preparation and care of diagnostic procedure gastrointestinal disorder

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Topic 2 Preparation and care client for
diagnostic procedure
Prepared by Noor Mariana Sharif, RN Victoria
international college
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Learning objective

• At the end of the course, the student be able to
• Identify the appropriate diagnostic procedure to
  determining the status of GIT
• Describe the indication each diagnostic
  procedure determining the status of GIT
• Explain health information and procedure teaching
  to patients and significant others.
• Describe preparation needed before, during and
  after procedure
• Identify abnormal finding that may indicate
  impaired in GIT function.
• Explain instruction about post procedure care and
  activity restrictions.

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• Oral Gastroduodenoscopy (Esophagogastroduodenoscop
  y) / OGDS
• Rectal Examination
• Sigmoidoscopy, Colonoscopy And Biopsy
• Abdominal paracentasis
• Barium Meal And Barium Enema
• Endoscopic Retrograde Cholangio-Pancreatography
• Ultrasound
• Oesophageal Ballon Tamponade
• Cholecystography
• Choleangiogram
• Ultra sonography
• Computed tomography (CT scan)
• Liver Biopsy
• Fractional test meal

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EsophagogastroduodenoscopyDefinition

• OGDS/ endoscopies/gastroscopy
• (OGDS) is a procedure during which a small
  flexible endoscope is introduced through the
  mouth (or with smaller caliber endoscopes,
  through the nose) and advanced through the
  pharynx, esophagus, stomach, and duodenum
• It considered a minimally invasive procedure.

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Indication

• Diagnostic evaluation for signs or symptoms
  suggestive of upper GI disease (eg, dyspepsia,
  dysphagia, noncardiac chest pain, recurrent
  emesis)
• Investigation for upper GI cancer in high-risk
  settings (eg, Barrett esophagus)

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Indication

• Biopsy for known or suggested upper GI disease
  (eg, malabsorption syndromes, neoplasms,
  infections)
• Therapeutic intervention (eg, retrieval of
  foreign bodies, control of hemorrhage, dilatation
  or stenting of stricture, ablation(removal) of
  neoplasms, gastrostomy placement)

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Contraindication

• Possible perforation, medically unstable
  patients, or unwilling patients.
• Relative contraindications include
  anticoagulation, pharyngeal diverticulum, or head
  and neck surgery.

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Complication

• Aspiration pneumonia
• Bleeding
• Perforation
• Cardiopulmonary problem

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Equipment

• Endoscope
• Stack - light source
• - insufflators
• - suction
• Instruments - biopsy forceps
• - snares
• - injecting needles

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Before procedure

• Keep patient NBM (nil by mouth)
• Obtain consent from the patient (risk for
  bleeding and perforation)
• Take blood for investigation - complete blood
  cell count, blood cross matching, coagulation
  studies, BUSE, electrocardiogram, and chest
  radiographs.
• Take vital sign for baseline

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During procedure

• Placed patient in the left lateral position.
• Administer topical and/or intravenous sedation to
  minimize gagging and to facilitate the procedure.
• Place a bite block (mouth guard) to prevent
  damage to the endoscope and to ease its passage
  through the mouth.

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• Under direct vision, the endoscope will passed
  through the pharynx, esophagus, stomach and
  duodenum.
• Liquid and particulate matter can be aspirated
  through the suction channel.
• The procedure and findings will be documented
  with pictures or a video system. Biopsy specimens
  can be obtained by passing forceps and taking
  small mucosal samples for histology studies.
• The procedure may last _at_ 5-30 minutes

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After procedure

• Close monitoring of vital sign for 1 2 hours,
  or until the sedative or analgesia has worn off.
• Keep patient nil by mouth until the local
  anesthetic has worn off (in the throat) and the
  gag reflex has returned (after two to four hours)
• Patient may complaint of hoarseness and a mild
  sore throat - drink cool fluids or gargle to
  relieve the soreness

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Rectal examination
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Definition

• Rectal examination consists of visual inspection
  of the perianal skin, digital palpation of the
  rectum, and assessment of neuromuscular function
  of the perineum.

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Indication

• May be used to diagnosed
• Rectal tumors
• Prostatic disorders and benign prostatic
  hyperplasia
• Appendicitis
• Piles
• Anyabnormalities

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• Indication
• for the estimation of the tonicity of the anal
  sphincter
• in females, for gynecological palpations of
  internal organs
• for examination of the hardness and color of the
  feces (eg. in cases of constipation, and fecal
  impaction)
• prior to a colonoscopy or proctoscopy.
• to evaluate hemorrhoids
• In newborns to exclude imperforate anus

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Before the procedure

• Provide privacy (is a very embarrassing
  examination)
• Advice patient to take a deep breath during the
  actual insertion of the finger into the rectum.

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During the procedure

• Put patient in left lateral position with the
  buttocks near the edge of the bedside. Keep the
  right knee and hip in slight flexion.

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During the procedure

• Put patient in well lit room, with total privacy.
• A chaperon is needed if the patient is female
• Using a gloved hand, the examiner inspects the
  buttocks for fistulous tracts, the skin tags of
  hemorrhoids, excoriations, blood, and rectal
  prolapsed.
• Next, using a generous amount of lubrication, the
  gloved index finger is inserted gently into the
  rectum.

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Sigmoidoscopy, Colonoscopy And Biopsy

• Definitions
• Colonoscopy is the endoscopic examination of the
  colon and the distal part of the small bowel
• Sigmoidoscopy is the medical examination of the
  large intestine from the rectum up to the sigmoid
• A biopsy is a removal of tissue to determine the
  presence or extent of a disease.

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Indication

• COLONOSCOPY
• Rectal bleeding
• Iron deficiency anaemia
• Cancer follow-up
• Polyp follow-up
• Abdominal pain
• Abnormal bowel habit

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• SIGMOIDOSCOPY
• Symptoms that suggest anorectal pathology,
  including colorectal neoplasia
• Prior to anorectal procedures
• To obtain biopsy of any bowel condition
• To assess the true height (distance from anal
  verge) of rectal cancers
• Conservative treatment of sigmoid volvulus
• During anterior resection of rectum to gauge the
  lower resection margin

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Before procedure

• Stop
• Aspirin and drugs for arthritis (ibuprofen,
  naproxen, etc.) A week before the procedure to
  prevent intestinal bleeding
• Iron pills, because it may cause constipation
  difficult for colon cleansing
• Barium swallow or enema, because barium can cover
  intestinal mucosa thus hiding it from doctors
  view 
• Anticoagulants to prevent risk of bleeding
• Insulin should not be taken during fasting

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• Bowel preparation
• Low residue diet 2-3 days pre operatively
• Administration of glycol-electrolyte solution
• (Go-LYTELY) x 2 bottles / Foltran / fleet
  solution _at_ 1 day pre op (evening).
• Clear fluids only after administration of
  Go-LYTELY
• Bowel washout _at_ morning of operation day (if
  necessary)

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During procedure

• Lie on left lateral
• Sedation will be given if necessary
• Doctor will administer the colonoscope through
  your anus into the colon and advance it toward
  the end of the colon.
• If necessary, doctor will perform a biopsy, stop
  the bleeding or remove the polyp.
• Investigation lasts about 30-45 minutes

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After procedure

• Rest for 1 2 hours
• Patient may experience some cramping or bloating
  (due to inflated air during the procedure) for
  the next day or 1-2 days
• Biopsy results will be ready in a week

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• Definition
• Abdominal paracentesis is a bed side clinical
  procedure in which needle is inserted into
  peritoneal cavity nd ascitic fluid is removed.
• TYPES-
• 1)diagnostic small quantity of fluid is removed
  for testing.
• 2) therapeuticgt5 litres of fluid is removed to
  reduce intraabdominal pressure and relieve the
  asso. Symptms like dyspnoea, abdominal pain

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Indication

• For evaluation of new onset ascites.
• Testing of ascitic fluid.
• For evaluation of pt with ascitis who has signs
  of clinical deterioration like fever,abd.pain,hepa
  tic encephalopathy,decreased renal function n
  metabolic acidosis.
• Paracentesis can identify unexpected diagnosis
  such as chylous, hemorrhagic or eosinophilia
  ascites useful to know etiology n antibiotic
  susceptibility.

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Patient preparation

• Explain the procedure Obtain Consent
• No fasting before Procedure
• EQUIPMENT STAFF
• Clinician Assistant
• Bottles should be labelled for tests prior doing
  paracentesis
• Bacterial culture is done in pts

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Choice of needle

• DIAGNOSTIC 1.5 Inch, 22 Gauge needle
• For Obese 3.5 Inch, 22 Gauge spinal needle
• THERAPEUTIC 15/ 16 Gauge needle to speed up the
  removal.
• KIMBERLY CLARK QUICK TAP PARACENTESIS TRAY
  CONTAINS CADWELL NEEDLE which has a sharp inner
  trocar blunt outer metal cannula with side
  holes to permit withdrawal of fluid if end hole
  is occluded by bowel/ Omentum

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Position

• Mostly Supine
• Head may be elevated
• Knee elbow position for removal of minimal fluid
  in dependent area

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Why left ????

• Abd. Wall is thinner.
• Pool of fluid is more.
• Pt can be rolled easily to left for drainage.
• WHY NOT RIGHT???
• Appedicectomy scar, caecum filled with gas in pts
  taking lactulose.
• Care must be taken not to injure inferior
  epigastic artery which bleeds massively which
  is located near pubic tubercle

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• Sterilise with Iodine or Chlorhexidine
• LA 1 Lignocaine
• It is removal of gt5 lit of fluid.
• In refractory ascites, removal of as much fluid
  as possible with sod.restricted diet n diuretics
  will extend the interval to next paracentesis.
• REMOVAL OF NEEDLE
• Needle is removed with one rapid smooth
  withdrawal motion.
• Distract the pt by asking him to cough bcoz cough
  will prevent pain sensation.

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Complication

• Ascitic fluid leak
• -improper Z track
• -using large bore needle
• -large skin nick
• Rx keep ostomy bag over nick.
• Bleeding
• -artery or vein
• In inferior epigastric bleed fig. of 8 suture is
  placed surrounding the needle site. Rarely
  laprotomy is needed to control bleeding in pts
  with renal failure n hyperfibrinolysis.
• Bowel perforation
• Infections
• Catheter residue broken into adbominal.wall.

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BARIUM MEAL / BARIUM ENEMA DEFINITION

• A barium meal is a procedure in which radiographs
  of the esophagus, stomach and duodenum are taken
  after barium sulfate is ingested by a patient.
• A barium enema is a procedure in which
  radiographs of the colon are taken after barium
  sulfate is infused into the colon

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INDICATION OF BARIUM MEAL

• Dysphagia
• Assessment of perforated region
• Esophageal reflux
• Carcinoma of esophagus

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INDICATION OF BARIUM ENEMA

• Changes in bowel habit
• Colitis
• Pain
• Ulcerative colitis
• Mass
• Diverticulam
• Neoplasm
• Volvulus

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BEFORE THE PROCEDURE

• Bowel preparation (as in sigmoidoscopy)

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DURING THE PROCEDURE

• Lie on the x-ray table and preliminary x-ray is
  taken. Bowel preparation (as in sigmoidoscopy)
• The doctor will gently insert a well-lubricant
  tube into the rectum.
• The tube is connected to a bag that contains the
  barium. The barium flows into the colon.
• The doctor will monitors the flow of the barium
  on an x-ray fluroscope screen
• Client will need to move into different position
  and the table slightly tipped to get different
  views.

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AFTER THE PROCEDURE

• Give bedpan or help client to toilet, so can
  empty bowels and remove as much of the barium as
  possible.
• Advise patient to drink plenty of fluids for the
  next 24 hours to avoid constipation (Barium is a
  dense substance, which may not be completely
  cleared from toilet by normal flushing. It may be
  necessary to use a toilet brush, or to flush more
  than once to clear any residue from the toilet.

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Endoscopic Retrograde Cholangio-pancreatography
DEFINITION

• Endoscopic retrograde cholangiopancreatography
  (ERCP) is a technique that combines the use of
  endoscopy and fluoroscopy to diagnose and treat
  certain problems of the biliary or pancreatic
  ductal systems

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INDICATION

• Gallstones
• Blockage of the bile duct
• Jaundice
• Undiagnosed upper-abdominal pain
• Cancer of the bile ducts or pancreas
• Pancreatitis

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BEFORE THE PROCEDURE

• Nil by mouth for 8 hours before procedure
• Inform doctor if known allergy to any drug / food
  
• Stop anticoagulant 1 week prior to procedure
• Remove the eyeglasses and dentures.
• Obtain the consent

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PROCEDURE

• Put patient in left lateral
• The throat is anesthetized with a spray or
  solution, and the patient is usually mildly
  sedated.
• The endoscope is then gently inserted into the
  upper esophagus to the main bile duct entering
  the duodenum.
• Dye is then injected into this bile duct and/or
  the pancreatic duct and x-ray films are taken

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PROCEDURE

• If a gallstone is found, steps may be taken to
  remove it.
• If the duct has become narrowed, an incision can
  be made using electrocautery to relieve the
  blockage / placement of stents
• The procedure takes from 20 to 40 minutes

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AFTER THE PROCEDURE

• Close monitoring for 1-2 hours
• Do not drive or operate machinery for at least
  eight hours.

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Ultrasound / SONOGRAPHYDefinition

• Also called ultrasound scanning or sonography,
  involves exposing part of the body to
  high-frequency sound waves to produce pictures of
  the inside of the body.
• Imaging is a noninvasive medical test that helps
  physicians diagnose and treat medical conditions.

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Indication

• Is a useful way of examining many of the body's
  internal organs e.g.
• heart and blood vessels, including the abdominal
  aorta and its major branches
• liver
• gallbladder
• spleen

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• Pancreas
• Kidneys
• Bladder
• Uterus, ovaries, and unborn child (fetus) in
  pregnant patients
• Eyes
• Thyroid and parathyroid glands
• Scrotum (testicles)

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Example images
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Ultrasound is also used to

• Guide procedures e.g. needle biopsies
• Image the breasts and to guide biopsy of breast
  cancer.
• Diagnose a variety of heart conditions and to
  assess damage after a heart attack or diagnose
  for valvular heart disease.

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Ultra sound machine

transducer
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Ultra Sonography

• of the gallbladder provides a noninvasive means
  of studying the gallbladder and the biliary ducts
  
• Advantages
• No ionizing radiation
• Detection of small calculi
• No contrast medium
• Less patient preparation

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Before the procedure

• Client should wear comfortable, loose-fitting
  clothing for the ultrasound exam.
• Client may need to remove clothing and jewelry in
  the area to be examined.
• They may be asked to wear a gown during the
  procedure.
• Other preparation depends on the type of
  examination that the client will have.

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Before the procedure

• For some scans the doctor may instruct not to eat
  or drink for 12 hours before appointment.
• For others client may be asked to drink up to
  six glasses of water two hours prior to exam and
  avoid urinating so that bladder is full when the
  scan begins.

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How the procedure performed

• In an ultrasound examination, a transducer both
  sends the sound waves and records the echoing
  waves.
• When the transducer is pressed against the skin,
  it directs small pulses of impossible to hear,
  high-frequency sound waves into the body.
• As the sound waves bounce off of internal organs,
  fluids and tissues, the sensitive microphone in
  the transducer records tiny changes in the
  sound's pitch and direction.

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Cont-

• These signature waves are instantly measured and
  displayed by a computer, which in turn creates a
  real-time picture on the monitor.
• One or more frames of the moving pictures are
  typically captured as still images.

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During the procedure

• A clear gel is applied to the area to be examined
  to augment the ultrasound transmission and
  reception.
• The sound waves produced by the transducer cannot
  penetrate air, so the gel helps to eliminate air
  pockets between the transducer and the skin.

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• Client will be asked to lie still and hold the
  breath from time-to-time to assist in acquisition
  of the best images.
• Sometimes patients need to roll to different
  positions
• Most ultrasound examinations are completed
  within 30 minutes to an hour.

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After the procedure

• Wiped off the gel from skin.
• After an ultrasound exam, client should be able
  to resume the normal activities immediately.

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Oesophageal Ballon Tamponade DEFINITION

• Balloon tamponade usually refers to the use of
  balloons inserted into the esophagus or stomach,
  and inflated to stop refractory bleeding from
  vascular structures including esophageal varices
  and gastric varices in the upper gastrointestinal
  tract.

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INDICATION

• A balloon tamponade tube is used when the
  bleeding from oesophageal varices is dangerous
  and the tube is usually inserted during an
  endoscopy.

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• EQUIPMENT
• GEBT tube
• Traction device or setup, including weights
• Manual manometer or sphygmomanometer
• Y-tube connector (if not already built into the
  tamponade balloon ports)
• Vacuum suction device, tubing, and connectors
• Soft restraints
• Topical anesthetic (spray and jelly) and
  water-soluble lubricating jelly

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• 3 or 4 tube clamps
• Large (e.g., 50 mL) catheter tip irrigating
  syringe
• Surgical scissors for emergency balloon
  decompression
• Standard NG tube (may not be required if GEBT has
  a built-in gastric aspiration port)

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PROCEDURE

• Consider endotracheal intubation prior to GEBT
  placement.

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• If used, the NG tube should secured 3 cm proximal
  to the esophageal balloon.

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• Clamp the inflation tube after inflation.

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• Use of the sponge-rubber cuff to secure the tube.

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• Monitor the inflation pressure of the esophageal
  balloon with a manometer.

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POST-PROCEDURE

• After bleeding has been controlled for
  several hours, reduce the pressure in the
  esophageal balloon by 5 mm Hg every 3 hours,
  until an intraesophageal balloon pressure of 25
  mm Hg is achieved without ongoing bleeding.
• If bleeding can be controlled with an
  intraesophageal balloon pressure of 25 mm Hg,
  maintain this pressure for the next 12 to 24
  hours.

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• Once satisfactory positioning of the GEBT tube
  has been confirmed, do not disturb the tube for
  20 to 24 hours, unless necessary because of
  complications.
• Provide the patient with analgesics and sedation.
• Apply soft restraints to the patients arms.
• If the bleeding does not remain controlled, other
  therapeutic interventions must be considered.

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• COMPLICATIONS
• Aspiration pneumonitis
• Asphyxia due to airway obstruction. Keep scissors
  at the bedside so that the tube can be cut and
  quickly removed if this complication occurs.
• Esophageal perforation or rupture

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• Uncommon major complications include duodenal
  rupture, tracheobronchial rupture, and
  periesophageal abscess formation.
• Common minor complications include pain,
  discomfort, local pressure effects of gastric or
  esophageal erosions or mucosal ulcers,
  regurgitation, chest discomfort, back pain, and
  pressure necrosis of the nose or lip.

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• Choleangiogram
• Radiographic examination of the biliary ducts
•  special x-ray procedure that is done with
  contrast media to visualize the bile ducts after
  the a cholecystectomy (removal of the
  gallbladder). The bile ducts drain bile from the
  liver into the duodenum (first part of the small
  bowel).

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Computed tomography

• is an imaging procedure that uses special x-ray
  equipment to create detailed pictures, or scans,
  of areas inside the body.
• It is also called computerized
  tomography and computerizedaxial tomography (CAT)

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CholecystographyDefinition

• Is a procedure that helps to diagnose gallstones.
• In the test, a special dye, called a contrast
  medium, is either injected into patient body or
  is taken as special pills (oral
  cholecystography).
• This contrast medium shows up the structure of
  the gallbladder and bile duct on x-ray.

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Before the procedure

• Explain the procedure to patient.
• Sign a consent form that gives permission to do
  the procedure.
• Fasting prior to the procedure.
• Notify the radiologic technologist if patient are
  pregnant or suspect patient may be pregnant.

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During the procedure

• Remove any clothing or jewelry that may interfere
  with the exposure of the body area to be
  examined.
• Patient may be given an enema prior to the
  procedure to clear the intestines of gas or feces
  that may interfere with imaging of the
  gallbladder.

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Cont..

• Body parts not being imaged may be covered with a
  lead apron (shield) to avoid exposure to the
  x-rays.
• Several x-rays will be taken while patient are in
  various positions.
• If testing of the gallbladders ability to
  contract is requested, patient will be given some
  type of fatty intake to stimulate gallbladder
  contraction.

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After procedure

• Generally, there is no special care following
  cholecystography.
• Because the contrast dye is excreted from the
  body through the kidneys, sometime patient may
  feel some slight discomfort with urination for a
  day or so.

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Liver biopsyDefinition

• Liver biopsy is the biopsy (removal of a small
  sample of tissue) from the liver. It is a medical
  test that is done to aid diagnosis of liver
  disease, to assess the severity of known liver
  disease, and to monitor the progress of treatment.

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Type of liver biopsy

• Percutaneous Liver Biopsy
• via a needle through the skin
• Transvenous Liver Biopsy
• through the blood vessels
• Laparoscopic Liver Biopsy
• technique that avoids making a large incision by
  instead making one or a few small incisions.

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Percutaneous Liver Biopsy
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Laparoscopic Liver Biopsy
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Indication

• Liver biopsy Diagnostic purposes 
• Alcoholic liver disease
• Elevated liver enzymes of unknown cause 
• Biliary tract obstruction/jaundice
• Fatty liver disease
• Hemochromatosis
• Wilson disease
• Autoimmune liver disease
• Alpha1-antitrypsin deficiency

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• Possible injury due to drug therapies
• Hepatitis B
• Hepatitis C
• Hepatomegaly (liver enlargement) of undetermined
  cause
• Cancers that originate in the liver
• Cancers that spread (metastasize) to the liver
  from other sites
• Noncancerous tumors or abnormalities in the
  liver 

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• Liver biopsy Monitoring therapy
• Chronic viral hepatitis  
• HIV/AIDS
• Liver transplantation (to rule out rejection or in
  fection)

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Before procedure

• Nil by mouth for 4 8 hours before the biopsy.
•  Sign a consent form
• Ask patient maybe have a allergy for medication.
• Asked to empty the bladder so that he or she will
  be more comfortable during the procedure.
• Check patient vital sign to identify any physical
  problem

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During procedure

• Patients lie on their back with their right hand
  resting above their head.
• A local anesthetic is applied to the area where
  the biopsy needle will be inserted. If needed, an
  IV tube is used to give sedatives and pain
  medication.
• The doctor makes a small incision in the abdomen,
  either toward the bottom of the rib cage or just
  below it, and inserts the biopsy needle.

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• Patients will be asked to exhale and hold their
  breath while the needle is inserted and a liver
  sample is quickly withdrawn.
• Several samples may be collected, requiring
  multiple needle insertions.

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After procedure

• lie on their right sides for 1-4 hours
• Monitor patient's vital signs.
•  Bed rest for a day is recommended, followed by a
  week of avoiding heavy work or strenuous exercise.
  
• The patient can resume eating a normal diet.

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Complications

• Prolonged internal bleeding
• Patient with liver cancer will develop a fatal
  hemorrhage from a percutaneous biopsy.
• Leakage of bile 
• Infection

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Fractional test meal

• Gastric analysis
• Gastric acid stimulation test
• pH monitoring
• For zollinger-Ellison syndrome (tumor at
  pancreas/ duodenum)/ actropic gastritis

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Preparation

• NPO for 8 -12 h
• Withhold medication that effect gastric secretion
  24-48h
• Positioning in a semi fowlers
• NGT insertion around 21, laying along the
  greater curve
• Gastric sample are aspirate and collected every
  15m for next 1 hour.

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Thank you.

• Any Question