The Digestive System

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The Digestive System

• Also known as the gastrointestinal (GI) tract or
  the alimentary system, it is responsible for
  breaking down the complex food into simple
  nutrients the body can absorb and convert into
  energy. This process is known as digestion.

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Major GI Function Organs

• Mouth
• Pharynx
• Esophagus
• Stomach
• Small intestine
• Large intestine

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Accessory GI Organs

• Liver
• Gallbladder
• Pancreas

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Figure 24-1 The gastrointestinal tract and
accessory organs of digestion. (Source Pearson
Education/PH College)
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Mouth

• Teeth chew and grind food into smaller parts
• Moistened with saliva for tasting, chewing, and
  swallowing

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Pharynx

• Muscles that propel the food from the mouth

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Esophagus

• Carries food through peristalsis
• Cardiac/lower esophageal sphincter
• Closes after food leaves esophagus

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Figure 24-2 Structures of the stomach and
duodenum, including the common bile duct and
pancreatic duct. The relationship of the pancreas
and gallbladder to the stomach also are shown.
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Stomach

• Holds the food
• Pyloric sphincter controls the emptying of the
  stomach

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Small Intestine

• Approximately 20 to 25 feet long and is
  responsible for absorbing nutrients from the
  chyme (semi-liquid mass of partially digested
  food).
• Small intestine divided into duodenum (first
  10-12 inches) jejunum (the middle 8-10 feet)
  and the ileum (the distal 12 feet).

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Large Intestine

• Begins at ileocecal valve, terminates at the anus
• 5 feet long
• Includes the appendix
• Nutrients absorbed and indigestible materials
  eliminated

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Large Intestine

• Also known as the colon, the large intestine is
  responsible for absorbing water, electrolytes,
  and salts.
• The last 5 inches of the large intestine comprise
  the rectum. The distal end of the rectum forms
  the anal canal composed of muscles that control
  defecation. The opening to the anal canal is
  called the anus.

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Large Intestine (continued)

• Parts
• Ascending
• Transverse
• Descending
• Sigmoid colon
• Rectum

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Liver

• Largest gland in the body
• Located in the right side of the abdomen
• Has four lobes
• Encased in a fibrous capsule
• Hepatocytes produce bile, which aids in digestion

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Gallbladder

• Stores bile
• Located on the inferior surface of the liver

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The liver, gallbladder, common bile duct, and
sphincter of Oddi.
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Pancreas

• Gland located between the stomach and small
  intestines
• Exocrine and endocrine functions
• Produce pancreatic juice to neutralize food
• Produce enzymes to digest food

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Digestion

• Mouth
• The upper opening of the GI tract
• Lined by mucous membranes
• The teeth chew and grind food into smaller parts
• Saliva (produced by the salivary glands) moistens
  food for tasting, chewing, and swallowing

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Mouth

• Digestive process starts here
• Enzymes in saliva begin the food breakdown
• Amylase
• Lysozyme

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Digestion

• Pharynx
• Muscles here move the food into the esophagus
• Esophagus
• Carries the food to the stomach through
  peristalsis

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Stomach

• Mechanical digestion in the stomach mixes
  partially digested food with gastric juices to
  produce chyme

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Nervous System

• Parasympathetic nervous system signals vagus
  nerve to increase gastric secretions in response
  to food
• Emotions (anxiety/stress) reduce gastric
  secretions and motility

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Small Intestine

• Location where food is chemically digested and
  most absorbed
• Enzymes break down carbohydrates, proteins, and
  fats
• Pancreatic buffers neutralize the stomach acid

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Small Intestine (continued)

• Microvilli enhance absorption
• Most of food, water, vitamins, and minerals are
  absorbed here into the blood or lymph

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Liver

• Digestive functions
• Metabolize carbohydrates, proteins, and fats
• Synthesize plasma proteins and enzymes
• Store blood, vitamins, and minerals
• Produce and secrete bile

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Pancreas

• Produces enzymes for digestion
• Secretion is controlled by the vagus nerve and
  the hormones secretin and cholecystokinin
• Lipase promotes fat breakdown and absorption
• Amylase digests starch

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Pancreas (continued)

• Trypsin, chymotrypsin, and carboxypeptidase
  digest protein
• Nucleases, which digest nucleic acids, are also
  present

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Large Intestine

• Major function eliminate indigestible food
• Absorbs water, salts, and vitamins forming it
  into feces or stool
• Feces move with peristalsis
• Goblet cells secrete mucus to aid with defecation
• Defecation reflex sigmoid colon walls contract
  and anal sphincter relaxes

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Nutrients

• Carbohydrates
• Proteins
• Fats
• Vitamins
• Minerals
• Water

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Carbohydrates

• Simple sugars
• Milk
• Sugar cane
• Sugar beets
• Honey fruits
• Complex starches
• Grains
• Legumes
• Root vegetables

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Proteins

• Complete proteins
• (all essential AA)
• Eggs
• Milk
• Milk products
• Meat
• Fish
• Poultry

• Plant proteins
• Legumes
• Nuts
• Grains
• Cereals
• Vegetables

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Additional Nutrients

• Fats
• Saturated fats
• Unsaturated fats
• Vitamins
• Minerals
• Water

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Assessment for Clients with GIComplaints
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Health History

• Current complaints, food intolerance
• Appetite, heartburn, nausea, vomiting
• Abdominal discomfort, diarrhea, constipation
• Weight changes
• Food allergies
• Pattern and amount of daily food intake

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Health History

• Teeth, mouth, ability to chew, swallow, dentures
• Change in stool frequency, amount, color, caliber
• Medications
• Chronic diseases
• Previous surgeries

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Physical Examination

• Overall health status
• Skin color, hair, nails
• Height and weight
• Inspect mouth, teeth, tongue
• Swallow

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Physical Examination

• Inspect abdomen, observe skin, peristalsis
• Auscultate bowel sounds
• Percuss the abdomen
• Palpate the abdomen

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Laboratory Tests

• Serum albumin and total protein
• Serologic H. pylori testing
• Stool specimen
• Liver function tests
• Pancreatic function tests

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Diagnostic Tests

• Gastric analysis
• Urea breath test
• Ambulatory pH monitoring
• Esophageal manometry
• Paracentesis

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Gastric Analysis

• Gastric analysis consists of a series of tests
  used to analyze the contents of the stomach. The
  complete series involves
• A- collecting residual gastric fluid from a
  fasting patient
• B- collecting basal secretions every 15 minutes
  for four hours
• C- intramuscular administration of a drug that
  stimulates gastric acid output
• D- collecting stomach secretions every 15 minutes
  for 90 minutes
• Instruct client to abstain from food, fluids,
  smoking, chewing gum, and some medications for 8
  to 12 hours before the test
• Insert NG tube and collect samples

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Urea Breath Test

• is a rapid diagnostic procedure used to identify
  infections by Helicobacter pylori, a spiral
  bacterium implicated in gastritis, gastric ulcer,
  and peptic ulcer disease. It is based upon the
  ability of H. pylori to convert urea to ammonia.
• Instruct client to abstain from food and fluids
  for 4 hours prior to the test
• Instruct client to abstain from antacids, bismuth
  sulfate, antibiotics, and Prilosec for 2 weeks
  prior to the test

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More Diagnostic Tests

• Ambulatory pH Monitor is a way for the doctor to
  see how much acid is backing up into the
  esophagus over a 24-hour period.The test
  involves placing a small catheter in the
  esophagus.  The catheter is connected to a small
  recording device called a Digitrapper.
• Instruct client how to care for the electrode and
  data recorder
• Esophageal Manometry is a test to assess motor
  function of the Upper Esophageal Sphincter (UES),
  Esophageal body and Lower Esophageal Sphincter
  (LES).
• Instruct client to abstain from food and fluids
  up to 8 hours prior to the test
• Assist with insertion of the tube
• Paracentesis is a medical procedure involving
  needle drainage of fluid from a body cavity, most
  commonly the peritoneal cavity in the abdomen.

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Diagnostic Imaging Procedures

• Ultrasonography
• Radiologic Studies

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Gastroesophageal Reflux Disease (GERD)

• 1. Definition
• a. Gastroesophageal reflux is the backward flow
  of gastric content into the esophagus.
• b. GERD common, affecting 15 20 of adults
• c. 10 persons experience daily heartburn and
  indigestion
• d. Because of location near other organs symptoms
  may mimic other illnesses including heart
  problems

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Gastroesophageal Reflux Disease (GERD)

• 2. Pathophysiology
• a. Gastroesophageal reflux results from transient
  relaxation or incompetence of lower esophageal
  sphincter, sphincter, or increased pressure
  within stomach
• b. Factors contributing to gastroesophageal
  reflux
• 1.Increased gastric volume (post meals)
• 2.Position pushing gastric contents close
  to gastroesophageal juncture (such as bending or
  lying down)
• 3.Increased gastric pressure (obesity or
  tight clothing)
• 4.Hiatal hernia

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Gastroesophageal Reflux Disease (GERD)

• c.Normally the peristalsis in esophagus and
  bicarbonate in salivary secretions neutralize any
  gastric juices (acidic) that contact the
  esophagus during sleep and with gastroesophageal
  reflux esophageal mucosa is damaged and inflamed
  prolonged exposure causes ulceration, friable
  mucosa, and bleeding untreated there is scarring
  and stricture
• 3. Manifestations
• a. Heartburn after meals, while bending over, or
  recumbent
• b. May have regurgitation of sour materials in
  mouth, pain with swallowing
• c. Atypical chest pain
• d. Sore throat with hoarseness
• e. Bronchospasm and laryngospasm

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Gastroesophageal Reflux Disease (GERD)

• 4. Complications
• a. Esophageal strictures, which can progress to
  dysphagia
• b. Barretts esophagus changes in cells lining
  esophagus with increased risk for esophageal
  cancer
• 5. Collaborative Care
• a. Diagnosis may be made from history of symptoms
  and risks
• b. Treatment includes
• 1.Life style changes
• 2.Diet modifications
• 3.Medications

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Gastroesophageal Reflux Disease (GERD)

• 6. Diagnostic Tests
• a. Barium swallow (evaluation of esophagus,
  stomach, small intestine)
• b. Upper endoscopy direct visualization
  biopsies may be done
• c. 24-hour ambulatory pH monitoring
• d. Esophageal manometry, which measure pressures
  of esophageal sphincter and peristalsis
• e. Esophageal motility studies

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Gastroesophageal Reflux Disease (GERD)

• 7. Medications
• a. Antacids for mild to moderate symptoms, e.g.
  Maalox, Mylanta, Gaviscon
• b. H2-receptor blockers decrease acid
  production given BID or more often, e.g.
  cimetidine, ranitidine, famotidine, nizatidine
• c. Proton-pump inhibitors reduce gastric
  secretions, promote healing of esophageal erosion
  and relieve symptoms, e.g. omeprazole (prilosec)
  lansoprazole (Prevacid) initially for 8 weeks or
  3 to 6 months
• d. Promotility agent enhances esophageal
  clearance and gastric emptying, e.g.
  metoclopramide (reglan)

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Gastroesophageal Reflux Disease

• 8. Dietary and Lifestyle Management
• a. Elimination of acid foods (tomatoes, spicy,
  citrus foods, coffee)
• b. Avoiding food which relax esophageal sphincter
  or delay gastric emptying (fatty foods,
  chocolate, peppermint, alcohol)
• c. Maintain ideal body weight
• d. Eat small meals and stay upright 2 hours post
  eating no eating 3 hours prior to going to bed
• e. Elevate head of bed on 6 8? blocks to
  decrease reflux
• f. No smoking
• g. Avoiding bending and wear loose fitting
  clothing

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Gastroesophageal Reflux Disease (GERD)

• 9. Surgery indicated for persons not improved by
  diet and life style changes
• a. Laparoscopic procedures to tighten lower
  esophageal sphincter
• b. Open surgical procedure Nissen
  fundoplication
• 10. Nursing Care
• a. Pain usually controlled by treatment
• b. Assist client to institute home plan

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Hiatal Hernia

• 1. Definition
• a. Part of stomach protrudes through the
  esophageal hiatus of the diaphragm into thoracic
  cavity
• b. Predisposing factors include
• Increased intra-abdominal pressure
• Increased age
• Trauma
• Congenital weakness
• Forced recumbent position

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Hiatal Hernia

• c. Most cases are asymptomatic incidence
  increases with age
• d. Sliding hiatal hernia gastroesophageal
  junction and fundus of stomach slide through the
  esophageal hiatus
• e. Paraesophageal hiatal hernia the
  gastroesophageal junction is in normal place but
  part of stomach herniates through esophageal
  hiatus hernia can become strangulated client
  may develop gastritis with bleeding

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Hiatal Hernia

• 2. Manifestations Similar to GERD
• 3. Diagnostic Tests
• a. Barium swallow
• b. Upper endoscopy
• 4. Treatment
• a. Similar to GERD diet and lifestyle changes,
  medications
• b. If medical treatment is not effective or
  hernia becomes incarcerated, then surgery
  usually Nissen fundoplication by thoracic or
  abdominal approach
• Anchoring the lower esophageal sphincter by
  wrapping a portion of the stomach around it to
  anchor it in place

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Impaired Esophageal Motility

• 1. Types
• a. Achalasia characterized by impaired
  peristalsis of smooth muscle of esophagus and
  impaired relaxation of lower esophageal sphincter
• b. Diffuse esophageal spasm nonperistaltic
  contraction of esophageal smooth muscle
• 2. Manifestations Dysphagia and/or chest pain
• 3. Treatment
• a. Endoscopically guided injection of botulinum
  toxin
• Denervates cholinergic nerves in the distal
  esophagus to stop spams
• b. Balloon dilation of lower esophageal sphincter
• May place stents to keep esophagus open

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Gastritis

• 1. Definition Inflammation of stomach lining
  from irritation of gastric mucosa (normally
  protected from gastric acid and enzymes by
  mucosal barrier)
• 2. Types
• a. Acute Gastritis
• 1.Disruption of mucosal barrier allowing
  hydrochloric acid and pepsin to have contact with
  gastric tissue leads to irritation,
  inflammation, superficial erosions
• 2.Gastric mucosa rapidly regenerates
  self-limiting disorder

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Gastritis

• 3. Causes of acute gastritis
• a. Irritants include aspirin and other NSAIDS,
  corticosteroids, alcohol, caffeine
• b. Ingestion of corrosive substances alkali or
  acid
• c. Effects from radiation therapy, certain
  chemotherapeutic agents
• 4. Erosive Gastritis form of acute which is
  stress-induced, complication of life-threatening
  condition (Curlings ulcer with burns) gastric
  mucosa becomes ischemic and tissue is then
  injured by acid of stomach
• 5. Manifestations
• a. Mild anorexia, mild epigastric discomfort,
  belching
• b. More severe abdominal pain, nausea, vomiting,
  hematemesis, melena
• c. Erosive not associated with pain bleeding
  occurs 2 or more days post stress event
• d. If perforation occurs, signs of peritonitis

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Gastritis

• 6. Treatment
• a. NPO status to rest GI tract for 6 12 hours,
  reintroduce clear liquids gradually and progress
  intravenous fluid and electrolytes if indicated
• b. Medications proton-pump inhibitor or
  H2-receptor blocker sucralfate (carafate) acts
  locally coats and protects gastric mucosa
• c. If gastritis from corrosive substance
  immediate dilution and removal of substance by
  gastric lavage (washing out stomach contents via
  nasogastric tube), no vomiting

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Chronic Gastritis

• 1. Progressive disorder beginning with
  superficial inflammation and leads to atrophy of
  gastric tissues
• 2. Type A autoimmune component and affecting
  persons of northern European descent loss of
  hydrochloric acid and pepsin secretion develops
  pernicious anemia
• Parietal cells normally secrete intrinsic factor
  needed for absorption of B12, when they are
  destroyed by gastritis pts develop pernicious
  anemia

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Chronic Gastritis

• 3. 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

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Chronic Gastritis

• 4. Manifestations
• a. Vague gastric distress, epigastric heaviness
  not relieved by antacids
• b. Fatigue associated with anemia symptoms
  associated with pernicious anemia paresthesias
• Lack of B12 affects nerve transmission
• 5. Treatment Type B eradicate H. pylori
  infection with combination therapy of two
  antibiotics (metronidazole (Flagyl) and
  clarithomycin or tetracycline) and protonpump
  inhibitor (Prevacid or Prilosec)

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Chronic Gastritis

• Collaborative Care
• a. Usually managed in community
• b. Teach food safety measures to prevent acute
  gastritis from food contaminated with bacteria
• c. Management of acute gastritis with NPO state
  and then gradual reintroduction of fluids with
  electrolytes and glucose and advance to solid
  foods
• d. Teaching regarding use of prescribed
  medications, smoking cessation, treatment of
  alcohol abuse

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Chronic Gastritis

• Diagnostic Tests
• a. Gastric analysis assess hydrochloric acid
  secretion (less with chronic gastritis)
• b. Hemoglobin, hematocrit, red blood cell
  indices anemia including pernicious or iron
  deficiency
• c. Serum vitamin B12 levels determine pernicious
  anemia
• d. Upper endoscopy visualize mucosa, identify
  areas of bleeding, obtain biopsies may treat
  areas of bleeding with electro or laser
  coagulation or sclerosing agent
• 5. Nursing Diagnoses
• a. Deficient Fluid Volume
• b. Imbalanced Nutrition Less than body
  requirements

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Peptic Ulcer Disease
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Definition

• A circumscribed ulceration of the
  gastrointestinal mucosa occurring in areas
  exposed to acid and pepsin and most often caused
  by Helicobacter pylori infection.
• (Uphold Graham, 2003)

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Peptic Ulcer Disease (PUD)

• Definition and Risk factors
• a. Break in mucous lining of GI tract comes into
  contact with gastric juice affects 10 of US
  population
• b. Duodenal ulcers most common affect mostly
  males ages 30 55 ulcers found near pyloris
• c. Gastric ulcers affect older persons (ages 55
  70) found on lesser curvature and associated
  with increased incidence of gastric cancer
• d. Common in smokers, users of NSAIDS familial
  pattern, ASA, alcohol, cigarettes

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Peptic Ulcer Disease (PUD)

• 2. Pathophysiology
• a. Ulcers or breaks in mucosa of GI tract occur
  with
• 1.H. pylori infection (spread by oral to oral,
  fecal-oral routes) damages gastric epithelial
  cells reducing effectiveness of gastric mucus
• 2.Use of NSAIDS interrupts prostaglandin
  synthesis which maintains mucous barrier of
  gastric mucosa
• b. Chronic with spontaneous remissions and
  exacerbations associated with trauma, infection,
  physical or psychological stress

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Peptic Ulcers Gastric Dudodenal
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Peptic Ulcer Disease

• Ulcer development
• Lower esophagus
• Stomach
• Duodenum
• 10 of men, 4 of women

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Compare and Contrast the symptoms of Duodenal and
Gastric Ulcers

• Duodenal

• Gastric

• Burning upper abd, pain 1-3 hrs after meals
• Worse pain when stomach empty
• Bleeding occurs with deep erosion
• Hematemesis
• Melena

• Relieved by food but pain may persist even after
  eating
• Anorexia, wt loss, vomiting
• Infrequent or absent remissions
• Small become cancerous
• Severe ulcers may erode through stomach wall

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Subjective Data

• Paingnawing, aching, or burning
• Duodenal ulcers occurs 1-3 hours after a meal
  and may awaken patient from sleep. Pain is
  relieved by food, antacids, or vomiting.
• Gastric ulcers food may exacerbate the pain
  while vomiting relieves it.
• Nausea, vomiting, belching, dyspepsia, bloating,
  chest discomfort, anorexia, hematemesis, /or
  melena may also occur.
• nausea, vomiting, weight loss more common with
  Gastric ulcers

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Objective Data

• Epigastric tenderness
• Guaic-positive stool resulting from occult blood
  loss

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Diagnostic Plan

• Stool for fecal occult blood
• Labs CBC (R/O bleeding), liver function test,
  amylase, and lipase.
• H. Pylori can be diagnosed by urea breath test,
  blood test, stool antigen assays, rapid urease
  test on a biopsy sample.
• Upper GI Endoscopy Any pt gt50 yo with new onset
  of symptoms or those with alarm markings
  including anemia, weight loss, or GI bleeding.
• Preferred diagnostic test b/c its highly
  sensitive for dx of ulcers and allows for biopsy
  to rule out malignancy and rapid urease tests for
  testing for H. Pylori.

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Peptic Ulcer Disease

• Treatment
• Rest and stress reduction
• Nutritional management
• Pharmacological management
• Antacids (Mylanta)
• Neutralizes acids
• Proton pump inhibitors (Prilosec, Prevacid)
• Block gastric acid secretion

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Peptic Ulcer Disease

• Pharmacological management
• 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 (PCN, Amoxicillin, Ampicillin)
• Treat H. Pylori infection

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Peptic Ulcer Disease

• NG suction
• 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

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Peptic Ulcer DiseaseSurgical Therapy
B. Billroth II Procedure
A. Billroth I Procedure
Fig. 40-16
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Billroth I
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Billroth II
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Peptic Ulcer Disease (PUD)

• 4. Complications
• a. Hemorrhage frequent in older adult
  hematemesis, melena, hematochezia (blood in
  stool) weakness, fatigue, dizziness, orthostatic
  hypotension and anemia with significant bleed
  loss may develop hypovolemic shock
• b. Obstruction gastric outlet (pyloric
  sphincter) obstruction edema surrounding ulcer
  blocks GI tract from muscle spasm or scar tissue
• 1.Gradual process
• 2.Symptoms feelings of epigastric fullness,
  nausea, worsened ulcer symptoms

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Peptic Ulcer Disease

• c. 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
• 1.Time of ulceration severe upper abdominal
  pain radiating throughout abdomen and possibly to
  shoulder
• 2.Abdomen becomes rigid, boardlike with absent
  bowel sounds symptoms of shock
• 3.Older adults may present with mental
  confusion and non-specific symptoms

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Peptic Ulcer DiseaseNursing Management

• Overall Goals
• Comply with prescribed therapeutic regimen
• Experience a reduction or absence of discomfort
  related to peptic ulcer disease

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Peptic Ulcer DiseaseNursing Management

• Overall Goals (cont.)
• Exhibits no signs of GI complications
• Have complete healing
• Lifestyle changes to prevent recurrence

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Peptic Ulcer DiseaseNursing Implementation

• Health Promotion
• Identify patients at risk
• Early detection and ? morbidity
• Encourage patients to take ulcerogenic drugs with
  food or milk
• Teach patients to report symptoms related to
  gastric irritation to health care provider

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Peptic Ulcer DiseaseNursing Implementation

• Acute Intervention
• Patient generally complains of ? pain, nausea,
  vomiting, and some bleeding
• May be maintained on NPO status for a few days,
  have NG tube inserted, fluids replaced
  intravenously
• Physical and emotional rest are conducive to
  ulcer healing

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Peptic Ulcer DiseaseNursing Implementation

• Hemorrhage
• Changes in vital signs, ? in amount and redness
  of aspirate signal massive upper GI bleeding
• ? amount of blood in gastric contents ? pain
  because blood helps neutralize acidic gastric
  contents
• Keep blood clots from obstructing NG tube

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Peptic Ulcer DiseaseNursing Implementation

• Perforation
• Sudden, severe abdominal pain unrelated in
  intensity and location to pain that brought
  patient to hospital

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Peptic Ulcer DiseaseNursing Implementation

• Perforation (cont.)
• Indicated by a rigid, boardlike abdomen
• Severe generalized abdominal and shoulder pain
• Shallow, grunting respirations

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Peptic Ulcer DiseaseNursing Implementation

• Perforation (cont.)
• Ensure any known allergies are reported on chart
• Antibiotic therapy is usually started
• Surgical closure may be necessary if perforation
  does not heal spontaneously

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Irritable Bowel Syndrome (IBS) (spastic bowel,
functional colitis)

• Definition
• a. Functional GI tract disorder without
  identifiable cause characterized by abdominal
  pain and constipation, diarrhea, or both
• b. Affects up to 20 of persons in Western
  civilization more common in females

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Irritable Bowel Syndrome (IBS) (spastic bowel,
functional colitis)

• Pathophysiology
• a. Appears there is altered CNS regulation of
  motor and sensory functions of bowel
• 1.Increased bowel activity in response to food
  intake, hormones, stress
• 2.Increased sensations of chyme movement
  through gut
• 3.Hypersecretion of colonic mucus
• b. Lower visceral pain threshold causing
  abdominal pain and bloating with normal levels of
  gas
• c. Some linkage of depression and anxiety

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Irritable Bowel Syndrome (IBS) (spastic bowel,
functional colitis)

• Manifestations
• a. Abdominal pain relieved by defecation may be
  colicky, occurring in spasms, dull or continuous
• b. Altered bowel habits including frequency, hard
  or watery stool, straining or urgency with
  stooling, incomplete evacuation, passage of
  mucus abdominal bloating, excess gas
• c. Nausea, vomiting, anorexia, fatigue, headache,
  anxiety
• d. Tenderness over sigmoid colon upon palpation
• 4. Collaborative Care
• a. Management of distressing symptoms
• b. Elimination of precipitating factors, stress
  reduction

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Irritable Bowel Syndrome (IBS) (spastic bowel,
functional colitis)

• 5. Diagnostic Tests to find a cause for clients
  abdominal pain, changes in feces elimination
• a. Stool examination for occult blood, ova and
  parasites, culture
• b. CBC with differential, Erythrocyte
  Sedimentation Rate (ESR) to determine if anemia,
  bacterial infection, or inflammatory process
• c. Sigmoidoscopy or colonoscopy
• 1.Visualize bowel mucosa, measure intraluminal
  pressures, obtain biopsies if indicated
• 2.Findings with IBS normal appearance
  increased mucus, intraluminal pressures, marked
  spasms, possible hyperemia without lesions
• d. Small bowel series (Upper GI series with small
  bowel-follow through) and barium enema
  examination of entire GI tract IBS increased
  motility

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Irritable Bowel Syndrome (IBS) (spastic bowel,
functional colitis)

• Medications
• a. Purpose to manage symptoms
• b. Bulk-forming laxatives reduce bowel spasm,
  normalize bowel movement in number and form
• c. Anticholinergic drugs (dicyclomine (Bentyl),
  hyoscyamine) to inhibit bowel motility and
  prevent spasms given before meals
• d. Antidiarrheal medications (loperamide
  (Imodium), diphenoxylate (Lomotil) prevent
  diarrhea prophylactically
• e. Antidepressant medications
• f. Research medications altering serotonin
  receptors in GI tract to stimulate peristalsis of
  the GI tract

104
Irritable Bowel Syndrome (IBS) (spastic bowel,
functional colitis)

• Dietary Management
• a. Often benefit from additional dietary fiber
  adds bulk and water content to stool reducing
  diarrhea and constipation
• b. Some benefit from elimination of lactose,
  fructose, sorbitol
• c. Limiting intake of gas-forming foods,
  caffeinated beverages
• 8. Nursing Care
• a. Contact in health environments outside acute
  care
• b. Home care focus on improving symptoms with
  changes of diet, stress management, medications
  seek medical attention if serious changes occur

105
Peritonitis

• Definition
• a. Inflammation of peritoneum, lining that covers
  wall (parietal peritoneum) and organs (visceral
  peritoneum) of abdominal cavity
• b. Enteric bacteria enter the peritoneal cavity
  through a break of intact GI tract (e.g.
  perforated ulcer, ruptured appendix)

106
Peritonitis

• Causes include
• Ruptured appendix
• Perforated bowel secondary to PUD
• Diverticulitis
• Gangrenous gall bladder
• Ulcerative colitis
• Trauma
• Peritoneal dialysis

107
Peritonitis

• Pathophysiology
• a. Peritonitis results from contamination of
  normal sterile peritoneal cavity with infections
  or chemical irritant
• b. Release of bile or gastric juices initially
  causes chemical peritonitis infection occurs
  when bacteria enter the space
• c. Bacterial peritonitis usually caused by these
  bacteria (normal bowel flora) Escherichia coli,
  Klebsiella, Proteus, Pseudomonas
• d. Inflammatory process causes fluid shift into
  peritoneal space (third spacing) leading to
  hypovolemia, then septicemia

108
Peritonitis

• 3. Manifestations
• a. Depends on severity and extent of infection,
  age and health of client
• b. Presents with acute abdomen
• 1.Abrupt onset of diffuse, severe abdominal
  pain
• 2.Pain may localize near site of infection (may
  have rebound tenderness)
• 3.Intensifies with movement
• c. Entire abdomen is tender with boardlike
  guarding or rigidity of abdominal muscle

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Peritonitis

• d. Decreased peristalsis leading to paralytic
  ileus bowel sounds are diminished or absent with
  progressive abdominal distention pooling of GI
  secretions lead to nausea and vomiting
• e. Systemically fever, malaise, tachycardia and
  tachypnea, restlessness, disorientation, oliguria
  with dehydration and shock
• f. Older or immunosuppressed client may have
• 1.Few of classic signs
• 2.Increased confusion and restlessness
• 3.Decreased urinary output
• 4.Vague abdominal complaints
• 5.At risk for delayed diagnosis and higher
  mortality rates

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Peritonitis

• 4. Complications
• a. May be life-threatening mortality rate
  overall 40
• b. Abscess
• c. Fibrous adhesions
• d. Septicemia, septic shock fluid loss into
  abdominal cavity leads to hypovolemic shock
• 5. Collaborative Care
• a. Diagnosis and identifying and treating cause
• b. Prevention of complications

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Peritonitis

• 6. Diagnostic Tests
• a. WBC with differential elevated WBC to
  20,000 shift to left
• b. Blood cultures identify bacteria in blood
• c. Liver and renal function studies, serum
  electrolytes evaluate effects of peritonitis
• d. Abdominal xrays detect intestinal
  distension, air-fluid levels, free air under
  diaphragm (sign of GI perforation)
• e. Diagnostic paracentesis
• 7. Medications
• a. Antibiotics
• 1.Broad-spectrum before definitive culture
  results identifying specific organism(s) causing
  infection
• 2.Specific antibiotic(s) treating causative
  pathogens
• b. Analgesics

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Peritonitis

• 8. Surgery
• a. Laparotomy to treat cause (close perforation,
  removed inflamed tissue)
• b. Peritoneal Lavage washing out peritoneal
  cavity with copious amounts of warm isotonic
  fluid during surgery to dilute residual bacterial
  and remove gross contaminants
• c. Often have drain in place and/or incision left
  unsutured to continue drainage

113
Peritonitis

• 9. Treatment
• a. Intravenous fluids and electrolytes to
  maintain vascular volume and electrolyte balance
• b. Bed rest in Fowlers position to localize
  infection and promote lung ventilation
• c. Intestinal decompression with nasogastric tube
  or intestinal tube connected to suction
• 1. Relieves abdominal distension secondary to
  paralytic ileus
• 2. NPO with intravenous fluids while having
  nasogastric suction

114
Peritonitis

• 10. Nursing Diagnoses
• a. Pain
• b. Deficient Fluid Volume often on hourly
  output nasogastric drainage is considered when
  ordering intravenous fluids
• c. Ineffective Protection
• d. Anxiety
• 11. Home Care
• a. Client may have prolonged hospitalization
• b. Home care often includes
• 1. Wound care
• 2. Home health referral
• 3. Home intravenous antibiotics

115
Client with Inflammatory Bowel Disease

• Definition
• a. Includes 2 separate but closely related
  conditions ulcerative colitis and Crohns
  disease both have similar geographic
  distribution and genetic component
• b. Etiology is unknown but runs in families may
  be related to infectious agent and altered immune
  responses
• c. Peak incidence occurs between the ages of 15
  35 second peak 60 80
• d. Chronic disease with recurrent exacerbations

116
Inflammatory Bowel Disease
117
Ulcerative Colitis

• Pathophysiology
• 1. Inflammatory process usually confined to
  rectum and sigmoid colon
• 2. Inflammation leads to mucosal hemorrhages and
  abscess formation, which leads to necrosis and
  sloughing of bowel mucosa
• 3. Mucosa becomes red, friable, and ulcerated
  bleeding is common
• 4. Chronic inflammation leads to atrophy,
  narrowing, and shortening of colon

118
Ulcerative Colitis

• Manifestations
• 1. Diarrhea with stool containing blood and
  mucus 10 20 bloody stools per day leading to
  anemia, hypovolemia, malnutrition
• 2. Fecal urgency, tenesmus, LLQ cramping
• 3. Fatigue, anorexia, weakness

119
Ulcerative Colitis

• Complications
• 1. Hemorrhage can be massive with severe attacks
• 2. Toxic megacolon usually involves transverse
  colon which dilates and lacks peristalsis
  (manifestations fever, tachycardia, hypotension,
  dehydration, change in stools, abdominal
  cramping)
• 3. Colon perforation rare but leads to
  peritonitis and 15 mortality rate
• 4. Increased risk for colorectal cancer (20 30
  times) need yearly colonoscopies
• 5. Abcess, fistula formation
• 6. Bowel obstruction
• 7. Extraintestinal complications
• Arthritis
• Ocular disorders
• Cholelithiasis

120
Ulcerative Colitis

• Diet therapy
• Goal to prevent hyperactive bowel activity
• Severe symptoms
• NPO
• TPN
• Less severe
• Vivonex
• Elemental formula absorbed in the upper bowel
• Decreases bowel stimulation

121
Ulcerative Colitis

• Diet therapy
• Significant symptoms
• Low fiber diet
• Reduce or eliminate lactose containing foods
• Avoid caffeinated beverages, pepper, alcohol,
  smoking

122
Ulcerative Colitis

• Ostomy
• 1. Surgically created opening between intestine
  and abdominal wall that allows passage of fecal
  material
• 2. Stoma is the surface opening which has an
  appliance applied to retain stool and is emptied
  at intervals
• 3. Name of ostomy depends on location of stoma
• 4. Ileostomy opening in ileum may be permanent
  with total proctocolectomy or temporary (loop
  ileostomy)
• 5. Ileostomies always have liquid stool which
  can be corrosive to skin since contains digestive
  enzymes
• 6. Continent (or Kocks) ileostomy has
  intra-abdominal reservoir with nipple valve
  formation to allow catheter insertion to drain
  out stool

123
Ulcerative Colitis

• Surgical Management
• 25 of patients require a colectomy
• Total proctocolectomy with a permanent ileostomy
• Colon, rectum, anus removed
• Closure of anus
• Stoma in right lower quadrant
• In selected patients an ileoanal anastamosis or
  ileal reservoir to preserve the anal sphincter
• J-shaped pouch is created internally from the end
  of the ileum to collect fecal material
• Pouch is then connected to the distal rectum

124
Proctocolectomy
125
Ulcerative Colitis

• Surgical management
• Total colectomy with a continent ileostomy
• Kocks ileostomy
• Intra-abdominal pouch where stool is stored
  untile client drains it with a catheter

126
Kocks pouch
127
Ulcerative Colitis

• Surgical management
• Total colectomy with ileoanal anastamosis
• Ileoanal reservoir or J pouch
• Removes colon and rectum and sutrues ileum into
  the anal canal

128
Ulcerative Colitis

• Home Care
• a. Inflammatory bowel disease is chronic and
  day-to-day care lies with client
• b. Teaching to control symptoms, adequate
  nutrition, if client has ostomy care and
  resources for supplies, support group and home
  care referral

129
Ulcerative Colitis

• Treatment
• Medications similar to treatment for Crohns
  disease

130
Ulcerative Colitis

• Nursing Care Focus is effective management of
  disease with avoidance of complications
• Nursing Diagnoses
• a. Diarrhea
• b. Disturbed Body Image diarrhea may control all
  aspects of life client has surgery with ostomy
• c. Imbalanced Nutrition Less than body
  requirement
• d. Risk for Impaired Tissue Integrity
  Malnutrition and healing post surgery
• e. Risk for sexual dysfunction, related to
  diarrhea or ostomy

131
Crohns Disease (regional enteritis)

• Pathophysiology
• 1. Can affect any portion of GI tract, but
  terminal ileum and ascending colon are more
  commonly involved
• 2. Inflammatory aphthoid lesion (shallow
  ulceration) of mucosa and submuscosa develops
  into ulcers and fissures that involve entire
  bowel wall
• 3. Fibrotic changes occur leading to local
  obstruction, abscess formation and fistula
  formation
• 4. Fistulas develop between loops of bowel
  (enteroenteric fistulas) bowel and bladder
  (enterovesical fistulas) bowel and skin
  (enterocutaneous fistulas)
• 5. Absorption problem develops leading to protein
  loss and anemia

132
Crohns disease
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134
Crohns Disease (regional enteritis)

• Manifestations
• 1. Often continuous or episodic diarrhea liquid
  or semi-formed abdominal pain and tenderness in
  RLQ relieved by defecation
• 2. Fever, fatigue, malaise, weight loss, anemia
• 3. Fissures, fistulas, abscesses

135
Crohns Disease (regional enteritis)

• Complications
• 1. Intestinal obstruction caused by repeated
  inflammation and scarring causing fibrosis and
  stricture
• 2. Fistulas lead to abscess formation recurrent
  urinary tract infection if bladder involved
• 3. Perforation of bowel may occur with
  peritonitis
• 4. Massive hemorrhage
• 5. Increased risk of bowel cancer (5 6 times)

136
Crohns Disease (regional enteritis)

• Collaborative Care
• a. Establish diagnosis
• b. Supportive treatment
• c. Many clients need surgery
• Diagnostic Tests
• a. Colonoscopy, sigmoidoscopy determine area
  and pattern of involvement, tissue biopsies
  small risk of perforation
• b. Upper GI series with small bowel
  follow-through, barium enema
• c. Stool examination and stool cultures to rule
  out infections
• d. CBC shows anemia, leukocytosis from
  inflammation and abscess formation
• e. Serum albumin, folic acid lower due to
  malabsorption

137
Crohns Disease (regional enteritis)

• Medications goal is to stop acute attacks
  quickly and reduce incidence of relapse
• a. Sulfasalazine (Azulfidine) salicylate
  compound that inhibits prostaglandin production
  to reduce inflammation
• b. Corticosteroids reduce inflammation and
  induce remission with ulcerative colitis may be
  given as enema intravenous steroids are given
  with severe exacerbations
• c. Immunosuppressive agents (azathioprine
  (Imuran), cyclosporine) for clients who do not
  respond to steroid therapy alone
• Used in combination with steroid treatment and
  may help decrease the amount of steroid use

138
Crohns Disease

• d. New therapies including immune response
  modifiers, anti-inflammatory cyctokines
• e. Metronidazole (Flagyl) or Ciprofloxacin
  (Cipro)
• For the fistulas that develop
• f. Anti-diarrheal medications

139
Crohns Disease (regional enteritis)

• Dietary Management
• a. Individualized according to client eliminate
  irritating foods
• b. Dietary fiber contraindicated if client has
  strictures
• c. With acute exacerbations, client may be made
  NPO and given enteral or total parenteral
  nutrition (TPN)
• Surgery performed when necessitated by
  complications or failure of other measures
• removal of diseased portion of the bowel

140
Crohns Disease

• a. Crohns disease
• 1. Bowel obstruction leading cause may have
  bowel resection and repair for obstruction,
  perforation, fistula, abscess
• 2. Disease process tends to recur in area
  remaining after resection