CLINICAL UPDATECLINICAL UPDATEGASTROENTEROLOGY

NURSING

Joe Garzia StafraceCertified Gastroenterology Nurse (Ch. US)

Anatomy, Physiology & Anatomy, Physiology &

Pathophysiology Pathophysiology ––

EsophagusEsophagusJGS

Gastrointestinal3

Anatomy and Physiology Anatomy and Physiology -- EsophagusEsophagus

� A hollow, muscular tube app 1O” x 1”.

� Conveyer; 3rd organ;

� Posterior to trachea and larynx.

� 3 Layers –

� UES and LES

Gastrointestinal4

MotilityMotility

� At rest, both UES and LES are closed

� Peristalsis

� 3 to 5 cm /sec

Gastrointestinal5

Pathophysiology Pathophysiology -- VaricesVarices

� Esophageal Varices

Related to Portal Hypertension,

alcoholic cirrhosis, cirrhosis.

Varices may be asymptomatic with a high risk for rupture. Graded I to IV.

Rx – Injection, EVL, IV vasopressin, balloon tamponade, PS Shunt.

Gastrointestinal6

Gastrointestinal7

Gastrointestinal8

PathophysiologyPathophysiology –– EsophagealEsophageal TumorsTumors

� Squamous Cell Carcinoma, Barrett’s, Adenocarcinoma.

� Chronic Irritation of the esophageal mucosa [caustic ingestion, chronic and persistent reflux, excessive smoking or drinking)

Prime Ind. – Dysphagia and Odynophagia, anorexia, weight loss, anemia, hoarseness.

OGD – Brushings and Biopsy

Survival rate only 3%.

Rx –Stenting, Palliative, Surgery.

Gastrointestinal9

Pathophysiology Pathophysiology -- OtherOther

� Diverticula – Zenker’s, Traction, Epiphrenic, Intramural.

� Strictures – caustic, Candidiasis, Reflux.

� Rings and Webs – thin, circumferential mucosal shelves

� Foreign bodies

� Infectious diseases

Gastrointestinal10

Pathophysiology Pathophysiology -- OtherOther

� Mallory-Weiss tears – Rx conservative

� Motility Disorders :–1. Achalasia – defective peristalsis and ↑ LES pressure =

dysphagia to solids and liquids, regurgitation, and weight loss. Rx – Pneumatic dilatation, Botox, Hellers, Nitrates.

2. DES – unknown cause. Dysphagia to solids and liquids (very H&C). Rx – long term anticholinergics, nitrates.

3. Nutcracker Esophagus – Rx as DES

� Caustic – Accidental and Suicidal ingestion of ↑ acid or alkaline.

Rx – acid (large volumes of milk and water)

� Congenital defects – atresia, fistula.

� Fistulas in adults – Cancer, benign inflammatory process or trauma. Chronic cough, fever, recurrent pulmonary infections, dysphagia. Rx – stenting, surgery.

Gastrointestinal11

Anatomy, Physiology & Anatomy, Physiology &

Pathophysiology Pathophysiology ––

StomachStomach� Joe Garzia Stafrace CGN

Gastrointestinal12

Anatomy and Physiology Anatomy and Physiology -- StomachStomach� J-Shaped, distensible, below diaphragm

� 10-12” Long x 4- 6” Wide

� Maintains relatively low levels of microbes

� Digests food and prepares nutrients for absorption

� Serves as a reservoir

� Mixes and delivers chyme to SI for

further digestion and absorption

� Originates signals for hunger

or satiety.

Gastrointestinal13

Pathophysiology Pathophysiology -- UlcersUlcers� When the normal balance between factors that

promote mucosal injury (e.g., gastric acid, pepsin, bile acids) and those that protect the mucosa(e.g., an intact epithelium, mucus) is upset, ulcers or inflammation may arise.

� Mechanical – Chemical – Infectious – Ischemic

Pyloric Sphincter

pressure -Reflux

NSAIDs, Alcohol

Atrophy

H.pylori

Gastrointestinal14

Gastrointestinal15

Pathophysiology Pathophysiology –– Ulcers Ulcers -- RxRx� PPI - decrease gastric acid by inhibiting the enzyme

responsible for completing the final step of acid secretion.

� H2 Blockers – reduce the amount of acid produced by the stomach and blocking H2 acid prod.

� Sucralfate – protects the site of disrupted mucosa by forming a protective gel layer.

� Antacids – neutralize pH, strengthen the gastric mucosal barrier, tones the LES.

{antacids should be taken 1 to 3 hours after meals and before sleep}

� Surgical Options -

16

Pathophysiology Pathophysiology –– Helicobacter pyloriHelicobacter pylori� Transmission via fecal-oral or oral-oral pathways

� Linked to gastritis, gastric and duodenal ulcers and cancer

� Investigate – serology, breath, tissue

� Rx – PPI + Metro +Tetra/Amox

Gastric Cancer

� Hereditary, Type A Blood, lower socioeconomic

� Incidence increases with age, +HP, high starch, nitrates, pickled vegetables, salted fish and meat

Anatomy, Physiology & Anatomy, Physiology &

Pathophysiology Pathophysiology ––

Small IntestineSmall IntestineJoe Garzia Stafrace CGN

Gastrointestinal18

Gastrointestinal19

Gastrointestinal20

Pathophysiology Pathophysiology –– Small IntestineSmall IntestinePathologic conditions of the small intestine can affect

absorption of nutrients in the affected area.

Duodenal Ulcer

Disease

Parasitic

Infestations

Bacterial and

Viral Infections

Crohn’s Disease

Meckel’s

diverticulum

Vitamin B12

deficiency

Small Bowel

TumorsCeliac Disease

Short Bowel

Syndrome

Whipple’s

disease

Lactose

Intolerance

Hirschsprung’s

disease

Appendicitis Intussusception

Gastrointestinal21

Gastrointestinal22

Anatomy, Physiology & Anatomy, Physiology &

PathophysiologyPathophysiology ––

Large Intestine (Colon)Large Intestine (Colon)� Joe Garzia Stafrace CGN

Gastrointestinal23

Anatomy Anatomy –– Large IntestineLarge Intestine� 4 to 5 feet long and

approximately 2” in diameter.

� 4 layers form the lining:-Serosa, Muscularis, Submucosa, Mucosa. The

rectum does not have the serosalayer.

� Secretes h2o, mucous, pot. and bicarbonate.

� Absorption – Receives 1-2Lts but retains 150-200mls. Sod, Chl, Water are absorbed (asc)

� Sterocobilin

� Protein metabolism; Bacteria; Toxins

Gastrointestinal24

PathophysiologyPathophysiology–– LargeLarge IntestineIntestine� Polyps – Sesile, Pedunculated,

� Juvenile, Familial polyposis coli- highly potentially cancerous

Gardner’s Syndrome Peutz-Jeghers SyndromePolyps are alsoPresent in Skull,Mandible andLong Bones.

Gastrointestinal26

Gastrointestinal27

PathophysiologyPathophysiology–– Large IntestineLarge Intestine

Angiodysplasia

OWR or HHT

Colitis – IBD Ischemic, Radiation,

Necrotizing, UC,

Crohn’s,

Pseudomembraneous

Ulcerative

Colitis

Gastrointestinal28

PathophysiologyPathophysiology–– Large IntestineLarge Intestine

� Ulcerative Colitis1. Affects mucosa & sub-

mucosa.2. Pain crampy, lower abdo,

relieved by bowel movement

3. Bloody stools4. No abdominal mass5. Continuous from rectum

Colon6. Fever, dehydration 7. Affects only and anemia in

severe cases8. Extraintestinal symptoms

– arthritis, conjunctivitis, pseudopolyps, rectal prolapse, hemorrhoids, anal fissures,, erythemanodosum, renal.

� Crohn’s Disease1. A transmural disease

(granulomas)2. Pain constant, not relieved by

bowel movement3. Not grossly bloody4. Abdominal mass (RIF)5. May be discontinuous (skip

areas)6. May affect any part of the GI

Tract7. Stricture and Fistula

formation are common8. Edema, mucosal ulceration

(cobblestone appearance), fissures, abscesses, granulomas, growth failure, malnutrition and weight loss

Gastrointestinal29

PathophysiologyPathophysiology–– Large IntestineLarge Intestine� IBS IBS IBS IBS –––– ‘‘‘‘The money spinnerThe money spinnerThe money spinnerThe money spinner’’’’---- 25 to 50% of visits to GI 25 to 50% of visits to GI 25 to 50% of visits to GI 25 to 50% of visits to GI

Specialists are IBS related problems.Specialists are IBS related problems.Specialists are IBS related problems.Specialists are IBS related problems.

an an an an exageratedexageratedexageratedexagerated motility response to environmental stressmotility response to environmental stressmotility response to environmental stressmotility response to environmental stress

A motility disorder without evidence of anatomical abnormality or organic illness. Symptoms vary in pattern and intensity. Not related to other diseases.

Rx – Sympathetic reassurance that organic causes have been ruled out. A high-fiber diet. Anticholinergic agents. Psychological support.

� Parasitic InfestationsParasitic InfestationsParasitic InfestationsParasitic Infestations

� DiverticularDiverticularDiverticularDiverticular DiseaseDiseaseDiseaseDisease

DiverticulosisDiverticulitis

Gastrointestinal30

PathophysiologyPathophysiology–– Large IntestineLarge Intestine

� MELANOSIS COLI

� Intestinal Obstruction – Congenital or Acquired

� Neurogenic Obstruction

� Vascular Obstruction

� Anorectal Disorders

Hemmohoids, Fecal Impaction, Encopresis, AnorectalAbscess, Anorectal Fistula, Anal Fissure, Rectal Prolapse.

Gastrointestinal31

PathophysiologyPathophysiology–– Large IntestineLarge IntestineColon Cancer – The Increased Risk Group

Risk category Age to Begin Recommendation Comments

People with a small, single adenoma

3-6 years after initial polypectomy

Colonoscopy N- screen as per average risk

Large (1cm+) adenoma, multiple, high-grade dysplasia / villous

Within 3 years after initial polypectomy

Colonoscopy N- repeat in 3 years

N- screen as per average risk

Personal history of CRC

Within 1 year after cancer resection

Colonoscopy N-repeat in 3 years

N-repeat in 5 years

Either CRC or adenomatous polyps

In any 1st degree relative before age 60, or in 2+ 1st degr

Relatives at any age

Age 40, or 10 years prior the youngest case in the immediate family

Colonoscopy Every 5 – 10 years. CRC in 2nd or 3rd

degree relatives less

ACS: NCS; ACG; SGA;WHO;ICS

Gastrointestinal32

The Horror Show

Gastrointestinal35

What goes in must come outWhat goes in must come out

ANAL PROBLEMS

Perianal haematoma

ANAL FISSURE

Gastrointestinal41

THE BILIARY SYSTEMTHE BILIARY SYSTEM� ANATOMY

Gallbladder, Hepatic, Cystic, and Common Bile ducts

3” x 1” and capable of holding 50mls of bile

Gastrointestinal42

THE BILIARY SYSTEMTHE BILIARY SYSTEM

� Physiology - GBTo Collect, Concentrate, and Store bile.

Bile is an alkaline, greenish-yellow fluid continuously secreted by the liver. 97% water; bile slats; fatty acids; lipids, mainly cholesterol and lecithin; electrolytes; bilirubin; other organic substances.

Functions of Bile:- emulsification of undigested fats; absorption of fat-soluble vitamins; activation of intestinal and pancreatic enzymes; bilirubin, sex, thyroid, adrenal hormones, and cholesterol elimination;

Gastrointestinal43

THE BILIARY SYSTEMTHE BILIARY SYSTEM

� PathophysiologyIncreases with age. 4Fs x 6.

Cholelithiasis – 5th leading cause of Hospitalization and accounts to 90% of all biliary diseases. ¾ are Cholesterol.

Choledocholithiasis – 40% are Pigment stones. Symptoms include colic, Obstructive jaundice with pruritis.

Acalculous Cholecystitis – related to typhoid, shigellosis; viral gastroenteritis; pneumonia.

Cholangitis – a rare bacterial infection {E.coli and Klebsiella} of the bile duct with poor prognosis – a Med & Surg emerg.

Cholecystitis – Acute or Chronic inflammation of the GB.

Gastrointestinal44

E.R.C.P. E.R.C.P.

((EndoscopicRetroCholangioPancreographyEndoscopicRetroCholangioPancreography))

Gastrointestinal45

Gastrointestinal46

Gastrointestinal47

Gastrointestinal48

Gastrointestinal49