Sonny M.

Moreno RN

GIT

COVERAGE
Anatomy and Physiology Assessment Laboratory and Diagnostic Procedures Special Diet Diseases Primary Diseases (mouth to anus) Secondary Diseases (accessory organs)

Anatomy and Physiology

GIT Accessory Organs?
Salivary Glands Pancreas Biliary System Liver

GIT Division
Upper GI
Mouth Esophagus Stomach Middle 3rd of Duodenum

Lower GI
Distal 3rd of Duodenum Jejunum (macro) Ileum (micro) Cecum (appendix) Colon (ascending, transverse, descending) Rectum, Anus

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GIT
Functions? I ngestion Digestion Mechanical Chemical Absorption Elimination

Gastric Enzymes
Z ymogen or Chief Cell
A L R P mylase=for starch digestion ipase=for fat digestion ennin=for milk and protein digestion (lactase) epsin=for protein digestion

(ZLARP)

P arietal Cell
H

(PHI)

Cl = maintains acidity 1.0 pH destroy some bacteria ingested aids also in digestion of food ntrinsic factor = aids in absorption of vit B12

Hormones
Gastrin (stomach) food & vagus Hcl Villikinin (small intestine) chyme movement of intestinal villi Enterogasterone (duodenum) fats motility Cholecystokinin (duodenum) fats bile and pancreatic enzyme secretions Secretin (duodenum) fats bile and pancreatic enzyme secretions

Small Intestine
Alkali environment Proteolytic enzymes permit bacterial growth Bacterial flora = vit K absorption and CHON synthesis Major absorption ileum (macro & micro)

Large Intestine
Alkali environment Permits growth of bacteria Putrefy and breakdown proteins Escherichia coli Aerobacter aerogenes Clostridium perfringens Lactobacillus Water is absorbed

Assessment
IAPP Achalasia Anorexia Hematemesis Nausea Hematochezia Vomiting Melena Diarrhea Steatorrhea Constipation Belching Abdominal pain Regurgitation Abdominal distention STOOL COLOR

Diagnostic Exams:
Upper GI Barium Lower GI Barium Gastric Analysis (NGT) Upper GI Scopic Lower GI Scopic Cholecystography ERCP Percutaneous Transhepatic Cholangiography Paracentesis Liver Biopsy Stool Specimen Hydrogen Breath Test Urea Breath Test Liver Enzyme and Pancreatic Enzyme Serum Bilirubin

Nursing Procedures:
Sengstaken Blakemore Tube NGT NIT TPN GASTROSTOMY TUBE JEJUNUSTOMY TUBE STOMA ENEMA

Therapeutic Diets
Clear Liquid Full Liquid Soft Diet Bland Diet Low Residue High Fiber Fat Controlled High Iron High Calorie Low Calorie Sodium Restriction Protein Restriction Low Purine High Protein Low Calcium High Calcium

DISORDERS
1.

STOMATITIS ESOPHAGEAL VARICES GASTROESOPHAGEAL REFLUX HIATAL HERNIA GASTRITIS PUD INTESTINAL OBSTRUCTION INFLAMMATORY BOWEL DISEASE IRRITABLE BOWEL SYNDROME APPENDICITIS DIVERTICULITIS HEMORRHOIDS CANCER OF THE STOMACH CANCER OF THE COLON

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

STOMATITIS
Inflammation of the mouth Cause by bacteria, virus, fungi, lack of vitamins, certain drugs Problem: pain, no intake Treat the cause Mouth care (NSS and hydrogen peroxide)

ESOPHAGEAL VARICES
Dilated tortuous esophageal veins Caused by PORTAL HPN, CHF, CIRRHOSIS Bleeding varices EMERGENCY

Click to edit Master text styles Prevention of bleeding Second level Third level Sengstaken Blakemore Tube Fourth level Drugs: Pitressin (constrict) and NTG, Fifth level

Sandostatin (selective splanchnic vasoconstriction) Surgery: Sclerotherapy

GASTROESOPHAGEAL REFLUX
Backflow of gastric and duodenal contents into the esophagus Due to incompetent upper and lower esophageal sphincter Symptoms may mimic heart problems (rule out by Bernsteins Test) s/sx: pyrosis (heart burn), dyspepsia, regurgitation, dysphagia, ptyalism Positioning (fowlers) Low fat high fiber DIET PUD drugs Surgery: Fundoplication

HIATAL HERNIA
herniates into the thoracic cavity Sliding (common) Rolling (severe) s/sx, intervention same as GERD Surgery: Fundoplication

Diaphragmatic Hernia
Herniation of intestinal content into the thoracic cavity Left side S/sx: respiratory difficulty, cyanosis, retractions, (-) breath sounds affected side, scaphoid abdomen Cx: pulmonary HPN Mx:E surgery

GASTRITIS
Inflammation of the gastric mucosa Caused by NSAID, highly seasoned food, alcohol intake, radiation therapy CHRONIC: H. pylori (rule out by Urea Breath Test) s/sx: abdominal discomfort, headache, anorexia, NV, hiccuping, Pernicious Anemia may occur if its CHRONIC

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Urea Breath Test

Indication: PUD, Gastritis Detects the presence of helicobacter pylori Client is instructed to avoid antibiotics and PUDs drug before the test (1-30days)

UREA BREATH TEST

The test takes approximately an hour and a half to complete. first step is to take a sample of your breath by blowing into a balloon or another container. Next, you will swallow either a drink or a capsule that contains urea attached to a carbon atom. You may also be given a citric acid drink (such as orange juice). Thirty minutes later, a technician will take more samples of your breath. The samples are sent to the laboratory for analysis.

Types: esophageal, gastric, duodenal Dx: SCOPIC

PUD

H. Pylori (most common cause) s/sx: pain, belching, bleeding Intervention: avoid gastric irritants, DRUGS, DAT, Surgery*

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KEY POINTS

Is an ulceration in the mucosal wall of the stomach, pylorus or duodenum. It occurs in portion that are accessible to gastric secretions.

PUD

Due to:
Bacterial invasion of H. pylori (common) UREASE Increased HCl secretions Zollinger Ellison Syndrome (HCl) Vagal Stimulation ASA, steroids and NSAIDs Smokers (high risk)

PUD
TO DIAGNOSE: Medical history and s/sx evaluation Gastroscopy (key test) Blood Exam (+ Antigen for H. pylori) Gastric biopsy (to detect cancer)

PUD
DRUGS: H A M A P T A C A (Metro Amox Tetra) O

Nursing Considerations: Avoid spicy foods Milk stimulates HCl secretion Avoid coffee, chocolate, cola, caffeine No snacks at bedtime ( HCL secretions) Diet SIPPY (neutralizing acidity of gastric juice. Small amounts of milk and cream every hour and alkaline powders every half hour. ) Bland, DAT

PUD

COMPLICATIONS: Hemorrhage (anemia, hematemesis, hematochezia, melena) Perforation Pyloric obstruction

PUD

2.

4.

GASTRIC ULCER 1. 50 y/o and above Lower socioeconomic class 3. 20% Normal to hyposecretion of HCl 5. Pain at meal 6. Hematemesis, N/V 7. With malignancy 8. At lesser curvature 9. Malnourished 10. Blood group O, A 11. Type B personality

PUD
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

DUODENAL ULCER 25-50 y/o Executives 80% Hypersecretion of HCl Pain after meals Melena No malignant growth With in 3 cm pylorus Well nourished Blood group O, B Type A personality

Zollinger-Ellison Syndrome
Non-beta tumor (pancreas) Gastrin secretions Severe peptic ulceration Treatment: H2 anatagonist and PPI

Stress Ulcer
Cushings Ulcer From head injury Curlings Ulcer From major burn injury

PUD
Surgery
Vagotomy (complication is diarrhea) give KAOPECTATE Antrectomy Pyloroplasty Billroth I and II Cx: bleeding, F and E loss (KCl), Dumping Syndrome, Pernicious Anemia
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Billroth I

Billroth II

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Intestinal Obstruction
Types: Mechanical, Neurogenic, Vascular Dx: s/sx, UTZ s/sx: decreased PM, abdominal distention, pain, vomiting Intervention: NPO, NIT (miller abott) Surgery*

KEY POINTS

Cause: unknown, JEWISH, auto immune Dx: SCOPIC s/sx: pain, bleeding, diarrhea, fever, weight loss, anemia, dehydration Intervention: low fiber, symptomatic, steroids*

IBD

KEY POINTS

IBD
Ulcerative Colitis?
1. 2.

Rectum to cecum

1. 2.

Anorexia, weight loss, malaise, abdominal cramping, severe diarrhea, bloody/mucoid stool, dehydration, anemia, electrolyte loss, vit K deficiency
3.

Crohns Disease? Mouth to anus Fever, pain after meal, diarrhea, pus/mucoid stool, weight loss, anemia, dehydration, electrolyre loss

3.
4.

Dx: Scopic
Surgery: not recommended (recur), Ileoanalanastomosis No malignancy Cx: same*

Dx: Scopic With malignancy

4.

Surgery: double, colectomy

5.

5. 6.

6.

Cx: fistula, ulceration, abscess (severe)

IBD
Drugs?
Anticholinergics (Sympa) Dicyclomine (Bentyl) Buscopan (Hyoscine Na Butylbromide) Antidiarrheal (Lomotil) Sedatives and Narcotics to decrease apprehension and pain Tranquilizer (to peristalsis) Immunosuppressive drugs to prevent another attack Sulfonamides or sulfa drugs(Anti infectives, antibacterial) Sulfasalazine (Azulfidine) anti inflammatory*

IRRITABLE BOWEL SYNDROME Unknown cause

Increased motility of the small and large intestine Young adults are affected Diarrhea and lower abdominal pain Relieved by passing flatus or stool Rule OUT other diseases (IBD, lactose intolerance and dysentery)*

KEY POINTS

Small Bowel Syndrome

Congenital or due to intestinal resection s/sx:( ileal resection) MALABSORPTION fat malabsorption, ADEK deficiency, fluids and electrolytes Intervention: symptomatic*

KEY POINTS

Appendicitis
Cause: fecalith, parasites, seeds Dx: s/sx, lab exam (WBC), Mc Burneys pain, UTZ s/sx: nausea and vomiting, low fever, pain, foul odor Intervention: no ENEMA, no LAXATIVE, no warm compress, surgery*

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KEY POINTS

Peritonitis
Cause: perforation, leakage, dialysis Dx: rebound tenderness, fever, WBC elevation, thoracentesis Cx: sepsis Intervention: massive antibiotics, Surgery

Intestinal Aneurysm
Cause: unknown, constipation Dx: BARIUM ENEMA, SCOPIC Diverticula-diverticulitis No intervention for Diverticula (diet: low fiber, no seeds and nuts, increase fluids) Diverticulitis same with appendicitis*

KEY POINTS

DIVERTICULITIS
Management: IVF Bedrest NPO rest the bowel NGT to decompress Antibiotics, analgesic, antispasmodic Low residue for severe type Avoid bulk forming foods SuRGERY to prevent repeated episodes. RESECTION of the COLON.

Hemorrhoids
Cause: increased INTRA abdominal pressure Dx: s/sx, rectal inspection s/sx: bleeding, pain, itchiness Intervention: daflon, surgery*

KEY POINTS

Cancer of the Stomach

Most common GI cancer, cured foods, low in fiber Click s/sx: vague fullness, bleeding LATE: to edit Master text style Second level ascites, palpable mass Third level Intervention: C&R, surgery Fourth level (Billroth I&II) Fifth level Follow post-op procedures Dumping Syndrome Pernicious Anemia*

Cancer of the Colon

Cause: low fiber high cholesterol diet, POLYPS Common in men s/sx: change in BM, bleeding, obstruction Adenocarcinoma Intervention: C&R, surgery Follow post-op procedures
Colostomy care*

ACCESSORY ORGANS

Salivary Glands
Parotid Sublingual Submandibular S-AP Amylase (catalyzes starch into smaller CHO) Ptyalin (hydrolyzes starch and glycogen)

Parotitis Ptyalism Stomatitis*

Pancreas
Mixed gland
Endocrine Beta=insulin Alpha=glucagon Delta= somatostatin (inhibitory) Exocrine PLAT

Lipase=FATS

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Amylase=CHO Trypsinogen=CHON
Other functions? Collect worn-out RBC/WBC Enzymes drain at the duodenum Indicator for pancreatitis = Serum lipase increased

Functions?

Biliary
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Gall bladder-stores and concentrates bile Bile? Bile-emulsifies fat for absorption Cholesterol Bilirubin 1 Hormone? CCK cholecystokinin

Gall Bladder
Bile Circulation right and left hepatic duct common hepatic duct cystic duct gall bladder bile is stored presence of fats in the intestine cholecystokinin stimulates sphincter of oddi contraction of gall bladder bile comes out cystic duct common bile duct drains at the ampulla of vater in the duodenum.

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RIGHT and LEFT lobe separated by falciform ligament Click to edit Master text styles Second level CAUDATE lobe near the IVC QUADRATE lobe between left lobe and gall bladder Hepatic Artery Portal Vein Hepatic Vein Blood from all sources mix in the liver sinusoids (hepatocytes)
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Liver

Liver Functions:
Synthesis, storage and release of vitamins and glycogen Synthesis of blood proteins Phagocytosis of worn-out RBC and WBC and bacteria Removal of toxic compounds (kupffers cells) (deamination) Bile production for fats emulsification Synthesis of clotting factors Conversion of hormone (estrogen to active metabolites) Conjugation of bilirubin B1=conjugated/metabolized by the liver B2=unconjugated

GIT Accessory Disorders

Gall Bladder
Stores, concentrate bile Stone: cholesterol, 4 Fs, statins use Cholelithiasis: Cholecystitis Choledocholithiasis: Cholangitis Dx: IAPP (murphys, TRIAD) , UTZ, ERCP, cholecystography, PTHC s/sx: fat intolerance, ADEK def., pain, fever, jaundice Drugs: CDCA chenodeoxycolic acid ( the size of stone), prohylactic antibiotic Intracorporeal lithotripsy, Surgery (T-Tube)*

Cause: obstructive, hemolytic, hepatic Dx: Hx, IPPA, s/sx s/sx: urine, frenulum, skin, sclera, brain Intervention: symptomatic, relieve itchiness (soothing), cholestyramine, treat the cause*

Jaundice

KEY POINTS

CIRRHOSIS
Pathogenesis: repeated destruction of hepatic cell

scar tissue formation (fibrotic)

regeneration of liver cell follows

another destruction will occur cycle (scarring and regeneration) until

hepatocytes become fibrotic compromising liver function

Liver Functions:
Synthesis, storage and release of vitamins and glycogen Synthesis of blood proteins Phagocytosis of worn-out RBC and WBC and bacteria Removal of toxic compounds (kupffers cells) (deamination) Bile production for fats emulsification Synthesis of clotting factors Conversion of hormone (estrogen to active metabolites) Conjugation of bilirubin B1=conjugated/metabolized by the liver B2=unconjugated*

Types?
Laennecs Cirrhosis most common alcoholic cirrhosis Biliary Cirrhosis biliary obstruction and infection Postnecrotic Cirrhosis hepatitis*

Clinical Course?
1. 2.

Liver enlargement GIT s/sx: fever, anorexia, weight loss, fatigue Liver function is impaired

3.

PRE ICTERIC ICTERIC NEUROLOGIC*

CIRRHOSIS s/sx and interventions?

glycogen storage (fatigue and hypoglycemia) increased breakdown of FFA (hyperlipidemia) metabolism of bile salts jaundice and fat intolerance (steatorrhea) and ADEK deficiency synthesis of CHON ( blood cells) estrogen-androgen imbalance estrogen (gynecomastia and edema) androgen (testicular dystrophy)*

CIRRHOSIS s/sx and interventions?

metabolism of nitrogenous waste products (deamination process) fetor hepaticus (foul smelling breath) leads to azotemia to hepatic encephalopathy (asterixis and decreased LOC), constructional apraxia*

CIRRHOSIS s/sx and interventions?

portal HPN?
1. 2. 3. 4. 5.

esophageal varices enlargement of pancreas and spleen ascites, , caput medusa, hemorrhoids venous return (DVT) Measurement: insert a tube similar to PCWP assessment SHUNT: Leveen and portacaval*

6.

SHUNT: Leveen and portacaval

CIRRHOSIS
Congestion of tiny blood vessels
1. 2. 3. 4. 5. 6.

vein distention (angioma) hemorrhoids spiderangioma (red dot) palmar erythema telangiectasia (permanent) esophageal varices

Cirrhosis
Diagnostic and Lab:
1. 2. 3. 4.

Key Tests Hepatic Scan, IPPA Liver enzymes Serum bilirubin Liver biopsy

Cirrhosis
Cause: Laennecs, Hepatitis, Biliary Hepatocytes fibrotic tissue (inflammation and healing) Dx: IPPA, Scan, Liver Enzymes, Biopsy s/sx: hepatomegaly, anorexia, fatigue, wt. loss, CHO, CHON, FATS, BILE, ESTROGEN, DEAMINATION, PVP INTERVENTION: symptomatic Drugs: symptomatic*

KEY POINTS

Cancer of the Liver

Usually a complication of CIRRHOSIS or from metastasis Hepatic failure s/sx: similar to cirrhosis Intervention: C&R, (Fluorouracil 5 FU, Cytoxan, Oncovin), liver transplant GALL BLADDER CA 1 YEAR SURVIVAL*

Pancreatitis
Acute and chronic Acute (obstruction) Chronic (malabsorption) alcoholics Dx: serum lipase, CT scan, biopsy s/sx: acute and chronic? Mx: Acute Chronic*

Cancer of the Pancreas

Mostly adenocarcinomas Head of the pancreas s/sx: obstruction of the CBD, anorexia, weight loss, pain (upper abdomen, left hypochondriac), jaundice Dx: increased serum lipase and bilirubin Intervention: C&R, surgery (WHIPPLES) pancreatoduodenectomy, anastomosis of stomach, duodenum, CBD and pancreatic duct*

Thank you

Pancreatitis
Autodigestion to severe internal bleeding Due to:
Alcoholism (Chronic) malabsorption Biliary obstruction Click to edit Master text styles Second level Third level Fourth level Fifth level

(Acute) pain, bleeding

Manifestations:
Abdominal pain? (constant mid epigastric, periumbilical that may radiates to back or flank Client assumes fetal (celiac plexus nerve)

position? to relieve pressure

Involuntary abdominal guarding or absent bowel sound Grey Turners Sign-purplish discoloration of the flank (BLEEDING) Cullens sign-periumbilical discoloration (BLEEDING)

Diagnostic:
Serum lipase (specific)? serum lipase, amylase, glucose LDH, AST and ALT calcium (it binds with area of necrosis) CT scan (accurate test)

Management:
IVF (plasma expander) Treat acidosis, pleural effusion and hypoxia Pain control NPO with NGT for decompression Maintain alkaline pH of stomach Removal of pancreas

Tnk u po!

END