Let’s Begin!

KEY TERMS
 Oral Disorders
 Esophageal Disorders
 Duodenal
 Intestinal Disorders
 Rectal Disorders
 Bowel Obstruction
 Upper GI series
 Lower GI series

OVERVIEW OF THE ANATOMY AND

PHYSIOLOGY OF THE
GASTROINTESTINAL SYSTEM

 The GIT is composed of 2 general parts:

 Main GIT: Mouth – Esophagus –
Stomach – Small intestines –
Large Intestines – Rectum
 Accessory Glands: Salivary gland,
Liver, Gallbladder, Pancreas

MOUTH

- Contains the lips, cheeks, palate,

tongue, teeth, salivary glands,
masticatory/facial muscles and bones
- Important for mechanical digestion of
food
- Saliva contains SALIVARY AMYLASE or
PTYALIN that starts the initial digestion of carbohydrates

ESOPHAGUS

- A hollow muscular tube

- Length- 25 cm
- Made up of stratified squamous epithelium
- Located in the mediastinum, anterior to the spine,posterior to the trachea and
heart
- The upper third contains skeletal muscles, contains the upper esophageal or
hypopharyngeal sphincter
- The middle third contains mixed skeletal and smooth muscles
- The lower third contains smooth muscles and the esophago-gastric/ cardiac sphincter is
found here
- Functions to carry or propel foods from the oropharynx to the stomach
 STOMACH

- J-shaped organ in the LUQ

- Contains four parts- the fundus, the cardia, the body and the pylorus
- The cardiac sphincter prevents the reflux of the contents into the esophagus (entrance)
- The pyloric sphincter regulates the rate of gastric emptying into the duodenum (exit)
- Capacity is 1,500 ml!
- The functions of the stomach are generally to digest the food (proteins) and to propel the
digested materials into the SI for final digestion
- Glands and cells in the stomach secrete digestive enzymes:
1. Parietal cells - HCl acid and Intrinsic factor
2. Chief cells- pepsin = digestion of PROTEINS!
3. Antral G -cells- gastrin
4. Argentaffin cells- serotonin
5. Mucus neck cells- mucus

SMALL INTESTINE

- Longest segment, about 2/3 of the total length

- Grossly divided into the Duodenum (proximal), Jejunum (middle) and
Ileum (distal)
- Duodenum w/ampulla of vater: common bile duct empties, passage of bile and pancreatic
secretions
- The ileum is the longest part (about 12 feet)
- The intestinal glands secrete digestive enzymes that finalize the digestion of all foodstuff
- Enzymes for carbohydrates  disaccharidases
- Enzymes for proteins  dipeptidases and aminopeptidases
- Enzyme for lipids  intestinal lipase
- duodenal secretions come from the accessory digestive organs- pancreas, liver and gallbladder
and the glands on the intestinal walls
- pancreatic secretions have alkaline pH due to the high concentration of bicarbonate- this
neutralizes the acid entering the duodenum from the stomach

2 Types of contractions in the small intestines

a. segmental contractions- mixing waves that move the intestinal contents back
and forth in a churning motion
b. intestinal peristalsis- propels the contents towards the colon
* both movements are stimulated by the presence of chime
- Finger like projections (villi) are present throughout the small intestines- absorption-begins in
the jejunum by active transport and diffusion

• Upper GIT study: Barium swallow

- Examines the upper GI tract
- Barium sulfate is usually used as contrast
- Pre-test: NPO post-midnight
- Post-test: Laxative is ordered, increase pt fluid intake, instruct that stools will turn white,
monitor for obstruction

chyme
Finger like projections/villi are present throughout the small intestines- absorption-begins in the
jejunum by active transport and diffusion

LARGE INTESTINE

- Approximately 5 feet long, with parts:

1. The cecum - widest diameter, prone to rupture
2. The appendix
3. The ascending colon
4. The transverse colon
5. The descending colon
6. The sigmoid = most mobile, prone to twisting
7. The rectum
8. The Anus

Terminologies:

• Digestion: phase of the digestive process that occurs when enzymes mix with ingested
food and when proteins, fats, and sugars are broken down into their component molecules
• Absorption: phase of the digestive process that occurs when small molecules, vitamins,
and minerals pass through the walls of the small and large intestine and into the
bloodstream
• Elimination: phase of the digestive process that occurs after digestion and absorption,
when waste products are eliminated from the body

FUNCTIONS OF THE GIT

• The breakdown of food particles into the molecular form for digestion
• The absorption into the bloodstream of small nutrient molecules produced by digestion
• The elimination of undigested unabsorbed foodstuffs and other waste products

Digestive Processes

• Chewing
- 1.5ml of saliva is secreted daily from the parotid, submaxillary and sublingual glands
- PTYALIN or SALIVARY AMYLASE is an enzyme that begins the digestion of starches

 Swallowing begins as a voluntary act, w/c is regulated by the swallowing center in the medulla
oblongata of the CNS

• Gastric Function
- stomach: secretes a highly acidic fluid in response to the presence of ingested food
- gastric fluid: 2.4L/day; pH as low as 1 and derives its acidity from hydrochloric acid (H
a. to breakdown food into more absorbable components
 b. to aid in the destruction of ingested bacteria

Gastric Enzymes
- Secreted by zymogens or chief cells
- Amylase=for starch digestion
- Lipase=for fat digestion
- Pepsin=for protein digestion
- Rennin=for milk and protein digestion

Parietal cells
- HCl - maintains acidity 1.0 pH destroy some bacteria ingested aids also in digestion of food
- Intrinsic factor - aids in absorption of vitamin B12
* pernicious anemia

Waste Products of Digestion

- Feces - undigested foodstuff, inorganic materials, water and bacteria
- 75% fluid 25% solid material
- brown color results from the breakdown of bile
- gases- methane, hydrogen sulfide and ammonia
- Elimination begins with distention of the rectum w/c initiates contractions of the rectal
musculature and relaxes the closed internal anal sphincter
- internal anal sphincter- autonomic nervous system
- external anal sphincter- cerebral cortex; maintained in tonic contraction

GASTROINTESTINAL ASSESSMENT

LABORATORY PROCEDURES

 Fecalysis
- Examination of stool consistency, color and the presence of occult blood.
- Special tests for fat, nitrogen, parasites, ova, pathogens and others

 FECALYSIS: Occult Blood Testing

- Instruct the patient to adhere to a 3-day meatless diet (NO RED MEAT)
- No intake of NSAIDS, aspirin and anti-coagulant (FALSE POSITIVE RESULT)
- No vitamin C – FALSE NEGATIVE RESULT
- Screening test for colonic cancer

 Upper GIT study: Barium swallow

- Examines the upper GI tract
- Barium sulfate is usually used as contrast
- Pre-test: NPO post-midnight
- Post-test: Laxative is ordered, increase fluid intake, instruct that stools will turn white,
- monitor for obstruction
• Lower GIT study: Barium enema
- Examines the lower GI tract
- Pre-test: Clear liquid diet and laxatives, NPO post- midnight, cleansing enema
prior to the test
- Post-test: Laxative is ordered, increase patient fluid intake, instruct that stools will turn
white, monitor for obstruction
•
Gastric analysis
- Aspiration of gastric juice to measure pH, appearance, volume and contents
- Pre-test: NPO 8 hours, avoidance of stimulants, drugs and smoking
- Post-test: resume normal activities

• EGD - esophagogastroduodenoscopy
- Visualization of the upper GIT by endoscope
- Pre-test: ensure consent, NPO 8 hours, pre-medications like atropine and anxiolytics

 Gastroscopy
- Intra-test: position : LEFT lateral to facilitate salivary drainage and easy access
- Post-test: NPO until gag reflex returns, place patient in SIMS position until he awakens,
monitor for complications, saline gargles for mild oral discomfort
• Lower GI- scopy
- Use of endoscope to visualize the anus,
rectum, sigmoid and colon
- Pre-test: consent, NPO 8 hours, cleansing
enema until return is clear
- Intra-test: position is LEFT lateral, right leg
is bent and placed anteriorly
- Post-test: bed rest, monitor for
complications like bleeding and perforation

ASSESSMENT AND MANAGEMENT OF PATIENTS WITH ORAL AND ESOPHAGEAL

DISORDERS

Conditions of the Oral Cavity Disorders of the Teeth

1. Dental Plaque and Caries

- tooth decay is an erosive process that begins w/ the action of bacteria on fermentable CHO in
the mouth, w/c produces acid that dissolve tooth enamel
- extent of damage to the teeth depends on the ff:
 presence of dental plaque: gluey, gelatin-like substance that adheres to the teeth
 strength of the acid and ability of the saliva to neutralize
 the length of time the acids are in contact
 susceptibility of the teeth to decay
- Prevention
 Mouth Care: brushing and flossing, normal mastication (chewing), normal flow of saliva
 Diet- ↓ the amount of sugar & starch
 Fluoridation
 Pit and Fissure Sealants- special coating to fill and seal pits and fissures, can last to 5-10
years

2. Dentoalveolar abscess or Periapical Abscess

- Collection of pus in the apical dental periosteum (fibrous membrane supporting the tooth
structure) and the tissue surrounding the apex (in the jaw bone)
- May be acute or chronic
 Acute - secondary to a suppurative pulpitis that arises from an infection from a
dental caries
  Chronic - slowly progressive, a fully formed abscess may occur without the
patient’s knowledge, leads to a “blind dental abscess” w/c is a periapical
granuloma, discovered on X-ray, treated w/ root canal therapy
Clinical Manifestations :
- Dull, gnawing, continuous pain w/ surrounding cellulitis and edema of the adjacent facial
structures and mobility of the involved tooth
- difficult to open the mouth
- fever
- malaise

Management:
- needle aspiration or drill an opening into the pulp chamber to relieve pressure and pain
- drainage thru an incision in the gingiva to the jawbone, antibiotics

Nursing Management:
- assess the patient for bleeding
- instruct to use warm saline
- take medications

3. Malocclusion
- Misalignment of the teeth of the upper and lower dental arcs when the jaws are closed
- Inherited or acquired
- Makes the teeth difficult to clean and can lead to decay, gum disease
- Corrections requires an orthodontist
- Treatment begins when the patient has shed the last primary tooth and the last permanent
successor has erupted

Disorders of the Salivary Glands

1. PAROTITIS: inflammation of the parotid gland

 MUMPS - epidemic parotitis, a communicable disease caused by a viral infection mostly
affect children
- elderly, acutely ill, debilitated people with decreased salivary flow from dehydration or
medications are at higher risk
- usually caused by staphylococcus aureus
- onset is sudden, fever, the gland swells and becomes tense and tender, pain, difficult
swallowing,
- management: adequate nutrition and fluid intake,

2. SIALADENITIS: inflammation of the salivary gland

- caused by dehydration, radiation therapy, stress, malnutrition, salivary gland calculi,
improper oral hygiene
 - organisms: Staph.aureus, Strep. viridans
- manifestations:
- pain, swelling, purulent discharge
- treatment:
- antibiotics
- massage
- hydration
- warm compresses
- corticosteroids
- surgical drainage of the gland or excision

3. SALIVARY CALCULUS (SIALOLITHIASIS)

- occurs in the submandibular glands
- formed mainly from calcium phosphate
- manifestations: gland is swollen, tender, palpable w/ stone
-Tx - extraction, lithotripsy
ESOPHAGEAL DISORDERS

1. Hiatal Hernia
- The opening in the diaphragm through w/c the esophagus passes becomes enlarged and
part of the upper stomach tends to move up
- More common among women
Two types:
 Sliding or type I hiatal hernia (most common- 90%) and
 Paraesophageal hiatal hernia: type II, III and IV ( IV- greatest herniation)
 - Assessment Findings:
1.Heartburn
2.Regurgitation
3.Dysphagia
4. Foul breath
5. 50%- without
symptoms
 implicated in reflux
 hemorrhage, obstruction,
strangulation
Diagnostics: BARIUM
SWALLOW
Nursing Interventions:
1. Provide small frequent feedings
2. AVOID supine position for 1
hour after eating
3. Elevate the head of the bed on 8-inch block
4. Provide pre-op and post-op care

2. Esophageal Varices
- Dilation and tortuosity of the submucosal veins in the distal esophagus
- ETIOLOGY: commonly caused by PORTAL hypertension secondary to liver cirrhosis
- This is an Emergency condition!
- ASSESSMENT findings:
1. Hematemesis
2. Melena
3. Ascites
4. Jaundice
5. hepatomegaly/splenomegaly
Complication: RUPTURED VARICES
 Signs of Shock- tachycardia, hypotension, tachypnea, cold clammy skin, narrowed pulse
pressure
- DIAGNOSTIC PROCEDURE : Esophagoscopy
- NURSING INTERVENTIONS:
1. Monitor VS strictly. Note for signs of shock
2. Monitor for LOC
3. Maintain NPO
4. Monitor blood studies
5. Administer O2
6. Prepare for blood transfusion
7. Prepare to administer Vasopressin and Nitroglycerin
8. Assist in NGT and Sengstaken-Blakemore tube insertion for balloon tamponade
 9. Prepare to assist in surgical management:
 Endoscopic sclerotherapy
 Variceal ligation
 Shunt procedures
3. Gastro-esophageal reflux
- Backflow of gastric contents into the esophagus
- Usually due to incompetent lower esophageal sphincter , pyloric stenosis or motility
disorder
- Symptoms may mimic ANGINA or MI
- Incidence increases w/ aging
- Assessment:
 Heartburn / Pyrosis
 Dyspepsia / Indigestion
 Regurgitation
 Odynophagia
 Dysphagia / Difficulty swallowing
 Excessive salivation
- Diagnostic test
 Endoscopy or barium swallow
 Gastric ambulatory pH analysis
 Note for the pH of the esophagus, usually done for 24 hours
 The pH probe is located 5 inches above the lower esophageal sphincter
 The machine registers the different pH of the refluxed material into the
esophagus
- Nursing Interventions:
1. Instruct the patient to AVOID stimulus that increases stomach pressure and
decreases LES pressure
2. Instruct to avoid spices, coffee, tobacco and carbonated drinks
3. Instruct to eat LOW-FAT, HIGH-FIBER diet
4. Avoid foods and drinks TWO hours before bedtime 5.Elevate the head of the
bed with an approximately 8-
inch block
6. Administer prescribed H2-blockers, PPI and prokinetic meds like cisapride,
metochlopromide
7. Advise proper weight reduction

2. Gastritis
- Inflammation of the gastric mucosa
- May be Acute or Chronic
- Etiology:
 Acute - irritating foods, highly seasoned or contaminated with disease causing
microorganism, NSAIDS, alcohol, bile reflux and radiation treatment
  Chronic- Ulceration, bacteria (Helicobacter pylori), Autoimmune disease
(pernicious anemia), diet (caffeine), alcohol, smoking, bile reflux
- Pathophysiology:

-
Insults cause gastric mucosal damage  inflammation,
- hyperemia and edema  superficial erosions  decreased
Assessment
gastric secretions of gastric juice (very little acid more
mucus),  ulcerations and bleeding
 (Acute)
 Abdominal discomfort
 Headache
 Anorexia
 Nausea/Vomiting
(Chronic)
 Pyrosis
 Singultus
 Sour taste in the mouth
 Dyspepsia
 N/V/
 anorexia
 Pernicious anemia
- Diagnostic Procedure
 EGD- to visualize the gastric mucosa for inflammation
 Absent (Achlorhydria) or Low levels of HCl (hypochlorhydria) or High Levels of
HCl (hyperchlorhydria)
 Biopsy to establish correct diagnosis whether acute or chronic
- NURSING INTERVENTIONS:
 Give BLAND diet
 Monitor for signs of complications like bleeding, obstruction and pernicious
anemia
 Instruct to avoid spicy foods, irritating foods, alcohol and caffeine, NSAIDS,
 Conditions of the Stomach
 Administer prescribed medications- H2 blockers, antibiotics, mucosal protectants
 Inform the need for Vitamin B12 injection if deficiency is present

3. Peptic Ulcer Disease

- An ulceration of the esophageal, gastric and duodenal lining
- May be referred as to location:
 Gastric ulcer in the pylorus of the stomach, or Duodenal ulcer in the
duodenum, or in the esophagus
- Most common Peptic ulceration: anterior part of the upper duodenum
- Common between 40-60 y/o, blood type O
- Causes: H.pylori infection, excessive secretion of HCl, stress, alcohol, smoking,
caffeinated beverage, spicy foods
- Pathophysiology:
Disturbance in acid secretion and mucosal protection

Increased acidity r decreased mucosal resistance (erosion and ulceration)
  Zollinger-Ellison Syndrome- severe peptic ulcer, extreme gastric hyperacidity, and
gastrin secreting benign or malignant tumors of the pancreas-resistant to standard
medical treatment
 Stress ulcer - occurs after physiological stressful events such as burns, shock, sepsis,
trauma, ventilator-assisted patient,
 Cushing’s ulcer - common in pts w/ head injury and brain trauma, more penetrating
and deeper than stress ulcer, involves esophagus, stomach and duodenum
 Curling’s ulcer - observed about 72 hours after extensive burns, involves stomach and
duodenum

Duodenal Ulcer
 Age: 30-60 y/o M/F=3:1
 80% of peptic ulcers are duodenal
 Weight Gain
 Hypersecretion of HCL acid
 Pain occurs 2-3 h after meal
 Ingestion of food relieves pain
 Vomiting uncommon
 Hemorrhage less likely
 Melena more common than hematemesis
 Most likely to perforate
 Possibility of Malignancy is rare
 Risk Factors: H.pylori, alcohol, smoking, stress

Gastric Ulcer
 Usually 50 and over
 Male:Female = 1:1
 Weight Loss
 Pain occurs ½ to 1 hour after meal
 Ingestion of food does not help, causes pain
 Vomiting common
 Hemorrhages more likely
 Hematamesis more common than melena
 Possibility of Malignancy: occasional
- Risk Factors: H.pylori, alcohol, smoking, NSAID
- Clinical Manifestations : dull, gnawing pain or a burning sensation in the midepigastrium or
in the back, pyrosis, vomiting, constipation or diarrhea, bleeding (melena- black tarry stool)
- Diagnostic Procedures:
 Endoscopy
 stool exam
 gastric secretory studies
 urea breath test
  Biopsy
- Management:
 Pharmacologic therapy- combination of antibiotics, proton pump inhibitors and
bismuth salt to eradicate H.pylori for 10-14 days, Histamine-2 (H2) receptor
antagonist and PPI are used to treat NSAID induced ulcers
➢ Histamine-2 (H2) receptor antagonists (PO/IV)
 Action: ↓ HCl production
 taken with meals or at H.S.
 cigarettes reduces its action
 SE: headache, dizziness, nausea/vomiting & urticaria
 8 weeks medication (if s/sx does not improve, start antibiotics)
 Cimetidine (Tagamet)
 Ranitidine (Zantac)
 Famotidine (Pepcid)
 Nizatidine (Axid)
➢ Antibiotics
 Action: antibacterial to eradicate H. pylori
 Amoxicillin (Amoxil)
 Clarithromycin (Biaxin)
 Metronidazole (Flagyl)
 Tetracycline
 Can be combined with other drugs
➢ Mucosal Barrier
 Action: forms protective barrier, adheres to ulcer surface
 30 min interval before taking antacids
 SE: constipation, and nausea/vomiting
 Give 1-2 hour after meal or during bedtime on an empty stomach
 5 hours duration
 Sucralfate (Carafate)
 Pharmacotherapy
➢ Antacids (non absorbable)
 Action: ↓ gastric acidity
 Chew then swallow, taken 1 hr after meals or at H.S.
 Aluminum Hydroxide SE: constipation
 Don’t give other drugs w/in 1-2 hrs after the antacids
 Magnesium Oxide SE: diarrhea
 Taken in between meals or at bedtime
 May increase serum Magnesium level in RF client
 Chew follow with water
 Calcium Carbonate SE: ↑ uric acid
 Taken in between meals or at bedtime with milk
 NaHCO3 SE: metabolic alkalosis and tetany
  Proton Pump Inhibitor
 Action: ↓ gastric acid secretion of the parietal cells
 4-8 weeks medications
 Esomeprazole (Nexium)
 Omeprazole (Prilosec)
 Lansoprazole (Prevacid)
 Pantoprazole (Protonix)
- Surgical Procedures:
 Total gastrectomy
 Vagotomy
 gastric resection
 Billroth I and II
 pyloroplasty
- Vagotomy – severing of the vagus nerve
 Decreases gastric acid
 Diminishing cholinergic stimulation to the parietal cells- less
responsive to gastrin
- Billroth I – Gastroduodenostomy
 Removal of the lower portion of the antrum
 Antrum contains the cells that secretes gastrin
 Small portion of duodenum and pylorus
 Remaining portion is anastomosed to the duodenum
 Feeling of fullness
 Dumping syndrome
 Diarrhea
 Recurrence rate is <1%

- Billroth II – Gastrojejunostomy
- Remaining portion is anastomosed to the jejunum
 Dumping syndrome
 Anemia
 Malabsorption
 Weight loss
 Recurrence rate of ulcer is 10-15%

Nursing Interventions:
1. Give BLAND diet, small frequent meals during the active phase of the disease
2. Administer prescribed medications- H2 blockers, PPI, mucosal barrier protectants and
antacids
3. Monitor for complications of bleeding, perforation and intractable pain
4. Provide teaching about stress reduction and relaxation techniques

Nursing Interventions For Bleeding

1. Maintain on NPO
2. Administer IVF and medications
3. Monitor hydration status, haematocrit and hemoglobin
4. Assist with SALINE lavage
5. Insert NGT for decompression and lavage
6. Prepare to administer blood transfusion
7. Prepare to give VASOPRESSIN to induce vasoconstriction to reduce bleeding
8. Prepare patient for SURGERY if warranted

Surgical Procedures:
Post-operative Nursing management
1. Monitor VS
2. Post-op position: FOWLER’S
3. NPO until peristalsis returns
4.Monitor for bowel sounds
5. Monitor for complications of surgery
6.Monitor I and O, IVF
7. Maintain NGT
8. Diet progress: clear liquid  full liquid  six bland meals
9. Manage DUMPING SYNDROME

Dumping Syndrome
- A condition of rapid emptying of the gastric contents into the small intestine usually
after a gastric surgery. Symptoms occur 30 minutes after eating
- Assessment Findings:
Early symptoms
1.Nausea and Vomiting
2.Abdominal fullness
3.Abdominal cramping
4.Palpitation
5.Diaphoresis
6. Weakness
7. Diarrhea
Nursing Interventions:
1. Advise patient to eat LOW-carbohydrate, HIGH-fat and HIGH-protein diet
2. Instruct to eat SMALL frequent meals, include MORE dry items.
3. Instruct to AVOID consuming FLUIDS with meals
4. Instruct to LIE DOWN after meals
5. Administer anti-spasmodic medications to delay gastric emptying

4. Gastric Cancer
- 40-70 y/o, more common among men
- Diet high in smoke foods, low in fruits and vegetables
- Chronic inflammation of the stomach
- Pernicious anemia
- Gastric ulcers
- H. Pylori infections
- Chronic Smoking
- Previous Subtotal Gastrectomy
- Genetics
Clinical Manifestations
- Asymptomatic in the early stage
- Pain relieved with antacids
 - Anorexia, dyspepsia, weight loss
- Constipation, anemia
- Nausea and vomiting
Assessment and Diagnostic Findings
- Advanced Gastric cancer- palpable mass
- Ascites and Hepatomegaly- if cancer cells metastasized to the liver
- Sister Mary Joseph’s Nodule- palpable nodules around the umbilicus
- EGD/Endoscopy w/ biopsy and cytology
- Barium x-ray exam
- CT Scan, Bone Scan, Liver Scan
- Medical Management
- Removal of the tumor
- Chemotherapy

LOWER GASTROINTESTINAL TRACT DISORDERS

Abnormalities of Fecal Elimination

5. Constipation
- Abnormal hardening of stools
- Irregularity of elimination
- Retention of stool for a prolonged period
Caused by:
- Medications (Iron, antacids with aluminium)
- Hemorrhoids
- Cancer of the bowel
- Endocrine disorders
Clinical Manifestation:
- Abdominal distention
- Borborygmus
- gurgling sound caused by passage of gas in the intestine
- Pain and pressure
- Indigestion
- Sensation of incomplete emptying
- Straining
- Hard, dry stools
Medical Management:
- Bowel habit training
- Increased fiber and fluid intake
- Discontinue laxative abuse
- Exercise to strengthening abdominal muscles

2. Diarrhea
 - Increased frequency of bowel movement more than 3x a day
- Increased amount of stool
- Altered consistency
Clinical Manifestations:
- Abdominal cramps, Distention
- Intestinal rumbling/borborygmus
- Anorexia and thirst
Assessment and Diagnostic Findings:
- CBC count
- Chemical profile
- Urinalysis
- Stool exam
Medical Management:
- Control symptoms
- Treat the underlying disease

3. Fecal Incontinence
- Involuntary passage of stool from the rectum
- Inability of the rectum to sense and accommodate stool
- Amount and consistency of the stool
- Integrity of the anal sphincter
- Rectal motility
Clinical Manifestation
- Soiling
- Occasional urgency and loss of control
- Complete incontinence
- Poor control of flatus
Medical Management
- Biofeedback therapy
- Bowel training programs
- Surgical reconstruction, sphincter repair or fecal diversion

4. Crohn’s Disease
- Also called Regional Enteritis
- An inflammatory disease of the GIT affecting usually the distal ileum and colon
- Usually first diagnosed in adolescents and young adults
- More often seen among smokers
- Etiology: unknown
- The terminal ileum thickens with edema formation, with scarring, ulcerations, abscess
formation and narrowing of the lumen
- The clusters of ulcers- CLASSIC COBBLESTONE APPEARANCE
Clinical Manifestations :
1.Fever
2.Abdominal distention
3.Diarrhea
4. Crampy RLQ abdominal pain
5.Anorexia/N/V
6.Weight loss
7.Anemia
Assessment and Diagnostic Findings:
- Proctosigmoidoscopy initially
- stool exam- maybe (+) for occult blood and steatorrhea
- barium study of the upper GI tract- is confirmatory w/c shows the classic string sign on
x-ray film indicating constriction the segment involved
- CBC, ESR (↑), Albumin and protein (↓)
Complications
- intestinal obstruction, strictures, perianal disease, fluid and electrolyte imbalances,
malnutrition

5. Ulcerative Colitis
- Recurrent ulcerative and inflammatory condition of the mucosal and submucosal layers of the
colon and rectum
- The colon becomes edematous and develops bleeding ulcerations
- Scarring develops overtime with impaired water absorption and loss of elasticity

Clinical Manifestations:
 SEVERE diarrhea (10-20 liquid stools/day) with Rectal bleeding
1.Weight loss
2.Fever
3.Anorexia
 4. Anemia and Hypocalcemia
5.Dehydration
6. LLQ Abdominal pain and cramping
7.Tenesmus
Assessment and Diagnostic Findings:
- assess for tachycardia, tachypnea, hypotension, fever and pallor, level of hydration and
nutritional status
- stool exam- (+) for blood
- ↓ hematocrit and hemoglobin and albumin
- ↑ WBC
- Sigmoidoscopy, colonoscopy
- Barium enema
- MRI and CT scan Complications
- toxic megacolon, perforation, bleeding, osteoporotic fracture

Complications:
- toxic megacolon, perforation, bleeding, osteoporotic fracture

Nursing Interventions (for Chrohn’s Disease and ulcerative Colitis)

1. Maintain NPO during the active phase
2. Monitor for complications like severe bleeding, dehydration, electrolyte imbalance
3. Monitor bowel sounds, stool and blood studies
4. Restrict activities = rest and comfort
5. Administer IVF, electrolytes and TPN if prescribed (Monitor complications of
diarrhea)
6. Instruct the patient to AVOID gas-forming foods, MILK products and foods such
as whole grains, nuts, RAW fruits and vegetables especially SPINACH, pepper, alcohol
and caffeine
7. Diet progression- clear liquid LOW residue, high protein diet
8. Administer drugs- anti-inflammatory, antibiotics, steroids, bulk-forming agents
and vitamin/iron supplements

6. Appendicitis
- Inflammation of the vermiform appendix
Etiology: usually fecalith, lymphoid hyperplasia, foreign body and helminthic obstruction

Assessment Findings
1. Abdominal pain: begins in the umbilicus then localizes in the RLQ (Mc Burney’s point)
2. Anorexia
3. Nausea and Vomiting
4. Fever
5. Rebound tenderness and abdominal rigidity (if perforated)
6. Constipation or diarrhea
Diagnostic Tests
- CBC- reveals increased WBC count
- Ultrasound
- Abdominal X-ray
Nursing Interventions
- Preoperative care
- NPO
- Consent
- Monitor for perforation and signs of shock
- Monitor bowel sounds, fever and hydration status
- POSITION of Comfort: RIGHT SIDELYING in a low Fowler’s
- AVOID laxatives, enemas and HEAT APPLICATION
- SURGERY: APPENDECTOMY
- Post operative Care:
- Monitor VS and signs of surgical complications
- Maintain NPO until bowel function returns
- If rupture occurred, expect drains and IV antibiotics
- POST OP. POSITION: RIGHT SIDE-LYING, SEMI-Fowler’s to decrease tension or
incision and legs flexed to promote drainage

7. Hemorrhoids
- Abnormal dilation and weakness of the veins of the anal canal
- Variously classified as Internal or External, Prolapsed, Thrombosed and Reducible

Internal hemorrhoids
 - These dilated veins lie above the internal anal sphincter
- Usually, the condition is PAINLESS

External hemorrhoids
- These dilated veins lie below the internal anal sphincter
- Usually, the condition is PAINFUL

ASSESSMENT:
- Internal hemorrhoids- cannot be seen on the peri-anal area
- External hemorrhoids- can be seen
- Bright red bleeding with each defecation
- Rectal/ perianal pain
- Rectal itching
- Skin tags
Diagnostic Test:
- Anoscopy
- Digital rectal examination
Trearments:
- Nonsurgical treatments
o Infrared photocoagulation
o Laser therapy
- Conservative surgical treatment
o rubberband ligation procedure
o cryosurgical hemorrhoidectomy
- Hemorrhoidectomy
o For advance thrombosed vein

Nursing Interventions:
- Advise patient to apply cold packs to the anal/rectal area followed by a SITZ bath
- Apply astringent like witch hazel soaks
- Encourage HIGH-fiber diet and fluids
- Administer stool softener as prescribed

Post-operative care for hemorrhoidectomy

- Position: Prone or Side-lying
- Maintain dressing over the surgical site
- Monitor for bleeding
- Administer analgesics and stool softeners
- Advise the use of SITZ bath 3-4 times a day

7. DIVERTICULOSIS AND DIVERTICULITIS

Diverticulosis
- Abnormal out-pouching of the intestinal mucosa occurring in any part of the LI most
commonly in the sigmoid

Diverticulitis
- Inflammation of the diverticulosis

Diverticular Disease
- Diverticulum: sac-like herniations of the lining of the bowel that extend through a defect in the
muscle layer
- May occur anywhere in the intestine, but are most common in the sigmoid colon
- Diverticulosis: multiple diverticula without inflammation
- Diverticulitis: infection and inflammation of diverticula
- Diverticular disease increases with age and is associated with a low-fiber diet
- Diagnosis is usually by colonoscopy
ASSESSMENT findings for D/D:
1. Left lower Quadrant pain
2.Flatulence
3. Bleeding per rectum
4. nausea and vomiting
5.Fever
6. Palpable, tender rectal mass

DIAGNOSTIC STUDIES
1. If no active inflammation, COLONOSCOPY and Barium Enema
2. CT scan is the procedure of choice!
3. Abdominal X-ray
NURSING INTERVENTIONS:
1. Maintain NPO during acute phase
2. Provide bed rest
3. Administer antibiotics, analgesics like meperidine (morphine is not used) and anti-spasmodics
4. Monitor for potential complications like perforation, hemorrhage and fistula
5. Increase fluid intake
6. Avoid gas-forming foods or HIGH-roughage foods containing seeds, nuts to avoid trapping
7. introduce soft, high fiber foods ONLY after the inflammation subsides
8. Instruct to avoid activities that increase intra-abdominal pressure

8. Intestinal Obstruction
- Partial or complete blockage prevents the flow of intestinal contents thru the intestinal tract

Mechanical Obstruction
 - Intraluminal obstruction or mural obstruction from pressure on the intestinal wall
occurs
 Stenosis, adhesions, hernias

Functional obstruction
- The intestinal musculature cannot propel the contents along the bowel
 Muscular dystrophy, endocrine disorders or neurologic disorders

Mechanical
- Adhesions – fibrous band of scar tissue from
surgery
- Hernias – incarcerated or strangulated
- Volvulus – twisting of bowel
- Intussusception – telescoping of the bowel
upon itself
- Tumors
- Hematoma
- Fecal impaction
- Intraluminal obstruction
- Intussusception

Volvulus

Neurogenic
- Paralytic ileus
- Adynamic ileus

Vascular
- Occlusion of arterial blood supply
- Mesenteric thrombosis
- Abdominal angina
- Small Bowel Obstruction
- Intestinal contents, fluids and gas accumulate above the intestinal obstruction
- Reduce the absorption of fluids and stimulate more gastric secretion
- Pressure within the intestinal lumen increases
- Decrease in venous and arteriolar capillary pressure
- Edema, congestion, necrosis, and rupture or perforation of intestinal wall →
peritonitis
- Reflux vomiting leads to ↓K+, ↓Clˉ in blood, with fluid losses resulting to shock
- Clinical Manifestations
- Crampy pain, wavelike and colicky
- May pass blood and mucous, but no fecal matter and flatus; vomiting occurs
- If obstruction is complete, vigorous peristalsis, and assume a reverse direction with the
intestinal content propelled toward the mouth
- If obstruction is in the ileum, fecal vomiting takes place
- Dehydration: thirst, drowsiness, malaise, and a parched tongue and mucous membranes
- The lower the GI obstruction, the more marked the abdominal distention
- Uncorrected obstruction leads to shock
Diagnostics
- Abdominal X-ray and CT Scan
- Electrolyte studies and CBC
Medical Management
- Decompression of the bowel through a nasogatric or small bowel tube
- Surgical treatment, if completely obstructed
 Removal, repair, and anastomosis

Large Bowel Obstruction

- Accumulation of intestinal contents, fluid, and gas proximal to the obstruction
- If blood supply is cut off, intestinal strangulation and necrosis occur
- Dehydration occurs more slowly
- Caused by adenocarcinoid tumors
- Symptoms develop slowly, constipation, bloody stool →
iron deficiency anemia
- Distented abdomen and crampy lower abdominal pain
- Fecal vomiting develops
- Shock may occur

Medical Management
- IV therapy, NGT aspiration & decompression
- Colonoscopy: untwist and decompress the bowel
- Cecostomy: surgical opening made into the cecum, urgent relief from obstruction
- Surgical resection: remove the obstruction
- A temporary or permanent colostomy
- Ileoanal anastomosis, if necessary to remove the entire large bowel
- Rectal tube used to decompress area lower in the bowel
Nursing Management
- intestinal tube insertion (miller abott, cantor tube) for decompression
- fluid and electrolyte replacement
- prophylactic antibiotic
- v/s, I&O
- stool exam
- surgery

Teacher’s Insight:

The Gastrointestinal tract serves a major role in maintaining optimum wellness. Its function
is vital in order to keep the body well nourished. Disorders associated with the GIT could
post serious effects that are detrimental to human health. Nurses must be equipped with
necessary skills and knowledge when caring for patients with specific gastrointestinal
disorders. Though, these are commonly seen in the clinical and community setting, some are
still unaware that diarrhea could cause dehydration. Therefore, it is imperative for nurses to
involve their patients in the treatment process. Communication and collaboration must also
be taken into account.

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