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GI System & its

Disorders
By,
Aswathy Krishnan,
1st Yr
M Sc. Nursing(2008-2010)
Bombay Hospital College of Nursing
GI System – Structure & Functions

Oral cavity  Pharynx  esophagus  stomach 


small intestine  large intestine  rectum

 Propulsion
 Peristaltic contractions
 Digestion
 Mixing
 Enzymatic breakdown
 Absorption of nutrients
 Defecation
GI System - Anatomy
 Mouth
 Anterioly bounded by lips
 Posteriorly bounded by the
oropharynx
 Mechanical and chemical
digestion (secretion of saliva by
salivary glands)

 Pharynx & Esophagus


 The pharynx is the common
passageway for both food and
air.
 Contracts when food enters.
 Forces food into the esophagus.
 The esophagus is the
passageway that connects
mouth to the stomach.
 Cardiac Sphincter muscle.

 Stomach
 Fundus (top)  body  pylorus
 Pyloric sphincter
 Mechanical and chemical
digestion: Mixing food and acid
and enzymes to create chyme.
 Goblet Cells
 Parietal Cells
 Chief Cells
 G Cells
 Blood supply : Celiac artery
 Venous drainage in to portal vein
GI System - Anatomy
 Small intestine
 ~ 5m (~16.7’) tube
 From Pyloris to Ileocecal Valve
 Duodenum  jejunum 
ileum
 Circular folds and villae to
increase surface area
 Most digestion and absorption
takes place here via intestinal
enzymes and exocrine
secretions from the liver and
pancreas (which enter the
duodenum via ducts)

 Large intestine: extends from


terminal ileum to rectum
 Ascending colon, transverse
colon
 descending colon, sigmoid
colon and the rectum
 Appendix extends from the
lower portion of the cecum and
is a blind sac
 chyme generated ends up
entering the colon
 Water and electrolytes are
absorbed out of the chyme
 Absorbs 1.5 L of water per
day
 Also absorbs Na, K & Cl
 Blood Supply: superior &
inferior mesenteric arteries
Accessory organs: pancreas and liver

Liver
 Located in the upper rt. Abdomen
 Rt, Lt.& caudate lobes ,subdivided into segments
 Blood supply: Portal Vein, Hepatic Artery
 Roles of the liver:
 Conjugation of billurubin
 Synthesis and deactivation of clotting factors
 Phagocytosis
 Detoxification
 Processes nutrients
Gallbladder
 Sac like organ attached to Liver
 Storage facility for bile(50ml.)
 CCK stimulates contraction of Gall bladder
 Bile composition: water, bile salts (emulsify lipids), bile pigments]
 Blood Supply: Cystic & hepatic artery
Biliary Ducts
 Ducts of the Billiary tract very imp in proper functioning of GIS
 Bile Calculli Left, Right Hepatic duct Common hepatic duct
 Cystic Duct + Common hepatic duct Common Bile Duct duodenum
Accessory organs: pancreas and liver

Pancreas
 Endocrine Functions
 Production of Insulin, glucagon, somatostatin
 Exocrine Function
 Pancreatic enzymes: Trypsin, lipase and amylase
 Bicarbonate: help neutralize the acidity of the chyme
 Blood Supply: Hepatic and cystic artery
Health Assessment- History Taking
 Dietary habits
 The number of meals ate per day.
 Meal times.
 Food restrictions or special diets followed.
 Changes in appetite. Increased? Decreased? No appetite?
 What foods, if any, have been eliminated from the diet? Why?
 What foods are not well tolerated?
 Alterations in taste.
 Personal Habits
 Use of Tobacco, alcohol
 Past History
 Previous GI disease?
 Past treatment and surgery?
 Medications used. Dosage and frequency
 Bowel patterns
 Frequency of bowel movements.
 Use of laxatives and/or enemas.
 Changes in bowel habits.
 Stool Description.
(a) Constipation.
(b) Diarrhoea.
(c) Blood in stool.
(d) Mucous in stool.
(e) Black, tarry stools.
(f) Pale or clay colored stools.
(g) Foul smelling stools.
(h) Pain with stool
 Abdominal Pain
 Location? Frequency? Duration? Character of the pain? Pattern? distribution
of reffered pain & associated factors
 Indigestion
 Frequency? Duration? Associated with specific foods? Relieved by?
 Gas (belching and flatus).
 Frequency? Associated with specific foods? Relieved by?
 Nausea, Vomiting
 Frequency? Duration? Associated with meals? Character of emesis?
Relieved by?
Health Assessment- Physical
 Perform a brief, general head-to-toe visual inspection of the
patient. Are height and weight within normal range for the
patient's age and body type
 Observe the skin for Color (pale, jaundiced), Surgery scars,
Bruises, Rashes, Lesions, Turgor and moisture content,
Edema.
 Examine the mouth and throat.
 Look at the lips, tongue, and mucous membranes, noting
abnormalities such as cuts, sores, or discoloration.
 Observe the condition of the teeth..
 Observe the gums. Are they healthy and pink? Examination
of the abdomen
 Physical examination of the abdomen involves visual
inspection, auscultation, and palpation
 patient is resting in a supine position, knees slightly flexed
to relax the abdominal muscles
 abdomen is viewed as four quadrants

AUSCULTATION
• Ausculate all four quadrants
•Listen for bowel sounds. The best location is
below and to the right of the umbilicus.
• Describe the sounds heard according to
location, frequency, and character of the sound.
• Abnormalities include absent bowel sounds
and the peristaltic rush of a hyperactive bowel.

PALPATION
• Palpate all four quadrants
•used to detect muscle guarding, tenderness,
and masses.
• Record Rigidity or Guarding, Pain or
Tenderness, Rebound Pain Masses.
Diagnostics
Laboratory Tests
 Blood Test
 Complete blood count RBC, Hb, HCT
 Electrolytes
 Sodium, Pottasium
 CEA : Blood tumor marker
 Colon cancer
 Serum enzymes
 amylase, lipase, alkaline phosphatase, SGOT, SGPT, and LDH
 Check liver function
 Eval serum protein levels, clotting times, serum liver enzymes, bilirubin levels
 Pancreatic function
 Serum enzyme levels

 Faecal Analysis
 occult blood, lipids, urobilinogen, ova, parasites, and other substances
 consider the patient's diet when assessing and documenting the character of a
patient's stool.
Gastric analysis
 presence, amount, or absence of hydrochloric acid
 presence of cancer cells
 types and amounts of enzymes present.
Abdominal Ultrasonography
Radiographic Test
 upper GI Series ( Barium swallow)
 normally held NPO
 gum chewing, smoking discouraged as it stimulates gastric action.
 Lower GI Series ( Barium Enema)
 patient is held NPO
 Constipation a side effect of the contrast medium
Endoscopy
 Upper GI endoscopy
 Upper Gastrointestanal Fibroscopy/ Esophagogastrodeodenoscopy
 patient must be fasting
 Lower GI endoscopy
 proctoscopy, sigmoidoscopy and colonoscopy
 Bowel should be free of stool to enhance visualization
 Endoscopy through Ostomy
Laproscopy

Computer Tomography & MRI


 Liver and pancreatic abnormalities
Gastrointestinal Disorders - Disorders of
Mouth
 Includes inflammation, infection, neoplastic lesions
 Pathophysiology
 Causes include mechanical trauma, irritants such as
tobacco, chemotherapeutic agents
 Oral mucosa is relatively thin, has rich blood supply,
exposed to environment
 Manifestations
 Visible lesions or erosions on lips or oral mucosa
 Pain
 Collaborative Care
 Direct observation to investigate any problems; determine underlying
cause and any coexisting diseases
 Any undiagnosed oral lesion present for > 1 week and not responding
to treatment should be evaluated for malignancy
 General treatment includes mouthwashes or treatments to
cleanse and relieve irritation
 Alcohol bases mouthwashes cause pain and burning
 Sodium bicarbonate mouthwashes are effective without pain
 Fungal (candidiasis): nystatin “swish and swallow” or clotrimazole
lozenges
 Herpetic lesions: topical or oral acyclovir
 Nursing Care
Goal: to relieve pain and symptoms, so client can continue food
and fluid intake
 Impaired oral mucous membrane
 Assess clients at high risk
 Assist with oral hygiene post eating, bedtime
 Teach to limit irritants: tobacco, alcohol, spicy foods
 Imbalanced nutrition: less than body requirements
 Assess nutritional intake; use of straws
 High calorie and protein diet according to client preferences
Oral Cancer
 Uncommon (5% of all cancers) but has high rate of morbidity, mortality
 Highest among males over age 40
 Risk factors include smoking and using oral tobacco, drinking alcohol,
marijuana use, occupational exposure to chemicals, viruses (human papilloma
virus)
Pathophysiology
 Squamous cell carcinomas
 Begin as painless oral ulceration or lesion with irregular, ill-defined borders
 Lesions start in mucosa and may advance to involve tongue, oropharynx,
mandible, maxilla
 Non-healing lesions should be evaluated for malignancy after one week of
treatment
Collaborative Care
 Elimination of causative agents
 Determination of malignancy with biopsy
 Determine staging with CT scans and MRI
 Based on age, tumor stage, general health and patients preference, treatment
may include surgery, chemotherapy, and/or radiation therapy
 Advanced carcinomas may necessitate radical neck dissection with temporary
or permanent tracheostomy; Surgeries may be disfiguring
Nursing Care
Health promotion:
 Teach risk of oral cancer associated with all tobacco use and excessive alcohol
use
 Need to seek medical attention for all non-healing oral lesions (may be
discovered by dentists); early precancerous oral lesions are very treatable
Nursing Diagnoses

 Ineffective airway clearance


 Acute pain
 Impaired oral mucous membrane
 Altered Nutrition: Less than body requirements
 Impaired Verbal Communication: establishment of specific communication plan
and method should be done prior to any surgery
 Knowledge deficit about disease process & treatment plan
 Risk for infection
Gastroesophageal Reflux Disease
(GERD)
Gastric contents flow back in to the oesophagus due to incompetent
oesophageal sphincter

Pathophysiology
 Gastroesophageal reflux results from transient relaxation or
incompetence of lower esophageal sphincter, or increased
pressure within stomach
 Prolonged reflux –oesophigitis
Clinical Manifestations
 Heartburn, dysphagia.

Diagnostic Tests
 Barium swallow (evaluation of esophagus, stomach, small
intestine)
 Upper endoscopy: direct visualization; biopsies may be done
 Esophageal manometry, which measure pressures of esophageal
sphincter and peristalsis
 Esophageal motility studies

Medications
 Antacids for mild to moderate symptoms
 H2-receptor blockers: decrease acid production; given BID or more
often, e.g. cimetidine, ranitidine, famotidine, nizatidine
 Proton-pump inhibitors: reduce gastric secretions, promote healing
of esophageal erosion and relieve symptoms, e.g. omeprazole;
lansoprazole initially for 8 weeks; or 3 to 6 months
 Promotility agent: enhances esophageal clearance and gastric
emptying, e.g. metoclopramide
Gastroesophageal Reflux Disease
(GERD)
Dietary and Lifestyle Management
 Elimination of acid foods (tomatoes, spicy, citrus foods,
coffee
 Avoiding food which relax esophageal sphincter or delay
gastric emptying (fatty foods, chocolate, alcohol)
 Eat small meals and stay upright 2 hours post eating; no
eating 3 hours prior to going to bed
 Elevate head of bed to decrease reflux
 No smoking

Surgical Management
 Laparoscopic procedures to tighten lower esophageal
sphincter
 Open surgical procedure: Nissen fundoplication - upper
portion of the stomach is wrapped around the distal
oesophagus and sutured, creating a tight LES
Nursing Care
 Pain usually controlled by treatment
 Assist client to institute home plan

Complications
Esophageal stricture , ulceration
of the esophagus, Barrett’s
oesophagus
Hiatal Hernia
A condition in which cardiac sphincter becomes enlarged
allowing the stomach to pass in to the thoracic cavity
 Sliding hernia
 More common

 Upper portion of stomach and gastro esophageal


junction are displaced upward into the thorax
 Esp. when supine
 Standing  herniated portion slides down into
abdominal cavity
 Rolling Hernia the gastro esophageal junction is in
normal place but part of stomach herniates through
esophageal hiatus; hernia can become strangulated;
client may develop gastritis with bleeding

Predisposing factors
 Increased intra-abdominal pressure
 Increased age
 Trauma
 Congenital weakness
Manifestations
 Heartburn
 Brief substernal burning sensation
 Freq belching
 Discomfort when lying supine
Diagnostic Tests
 Barium swallow
 Endoscopy
Treatment
 Similar to GERD
NSG Management
Gastritis
Inflammation of stomach lining from irritation of gastric mucosa
(normally protected from gastric acid and enzymes by mucosal
barrier)
 Acute Gastritis
 Disruption of mucosal barrier allowing hydrochloric acid and pepsin
to have contact with gastric tissue: leads to irritation, inflammation,
superficial erosions
 Gastric mucosa rapidly regenerates; self-limiting disorder
Causes of acute gastritis
 Irritants include aspirin and other NSAIDS, alcohol, caffeine
 Ingestion of corrosive substances: alkali or acid
 Effects from radiation therapy, certain chemotherapeutic agents
 Erosive Gastritis: form of acute which is stress-induced, complication
of life-threatening condition (Curling’s ulcer with burns); gastric
mucosa becomes ischemic and tissue is then injured by acid of
stomach
Manifestations
 Mild: anorexia, mild epigastric discomfort, belching
 More severe: abdominal pain, nausea, vomiting, hematemesis,
melena
 Diaehoea, the contaminated food is the cause of gastritis

Treatment
 NPO status to rest GI tract for 6 – 12 hours, reintroduce clear liquids
gradually and progress; intravenous fluid and electrolytes if indicated
 Medications: proton-pump inhibitor or H2-receptor blocker; sucralfate
acts locally; coats and protects gastric mucosa
 If gastritis from corrosive substance: immediate dilution and removal
of substance by gastric lavage (washing out stomach contents via
nasogastric tube), no vomiting
Gastritis - Chronic
 Superficial Gastritis
 Atrophic Gastritis
 Type A: Parietal cells normally secrete intrinsic factor
needed for absorption of B12, when they are destroyed by
gastritis pts develop pernicious anemia
 Type B: more common and occurs with aging; caused by
chronic infection of mucosa by Helicobacter pylori; associated
with risk of peptic ulcer disease and gastric cancer
 Hypertrophic Gastritis
 Manifestations
 Vague gastric distress, epigastric heaviness not relieved by
antacids
 Fatigue associated with anemia; symptoms associated with
pernicious anemia
 Treatment
 Type B: eradicate H. pylori infection with combination therapy
of two antibiotics (metronidazole (Flagyl) and clarithomycin or
tetracycline) and proton–pump inhibitor (Prevacid or Prilosec)
 Bland Diet
 Small Frequent meals
 Antacids
 Administer vitamin B12
 Diagnostic Tests
 Gastric analysis: assess hydrochloric acid secretion (less with
chronic gastritis)
 Hemoglobin, hematocrit, red blood cell indices: anemia
including pernicious or iron deficiency
 Serum vitamin B12 levels: determine pernicious anemia
 Upper endoscopy: visualize mucosa, identify areas of bleeding,
obtain biopsies; may treat areas of bleeding with electro or laser
coagulation or sclerosing agent
Peptic Ulcer Disease (PUD)
refers to ulcerrations in the mucosa of the lower oesophagus , stomachor dueodenum
Incidence
 Duodenal ulcers: most common; affect mostly males ages 30 – 55; ulcers found near
pyloris
 Gastric ulcers: affect older persons (ages 55 – 70); found on lesser curvature and
associated with increased incidence of gastric cancer

Pathophysiology
 ACTH & Cortisone
 Structure of mucosa
 Amount of Mucous produced
 Trauma, infection, physical or psychological stress can cause increase in gastric
secretion, blood supply and gastric motility by way of thalamus stimulus to vagal nerve
 Use of NSAIDS: interrupts prostaglandin synthesis which maintains mucous barrier of
gastric mucosa

Types
 Duodenal Ulcers
 Ususlly occur 1.5 cm. from pylorus
 Hypersecretion of acid
 Protien rich meals, Calcium, vagal stimulation
 Gastric ulcers
 Junction of fundus and pylorus
 Caused by break in mucosal barrier due to incompetent pylorus
Peptic Ulcer Disease (PUD)
Manifestations
 Pain: gnawing, burning, aching, cramplike
 Gastric
 when stomach is full and relieved by vomiting
 Upper epigastric region
 Duodenal
 when stomach is empty and relieved by food
 Left epigastric region
 Nausea and vomiting
 generally associated with Gastric ulcers
Treatment
 Rest and stress reduction
 Nutritional management
 Pharmacological management
 Antacids (Mylanta)
 Neutralizes acids
 Proton pump inhibitors (Prilosec, Prevacid)
 Block gastric acid secretion
 Histamine blockers (Tagamet, Zantac, Axid)
 Blocks gastric acid secretion
 Carafate
 Forms protective layer over the site
 Mucosal barrier enhancers (colloidal bismuth, prostoglandins)
 Protect mucosa from injury
 Antibiotics (Amoxicillin, Ampicillin)
 Treat H. Pylori infection
 Surgical intervention
 Minimally invasive gastrectomy
 Partial gastric removal with laproscopic surgery
 Bilroth I and II
 Removal of portions of the stomach
 Vagotomy
 Cutting of the vagus nerve to decrease acid secretion
 Pyloroplasty
 Widens the pyloric sphincter
Nursing Management
 Administer medication as ordered
 Client Teaching & discharge plan
 Medical regimen
 Diet
 Avoidance of stress producing situations
Complications
 Hemorrhage: frequent in older adults
 Gastric outlet (pyloric sphincter) obstruction: edema surrounding ulcer blocks GI tract
from muscle spasm or scar tissue
 Perforation: ulcer erodes through mucosal wall and gastric or duodenal contents enter
peritoneum leading to peritonitis; chemical at first (inflammatory) and then bacterial in 6
to 12 hours
Cancer of Stomach
Malignant neoplasms found in the stomach,usually Adenocarcinoma
Etiology and risk factors
 Presence of H pylorai inf. in the stomach
 Chronic atrophic gastritis, adenomatous polyps, pernicious anemia
 Increase in absorption of carcinogens from diet
 Genetic factors
Pathophysiology
 Adenocarcinoma most common form involving mucus-producing cells
of stomach in distal portion
 Begins as localized lesion (in situ) progresses to mucosa; spreads to
lymph nodes and metastasizes early in disease to liver, lungs, ovaries,
peritoneum
Manifestations
 Disease often advanced with metastasis when diagnosed
 Early symptoms are vague: early satiety, anorexia, indigestion,
vomiting, pain after meals not responding to antacids
 Later symptoms weight loss, cachexia (wasted away appearance),
abdominal mass, stool positive for occult blood
 Presence of lactic acid and LDH
Diagnostic tests
 Upper GI tract X ray exam
 Upper endoscopy: visualization and tissue biopsy of lesion
Medical Management
 Client may receive Chemotherapy or radiation therapy
 Primary treatment is surgical management
 Surgery, if diagnosis made prior to metastasis
 Partial gastrectomy with anastomosis to duodenum: Bilroth I or gastroduodenostomy
 Partial gastrectomy with anastomosis to jejunum: Bilroth II or gastrojejunostomy
 Total gastrectomy (if cancer diffuse but limited to stomach) with esophagojejunostomy
Appendicitis
It is an inflammation of the vermiform
appendix that develops most
commonly in adolescents and young
adults
Etiology
A fecalith which occludes the lumen of
appendix
 Kinking
 Swelling of the bowel wall
 External occlusion of the bowel
Pathophysiology
 Appendix obstructed > intrlumunar
pressure increases > Venus drainage
decreases > thrombosis, edema bacterial
infection > hyperaemia of appendix
Manifestations

Surgical Management

Complictions
 Perforation of the bowel
Colon Cancer
Pathophysiology
 Most malignancies begin as adenomatous polyps and arise in rectum and
sigmoid
 Spread by direct extension to involve entire bowel circumference and
adjacent organs
 Metastasize to regional lymph nodes via lymphatic and circulatory systems
to liver, lungs, brain, bones, and kidneys
Manifestations
 Often produces no symptoms until it is advanced
 Presenting manifestation is bleeding; also change in bowel habits (diarrhea
or constipation); pain, anorexia, weight loss, palpable abdominal or rectal
mass; anemia
Complications
 Bowel obstruction
 Perforation of bowel by tumor, peritonitis
 Direct extension of cancer to adjacent organs; reoccurrences within 4 years
Diagnostic Tests
 CBC: anemia from blood loss, tumor growth
 Fecal occult blood (guiac or Hemoccult testing): all colorectal cancers bleed
intermittently
 Carcinoembryonic antigen (CEA): not used as screening test, but is a tumor
marker and used to estimate prognosis, monitor treatment, detect
reoccurrence may be elevated in 70% of people with CRC
 Colonoscopy or sigmoidoscopy; tissue biopsy of suspicious lesions, polyps
 Chest xray, CTscans, MRI, ultrasounds: to determine tumor depth, organ
involvement, metastasis
Pre-op care
 Consult with ET nurse if ostomy is planned
 Bowel prep with GoLytely
 NPO
 NG
Surgery
 Surgical resection of tumor, adjacent colon, and regional lymph nodes is
treatment of choice
 Whenever possible anal sphincter is preserved and colostomy avoided;
anastomosis of remaining bowel is performed
 Tumors of rectum are treated with abdominoperineal resection (A-P
resection) in which sigmoid colon, rectum, and anus are removed through
abdominal and perineal incisions and permanent colostomy created
Colostomy
 Ostomy made in colon if obstruction from tumor
 Temporary measure to promote healing of anastomoses
 Permanent means for fecal evacuation if distal colon and rectum removed
 Named for area of colon is which formed
 Sigmoid colostomy: used with A-P resection formed on LLQ
 Double-barrel colostomy: 2 stomas: proximal for feces diversion; distal is mucous
fistula
 Transverse loop colostomy: emergency procedure; loop suspended over a bridge;
temporary
 Hartman procedure: Distal portion is left in place and oversewn; only proximal
colostomy is brought to abdomen as stoma; temporary; colon reconnected at later
time when client ready for surgical repair
Post-op care
 Pain
 NG tube
 Wound management
 Stoma
 Should be pink and moist
 Drk red or black indicates ischemic necrosis
 Look for excessive bleeding
 Observe for possible separation of suture securing stoma to abdominal wall
 Evaluate stool after 2-4 days postop
 Ascending stoma (right side)
 Liquid stool
 Transverse stoma
 Pasty
 Descending stoma
 Normal, solid stool

Radiation Therapy
 Used as adjunct with surgery; rectal cancer has high rate of regional recurrence if tumor
outside bowel wall or in regional lymph nodes
 Used preoperatively to shrink tumor
 Provides local control of disease, does not improve survival rates
Chemotherapy:
 Used postoperatively with radiation therapy to reduce rate of rectal tumor recurrence and
prolong survival
Nursing Care
 Prevention is primary issue
 Client teaching
 Diet: decrease amount of fat, refined sugar, red meat; increase amount of fiber; diet
high in fruits and vegetables, whole grains, legumes
 Screening recommendations
 Seek medical attention for bleeding and warning signs of cancer
 Risk may be lowered by aspirin or NSAID use
Nursing Diagnoses for post-operative colorectal client
 Pain
 Imbalanced Nutrition: Less than body requirements
 Anticipatory Grieving
 Alteration in Body Image
 Risk for Sexual Dysfunction