Medical Surgical Care of the Patient with a Gastrointestinal Disorder Edited by M. Myers Mosby items and derived items © 2011, 2006, 2003, 1999, 1995,

Medical SurgicalMedical Surgical

Care of the Patient with aGastrointestinal Disorder

Edited by M. Myers

Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.

Slide 2Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.

Digestive system◦ Organs and their functions

Mouth: Beginning of digestion Teeth: Bite, crush, and grind food Salivary glands: Secrete saliva Esophagus: Moves food from mouth to stomach Stomach: Churn and mix contents with gastric juices Small intestine: Most digestion occurs here Large intestine: Forms and expels feces Rectum: Expels feces


Location of digestive organs.

(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)


Accessory organs of digestion◦ Organs and their functions

Liver: Produces bile; stores it in the gallbladder Pancreas: Produces pancreatic juice

Regulation of food intake◦ Hypothalamus

One center stimulates eating and another signals to stop eating


Upper GI series Gastric analysis Esophagogastroduodenoscopy (EGD) Barium swallow Bernstein test Stool for occult blood Sigmoidoscopy Barium enema Colonoscopy Stool culture and sensitivity; stool for ova

and parasites Flat plate of the abdomen


Dental plaque and caries◦ Etiology/pathophysiology

Erosive process that results from the action of bacteria on carbohydrates in the mouth, which produces acids that dissolve tooth enamel

◦ Medical management/nursing interventions Remove affected area and replace with dental

material


Candidiasis◦ Etiology/pathophysiology

Infection caused by a species of Candida, usually Candida albicans

Fungus normally present in the mouth, intestine, and vagina, and on the skin

Also referred to as thrush and moniliasis◦ Clinical manifestations/assessment

Small white patches on the mucous membrane of the mouth

Thick white discharge from the vagina


Candidiasis (continued)◦ Medical management/nursing interventions

Pharmacological management Nystatin Ketoconazole oral tablets

Half-strength hydrogen peroxide/saline mouthwash Meticulous handwashing Comfort measures


Carcinoma of the oral cavity◦ Etiology/pathophysiology

Malignant lesions on the lips, oral cavity, tongue, or pharynx

Usually squamous cell epitheliomas◦ Clinical manifestations/assessment

Leukoplakia Roughened area on the tongue Difficulty chewing, swallowing, or speaking Edema, numbness, or loss of feeling in the mouth Earache, face ache, and toothache


Carcinoma of the oral cavity (continued)◦ Diagnostic tests

Indirect laryngoscopy Excisional biopsy

◦ Medical management/nursing interventions Stage I: Surgery or radiation Stage II & III: Both surgery and radiation Stage IV: Palliative

Esophagus

• Tracheoesophageal fistula

• Newborn: copious saliva

choking, coughing

cyanosis on food intake

• Most common form: lower part of esophagus joins the trachea (near the bifurcation)

Esophagus

• Tracheoesophageal fistula

• Newborn: copious saliva

choking, coughing

cyanosis on food intake

• Most common form: lower part of esophagus joins the trachea (near the bifurcation)

Esophageal diverticula

• Outpocketing of the esophageal wall• False( pulsion) type: the mucosa herniates into

the muscular layer• True (traction) type: outpocketing of all the

layers• 3 common locations:• 1. above UES (Zenker diverticulum)• 2. midpoint of the esophagus• 3. above LES (Epiphrenic diverticulum)

Zenker’s diverticulum Epiphrenic diverticulum


Gastroesophageal reflux disease (continued)◦ Diagnostic tests

Esophageal motility and Bernstein tests Barium swallow Endoscopy

◦ Medical management/nursing interventions Pharmacological management

Antacids or acid-blocking medications Dietary recommendations Lifestyle recommendations Comfort measures Surgery


Gastroesophageal reflux disease◦ Etiology/pathophysiology

Backward flow of stomach acid into the esophagus◦ Clinical manifestations/assessment

Heartburn (pyrosis) 20 min to 2 hours after eating Regurgitation Dysphagia or odynophagia Eructation

Gastroesophageal reflux

• Reflux of gastric contents into the esophagus

• Heartburn, substernal pain, burning sensation

• Predisposing factors: alcohol, smoking, pregnancy

• May lead to: esophagitis, strictures, Barrett esophagus

Barrett esophagus

• Normal epithelium: squamous type

• Barrett: becomes columnar with many Goblet cells

• Precursor for adenocarcinoma of the esophagus

Barrett esophagus

Barrett esophagus

Cancer of the esophagus

• Most frequent type: squamous cell carcinoma

• Dysphagia, weight loss, anorexia

• Upper and middle thirds of the esophagus

• Adenocarcinoma type : lower third of the esophagus


Carcinoma of the esophagus◦ Etiology/pathophysiology

Malignant epithelial neoplasm that has invaded the esophagus 90% are squamous cell carcinoma associated with

alcohol intake and tobacco use 6% are adenocarcinomas associated with reflux

esophagitis

◦ Clinical manifestations/assessment Progressive dysphagia over a 6-month period Sensation of food sticking in throat


Carcinoma of the esophagus (continued)◦ Medical management/nursing interventions

Radiation: May be curative or palliative Surgery: May be palliative, increase longevity, or

curative Types of surgical procedures

Esophagogastrectomy Esophagogastrostomy Esophagoenterostomy Gastrostomy

Cancer of the esophagus


Achalasia◦ Etiology/pathophysiology

Cardiac sphincter of the stomach cannot relax Possible causes: Nerve degeneration, esophageal

dilation, and hypertrophy◦ Clinical manifestations/assessment

Dysphagia Regurgitation of food Substernal chest pain Loss of weight; weakness Poor skin turgor


Achalasia (continued)◦ Diagnostic tests

Radiologic studies; esophagoscopy◦ Medical management/nursing interventions

Pharmacological management Anticholinergics, nitrates, and calcium channel blockers

Dilation of cardiac sphincter Surgery

Cardiomyectomy

Gastritis

• Acute gastritis• Causes:

NSAIDSsmokingalcholic drinksburns :

Curlings ulcerCushings ulcer

• Chronic gastritis• Chronic inflammation,

atrophy of the mucosa

• Helicobacter pylori gastritis: most common form

• Increases risk of gastric cancer

Acute Gastritis

Peptic ulcers

• Common locations:lesser curvatureantrumprepyloric areas

• Causes: H.pylori infection bile-induced gastritis

• Not a precursor lesion of carcinoma of the stomach

Benign Gastric Ulcers


Acute gastritis◦ Etiology/pathophysiology

Inflammation of the lining of the stomach May be associated with alcoholism, smoking, and

stressful physical problems◦ Clinical manifestations/assessment

Fever; headache Epigastric pain; nausea and vomiting Coating of the tongue Loss of appetite


Acute gastritis (continued)◦ Diagnostic tests

Stool for occult blood; WBC; electrolytes◦ Medical management/nursing interventions

Pharmacological management Antiemetics Antacids Antibiotics IV fluids

NG tube and administration of blood, if bleeding NPO until signs and symptoms subside Monitor intake and output


Gastric ulcers and duodenal ulcers◦ Ulcerations of the mucous membrane or deeper

structures of the GI tract◦ Most commonly occur in the stomach and

duodenum◦ Result of acid and pepsin imbalances◦ H. pylori

Bacterium found in 70% of patients with gastric ulcers and 95% of patients with duodenal ulcers


Gastric ulcers (continued)◦ Etiology/pathophysiology

Gastric mucosa are damaged, acid is secreted, mucosal erosion occurs, and an ulcer develops

Duodenal ulcers (continued)◦ Etiology/pathophysiology

Excessive production or release of gastrin, increased sensitivity to gastrin, or decreased ability to buffer the acid secretions


Gastric and duodenal ulcers (continued)◦ Clinical manifestations/assessment

Pain: Dull, burning, boring, or gnawing, epigastric Dyspepsia Hematemesis Melena

◦ Diagnostic tests Esophagogastroduodenoscopy (EGD) Breath test for H. pylori


Fiberoptic endoscopy of the stomach.

(from Monahan, F.D., et al. [2007]. Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis: Mosby.)


Gastric and duodenal ulcers (continued)◦ Medical management/nursing interventions

Pharmacological management Antacids Histamine H2 receptor blockers Proton pump inhibitor Mucosal healing agents Antibiotics

Dietary recommendations High in fat and carbohydrates; low in protein and milk

products; small frequent meals; limit coffee, tobacco, alcohol, and aspirin use


Gastric and duodenal ulcers (continued)◦ Medical management/nursing interventions

Surgery Antrectomy Gastroduodenostomy (Billroth I) Gastrojejunostomy (Billroth II) Total gastrectomy Vagotomy Pyloroplasty


Types of gastric resections with anastomoses.

A, Billroth I. B, Billroth II.


Gastric and duodenal ulcers (continued)◦ Complications after gastric surgery

Dumping syndrome Pernicious anemia Iron deficiency anemia

Cancer of the Stomach

• Common: more than 50 years old, men, Blood group A

• Predisposing factors:H. pylori infectionNitrosaminesexcessive salt intakelow fresh fruits, vegetables dietachlorhydiachronic gastritis

Cancer of the stomach

• Most common type: adenocarcinoma• Rare in the fundus• Aggressive spread to adjacent organs• Virchow node: large supraclavicular node• Krukenberg tumors: bilateral, enlarged ovaries,

“signet ring” cells• Two types:• 1. intestinal type: fungating mass; ulcer with

irregular necrotic base and firm, raised margins• 2. infiltrating or diffuse type: linitis plastica

Signet ring cells

Cancer of the stomach

Krukenberg tumors


Cancer of the stomach◦ Etiology/pathophysiology

Most commonly adenocarcinoma Primary location is the pyloric area Risk factors:

History of polyps Pernicious anemia Hypochlorhydria Gastrectomy; chronic gastritis; gastric ulcer Diet high in salt, preservatives, and carbohydrates Diet low in fresh fruits and vegetables


Cancer of the stomach (continued)◦ Clinical manifestations/assessment

Early stages may be asymptomatic Vague epigastric discomfort or indigestion Postprandial fullness Ulcer-like pain that does not respond to therapy Anorexia; weight loss Weakness Blood in stools; hematemesis Vomiting after fluids and meals


Cancer of the stomach (continued)◦ Diagnostic tests

GI series Endoscopic/gastroscopic examination Stool for occult blood RBC, hemoglobin, and hematocrit

◦ Medical management/nursing interventions Surgery

Partial or total gastric resection Chemotherapy and/or radiation

Congenital pyloric stenosis

• Hypertrophy of the circular muscle layer of the pylorus

• Projectile vomiting in 1st 2 weeks of life

• Palpable mass


Infection◦ Etiology/pathophysiology

Invasion of the alimentary canal by pathogenic microorganisms

Most commonly enters through the mouth in food or water

Person-to-person contact Fecal-oral transmission Long-term antibiotic therapy can cause an

overgrowth of the normal intestinal flora (C. difficile)


Infection (continued)◦ Clinical manifestations/assessment

Diarrhea Rectal urgency Tenesmus Nausea and vomiting Abdominal cramping Fever


Infection (continued)◦ Diagnostic tests

Stool culture◦ Medical management/nursing interventions

Antibiotics Fluid and electrolyte replacement Kaopectate Pepto-Bismol


Irritable bowel syndrome◦ Etiology/pathophysiology

Episodes of alteration in bowel function Spastic and uncoordinated muscle contractions of the

colon◦ Clinical manifestations/assessment

Abdominal pain Frequent bowel movements Sense of incomplete evacuation Flatulence, constipation, and/or diarrhea


Irritable bowel syndrome (continued)◦ Diagnostic tests

History and physical examination◦ Medical management/nursing interventions

Pharmacological management Anticholinergics Milk of magnesia Mineral oil Opioids Antianxiety agents

Dietary recommendations Bulking agents

Crohn disease

• Chronic inflammatory disease of ALL the layers of the intestinal wall with thickening; narrow lumen

• 20 – 30 year old, Jewish descent• Small intestine and colon• May lead to carcinoma• Skip lesions• Cobblestone appearance• Fistulas• Noncaseating granulomas

Crohn’s disease

• Presents as:

abdominal pain

diarrhea

fever

malabsorption

obstruction

fistula to bladder, vagina, skin

Crohn’s disease

Meckel’s diverticulum

• Most common congenital abnormality of the small intestine

• Remnant of the vitelline duct in the distal small bowel

• Peptic ulceration, bleeding, perforation

• Intussusception

• volvulus

Celiac disease

• Malabsorption disease

• Sensitivity to gluten products

• Blunting of the intestinal villi

• Diarrhea:bulky, frothy, foul-smelling

• Weight loss, failure to thrive, weakness

• Treatment: gluten-free diet

Cancer of the small intestine

• Mostly adenocarcinoma• Appendix: carcinoid type; when it metastasizes

to the liver carcinoid syndrome:• Flushed skin• Watery diarrhea, abdominal cramps• Bronchospasm• Valvular lesions of the heart

Colon

Ulcerative colitis

• Ulcers in the large intestine or entire colon• Pseudopolyps• Crypt abscesses• Chronic diarrhea• Most frequent presentation: rectal bleeding• Complications:

Toxic megacolonColon perforationColon cancer


Ulcerative colitis◦ Etiology/pathophysiology

Ulceration of the mucosa and submucosa of the colon

Tiny abscesses form that produce purulent drainage, slough the mucosa, and ulcerations occur

◦ Clinical manifestations/assessment Diarrhea—pus and blood; 15 to 20 stools per day Abdominal cramping Involuntary leakage of stool


Ulcerative colitis (continued)◦ Diagnostic tests

Barium studies, colonoscopy, stool for occult blood◦ Medical management/nursing interventions

Pharmacological management Azulfidine, Dipentum, Rowasa, corticosteroids, Imodium

Dietary recommendations: No milk products or spicy foods; high-protein, high-calorie; total parenteral nutrition

Stress control Assist patient to find coping mechanisms


Ulcerative colitis (continued)◦ Medical management/nursing interventions

Surgical interventions Colon resection Ileostomy Ileoanal anastomosis Proctocolectomy Kock pouch


Kock pouch (Kock continent ileostomy).


Ileostomy with absence of resected bowel.


Crohn’s disease◦ Etiology/pathophysiology

Inflammation, fibrosis, scarring, and thickening of the bowel wall

◦ Clinical manifestations/assessment Weakness; loss of appetite Diarrhea: 3 to 4 daily; contain mucus and pus Right lower abdominal pain Steatorrhea Anal fissures and/or fistulas


Crohn’s disease (continued)◦ Medical management/nursing interventions

Pharmacological management Corticosteroids Azulfidine Antibiotics Antidiarrheals; antispasmodics Enteric-coated fish oil capsules B12 replacement


Crohn’s disease (continued)◦ Medical management/nursing interventions

Dietary recommendations High-protein Elemental Hyperalimentation Avoid

Lactose-containing foods, brassica vegetables, caffeine, beer, monosodium glutamate, highly seasoned foods, carbonated beverages, fatty foods

Surgery Segmental resection of diseased bowel


Appendicitis◦ Etiology/pathophysiology

Inflammation of the vermiform appendix Lumen of the appendix becomes obstructed, the

E. coli multiplies, and an infection develops◦ Clinical manifestations/assessment

Rebound tenderness over the right lower quadrant of the abdomen (McBurney’s point)

Vomiting Low-grade fever Elevated WBC


Appendicitis (continued)◦ Diagnostic tests

WBC Roentgenogram Ultrasound Laparoscopy

◦ Medical management/nursing interventions Appendectomy


Diverticular disease◦ Etiology/pathophysiology

Diverticulosis Pouch-like herniations through the muscular layer of the

colon Diverticulitis

Inflammation of one or more diverticula


Diverticulosis.


Diverticular disease (continued)◦ Clinical manifestations/assessment

Diverticulosis May have few, if any, symptoms Constipation, diarrhea, and/or flatulence Pain in the left lower quadrant

Diverticulitis Mild to severe pain in the left lower quadrant Elevated WBC; low-grade fever Abdominal distention Vomiting Blood in stool


Diverticular disease (continued)◦ Medical management/nursing interventions

Diverticulosis with muscular atrophy Low-residue diet; stool softeners Bed rest

Diverticulosis with increased intracolonic pressure and muscle thickening High-fiber diet Sulfa drugs Antibiotics; analgesics


Diverticular disease (continued)◦ Medical management/nursing interventions

(continued) Surgery

Hartmann’s pouch Double-barrel transverse colostomy Transverse loop colostomy


Peritonitis◦ Etiology/pathophysiology

Inflammation of the abdominal peritoneum Bacterial contamination of the peritoneal cavity from

fecal matter or chemical irritation◦ Clinical manifestations/assessment

Severe abdominal pain; nausea and vomiting Abdomen is tympanic; absence of bowel sounds Chills; weakness Weak rapid pulse; fever; hypotension


Peritonitis (continued)◦ Diagnostic tests

Flat plate of the abdomen CBE

◦ Medical management/nursing interventions Pharmacological management

Parenteral antibiotics Analgesics IV fluids

Position patient in semi-Fowler’s position Surgery

Repair cause of fecal contamination Removal of chemical irritant

NG tube to prevent GI distention


External hernias◦ Etiology/pathophysiology

Congenital or acquired weakness of the abdominal wall or postoperative defect Abdominal Femoral or inguinal Umbilical


External hernias (continued)◦ Clinical manifestations/assessment

Protruding mass or bulge around the umbilicus, in the inguinal area, or near an incision

Incarceration Strangulation

◦ Diagnostic tests Radiographs Palpation


External hernias (continued)◦ Medical management/nursing interventions

If no discomfort, hernia is left unrepaired, unless it becomes strangulated or obstruction occurs

Truss Surgery

Synthetic mesh is applied to weakened area of the abdominal wall


Hiatal hernia◦ Etiology/pathophysiology

Protrusion of the stomach and other abdominal viscera through an opening in the membrane or tissue of the diaphragm

Contributing factors: obesity, trauma, aging◦ Clinical manifestations/assessment

Most people display few, if any, symptoms Gastroesophageal reflux


Hiatal hernia. A, Sliding hernia. B, Rolling hernia.


Hiatal hernia (continued)◦ Medical management/nursing interventions

Head of bed should be slightly elevated when lying down

Surgery Posterior gastropexy Transabdominal fundoplication (Nissen)


Intestinal obstruction◦ Etiology/pathophysiology

Intestinal contents cannot pass through the GI tract Partial or complete Mechanical Non-mechanical

◦ Clinical manifestations/assessment Vomiting; dehydration Abdominal tenderness and distention Constipation


Intestinal obstructions. A, Adhesions. B, Volvulus.


Intestinal obstruction (continued)◦ Diagnostic tests

Radiographic examinations BUN, sodium, potassium, hemoglobin, and

hematocrit◦ Medical management/nursing interventions

Evacuation of intestine NG tube to decompress the bowel Nasointestinal tube with mercury weight

Surgery Required for mechanical obstructions


Colorectal cancer◦ Etiology/pathophysiology

Malignant neoplasm that invades the epithelium and surrounding tissue of the colon and rectum

Second most prevalent internal cancer in the United States

◦ Clinical manifestations/assessment Change in bowel habits; rectal bleeding Abdominal pain, distention, and/or ascites Nausea Cachexia


Cancer of the colon (continued)◦ Diagnostic tests

Proctosigmoidoscopy with biopsy Colonoscopy Stool for occult blood

◦ Medical management/nursing interventions Radiation Chemotherapy


Cancer of the colon (continued)◦ Medical management/nursing interventions

(continued) Surgery

Obstruction One-stage or two-stage resection Two-stage resection

Colorectal cancer Right or left hemicolectomy Anterior rectosigmoid resection


Hemorrhoids◦ Etiology/pathophysiology

Varicosities (dilated veins) External or internal

Contributing factors Straining with defecation, diarrhea, pregnancy, CHF,

portal hypertension, prolonged sitting and standing

◦ Clinical manifestations/assessment Varicosities in rectal area Bright red bleeding with defecation Pruritus Severe pain when thrombosed


Hemorrhoids (continued)◦ Medical management/nursing interventions

Pharmacological management Bulk stool softeners Hydrocortisone cream Topical analgesics

Sitz baths Ligation Sclerotherapy; cryotherapy Infrared photocoagulation Laser excision Hemorrhoidectomy


Anal fissure◦ Linear ulceration or laceration of the skin of the

anus◦ Usually caused by trauma◦ Lesions usually heal spontaneously◦ May be excised surgically

Anal fistula◦ Abnormal opening on the surface near the anus◦ Usually from a local abscess◦ Common in Crohn’s disease◦ Treated by a fistulectomy or fistulotomy


Nursing diagnoses Activity intolerance Anxiety Body image,

disturbed Constipation Coping, ineffective Diarrhea Fear Fluid volume,

deficient, risk for

Home management, impaired Management of therapeutic

regimen, ineffective Nutrition, imbalanced: less

than body requirements Pain, chronic/acute Skin integrity, risk for impaired Sleep pattern, disturbed Social isolation Tissue perfusion, ineffective


Fecal incontinence◦ Potential causes◦ Medical management/nursing interventions

Biofeedback training Bowel training Patient education Dietary recommendations

Small Intestine

Peptic ulcer of the Small intestine

• Always associated with increased secretion of gastric acid and pepsin

• High risk in H. pylori infection• Other predisposing factors:

aspirin, NSAIDSsmokingZollinger-Ellison syndrome: gastrin-secreting tumor of the pancreasprimary hyperparathyroidism

• Not a precursor of malignancy

Colon Polyps

• Elevation of he intestinal surface

• Peutz-Jeghers polyps: polyps in the colon + dark spots on lips, hands, genitalia

• Villous adenomas: highest potential of the adenomatous polyps to become malignant

• Familial polyposis: malignant changes in 100% of cases

Adenocarcinoma of the colon

• 60 to 70 years old• Cancer marker: CEA • Predisposing factors:

adenomatous polypsfamilial polypposis4x higher in relatives with colon cancerlow fiber, high animal fat diet

• Cancer of the rectosigmoid: annular enlargement; obstruction

• Cancer of the right colon: late obstruction; chronic blood loss; iron deficiency anemia

Documents

Medical Surgical Care of the Patient with a Gastrointestinal Disorder Edited by M. Myers Mosby items and derived items © 2011, 2006, 2003, 1999, 1995,