GASTROINTESTINAL SYSTEM

The GI system has the critical task of supplying essential nutrients to fuel the brain, heart, and lungs.
Gi function also profoundly affects the quality of life through its impact on overall health.
What is Digestion?
 Digestion is the complex process of turning the food you
eat into nutrients, which the body uses for energy, growth
and cell repair needed to survive. The digestion process
also involves creating waste to be eliminated.
 The digestive tract is a long twisting tube that starts from
the mouth and ends at the anus.
 It is made up of series of muscles that coordinate the
movement of food and other cells that produce enzymes
and hormones to aid in the breakdown of food. Along the
way are three other organs that are needed for digestion:
the (1)liver, (2)gallbladder, and (3)pancreas.

Description of the Digestive System

o Also known as the GI tract, the digestive system begins at the mouth, includes the esophagus,
stomach, small intestine, large intestine (colon), rectum, and ends at the anus. The entire
system – from mouth to anus – is about 30 feet (9 meter) long.
o The small intestine is a 20-feet (6 meter) tube-shaped organ. The large intestine is about 5 feet
long (1.5 meters) and primary functions as storage and fermentation of indigestible matter.
Also called the colon, it has four parts: (1) the ascending colon, (2) the transverse colon, (3)
the descending colon, and the (4) sigmoid colon.

INTRODUCTION

The digestive system is used for breaking down food into nutrients which then pass into the
circulatory system and are taken to where they are needed in the body.

There are four stages of food processing:

1. Ingestion: taking in food 3. Absorption: taking in nutrients by cells
2. Digestion: breaking down food into 4. Egestion: removing any leftover waste
nutrients

MOUTH & TEETH

o Begins when food enters the mouth

o It is physically broken down by the teeth
o It is begun to be chemically broken down by amylase,
an enzyme in saliva that break down carbohydrates
TONGUE

o The average length of the human tongue from the oropharynx to the tip is 10 cm
o The tongue moves the food around until it forms a ball called bolus.
o The bolus is passed to the pharynx and the epiglottis makes sure the bolus passes into the
esophagus and not down the windpipe

ESOPHAGUS

o The esophagus is a 25-cm long muscular tube that connects the

pharynx to the stomach.
o The bolus passes down to the esophagus by peristalsis
o Peristalsis is a wave of muscular contractions that push the bolus
down towards the stomach. It is an involuntary constriction and
relaxation of the muscles of the intestine or other canal, creating a
wave-like movement that push the contents of the canal forward.

STOMACH

o To enter the stomach, the bolus must pass through the lower esophageal sphincter, a tight
muscle that keeps stomach acid out of the esophagus.
o The stomach has folds called rugae and is a big muscular pouch which churns the bolus
(physical digestion) and mixes it with gastric juice, a mixture of stomach acid, mucus, and
enzymes.
o The acid kills off any invading bacteria or viruses
o The enzymes help breakdown proteins and lipids
o The mucus protects the lining of the stomach from being eaten away by the acid.
o The stomach does do some absorption too.
o Some medicines (i.e., aspirin), water, and alcohol are all absorbed through the stomach.
o The digested bolus is now called chyme and it leaves the stomach by passing through the
pyloric sphincter.

PANCREAS

o The pancreas is about 6 inches long and sits across the back of the abdomen, behind the
stomach.
o The pancreas secretes digestive enzymes into the duodenum, the first segment of the small
intestine. These enzymes break down protein, fats, and carbohydrates. The pancreas also
makes insulin, secreting it directly into the bloodstream. Insulin is the chief hormone for
metabolizing sugar.

LIVER

o The liver has multiple functions but its main function within the digestive system is to process
the nutrients absorbed from the small intestine. Bile from the liver secreted into the small
 intestine also plays an important role in digesting fat. The liver also detoxifies potentially
harmful chemicals. It breaks down many drugs.

GALLBLADDER

The gallbladder stores and concentrates bile, and then releases it into the duodenum to help absorb
and digest fats.

SMALL INTESTINE

- About 6 meters or 20 feet long. - The majority of absorption occurs here.

- Chyme is now into the small intestine - The liver and Pancreas help the SI maximize
absorption

The small intestine is broken down into three parts:

1. Duodenum
- Bile, produced in the liver but stored in the gall bladder, enters through the bile duct. It
breaks down fats.
- The pancreas secretes pancreatic juice to
reduce acidity of the chyme.
2. Jejunum
- It is where the majority of absorption takes
places.
- It has tiny fingerlike projections called villi
lining it, which increase the surface area for
absorbing nutrients.
- Each villus itself has tiny fingerlike projections
called microvilli, which further increase the
surface area for absorption.
-
3. Ileum
- The last portion of the small intestine which has
fewer villi and basically compacts the leftovers to
pass through the caecum into the large intestine.

LARGE INTESTINE (COLON)

o The large intestine is about 1.5 meters or

5 feet long.
o It is used to absorb water from the
material leftover and to produce vitamin
K and some B vitamin using the helpful
bacteria that live here.
 o All leftover waste is compacted and stored at the end of the large intestine called the rectum
o When full, and the anal sphincter loosens and the waste now called feces passes out of the
body through the anus.

RECTUM

o The rectum is an 8-inch chamber that connects the colon to the anus. It is the rectum’s job to
receive stool from the colon. When anything (gas or stool) comes into the rectum, sensors
send message to the brain. The brain then decides if the rectal contents can be released or
not.

ANUS

o The anus is the last part of the digestive tract. It is a 2-inch-long canal consisting of the pelvic
floor muscles and the two anal sphincters (internal and external). The lining of the upper anus
is specialized to detect rectal contents. It lets you know whether the contents are liquid, gas, or
solid. The anus is surrounded by sphincter muscles that are important in allowing control of
stool.

FUNCTIONS OF THE DIGESTIVE SYSTEM

o Secrete enzymes o Secretion of fluids

o Absorption of nutrients o Breakdown food into small particles
o Excretion of waste products o Ingestion of food

ASSESSMENT

• Physical Examination
– Inspection – Palpation
– Auscultation – Percussion

HISTORY

Current Health Status

o Ask the patient about changes in appetite, difficulty chewing or swallowing, indigestion,
nausea, vomiting, diarrhea, constipation, and abdominal pain. Has he noticed a change in
bowel movements? Has he ever seen blood in his stool?
o Ask the patient if he’s taking any medications. Some drugs – including aspirin, sulfonamides,
nonsteroidal anti-inflammatory drugs (NSAIDS), and some antihypertensive –can cause GI
signs and symptoms.
o Don’t forget to ask about laxative use; habitual use may cause constipation. Also ask the
patient’s if he’s allergic to medications or food. Such allergies commonly cause GI symptoms.

Previous Health Status

 o To determine if your patient’s problem is a new or recurring, ask about past GI illness, such as
ulcers, gallbladder disease, inflammatory bowel disease, gastroesophageal reflux, or trauma.

Family History

o Because some GI disorders are hereditary, ask the patient whether anyone in his family has
had a GI disorder. Disorders with a familial link include:
o Ulcerative colitis o Stomach Ulcers o Alcoholism
o GI cancer o Diabetes o Crohn’s Disease

Lifestyle Patterns

o Inquire about your patient’s occupation, home life,

o financial status, stress level, and recent life changes. Be sure to ask about alcohol, caffeine,
and tobacco use as well as food consumption, meal frequency, exercise habits, and oral
hygiene. Also ask about sleep patterns. How many hours of sleep does he feel he needs? How
many does he get?

PHYSICAL EXAMINATION

Physical assessment of the GI system includes evaluation of the mouth, abdomen, liver, and rectum.
To perform an abdomen al assessment, use this section: Inspection, Auscultation, percussion, and
palpation. Palpating or percussing the abdomen before auscultation can change the character of the
patient’s bowel sounds and lead to an inaccurate assessment.

MOUTH

 Use inspection and palpation to assess the mouth.

ABDOMEN

 Have the patient lie in the supine position, with knees slightly flexed. Use inspection,
auscultation, and palpation to examine the abdomen. Assess painful areas last to help prevent
the patient from experiencing increased discomfort and tension.

 Observe the abdomen for symmetry, checking for bumps, bulges, or masses. Also note the
patients abdominal shape and contour.

 Assess the umbilicus, which should be located midline in the abdomen and inverted. If his
umbilicus protrudes, the patient may have an umbilical hernia.
  The skin of the abdomen should be smooth and uniform in color. Note stretch marks, or striae,
and dilated veins. Record the length of any surgical scars on the abdomen.

What do I do?
EMERGENCY SIGNALS

When assessing a patient with a GI problem, stay alert for the signs and symptoms described here
because they may signal an emergency. If you note any of these signs or symptoms, notify the
practitioner and assess the patient for deterioration such as signs of shock. Intervene, as necessary,
by providing oxygen therapy and I.V. fluids as ordered. Place the patient on a cardiac monitor if
appropriate. Provide emotional support.

Abdominal Pain
 Progressive, severe, or colicky pain for more than 6 hours without improvement.
 Acute pain associated with hypertension
 Acute pain in an elderly patient(such a patient may have minimal tenderness, even with a
ruptured abdominal organ or appendicitis.
 Severe pain with guarding and a hx of recent abdominal surgery.
 Pain accompanied by X-ray evidence of free intraperitoneal air (gas) or mediastinal gas
 Disproportionately severe pain under benign conditions (soft abdomen with normal physical
findings).

Vomitus and Stools

 Vomitus containing fresh blood
 Prolonged vomiting or heaving, with or without obstipation( intractable constipation)
 Bloody or black, tarry stools

Abdominal Tenderness
 Abdominal tenderness and rigidity, even when the patient is distracted
 Rebound tenderness
Other Signs
- Fever - Hypotension
- Tachycardia - Dehydration
 DIAGNOSTIC TESTS

Using a fiber-optic endoscope, the doctor can directly view hallow visceral linings to diagnose
inflammatory, ulcerative, and infectious diseases, benign and malignant neoplasm, and other
esophageal, gastric, and intestinal mucosal lesions. Endoscopy can also be used for therapeutic
interventions or to obtain biopsy specimens.

Lower GI Endoscopy

 Lower GI endoscopy also called colonoscopy or proctosigmoidoscopy, helps diagnose

inflammatory and ulcerative bowel disease, pinpoints lower GI bleeding and detects lower GI
abnormalities, such as tumors, polyps, hemorrhoids, and abscesses.

NURSING CONSIDERATIONS

o Tell the patient that he will need to undergo a bowel preparation consisting of laxatives and
enemas for 1 to 2 days before the procedure.
o Tell him that he must maintain a clear liquid diet the day before the procedure and then fast the
morning of the test.
o Explain that he should review the medications he should take before the procedure with his
practitioner.
o If the patient will undergo a sigmoidoscopy, explain that he most likely won’t be sedated; if he
will undergo a colonoscopy, tell him he’ll be under I.V. sedation.
o Inform the patient that the doctor will insert a flexible tube into his rectum.
o Tell him that he may feel some lower abdominal discomfort and the urge to move his bowels
as the tube is advanced. To control the urge to defecate and ease the discomfort, instruct him
to breathe deeply and slowly through his mouth.
o Explain that air may be introduced into the bowel through the tube. If he feels the urge to expel
some air, tell him not to try to control it.
o Tell him that he may hear a suction machine removing any liquid that may obscure the doctor’s
view, but it won’t cause any discomfort.
o Let him know he can eat after recovering from the sedative, usually about 1 hour after the test.
o If air was introduced into the bowel, the patient may pass large amounts of flatus. Explain that
this is normal and helps prevent abdominal cramping.
o Tell him to report any blood in his stool.

Upper GI endoscopy

 Also called esophagogastroduodenoscopy identifies abnormalities of the esophagus, stomach

and small intestine such as esophagitis, inflammatory bowel disease, Mallory- Weiss
syndrome, lesions, tumors, gastritis, and polyps. During endoscopy biopsies may be taken to
detect the presence of Helicobacter pylori or to rule out gastric carcinoma

NURSING CONSIDERATIONS
 o Tell the patient that he must restrict food and fluids for at least 6 hours before the test.
o If the test is an emergency procedure, inform the patient that he’ll have his stomach contents
suctioned to permit better visualization.
o Explain that he’ll be given I.V. sedation to help keep him comfortable.
o Before insertion of the tube, the patient’s throat will be sprayed with a local anesthetic. Explain
that the spray will taste unpleasant and will make his mouth feel swollen and numb, causing
different swallowing.
o Reassure the patient that he’ll have a mouthguard to protect his teeth from the tube.
o Before the test, ask the patient to remove dentures and dental appliances, as applicable.
o Tell the patient that he can expect to feel some pressure in the abdomen and some fullness or
bloating as the tube is inserted and advanced and as air is introduced to inflate the stomach
o The patient can resume eating when his gag reflex returns – usually in about 1 hour.

LABORATORY TESTS

Common laboratory test used to diagnose GI disorders include studies of stool, urine, and
esophageal, gastric, and peritoneal contents as well as percutaneous liver biopsy.

24-hour pH testing

 Performed on an outpatient basis, 24-hour pH testing provides 24 hours of continuous acidity

data
.
Fecal Studies

 Most stool contains 10% to 20% fat. However, higher fat content can turn stool pasty or greasy
– a possible sign of intestinal malabsorption or pancreatic disease.

NURSING CONSIDERATIONS

o Collect the stool specimen in a clean, dry container.

o Don’t use stool that has been in contact with toilet-bowl water or urine.
o Send the specimen to the laboratory immediately for accurate results.
o Keep in mind that serial stool specimens are usually collected once per day with the first
morning stool.
o Instruct the patient being tested for fecal occult blood to avoid eating red meat, poultry, fish,
turnips, or horseradish or taking iron preparations, ascorbic acid (vitamin c), or anti-
inflammatory agents for 48 to 72 hours before the
specimens are collected.
o Use commercial Hemoccult sides as a simple
method of testing for blood in stool. Follow the
package directions.

Percutaneous liver biopsy

In a liver biopsy, a Menghini needle attached to a 5-ml syringe containing normal saline solution is
introduced through the chest wall and intercostal space. Negative pressure is created in the syringe.
The needle is then pushed rapidly into the liver and pulled out of the body entirely to obtain a tissue
specimen.

NURSING CONSIDERATIONS
o Tell the patient to restrict food and flush for at least 4 hours before the test.
o Explain the testing procedure to the patient.
- He will be able to wake up during the test and, although the test is uncomfortable,
medication is available to help him relax.
- The doctor will drape and clean an area on his abdomen. Then he’ll receive a local
anesthetic, which may sting and cause brief discomfort.
- He’ll be instructed how and when to hold his breath and to hold his breath and to lie still as
the doctor inserts the biopsy needle into the liver.
- The needle may cause a sensation of pressure and some discomfort in the right upper
back but will remain in his liver for only a few seconds.

Peritoneal Fluid Analysis

The peritoneal fluid analysis series includes examination of gross appearance, erythrocyte and
leukocyte counts, cytologic studies, microbiological studies for bacteria and fungi, and determinations
of protein, glucose, amylase, ammonia, and alkaline phosphatase levels. A sample of peritoneal
fluids. A sample of peritoneal fluids is obtained by paracentesis, which involves inserting a trocar and
cannula through the abdominal wall while the patient is under a local anesthetic. If the sample of fluid
is being removed for therapeutic purposes, the cannula can be connected to a drainage system.

NURSING CONSIDERATIONS

o Before the procedure, have the patient empty his bladder.

o Observe the patient for dizziness, pallor, perspiration, and increased anxiety.
o Check the site for peritoneal fluid leakage.
Urine Tests

Urinalysis provides valuable information about hepatic and billary function. Urinary bilirubin and
urobilinogen tests are commonly used to evaluate liver function.

NURSING CONSIDERATIONS

o Collect a freshly voided random urine specimen in the container provided.

Nuclear Imaging and Ultrasonography

Nuclear imaging methods whivh include liver spleen scanning an=d magnetic resonance imaging
(MRI), analyze concentrations of injected or ingested radiopaque substances to enhance visual
evaluation of possible disease processe. Nuclear Imaging methods can study the liver, spleen, and
other abdominal organs. Ultrasonogrpahy creates images of internal organs, such as the gallbladder
and liver. Gas-filled structures, such as the intestines, can’t be seen with this technique.

Liver-Spleen Scan
In a liver-spleen scan , a scanner or gamma
camera records the distribution of radioactivity
within the liver and spleen after I.V injection of a
radioactive colloid.

NURSING CONSIDERATIONS

o Explain the testing procedures to the patient

- This test examines the liver and spleen through pictures taken with a special scanner or
camera.
- The patient will receive an injection of a radioactive substance(technetium-99m) through
an IV line in his hand or arm to allow better visualization of the liver and spleen. T he
injection copntains only trace amounts of radioactivity, and he won’t be radioactive after the
test.

MRI

Used in imaging the liver and abdominal organs, MRI generates an

image by energezing protons into a strong magnetic field. Radio waves
emitted as protons return to their former equilibrium state and are
recorded.

NURSING CONSIDERATIONS

o Explain the tesing procedure to the patient.

 - He must lie still during the procedure , which may last from 30 to 90 mins
- He must remove any metal, such as jewelry, before the procedure
- If he becomes claustrophobic during the test, he may be given mild sedation.

Ultrasonography
 Uses a focused beam of high-frequency sound waves
to create echoes , which then appear as images on a
monitor. Echoes vary with tissue density.
 When used with liver-spleen scanning, it can clarify
the nature of cold spots, such as tumors, abscesses,
and cysts. The technique also helps diagnose
pancreatitis, pseudocysts, pancreatic cancer, ascites,
and splenomegaly.

NURSING CONSIDERATIONS

o If the patient is undergoing pelvic ultrasonogrpahy, he’ll need a full bladder, therefore, he must
drink three or four glasses of water before the test and must avoid urinating until after the test.
o For gallbladder evaluation, tell the patient that he shoudn’t eat solid food for 12 hours before
the test.
o For pancreas, liver, and spleen evaluation, tell the patient that he should fast for 8 hours
before the test.
o If the patient is undergoing a barium enema or an upper GI series, make sure it occurs after
abdominal ultrasonography because sound waves can’t penetrate barium.

Radiographic Tests

This includes abdominal X-rays, CT scans, varioys contrast medium

studies, and virtual colonoscopy.

Abdominal X-ray

Also called flat plate of the abdomen or kidney-ureter-bladder

radiography. It helps detect and evaluate tumors, kidney stones, abn
ormal gas collection, an d other abdominal disorders.

NURSING CONSIDERATIONS

o Radiography requires no special pretest or posttest care.

o Explain the procedure to the patient.
o X-ray interpretation involves locating normal anatomic structures, discerning any abnormal
images, and correlating findings with assessment data.

CT Scan
In CT scanning, a computer translates the action of multiple X-ray beams into three-dimensional
oscilloscope images of the biliary tract, liver, and pancreas. The test can be done with or without a
contrast medium, but contrast is preferred (unless the patient is allergic to contrast medium).
This test:

- Help distinguish between obstructive and nonobstructive

jaundice
- Identifies abscesses, cysts, hematomas, tumors, and
pseudocysts
- Can help evaluate the cause of weight loss
- Detects occult malignancy
- Can help diagnose and evaluate pancreatitis.

NURSING CONSIDERATIONS

o Tell the patient to restrict food and fluids after midnight before the test but to continue any drug
regimen, as ordered.
o Explain that the patoient should lie still, relax, breathe normally, and rema in quiet during the
test because movement blurs the X-ray picture and prolongs the test.

Contrast Radiography

Some X-ray require contrast media to more accurately assess the GI system because the media
accentuate differences among densities of air, fat, soft tissue, and bone. These tests include barium
enema, barium swallow test, cholangiography, endoscopic retrograde cholangiopancreatography
(ERCP), small-bowel series and enema, and upper GI series.

NURSING CONSIDERATIONS

o Tell the patient where and when the test will take place.
o Explain that the test will take only 30 to 40 mins for a barium swallow or enema but can take
up to 6 hours for an upoer GI or small-bowel series.
o Instruct the patient to maintain a low-residue diet for 2 to 3 days and restrict food , fluids, and
smoking after midnight before the test . he’ll receive a clear liquid diet for 12 to 24 hours before
the test. As ordered, he’s to stop taking medications for up to 24 hours before the test.
o Unless he’s undergoing a barium swallow test, the patient will receive a laxative the afternoon
before the test and up to three cleaning enemas the evening before or the morning of the test.
Explain that the presence of food or fluid may obscure details of the structures being studied.
o Let the patient having a barium enema know that he will lie on his leftside while the practitioner
inserts a small, lubricated tube into his rectum. Instruct the patient to keep his anal sphincter
tightly contracted against the tube to hold it in position and help
prevent barium leakage. Stress the importance of retaining the
barium.
Virtual Colonoscopy

It is a nonsurgical approach to evaluate the colon. A soft-tipped catheter introduces air into the colon
while a three-dimensional CT scan is performed.

NURSING CONSIDERATIONS

o Tell the patient that he may feel discomfort when air is introduced into the colon.
o Instruct the patient to remain still while images are taken.
o Tell the patient that he’ll have no restrictionsafter the test but that he may feel blooded from the
air introduced into his colon.

TREATMENT

Drug Therapy

The most commonnly used GI drugs include antacids, digestants, histamine-2(H 2) receptor
antagonists, proton pump inhibitors, anticholinergics, antidiarrheal agents, laxatives, emetics, and
antiemetics.

Surgery

The patient who has undergone GI surgery may need special postoperative support because he may
have to make permanent and difficult changes in his lifestyle.

Esophageal Surgeries

Surgery may be necessary to manage an emergency, such as acute constriction, or to provide

palliative care for an incurable disease such as advanced esophageal cancer.
Major esophageal include cardiomyotomy, cricopharyngeal myotomy. Nissen fundoplication,
esophagectomy, esophagogastrostomy, and esophagomyotomy. The surgical approach is through
the neck, chest, or abdomen, depending on the location of the problem.

Gastric Surgeries

If chronic ulcer diesnt respond to medication, diet, and rest, gastric

surgery is used to remove diseased or malignant tissue, to prevent
ulcers from recurring, or to relieve an obstruction or perforation.

Vagotomy with Gastroenterostomy

In this procedure, the surgeon resects the vagus nerves and creates a stoma for
gastric drainage. He’ll perform selective, truncal, or parietal cell vagotomy,
depending on the degree of decreased gastric acid secretion.
Vagotomy with Antrectomy

After resecting the vagus nerves, the surgeon removes

the antrum. Then he anastomoses the remaining
stomach segment to the jejunum and closes the
duodenal stump.

Vagotomy with Pyloroplasty

In this procedure, the surgeon resects the vagus nerves and

refashions the pylorus to widen the lumen and aid in gastric
emptying.

Billroth I

In this partial gastrectomy with a gastroduodenostomy, the surgeon exercises

the distal one-third to one-half of the stomach and anastomoses the remaining
stomach to the duodenum.

Billroth II

In this partial gastrectomy with a gastrojejunostomy, the

surgeon removes the distal segment of the stomach and
antrum. Then he anastomoses the remaining stomach and
the jejunum and closes the duodenal stump.

Bowel Surgery with Ostomy

In bowel surgery with ostomy, the surgeon removes diseased

colonic and rectal segments and creates a stoma on the
outer abdominal wall to allow fecal elimination. This surgery
is performed for such intestinal maladies as inflammatory
bowel disease, familial polyposis, diverticulitis, and advanced
colorectal cancer if conservative surgery and other
treatments aren’t successful or if the patient develops acute
complications, such as obstruction, abscess, and fistula.