Gastrointestinal Disorder

Abja Sapkota
Assistant Professor
Nepal Medical College

06/29/2021 Ms. Abja Sapkota 1

 The physician orders a high cleansing enema for a client . What
is the maximum height at which the container of fluid should be
held by the nurse when administering this enema ?

a. 30 cm (12 inches)
b. 37 cm (15 inches)
c. 45 cm (20 inches)
d. 66 cm (26 inches)

Answer: 37 cm (15 inches)

3/21/2021 Ms. Abja Sapkota

Cholecystokinin is the
hormone produced from
a. Gall bladder
b. Pancreas
c. Liver
d. Duodenal mucosa

Answer: d
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Liver, Biliary tract and Pancreas
• Liver- largest internal organs, right epigastric
regions, it has fibrous capsules
• Functional units of liver- lobules and lobules
consists of hepatocytes
• Capillaries (sinusoids) are located between
heaptocytes lined with “Kupffer cells “
• Blood supply:1/3rd from Hepatic Artery and 2/3rd
from portal Vein

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Functions of liver
• Synthesis of lipoproteins; Breakdown of fatty
acids and glycerols
• Formation of ketone bodies
• Synthesis of fatty acids from aminoacids and
glucose; Synthesis and breakdown of cholesterol
• Detoxification, steroid metabolism
• Storage: glycogen, Vit A,D,E,K, Vit. B1,B2,
cobalamin ,Folic Acid, minerals amino acids
• Bile production and excretion

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Conjugated
with
glucorunic
acid

Break down of RBC’s

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Pancreas
• Has both exocrine and endocrine glands
• Exocrine glands- secretes pancreatic
enzymes; sodium bicarbonate
• Endocrine- islet of Langerhans
• Alpha cells: glucagan
• Beta cells: insulin
• Delta cells: Somatostatin

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Trans umbilical and median planes divide in
to four quadrant

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Essential amino acids
• Cannot be made by the body.
• As a result, they must come from food.
• The 9 essential amino acids are: histidine,
isoleucine, leucine, lysine, methionine,
phenylalanine, threonine, tryptophan, and
valine.

06/29/2021 Ms. Abja Sapkota 13

The following is an enzyme required for
glycolysis:
a. Pyruvate kinase
b. Pyruvate carboxylase
c. Glucose-6-phosphatose
d. Glycerokinase

06/29/2021 Ms. Abja Sapkota 14

The organ involved in production of bile is :

a. Gall bladder
b. Liver
c. Pancreas
d. Stomach

06/29/202 Ms. Abja Sapkota 15

Digestion and absorption contd..
• The physical presence of Chyme ( food mixed with
gastric secretions)- stimulates motility and
secretions
• When food enters the stomach and small intestine
hormones released in to blood stream
• Hormones stimulates pancreas to secretes
bicarbonate
• Chyme stimulate production of hormone
cholecystokinin from duodenal mucosa

06/29/2021 Ms. Abja Sapkota 16

Topic to be covered
• Dumping •Pancreatitis
Syndrome •Cirrhosis
• Intestinal
obstruction
•Liver failure
• Hernia •Hepatic
• Diverticulitis Encephalopathy
• Peritonitis •GI Bleeding
• Cholelithiasis •Hepatitis
06/29/2021 Ms. Abja Sapkota 17
Postop mgmt. Care of patients with
Gastrectomy
• Avoiding dumping syndrome

• Gradually shift from NPO to Sips of clear

water to six small bland meals a day when
bowel sounds returns

• Monitor for post operative hemorrhages,

Dumping syndrome , diarrhea, hypoglycemia,
Vitamin B12 deficiency , pneumonia,
pernicious anemia

06/29/2021 Ms. Abja Sapkota 18

 Dumping syndrome
• Rapid passage of food from stomach to jejunum ;food
(especially high in Carbohydrates) will draw fluid from
circulating blood into jejunum
• Osmotic shift of fluid from intravascular compartment
into intestine
• Assessment- occurring 30 minutes to 90 min after
eating, Nausea/vomiting, feeling of abdominal fullness
• Abdominal cramping, diarrhea, palpitations,
tachycardia, perspiration, weakness, dizziness,
borborygmi (indicate hyper peristalsis)
06/29/2021 Ms. Abja Sapkota 19
 Dumping syndrome

• Management:
• Small frequent feeds
• Limit fluid intake with meals

• Prevention
 Avoid, sugar, salt and milk, Lie down after meals
 Eat a high protein, high fat and low CHO diet
 Eat small meals and avoid consuming fluids at
meal
 Take antispasmodic medications as prescribed to
delay gastric emptying
06/29/2021 Ms. Abja Sapkota 20
 Q. The nurse is caring for patient who underwent a
Billroth II procedure for treatment of a peptic
ulcer. Which findings suggest that the
patient is developing dumping syndrome?
a. Flushed, dry skin
b. Headache and bradycardia
c. Dizziness and sweating
d. Dyspnea and chest pain

Answer: c

06/29/2021 Ms. Abja Sapkota 21

Q A patient has undergone a partial gastrectomy for
adenocarcinoma of the stomach. An NG tube is in
place and is connected to low continuous suction.
During the immediate postoperative period, you
expect the gastric secretions to be which color?

a. Brown
b. Clear
c. Red
d. Yellow

Answer: C (red)
06/29/2021 Ms. Abja Sapkota 22
 After abdominal surgery, your patient has a severe
coughing episode that causes wound evisceration. In
addition to calling the doctor, which intervention is
most appropriate?

a. Irrigate the wound & organs with Betadine

b. Cover the wound with a saline soaked sterile dressing.
c. Apply a dry sterile dressing & binder.
d. Push the organs back & cover with moist sterile
dressings

Answer: b (cover the wound with saline soaked dressing )

06/29/2021 Ms. Abja Sapkota 23

 Appendicitis
• Compromised circulation and inflammation
of the vermiform appendix
• Causes- obstruction by fecalith, foreign body,
kinking
• Edema, necrosis rupture and peritonitis
• Gangrene formation and perforation can
develop within 36 hrs resulting in peritonitis
and sepsis

06/29/2021 Ms. Abja Sapkota 24

 Clinical features

• Pain : periumbilical that descends to

right lower quadrant Pain at right lower
abdomen (Mc burney’s point), pain:
diffuse if perforated
• Rebound tenderness (intensification of
pain when pressure is released)
• Guarding, Rovsing’s sign: pain in rt
lower quadrant that occurs with
palpation of left lower quadrant
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 Clinical Features

• Psoas sign: Abdominal pain that occur

when flexing the hip, when pressure is
applied to the knee
• Obturator sign: abdominal pain that
occurs when hip is rotated
• Fever, anorexia, nausea, vomiting, WBC:
high

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 Observed for ruptured appendix and
peritonitis
• Guarding of the abdomen
• Increased fever and chills
• Pallor
• Progressive abdominal distension and
abdominal pain
• Restlessness
• Tachycardia and tachypnea
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Management

• NPO, IV fluids
• Fowlers position
• Administer IV fluids
• Analgesics
• Apply ice packs to the abdomen for 20-
30 min every hour
• Heat, enema, laxatives is not applied:
may rupture
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Q. Which of the following is thought to be the
most common cause of appendicitis?
a. A fecalith
b. Bowel kinking
c. Internal bowel occlusion
d. Abdominal bowel swelling

Answer: a

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Clue

• A fecalith is a fecal calculus, or stone

• Occludes the lumen of the appendix
• Considered as the most common cause
of appendicitis
• Bowel wall swelling, kinking of the
appendix, and external occlusion

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Crohn’s disease

• Regional enteritis, Inflammatory disease of

the small bowel that mainly affects terminal
ileum, can affect all areas, all layers
• Leads to thickening, scarring, narrowed lumen ,
fistula ulceration and abscess
• Characterized by remission and exacerbation
• Skip lesions (cobblestone appearance): clusters
of ulcers separated by normal tissue), edematous,
reddish purple areas with granulomas
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Crohn’s Disease

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• Cause: Genetic, autoimmune, infection, low fiber
diet
• Sign and Symptoms: fever, cramp like colicky
pain after meal, Abdominal distension, diarrhea
without visible blood, anemia, cramping abdominal
pain, dehydration and fluid and electrolyte
imbalance, abscess, fistula and fissure, extra:
conjunctivitis, arthritis)
• Diagnosis:
• Occult steatorrhea ,Classic string sign on x-ray
film of terminal ileum ( indicating constriction)
• Barium enema: cobblestone

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Management

• NPO
• TPN
• Clear fluid-bland-low fat diet
• Antidiarrheals
• Immunosuppresants ( Infliximab)
• Antibiotics
• IM: Vit B12
• Steroids
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Ulcerative colitis

• Chronic inflammatory disease of large intestine

commonly in sigmoid and rectal areas and
spreads upwards to the cecum
• Chronic-muscular hypertrophy, thickening,
shortening, narrowing
• > 10 years: cancer may develop
• Stool: Liquid with blood, pus and mucus
• Nausea, anorexia, weakness, abdominal cramp,
dehydration, anemia

06/29/2021 Ms. Abja Sapkota 38

Assessment

• Anorexia, weight loss, malaise

• Abdominal tenderness, cramping,
• Severe diarrhea
• Dehydration
• Electrolyte imbalances
• Anemia
• Vitamin K deficiency

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Management

• Acute phase: NPO, Monitor bowel sounds

• Low residue, high protein, high vitamin and
iron
• Avoid gas forming – milk whole wheat, grains,
raw fruits, vegetables, peppers
• Administer-salicylates, corticosteroids,
immunosuppressant, antidiarrheal
• IV Fluid, Avoid food allergies, TPN,
Colectomy

06/29/2021 Ms. Abja Sapkota 40

Management contd..

•High protein, high calorie, low fat low

fiber diet
• Analgesics, anticholinergic, anti
diarrheals
•Maintain fluid and electrolyte balance
•Monitor electrolyte
•Ileostomy in severe case

06/29/2021 Ms. Abja Sapkota 41

 Q. A patient is experiencing an acute
episode of ulcerative colitis. Which is
priority for this patient?
a. Replace lost fluid and sodium.
b. Monitor for increased serum glucose level
from steroid therapy.
c. Restrict the dietary intake of foods high in
potassium.
d. Note any change in the color and consistency
of stools
Answer: a

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Stoma

• Viability
• Expected: brick red
• Inadequate perfusion: gray, pale, pink,
dark purple
• Avoid seeds that can cause obstruction
• Increase fluid intake
• Avoid gas forming foods

06/29/2021 Ms. Abja Sapkota 43

 Q. The nurse is advising a patient with a
colostomy who reports problems with
flatus. What food should the nurse
recommend?
a. Peas
b. Cabbage
c. Broccoli
d. Yogurt

Answer: d
06/29/2021 Ms. Abja Sapkota 44
List of gas forming foods

• Beans and lentils

• Cabbage
• Brococcoli
• Onions
• Dairy products
• Beer

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 Intestinal obstruction

• When blockage prevent the normal flow of

intestinal contents through intestinal tract
• Most common: SI obstruction
• Cause: Mechanical: Tumor, stenosis, strictures,
hernia, abscess, volvulus, intussuception,
adhesions
• Functional: Cannot propel the content along
the bowel -Muscular dystrophies, DM, surgery
• Neurologic: Parkinson's disease
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 Terminologies

• Volulus: twisting of bowel

• Intussuception: (like a telescope
shortening)
• Adhesions:
• Paralytic ileus: interfere with neural
innervations of intestine (absence of
peristalsis caused by surgical manipulation,
electrolyte imbalance or infection

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Small intestine obstruction

•Reflux vomiting: 1st stomach

content, bile stained and then fecal
•Cramping pain: Wavelike and
colicky
•Blood and mucus
•Dehydration, shock
•If complete: Peristaltic waves
initially become extremely vigorous
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Treatment

•NPO, IV fluids with electrolytes: 1st

•Decompression of bowel through
NG tube
•Surgical repair

06/29/2021 Ms. Abja Sapkota 50

Q. Which stoma would you expect a
malodorous, enzyme-rich, caustic liquid
output that is yellow, green, or brown?
a. Ileostomy.
b. Ascending colostomy.
c. Transverse colostomy.
d. Descending colostomy.

Answer: a (ileostomy)
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Q. Which of the following is the priority
intervention for a patient with possible bowel
obstruction?
a. Obtain daily weights.
b. Measure abdominal girth.
c. Keep strict intake and output.
d. Encourage her to increase fluids

Answer :b

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Large Intestinal Obstruction

• Dehydration more slowly than S.I. as colon

can absorb its fluid content
• If sigmoid colon or rectum: Constipation
• Lower abdominal pain, marked distention,
loop of large bowel become visibly outlined
through the abdomen, fecal vomiting, shock.

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Treatment

• NPO, IV fluids, NG decompression

• Colonoscopy: to untwist and decompress
bowel
• Rectal tube: Decompress bowel
• Barium studies are contraindicated
• Antibiotics, Analgesics
• Surgical resection

06/29/2021 Ms. Abja Sapkota 55

GI bleeding

• 85% Upper GI tract

• Cause: PUD, varices, diverticular disease, tumor,
ulcer, colitis
• C/F: Coffee ground vomitus, bloody maroon
colored or black tarry stool, abdominal cramping,
anemia, s/s of hypovolemia
• Treatment: NG tube lavage to remove blood clots,
treat the cause, vasopressin, avoid aspirin, NPO
until bleeding controlled

06/29/2021 Ms. Abja Sapkota 56

Esophageal varices

• Dilated tortuous veins in the submucosa of the

esophagus
• Caused by portal hypertension often associated with
liver cirrhosis
• Assessment- hematemesis, melena, tarry stools,
ascites, jaundice, hepatomegaly , dilated abdominal
veins, level of consciousness

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Esophageal varices
• Signs of shock
• Interventions: vital signs, elevate head of bed,
auscultate lungs signs, administer O2
• NPO, fluid IV as prescribed, NG tube , ice
saline irrigation, administer vasopression, NTG,
prevent activities that leads to vasovagal
response
• Surgery: endoscopic injection of
sclerotherapy endoscopic variceal ligation
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• The promotion of hemodynamic stability in a
patient with upper GI bleeding is maintained
by:
a. Encouraging oral fluid intake.
b. Monitoring central venous pressure.
c. Monitoring laboratory test results and vital
signs.
d. Giving blood, electrolyte and fluid
replacement

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 Thank You

06/29/2021 Ms. Abja Sapkota 61