount of beta carotene in broccoli and twice the calcium
content of spinach. Characteristically bitter-tasting, slight soaking in salty water before
cooking removes some of the bitter taste of the fruit.

Diagnostic Assessment

i. Non Invasive
 Urinalysis
 24-urine collection
 Renal ultrasound
ii. Invasive
 Serum studies intravenous pyelography
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