Digestive system

Anatomy and physiology

• Upper GI
• Gastrointestinal tract layers
– Mucosa
• Epithelial layer- Absorb and secretes mucus and digestive
enzymes
• Lamina propia – contains blood and lymph vessels
• Muscularis mucosa- smooth muscle responsible for peristaltic
movements
– Submucosa
– Muscle
– Adventitia
Gastric Mucosa vs. Esophageal
mucosa
 Gastric Mucosa
• Has Gastric pits and contains secretory cells
– G cells- secretes gastrin
– Parietal Cells (stimulated by gastrin) – Produce HCl
Acid
– Chief Cells- Produce pepsinogen
– Foveolar Cells- produce mucus
 Esophageal mucosa
• Stratified Squamous Epithelium

• Duodenum- Brunner Glands- Secrete mucus

 GERD
• Pathological persistent of acid reflux to
esophagus leading to damage in esophageal
mucosa

• Poses a risk esophageal carcinoma

(Adenocarcinoma)
 Risk Factors
• Obesity
• Pregnancy
• Diet: Caffeine, Acidic Diet
• Alcohol (binge)
• Smoking
• Glucocorticoids
• Ca channel Blockers
 Signs and symptoms
• Pyrosis
• Dyspepsia
• Regurgitation
• Dysphagia
• Chronic Cough
 Diagnosis
• Clinical Symptoms
• Therapeutic Challenge- Administering PPI ->
symptoms resolves
• X –ray with Barium Swallow contrast
• Endoscopy with biopsy
 Treatment
• Medications
– Proton Pump Inhibitor (Omeprazole, Lanzoprazole,
Pantoprazole)
– H2 Receptor Blockers (Ranitidine, Famotidine)
– Antacids- (AlOH, MgOH, Maalox) – Neutralize Acidity
• Surgery
– Fundoplication- tying of LES
• Laser Ablation
• Resection
 Health Teachings
• Lifestyle change
– Safe weight loss
– Avoid Acidic food
– Avoid alcohol
– No smoking
– Avoid tight fitting clothes
• Place on moderate high back rest after eating
– No eating 2 hours before bedtime
– No lying down after meals
Peptic Ulcer Disease

PUD
 Peptic Ulcer Disease
Stomach Ulcer – Break in the membrane along
Stomach mucosal lining
• Causes
1. Gram neg H. pylori- causes damage to
mucosal cells in stomach/duodenum

2. NSAIDs- side effects

 Gastric Ulcer VS. Duodenal Ulcer
Gastric Duodenal
Age 50-70y.o 30-60 y.o
Family history None present
Gender equal equal
Cancer Risk High Minimal
Stress related Yes No
Associated Gastritis High Minimal
H. pylori related 60%-80% 95%-100%
Pain
Location Epigastric Pain Epigastric Pain
Pattern Pain –Antacid Relief - Pain –Antacid/Food Relief
Food Pain Pattern pattern
- Nocturnal pain
Gastric Ulcer VS. Duodenal Ulcer
Gastric Duodenal
Clinical Course Chronic Ulcer w/o Pattern of remission and  
remission Exacerbation
Weight Loss Weight Gain
Vomiting common Vomiting Uncommon
Hematemesis more Melena more common
common
 Stress Related PUD
• Acute form of PUD in response to severe
illness, trauma or neural injury
• Ischemic ulcer
– develop within hours in response to hemorrhage,
multisystem trauma and heart failure
• Curling’s ulcer
– result after burn injury
• Cushing’s ulcer
– severe head trauma or brain injury
 Diagnosis
• Endoscopy
• H. pylori stool antigen test
• FOBT- fecal occult blood test
– Prep: For 72 hours- avoid red meat, FeSO4,
NSAIDs, Indomethacin
 Treatment
• Lifestyle modification
– Stress Reduction
– Smoking Cessation
– Diet
• Avoid Acidic food
– Avoid Alcohol
• Medications
– Proton Pump Inhibitor- Omeprazole, Pantoprazole
– H2 Blockers
– Anticholinergics- suppress vagal stimulation (Atropine, Ipratropium)
– Cytoprotective agents (Misoprostol, Sucralfate)
– Antacids
– Antibiotics for H. pylori (Clarithromycin, Metronidazole, Amoxicillin); combined
with PPI
 Treatment
• Surgery
– Vagotomy and pyloroplasty
– Gastroduodenostomy Billroth I reattachment of
stomach to duodenum
– Gastrojejunostomy Billroth II reattachment of
stomach to jejunum
 Complications of Billroth Surgery
• Dumping syndrome- rapid stomach emptying
– S/sx
• 3Ds: Diarrhea, Diaphoresis, Dizziness
• Steatorrhea
• Tachycardia
• Abdominal Cramping
• Borborygmi sound (growling sound in abdomen)
• Nursing Interventions
– Small Frequent feeding
– Fluids after meals
– Lie down after meals
– Low carbohydrate diet
– Anti Spasmodics (HNBB) delays gastric emptying
 Complications of Billroth Surgery
• Pernicious Anemia- loss of intrinsic factor
– Signs and symptoms
• Red Beefy Tongue
• Neurologic Symptoms- Peripheral Neuropathy
– Diagnosis Schillings Test- sample taken: 24 hour
Urine
– Treatment: lifetime Vitamin B12 IM injection
Pancreatitis
 Pancreas
• Both serve Exocrine and endocrine gland
- As exocrine it produces: Amylase (carbohydrate
digestion), Lipase (fat digestion), Trypsin
(protein digestion)
 Acute Pancreatitis
• A.K.A Acute Hemorrhagic Pancreatitis
• Sudden inflammation and hemorrhaging of
pancreas due to autodigestion

• Inflammation of the pancreas ranging from

mild self limiting to severe form
 Acute Pancreatitis
• Causes
• Mainly Idiopathic
• Linked to 
– Alcoholism- increase of proenzyme production
while lowering fluid and HCO3 ions in pancreatic
ducts
– Obstruction in pancreatic sphincter
– Complication of ERCP
– Stab Injury
 Signs and Symptoms
• Pain (epigastric and radiates at back
• Nausea, Vomiting, and Steatorrhea
• Fever
• Signs of hypovolemia
• Jaundice
• Cullen’s sign - bluish discoloration/ecchymosis at
umbilicus
• Turner’s Sign - bluish discoloration/ ecchymosis at
flank/ lateral of the trunk
 Diagnostic Test
• Serum Amylase (increases within 12hours
after onset)
• S. Lipase
• C reactive Protein –indicates inflammation
• CT scan for Pseudocyst
 Treatment

• Main Goal: Stop Autodigestion and prevent further

complications
• NPO
• IV fluids- restore blood volume and prevent shock
• Pain medications – Meperidine (Demerol) and
Morpine
• Antibiotics for treatment of pseudocysts
• Low fat diet and alcohol cessation
• Treatment of underlying cause
 Chronic Pancreatitis
• common complication of recurrent acute
pancreatitis and chronic alcoholism
 Signs and Symptoms
• Recurring Attacks of severe upper
abdominal(epigastric) and back pain
• weight loss and anorexia
• Steatorrhea
 Diagnostic
• Serum Amylase, Lipase and Calcium
• CBC
 Treatment
• Administer Prescribed medications
– Pain medications – Meperidine (Demerol),
Morphine
– H2 receptor antagonist
– PPI
• Manage endocrine insufficiency: Most
Common complication: Diabetes Mellitus
– Insulin and OHA therapy
 Treatment
• Surgery
– Pancreatic jejunostomy- Rous-en-Y procedure
• Joining of the pancreatic duct to the jejunum
• allows drainage of the pancreatic duct to jejunum
– Whipple’s Procedure/ Whipple’s Resection-
Pancreaticoduodenectomy
• Part of the pancreas and duodenum is removed
• post op diet: Gradual transition form clear liquids to
soft diet and to diet as tolerated
 Treatment
• Lifestyle Change
– Avoid alcohol
– Small Frequent feeding
– Avoid Binge eating
– Weight loss
– Low fat diet
– Pancreatic Enzymes supplements
• Creon, Pancreaze, Zenpep, Ultresa, Viokace, and
Pertzye
 Cholecystitis and Cholelithiasis
• Cholecystitis- inflammation of gallbladder

• Cholelithiasis- Stone formation within

gallbladder
 Cholecystitis and Cholelithiasis
• Risk Factors- Fat, Fertile, Female, forty

• Cause- Idiopathic
 Cholecystitis and Cholelithiasis
• If obstruction is on cystic duct- symptoms
either subsides or perforates

• Common bile duct- backflow of bile to liver

and leak to blood vessels- increase  in serum
conjugated bilirubin
 Signs and Symptoms
Cholelithiasis
• Episodic  cramping pain in the RUQ if the
abdomen or the epigastrium, radiating to the
back near the scapular tip
• Nausea and vomiting
• Fat intolerance
• Fever
• Jaundice
 Signs and Symptoms
Cholecystitis
• Tenderness and rigidity in the RUQ elicited on
palpation
• Murphy’s sign
• Fever
• Nausea and vomiting
• Fat intolerance
• Heartburn
• Vitamin deficiency (A,D,E,K)
 Diagnostics

• Ultrasonography
• Serum Bilirubin
• ERCP- Endoscopic Retrograde
Cholagiopancreatography
• MRCP- Magnetic Resonance
Cholagiopancreatography
 Treatment
• Medication
– Ursodeoxycholic acid (UDCA) dissolves small
stones
– Analgesics
• Intracorporeal Lithotripsy- fragmentation of
stones by means of laser pulse
• Extracorporeal shockwave Lithotripsy
 Treatment
• Diet: Low fat diet and high protein and
carbohydrates
• Surgery
– Laparoscopic Cholecystectomy- removal of
gallbladder with use of laparoscope.
– Cholecystectomy- removal of gallbladder through
abdominal incision. A drain is placed in order to
prevent bile leak