I.

INTRODUCTION

Gastroenteritis is a condition that causes irritation and inflammation of the stomach and intestines (the gastrointestinal tract). Diarrhea, crampy abdominal pain, nausea, and vomiting are the most common symptoms. Viral infection is the most common cause of gastroenteritis but bacteria, parasites, and food-borne illness (such as shellfish) can be the offending agent. Many people who experience the vomiting and diarrhea that develop from these types of infections or irritations think they have "food poisoning," and they may indeed have a food-borne illness. Many people also refer to gastroenteritis as "stomach flu," although influenza has nothing to do with the condition. Travelers to foreign countries may experience "traveler's diarrhea" from contaminated food and unclean water. The severity of infectious gastroenteritis depends on the immune system's ability to resist the infection. Electrolytes (these include essential elements of sodium and potassium) may be lost as you vomit and experience diarrhea. Most people recover easily from a short bout with vomiting and diarrhea by drinking fluids and easing back into a normal diet. But for others, such as infants and the elderly, loss of bodily fluid with gastroenteritis can cause dehydration, which is a life-threatening illness unless the condition is treated and fluids restored. Bacterial gastroenteritis is frequently a result of poor sanitation, the lack of safe drinking water, or contaminated food-conditions common in developing nations. Natural or man-made disasters can make underlying problems in sanitation and food safety worse. In developed nations, the modern food production system potentially exposes millions of people to diseasecausing bacteria through its intensive production and distribution methods. Common types of bacterial gastroenteritis can be linked to Salmonella and Campylobacter bacteria; however, Escherichia coli 0157 and Listeria monocytogenes are creating increased concern in developed nations. Cholera and Shigella remain two diseases of great concern in developing countries, and research to develop long-term vaccines against them is underway. The symptoms of gastroenteritis are usually enough to identify the illness. Unless there is an outbreak affecting several people or complications are encountered in a particular case, identifying the specific cause of the illness is not a priority. However, if identification of the infectious agent is required, a stool sample will be collected and analyzed for the presence of viruses, disease-causing (pathogenic) bacteria, or parasites.

II. ANATOMY AND PHYSIOLOGY

` Digestion is the process by which food is broken down into smaller pieces so that the body can use them to build and nourish cells and to provide energy. Digestion involves the mixing of food, its movement through the digestive tract (also known as the alimentary canal), and the chemical breakdown of larger molecules into smaller molecules. Every piece of food we eat has to be broken down into smaller nutrients that the body can absorb, which is why it takes hours to fully digest food. The digestive system is made up of the digestive tract. This consists of a long tube of organs that runs from the mouth to the anus and includes the esophagus, stomach, small intestine, and large intestine, together with the liver, gall bladder, and pancreas, which produce important secretions for digestion that drain into the small intestine. The digestive tract in an adult is about 30 feet long.

Mouth and Salivary Glands Digestion begins in the mouth, where chemical and mechanical digestion occurs. Saliva or spit, produced by the salivary glands (located under the tongue and near the lower jaw), is released into the mouth. Saliva begins to break down the food, moistening it and making it easier to swallow. A digestive enzyme (called amylase) in the saliva begins to break down the carbohydrates (starches and sugars). One of the most important functions of the mouth is chewing. Chewing allows food to be mashed into a soft mass that is easier to swallow and digest later. Movements by the tongue and the mouth push the food to the back of the throat for it to be swallowed. A flexible flap called the epiglottis closes over the trachea (windpipe) to ensure that food enters the esophagus and not the windpipe to prevent choking.

Esophagus Once food is swallowed, it enters the esophagus, a muscular tube that is about 10 inches long. The esophagus is located between the throat and the stomach. Muscular wavelike contractions known as peristalsis push the food down through the esophagus to the stomach. A muscular ring (called the cardiac sphincter) at the end of the esophagus allows food to enter the stomach, and, then, it squeezes shut to prevent food and fluid from going back up the esophagus.

Stomach The stomach is a J-shaped organ that lies between the esophagus and the small intestine in the upper abdomen. The stomach has 3 main functions: to store the swallowed food and liquid; to mix up the food, liquid, and digestive juices produced by the stomach; and to slowly empty its contents into the small intestine. Only a few substances, such as water and alcohol, can be absorbed directly from the stomach. Any other food substances must undergo the digestive processes of the stomach. The stomach's strong muscular walls mix and churn the food with acids and enzymes (gastric juice), breaking it into smaller pieces. About 3 quarts of the gastric juice is produced by glands in the stomach every day.

The food is processed into a semiliquid form called chyme. About 4 hours or so after eating a meal, the chyme is slowly released a little at a time through the pyloric sphincter, athickened muscular ring between the stomach and the first part of the small intestine called the duodenum.

Small Intestine Most digestion and absorption of food occurs in the small intestine. The small intestine is a narrow, twisting tube that occupies most of the lower abdomen between the stomach and the beginning of the large intestine. It extends about 20 feet in length. The small intestine consists of 3 parts: the duodenum (the C-shaped part), the jejunum (the coiled midsection), and the ileum (the last section). The small intestine has 2 important functions. First, the digestive process is completed here by enzymes and other substances made by intestinal cells, the pancreas, and the liver. Glands in the intestine walls secrete enzymes that breakdown starches and sugars. The pancreas secretes enzymes into the small intestine that help breakdown carbohydrates, fats, and proteins. The liver produces bile, which is stored in the gallbladder. Bile helps to make fat molecules (which otherwise are not soluble in water) soluble, so they can be absorbed by the body. Second, the small intestine absorbs the nutrients from the digestive process. The inner wall of the small intestine is covered by millions of tiny fingerlike projections called villi. The villi are covered with even tinier projections called microvilli. The combination of villi and microvilli increase the surface area of the small intestine greatly, allowing absorption of nutrients to occur. Undigested material travels next to the large intestine.

Large Intestine The large intestine forms an upside down U over the coiled small intestine. It begins at the lower right-hand side of the body and ends on the lower left-hand side. The large intestine is about 5-6 feet long. It has 3 parts: the cecum, the colon, and the rectum. The cecum is a pouch at the beginning of the large intestine. This area allows food to pass from the small intestine to the large intestine. The colon is where fluids and salts are absorbed and extends from the cecum to the rectum. The last part of the large intestine is the rectum, which is where feces (waste material) is stored before leaving the body through the anus.

The main job of the large intestine is to remove water and salts (electrolytes) from the undigested material and to form solid waste that can be excreted. Bacteria in the large intestine help to break down the undigested materials. The remaining contents of the large intestine are moved toward the rectum, where feces are stored until they leave the body through the anus as a bowel movement.

Rectum The rectum is a short, muscular tube that forms the lowest portion of the large intestine and connects it to the anus. Feces collects here until pressure on the rectal walls cause nerve impulses to pass to the brain, which then sends messages to the voluntary muscles in the anus to relax, permitting expulsion.

ACCESSORY ORGANS: Spleen The spleen is the largest of the lymphoid tissues. It is just about the size of the heart and is a spongy material which will hold up to .3 gallons of blood. It is located on the left side of the body, just behind the stomach. The spleen is a valuable organ which produces some of the white blood cells, filters the blood, destroys old, worn-out red blood cells and returns needed iron to the blood, disposing of the rest as waste. The spleen also stores excess blood for emergencies; for example, when oxygen in the circulatory system is short. We often hear that the victim of an auto accident has had a ruptured spleen which has been removed surgically. Because the spleen is so soft and spongy, it cannot be repaired by surgery, so it is removed to stop the loss of blood. Gallbladder The gallbladder is an active storage shed, which absorbs mineral salts and water received from the liver and converts it into a thick, mucus substance called "bile," to be released when food is present in the stomach. The gallbladder is a small, pear-shaped sac which is situated just below the liver and is attached to it by tissues. It stores bile and then releases it when food passes from the stomach to the duodenum (the first part of the small intestine) to help in the process of digestion. It has a capacity of around one and one-half fluid ounces. When food leaves the stomach, a secretion causes the gallbladder to contract and expel its contents into the duodenum, where the bile disperses the fats in the food into liquid.

Liver Thirty per cent of the blood pumped through the heart in one minute passes through the body's chemical factory, which is called the liver. The liver cleanses the blood and processes nutritional molecules, which are distributed to the tissues. The liver also receives bright red blood from the lungs, filled with vital oxygen to be delivered to the heart. The only part of the body which receives more blood than the liver is the brain. The liver is located at the top of the abdomen, just below the diaphragm and has two main lobes. It is the largest gland in the body, weighing 2.5 to 3.3 pounds. When we eat, more blood is diverted to the intestines to deal with digestive processes; when not eating, three-fourths of the blood supply to the liver comes from the intestines. It also produces about two and one-half pints of bile in its ducts, which is delivered to the gallbladder through a small tube called the "cystic duct" for storage. "Liver" is probably an appropriate name for this gland, which makes the important decision as to whether incoming substances are useful to the body or whether they are waste. The liver is an extremely important organ and has multiple functions. The liver detoxifies blood cells by mixing them with bile and by chemical alteration to less toxic substances, such as the alteration of ammonia to urea. Many chemical compounds are inactivated by the liver through modification of chemical structures. The liver converts glucose to a storage form of energy called glycogen, and can also produce glucose from sugars, starches, and proteins. The liver also synthesizes triglycerides and cholesterol, breaks down fatty acids, and produces plasma proteins necessary for the clotting of blood, such as clotting factors I, III, V, VII, IX and XI. The liver also produces bile salts and excretes bilirubin. A "lily-livered coward" was someone whose liver contained no blood. The Greeks and Romans sacrificed animals to the gods before going into battle. When the liver was examined, if it was healthy and the blood was bright red, a victory was promised; if it was diseased or the blood was pale, defeat was predicted.

III. PATHOPHYSIOLOGY Predisposing Factors: Age: Very Young Precipitating Factors: Fecal-contaminated food Sanitation, improper handling

Entamoeba histolytica

Ingestion of fecal-contaminated food & water by susceptible host

Endotoxins are released

Stimulation and destruction of mucosal lining of the stomach and bowel wall

Stomach: >Pain >Nausea &vomiting >Tenderness & bloatedness

Intestines: >Melena >Slow absorption >Frequent defecation

Attempted defecation (tenesmus)

\ Secretion of F&E in the intestinal lumen

Inhibition of Na reabsorption (Hypernatremia)

F&E imbalance

Metabolicacidosis

Large intestine is overwhelmed & unable to reabsorb the lost fluid

Diarrhea (>6x)(watery stool)

Serious fluid volume deficit

Hypovolemic shock and Hypotension

DEATH

VI. NURSING AND MEDICAL MANAGEMENT Fluids

It is imperative that the patient's input and output be monitored and documented at regular intervals. He should be encouraged to take as many fluids as he can, since this will help flush the illness out of his system and prevent dehydration, which is a risk of acute gastroenteritis. The patient should sip fluids slowly as to not upset the stomach. Avoid giving her sugary drinks, instead offering water, Powerade or something similar.

Food

If the patient is able to keep fluids down, he might try eating something small, like a saltine cracker. Keep track of what he eats and what he can and cannot keep down. The patient should eat slowly at first, gradually increasing the amount. As her condition improves, she may be able to eat soups or soft, pureed foods that don't have a lot of spices in them.

Dehydration

If the patient becomes dehydrated, he may require IV fluids, which the nurse should closely monitor. The doctor should be informed if the patient's urine output is below 500 milliliters per day or serum electrolyte levels are abnormal. The patient may be very weak if dehydrated, so she should be helped in getting out of bed to go the bathroom, since she could become dizzy and fall.

Rest

Make sure the patient's room has a restful mood by keeping noise to a minimum and maintaining the patient's privacy. This can be difficult in a hospital setting, but even closing his curtains or the door might help. He might try methods such as visual imagery to help focus on things besides his illness and pain. For example, he could visualize being in Hawaii with the waves lapping at his feet, making a gentle, soothing sound. This kind of visualization may help relieve his symptoms. The nurse can talk him through this visualization the first few times.

Medications

It's important to follow doctor's orders with all medications. If the doctor prescribes PRN (as-needed) medications for the nausea, these can be given to the patient. Medications that might be prescribed by the physician include Compazine, Phenergan, Reglan, Emetrol, Tigan, and Zofran. These medications might give the patient some relief from the nausea and vomiting. If the diarrhea is not resolved, other medications may also be prescribed, such as dicyclomine, Lomotil and Imodium.

St. Marys College Quezon City

ACUTE GASTROENTERITIS
Submitted by: AIZA F. ORONCE

Submitted to: Ms. Lanie Ann Rebano