DISORDERS OF THE GASTROINTESTINAL SYSTEM AND • it is also known as the cardiac sphincter

ENDOCRINE SYSTEM • this sphincter prevents gastric reflux

• stomach located in the LUQ of the abdomen

• capacity 1500ml

REGIONS OF THE STOMACH

• Cardiac
• fundus
• body
• pyloric

FUNCTION OF THE STOMACH

1. mechanical digestion
• mixing, liquefaction and storage of food
bolus into a semisolid mixture (chyme)
• grind food
2. secretion
• secretion of gastric juices (1500-3000ml) in
the gastric mucosa
• the gastric juices is composed of mucous,
hcl, pepsinogen and water.
• Protection-the acid medim is responsible for
the reduced activity of harmful bacteria that
Overview of the GIT functions. may have been taken with food.
• starts digestion of proteins through the action
1. Digestion:
of pepsin which then converts protein into
2. Absorption
polypeptides
3. Metabolism
• digestion of emulsified fats
4. Eliminate waste products
3. absorption:
TYPES OF DIGESTION: • absorption of minimal water, alcohol,
glucose, and some drugs in the gastric
 MECHANICAL DIGESTION mucosa
 CHEMICAL DIGESTION  controls passage of chyme into the duodenum
through peristaltic waves.
MECHANICAL DIGESTION  carbohydrates are emptied within 1-2 hours
• changes the physical state of food  proteins 3-4 hours
• propels food along the alimentary tracts  fats withn 4-6 hrs
• processed by  once acidic chyme is
 deglutition: swallowing formed, slow
 peristalsis: wavelike movements that squeeze peristaltic waves
food downward in the tract travel from the fundus
 sequential contractions: movements that mix to the pylorus.
gastric and intestinal contents with digestive  pressure builds up
juices and pyloric sphincters
opens.
CHEMICAL DIGESTION – it is a series of hydrolytic processes
dependent on specific enzymes and chemicals that act as • small intestine
catalyst to facilitate the digestion process.
 6 m long
GIT FUNCTION o divided into three parts:
 duodenum, jejunum, ileum
 absorption: passage of small molecules from food  majority of the digestive process is completed in the
sources through the intestinal mucousa into the blood duodenum
or lymph  absorption of foods occur primarily in the small
 metabolism: metabolism of carbohydrates, glucose is intestine
transported through the cell membranes. conversion
of glucose to glycogen for storage. FUNCTIONS OF THE SMALL INTESTINE
 eliminate waste: by defecation.
1. mucus secretion – goblet cells and duodenal glands secrete
STRUCTURES AND FUNCTIONS OF THE GIT mucus to protect the mucosa

• mouth –where the digestive process begins
- where the mechanical (through chewing) and
chemical digestion occurs (through action of
salivary amylase ptyalin which break down
starches to maltose
deglutition (swallowing) occurs when the food is broken down
into small pieces and is mixed well with saliva (food bolus)
• esophagus serve as a passage for food bolus from mouth to
stomach by peristalsis
• the distal end of the esophagus is guarded by a lower
esophageal sphincter (les).
2. secretion of enzymes – brush border cells secrete sucrase,
maltase and enterokinase which act on disaccharides
(carbohydrates)
3. secretion of hormones-endocrine cells secrete
cholecystokinin, secretin and enterogastrone that regulate the
secretion of bile, pancreatic juice and gastric juice
4. chemical digestion: in the presence of acidic chyme in the
duodenum the following will occur:
(1) the presence of carbohydrates, fats, and protein stimulate
secretion of pancreozymin.
this enzyme stimulates enzyme secretion of pancreatic
amylase, lipase and trypsin amylase that will complete the
digestion of carbohydrates. lipase completes digestion of fats, FUNCTIONS OF THE LIVER
trypsin completes digestion of protein. functions of the small
intestine 1. 1.carbohydrate metabolism: converts glucose to
glycogen by glycogenesis, converts glycogen to
(2) in the presence of fats in the acidic chyme, the duodenum glucoose by glycogenolysis, and forms glucose from
secretes cholecystokinin which causes contraction of the proteins and fats by gluconeogenesis
gallbladder, relaxation of sphincter of oddi, thereby releasing 2. fat metabolism a. ketogenesis: fatty acids are broken
the bile emulsifies fats, thereby enabling pancreatic lipase to down into molecules of acetyl coenzyme
complete digestion of fats. a. (acetyl-coa) (beta oxygenation), which form
ketone bodies (acetoacetic acid, acetone,
• the bile and pancreatic juice are alkaline, therefore they beta-hydroxybutyric acid)
neutralize the acidic chyme the small bile occur b. fat storage
c. synthesis of triglycerides, phospholipids,
(3). absorption of water and nutrients by active transport
cholesterol, and b complex factor choline
osmosis and diffusion into the
3. protein metabolism
blood capilliaries and lacteals
a. anabolism: synthesis of various blood
in the villi.
proteins (e.g., prothrombin, fibrinogen,
(4) motor activities such as albumins, alpha and beta globulins, and
mixing movements and clotting factors v, vil, 1x, and x)
peristalsis propel the chyme b. deamination: chemical reaction by which
through the small intestine. amino group splits off from amino acid to
form ammonia and a keto acid
• this chyme remains in the c. urea formation: liver converts most of
small intestine for 3-10 hours ammonia formed by deamination to urea
and the residue moves into the 4. secretes bile, substance important for emulsifying fats
large intestine before digestion and as a vehicle for excretion of
cholesterol and bile pigments
• large intestine
5. detoxifies various substances (e.g., drugs, hormones)
 extends from the 6. vitamin metabolism: stores vitamins a, d, k, and b12;
ileocecal valve to the anus bile salts needed to absorb fat-soluble vitamins a, d,
e, and k
 approx. 1.5 m (5-6 feet) long
7. chief source is synthesized by bacteria in large
 divided into the following parts: cecum, colon, rectum
intestine; vitamin k is a fat soluble vitamin that
and anus
requires bile for its absorption
 where the vermiform appendix is attached
 divided into ascending, descending and sigmoid • gallbladder
sections
a. lies on undersurface of liver
FINAL SEGMENTS OF THE LARGE INTESTINE RECTUM b. sac made of smooth muscle, lined with mucosa
AND ANUS arranged in rugae
c. functions: concentrates and stores bile
FUNCTIONS OF LARGE INTESTINE
• pancreas
 churning and peristalsis
 secretion: mucus to protect the mucosa from injury, a. structure
binds fecal particles into a formed mass, lubricates
and allows passage of fecal residue and counteracts 1. fish-shaped, with body, head, and tail; extends from
the effects of acid forming bacteria duodenal curve to spleen
 absorption of water, sodium, and chloride 2. duct and ductless gland
a. pancreatic cells: secrete pancreatic juice via duct to
 approx 800-100oml of water is absorbed in the large
duodenum; enzymes include trypsin, lipase, and
intestine
amylase; stimulated by duodenal hormones secretin
 synthesis of vitamins: colonic bacterial flora
and pancreozymin and by parasympathetic impulses
synthesizes vit k, thiamine, riboflavin, vit b12, folic
b. islets of langerhans: clusters of cells not connected
acid, biotin and nicotinic acid
with pancreatic ducts; composed of alpha and beta
 formation of feces
cells
o fecal matter is 3/4 water and 1/4 solid
material FUNCTIONS OF THE PANCREAS
o defecation: the act of expulsion of feces from
the body 1. pancreatic juice composed of enzymes that help digest
carbohydrates, proteins, and fats
VERMIFORM APPENDIX
2. islet cells constitute
a. blind-end tube of cecum just beyond ileocecal valve endocrine gland
b. function: part of immune system
a. alpha cells secrete the
ACCESSORY ORGANS: LIVER hormone glucagon, which
accelerates liver
a. occupies most of right hypochondrium and part of glycogenolysis and
epigastrium initiates gluconeogenesis;
b. divided into thousands of lobules tends to increase blood
c. ducts glucose level
1. hepatic duct: from liver gallbladder
2. cystic duct: from gallbladder  beta cells secrete insulin, which exerts profound
3. common bile duct: formed by union of hepatic influence on metabolism of carbohydrates, proteins,
and cystic ducts; drains bile into duodenum at and fats
sphincter of oddi
(1) accelerates active transport of glucose, along with
potassium and phosphate 1ons, through cell membranes;
decreases blood glucose level and increases glucose
utilization by cells for either catabolism or anabolism

(2) stimulates production of liver cell glucokinase; promotes

liver glycogenesis, which lowers blood glucose concentration

(3) inhibits liver cell phosphatase and therefore inhibits liver

glycogenolysiss

(4) accelerates rate of amino acid transfer into cells, promoting

anabolism of proteins within cells

(5) accelerates rate of fatty acid transfer into cells, promotes fat
anabolism (lipogenesis); inhibits fat catabolism

ASSESSMENT OF CLIENTS WITH GI DISORDERS

 history
 demographic data, religion, personal and
 family history
 general health status previos gi disorders and surgery
change in bowel habits, gi bleeding, jaundice, weight
loss
 assessment of clients with gi disorders
 any medications taken routinely.
 long term use of laxatives.
 family history of g.i. disorders.
 diet history: usual foods and fluids that are typically
consumed.
 quality and quantity of foods ingested. relationship of
food intake and g.i. symptoms usual and current
appetite. symptoms such as nausea and vomiting,
difficulty of swallowing
 chief complaint (e.g., abdominal pain)
 the nurse should ask the following questions: onset,
duration, quality and characteristics severity location
 precipitating factors relieving factors associated
symptoms
 medical history
 major illnesses and hospitalizations
 use of medications allergies tod foods and other
substances
 assessment of clients with gi disorders
 family history history of cancer, ulcers, colitis,
hepatitis, obesity
 psychosocial history and lifestyle
 occupation: meal times and travel
 social stress-provoking situations alcohol and nicotine

ASSESSMENT OF CLIENTS WITH GI DISORDERS

PHYSICAL EXAMINATION

 assessing oral cavity

 inspection:
o lips-for abnormal color, lesions, nodules, +epigastric
symmetry.
o oral mucosa- redness, pallor, swelling, +umbilical
gums- redness, pallor, ulcers, bleeding. o +suprapubic
ulcers or leukoplakia.
 assessing oral cavitty • rectal exam
 inspection:
• internal
o teeth-dental caries, dentures, missingbroken
teeth. • external
o tongue - color, ulcers, abnormal coating,
swelling or deviation to one side, movement  positi1on: supine with knees flexed (dorsal recumbent
o pharynx - tonsil abnormalities, lesions, position)
ulcers, uvular deviation, unusual mouth odor. o dorsal recumbent position
 palpation: lips, gingival, buccal mucosa,tongue  assessing the abdomen :sequence iapp
 area is checked for masses, swelling, tenderness o inspection
o auscultation
o percussion
o palpation

REMEMBER

 auscultation is performed in the abdomen before

percussion and palpation. this is because percussion
 and palpation can increase intestinal activity and
therefore alter bowel sounds.
 no abdominal palpation is done in clients with tumor
of the liver or kidney. to prevent rupture of the tumor
and massive internal hemorrhage.
PE: INSPECTION
 abdomen-condition of the skin, contour skin should be
smooth,intact
 contour of the abdomen is flat, concave, rounded or
distended depending on the client's body type.
 inspect umbilicus-shape, position, color (concave,
located at midline, same color as the abdominal skin)
 note abdominal movements, pulsations, peristaltic
movements. normally, peristaltic movements are not
visible
PE: AUSCULTATION
 bowel sounds (5 to 35/minute) rapid, high- pitched,
loud bowel sounds are hyperactive (e.g., in
gastroenteritis). hypoactive bowel sounds occur at a
rate of one every minute or longer (paralytic ileus) or
after bowel surgery.
 note: empty the bladder before auscultation of the
abdomen, because a full bladder can interfere with
sounds.
PE: PERCUSSION
 to determine the size and location of abdominal
organs and to detect fluid, air and masses.
 percussion sounds over abdomen:tympanic-high-
pitched, loud, musical over air dull-thud-like sound
over fluid or solid organs
 note: avoid abdominal percussion in clients with
suspected abdominal aneurysms and in those clients
with abdominal organ transplants.
PALPATION
 palpate the abdomen by lightly pressing 1-2cm in
quadrant to quadrant mianner
 assess for masses, rebound tenderness and
abdominal rigidity
 deep palpation should be performed cautiously only
by a skilled nurse.
DIAGNOSTIC TESTS
laboratory tests:
 cea (carcinoembryonic antigen) (+) in colorectal ca
 avoid heparin for 2 days specimen is obtained by
venipuncture
 diagnostic tests: laboratory test
 d-xose absorption test
 initial blood/urine specimen are collected npo for 10-
12 hourss
 blood/urine levels are measured
 done for diagnosis of malabsorption
 exfoliattve cytoloogy
o done to detect malignant cells
o >written consent is obtained
o >liquid diet is given
o upper gl: nasogastric tube (ngt) insertion is
don >elower gi: laxative the night before and
enema in the moming
o >cells are obtained from saline lavage-via
ngt for ugi/via procto for lgi
 fecal analysiss
o stool for occult blood (gualac stool exam)
done to detect g.i. bleeding
o provide high fiber diet fror 48-72 hours
o no red meats, poultry, fish, tumips,
horseradish, cauliflower, broco and melon.
red meats, poultry, fish contain hemoglobin
fibers who may be mistaken as blood.,
horseradish, cauliflower, brocos and melon
are high in peroxidase and will cause false
positive results. vitamin c causes false
negative reading
 occult blood test is done by placing hydrogen
peroxide to the stool specimen.
 if blue ring is formed, this indicates bleeding withhold
for 48 hrs: iron, steroids, indomethacin, colchicine iron
causes blackish greenish discoloration of stool. this
may be mistaken as bleeding.
 steroids, indomethacin, calchicine may cause g.
imitation thereby, bleeding. this causes false positive
result 3 stool specimen will be collected (3 successive
days)
 Stool for ova and parasites
o send fresh, warm stool specimen, especially
if the purpose of the test is to detect
amoebiasis.
 stool culture
o use sterile test tube and cotton - tipped
applicator to collect specimen. this ensures
that the specimen is not contaminated
 stool for lipidds
o done to assess steatorrhea.
o include fats in the diet.
o to assess ability ofthe gi to metabolize fats
o avoid alcohol for 3 days, alcohol mobilizes
fats
o avoid mineral oil, neomycin so4 and other
oily medications.
DIAGOSTIC TESTS: GASTRIC
ANALYSIS
 measures secretion of
hci and pepsin.. npo for
12 hours.
 ngt is inserted,
connected to suction.
gastric contents are
collected every 15
minutes to 1 hour.
 if inc hcl - duodenal ulcer if dec hcl -pernicious
anemia
 bernstein test (acid perfusion test)
 to assess if chest pain is related to gastroesophageal
reflux
 npo 6-8 hours
 ngt insertion
 alternate instillation of nss and 0.1% hcl
 if no pain is experienced (-) for gastroesophageal
reflux; if pain is experienced (+) for gatroesophageal
reflux.
 antacid is administered after the procedure to relieve
discomfort
DIAGNOSTIC TESTS
1. radiographic tests:
• •scout film/flat plate of the abdomen
o plain xray
o avoid belts, jewelries, metals
2. ultrasound of the abdomen
• npo 8-12 hrs
• laxative as ordered to reduce bowel gas
3. mri
• produce cross sectional images of organs by using
magnetic fields
• npo 6-8 hrs
• instruct client to remain still during the procedure
• inform that procedure may last 60-90 minutes
• remove jewelries and metals
 • contraindicated: pacemakers, aneuryms, orthopedic
screws
radiographic tests: ugis upper gi series / barium swallow
• visualize the upper gi tract (esophagus, stomach,
duodenum and jejunum)
• pretest: npo 6-8hrs
• barium sulfate is administered per Orem (barium
sulfate is a white chalky substance)
• xrays are taken on standing and lying position
• post test: laxative administration, as barium sulfate
causes constipation
o inc fluid intake
o inform client that the stool will be white for
24-72hrs due to evacuation of barium sulfate
o observe for signs of barium
impaction:distended abdomen & constipation
• lgis / barium enema
• intestinal evacuant like golytely may be administered
in place of enema. Instruct client to take 240 cc every
10 minutes up to 2 hours. it is expected that the client
will have watery stools (diarrhea).
• place the client in knee- chest / lateral position during
the procedure.
• assess for signs of vasovagal stimulation. the gi tract
is supplied by the vagus nerve.
• after the procedure :
• supine position for few minutes. to prevent postural
hypotension.
• assess for signs of perforation - bleeding, pain, and
fever.
• hot sitz bath to relieve discomfort in the anorectal
area.
COLONOSCOPY
• preparation of the client is same as in
proctosigmoidoscopy sedation is done to relax the
client.
• position during the procedure: left side, knees flexed.

• to visualize the colon o after the procedure;

• pretest: low residue diet/clear liquid diet for 2 days
• laxativ for cleansing the bowel • monitor vs (note for vasovagal response, eg
• suppository / cleansing enema in the am bradycardia. hypotension)
• assess for signs and symptoms of perforation.
• barium sulfate is administerd per rectum
NURSING PROCEDURES FOR GI SYSTEM
• post procedure: same with ugis
•1. Gastric and intestinal
• ct scan- uses beam radiation to assess cross sections of the decompression
body
• it is removal of fluid
• pretest: clear liquid diet in the am and gas, to prevent
• if ct scan with contrast medium : npo 2-4 hrs gastric and intestinal
• assess for allergy to seafood and asses for distention.
claustrapobia nasogastric tubes
• procedure is painless (ngts) and
• advise client to remain still during the procedure nasoenteric tubes
are used for gastric
ENDOSCOPIC PROCEDURES and intestinal
• ugi endoscopy direct visualization of esophagus, decompression.
stomach, and duodenum LEVINE TUBE
• obtain written consent
• npo for 6-8 hours • is single- lumen ngt.
• administer anticholinergic (atso4) as ordered. • it is primarily used for ngt feeding (gastric gavage)
secretions and prevent aspiration.
• mucus sedatives, narcotics, tranquilizers. to relax the SALEM-SUMP TUBE
client.
• is double - lumen ngt used for decompression.
• e.g. diazepam, meperidine hci
• the air vent (blue pigtail) prevents adherence of the
• remove dentures, bridges. To prevent airway
tube to the gastric mucosa.
obstruction.
• the other lumen is to be connected to lowpressure,
• local spray anesthetic (lidocaine) on posterior pharynx
continuous gastric suction.
is administered to depress the gag reflex.
• instruct the client not to swallow saliva. maximum
effect of the anesthetic. lidocaine is unpalatable.

• after the procedure

• place the client in side-lying position. to prevent

aspiration.
• npo until gag reflex returns (2-4 hrs).
• nss gargle; throat lozenges. to soothe the throat.
• monitor vs (vital signs).
• assess: bleeding, crepitus (neck), fever, neck / throat
pain, dyspnea, dysphagia, back / shoulder pain
• advise to avoid driving for 12 hours if sedative was
used.

LGI ENDOSCOPY

• proctosigmoidoscopy (sigmoid, rectum)

• clear liquid diet 24 hours before the procedure.
• administer cathartic / laxative as ordered. o
• cleansing enema. CANTOR TUBE.
• is a single-lumen nasoenteric tube. its balloon is inflated with • after each feeding, instill 30 to 60 ml. of tap water (if
mercury before insertion. syringe is used).
• have client remain in semi- to high- fowler's position
or in slight elevated
• side - lying position 30 to 60 minutes after feeding to
prevent gastric reflux and aspiration.
MILLER - ABBOT TUBE. • note: avoid placing end of ngt in water to
check for placement. Water may be
• is a double- lumen aspirated if ngt is in the trachea.
nasoenteric tube
used for • b. gastrostomy feeding
decompression.
• the feeding
• the main lumen is
should be
connected to low-pressure gastric suction. the other
at room temperature.
lumen serves as an air vent to prevent adherence of
o the client
the tube to intestinal mucosa. its balloon is inflated
with mercury after insertion. should be
placed in semi-
2. esophageal balloon tamponade to high-
fowler's
• the procedure is position.
done to control o check
bleeding of ruptured placement of
esophageal varices gastrostomy
in clients with liver tube by instilling 15 to 30 mis. Of water.
cirrhosis. • use infusion pump for continuous feeding,
• the catheter used is • to infuse formula in 3 hours check residuals every 4 to
sengstaken- 6 hours. Then reinstill the gastric aspirate and flush
blakemore tube. tubing with 30 to 60 ml. of water. (if 100 ml. or more,
• it is a triple - lumen hold feeding notify physician).
tube with 2 balloons. • have client remain in semi- to high - fowler's or in
• the three lumen have slightly elevated side lying position 30 to 60 mins.
the following after feeding. to prevent gastroesophageal reflux and
functions: aspiration.
(a) for inflation of esophageal balloon,
(b) for inflation of gastric balloon, total parenteral nutrition
(c) the middle lumen is to be connected to gastric
suction. 4. tpn is indicated in clients who need extensive nutritional
• the 2 balloons have the following functions: support over an extended period, e.g., major gi diseases,
(a) the esophageal balloon compresses the ruptured severe malnutrition, cancer.
esophageal varices, to stop the bleeding:
• the usual site for tpn catheter insertion in subclavian
(b) the gastric balloon serves as an anchor to
vein.
prevent upward displacement of the esophageal
• the clavicle provides good support to the catheter.
balloon
• client in during tpn catheter insertion into the
3. enteral feeding. subclavian vein, place the client in Trendelenburg
position. to engorge the vein and facilitate insertion of
•a. nasogastric tube feeding the catheter.
• this position also prevents air embolism. The primary
• this is also called gastric purpose of tpn is to administer glucose.
gavage, ngt feeding. • administer tpn at room temperature. Cold temperature
• the feeding formula of solution cause chills.
should be at room • consume tpn formula within 24 hours to prevent
temperature. contamination
• the client should be
placed in semi- to high-
fowler's position to
prevent cramping and discomfort from cold formula.
• prevent gastric reflux and aspiration.
• check placement of ngt before feeding.
• check ph of gastric aspirate (should be acidic ph of 1
to 3).
• gastric aspirate appears greenish or yellowish.
• introduce 10 ml. of air into ngt and auscultate at
epigastric area for gurgling sounds.
• aspirate all stomach content to check for residual
feeding.
• if residual feeding is 100 mls. or more than half of the
last feeding is aspirated the feeding. notify the
physician.
• reinstillthe aspirated gastric content to prevent
metabolic alkalosis.
• use infusion pump if gavage bag is used to allow
feeding to flow slowly.
• feedings given too rapidly cause nausea, vomiting,
flatulence abdominal cramps.
• gastric residuals are checked every 4 to 6 hours,
• then flushed with 30 to 60 ml. of water.