As discussed by Nurse Joel C. Pascua.
Anatomy and Physiology
- Digestion begins in the mouth, occuring in both mechanical (chewing) and chemical forms (salivary amylase)
- Through the esophagus, chewed food (bolus) makes its way to the stomach through voluntary swallowing (upper third of the esophagus) and peristalsis (lower two-thirds of the esophagus).
- In the stomach, both chemical (hydrochloric acid, gastrin, pepsin, IF) and mechanical digestion (whirlpool) still occurs. It ends at the pylorus, which has a sphincter that connect the stomach and the small intestine.
- The small intestine is divided into three portions: the duodenum, the jejunum, and the ileum.
- Duodenum: the primary site of intestinal digestion from the pancreatic enzymes (amylase, lipase, trypsin). This is also where bile emulsifies fats that allow it to enter the body. This is important for the absorption of the fat-soluble
- Jejunum: the primary site of absorption.
- Ileum: final absorption of vitamins and minerals.
- The large Intestine follows the small intestines, starting with the cecum and ending in the sigmoidal colon, leading to the rectum then anus. The colon mainly functions for fluid reabsorption and electrolyte balance.
- Ascending colon
- Transverse colon
- Descending colon
- Sigmoidal colon
- Rectum: the temporary holding space for feces. It may undergo tenesmus (involuntary stool evacuation) with the presence of feces.
Epidemic Parotitis
A potentially infectious inflammation of the parotid glands, also known as mumps. It is caused by the infectious agent Paramyxo viridae.
- Signs and Symptoms:
- Suddenly swollen parotid glands, giving it its distinctive physical appearance.
- Pain
- Fever
- Dysphagia
- Management:
- Increase oral fluid intake, at least 6 to 8 glasses of water (according to body mass).
- Increase immune system starting with PPE, the consumption of vitamin C, and iron.
- Complications:
- Orchitis and/or epididymitis. In young adults, this is the most common cause of sterility or decreased sperm viability.
- Viral pneumonia is the common cause of death as a complication of parotitis. Sputum produced in viral pneumonia is more yellow in color, while bacterial pneumonia is more green in color.
Achalasia
The absence or ineffectiveness of peristalsis of the esophagus. This is primarily caused by the failure of the esophageal sphincter to relax in response to swallowing. This results in the accumulation of bolus in the esophagus during feeding.
- Risk Factors: >40 years old
- Signs and Symptoms: dysphagia, sensation of food sticking onto the lower esophagus, and spontaneous/intentional regurgitation.
- The patient often reports non-cardiac chest pain.
- A late sign may include pyrosis as the sphincter loosens from overfilling.
- Complications:
- Aspiration from backflow of food with regurgitation.
- Perforation from tearing of the esophagus, which may result in peritonitis
- Diagnostic Evaluation:
- X-ray studies, Barium swallow, CT scan: Check for allergies to iodine, shellfish, shrimps, etc.
- Endoscopy for visualization
- Monometry: measurement of the electrical activity of the esophageal musculature.
- Management:
- Diet: eat and drink slowly. Fluid intake is encouraged during meals to aid the food in being moved.
- Pharmacology:
- Oral calcium channel blockers and nitrates for smooth muscle relaxation.
- Botulinum injection (botox) that relaxes the contracted sphincter.
- Surgery:
- Esophagomyotomy or Endoscopic Myotomy: cutting/severing of contracted esophageal muscle fibers.
- Pneumatic Dilation: the use of air to dilate the sphincter.
Gastroesophageal Reflux Disease
GERD is the backflow of gastric contents to the esophagus most commonly due to an incompetent or weak lower esophageal sphincter, but also potentially due to pyloric stenosis, increased abdominal/gastric pressure, hiatal herniation, motility disorders (such as achalasia).
- Risk Factors: Irritable Bowel Syndrome (IBS), Chronic Obstructive Pulmonary Disorders (COPD)/CAL, Cystic Fibrosis, Peptic Ulcer Disease (PUD), Angina Pectoris (AP), Tobacco Use, Alcohol Consumption, Overuse of Caffeine, Gastric Infections
- Signs and Symptoms:
- Pyrosis (heartburn)
- Dyspepsia (indigestion)
- Regurgitation (backflow of food)
- Dysphagia (discomfort) and/or odynophagia (pain)
- Hypersalivation, which may result in water brash regurgitation; the regurgitation of saliva rather than of bolus/chyme.
- Esophagitis
- Complications:
- Barrett’s Esophagus or Barrett’s Epithelium: the conversion of the cells of the esophageal lining due to repeated irritation and inflammation into thickened, columnar, pre-malignant cells.
- Diagnostic Examination: visualization via endoscopy and subsequent biopsy of abnormal cells.
- Barium swallow may be used.
- Ambulatory 12 to 36 hour esophageal pH monitoring
- Wireless Capsule pH monitoring
- Management:
- Lifestyle
- Avoid tobacco and alcohol use
- Avoid tight-fitting clothes, bending over, and constipation that can increase gastric/abdominal pressure.
- Diet:
- Avoid irritating foods and drinks such as caffeine, hot foods and fluids, spicy foods, milk (lactic acid), peppermint, and carbonated beverages
- Avoid eating and drinking 2 hours before bedtime to prevent nighttime reflux.
- Low fat, high-fiber diet to promote gastric emptying.
- Maintain normal weight, as obesity increases gastric pressure. Weight is measured daily in the morning, before breakfast.
- Eat slowly, and in small portions in more frequent intervals. Food should be chewed thoroughly.
- Position: Semi Fowler’s is used to prevent reflux. High Fowler’s is not used as it compresses the abdomen, which can exacerbate the disorder.
- Pharmacologic:
- Antacids: aluminum hydroxide, aluminum magnesium, calcium carbonate
- Histamine-2 Receptor Blockers: cimetidine, ramitidine
- Prokinetic Agents: metoclopramide
- Proton Pump Inhibitors: omeprazole, esomeprazole (-prazoles).
- Reflux Inhibitors: bethanedol chloride
- Surface Agents (protectants): sucralfate
- Surgical:
- Nissen Fundoplication (gastric wrap-around): a procedure that wraps the upper portion of the stomach around the esophageal sphincter to improve closure and prevent gastric reflux.
- Lifestyle
- Nursing Diagnoses:
- Imbalanced Nutrition: Less than body requirements
- Risk for Aspiration
- Acute Pain
- Knowledge Deficit
Gastrointestinal Bleeding
This is divided between the upper gastrointestinal tract (upper GI bleeding; UGIB) and the lower gastrointestinal tract (lower GI bleeding; LGIB), with the upper GIT ending at the duodenum.
Esophageal Bleeding
Bleeding of the esophagus due to ruptured esophageal veins due to esophageal varices due to portal vein hypertension.
Portal Hypertension
Portal vein hypertension develops most commonly due to liver cirrhosis, 95% of which is classified as Laennec’s Cirrhosis (alcoholism).
- Signs and Symptoms:
- Retrosternal chest pain due to tissue damage from the rupture itself.
- Hematemesis, vomiting of fresh blood.
- Melena, black tarry stool.
- Hematochezia, fresh blood in the stool that occurs once profuse bleeding has inactivated the conversion of blood into its black, tarry stool.
- Complications:
- Hypovolemic Shock
- Management:
- Monitor vital signs: blood pressure, pulse rate, respiratory rate, and level of consciousness.
- Blood Studies
- Administer: oxygen, blood transfusion, vasopressin (drug of choice)
- Sengstaken-Blakemore Tube: a three or four-lumen catheter inserted into the esophagus in order to apply direct pressure to the ruptured varices. It contains a balloon that may be inflated.
- The airway is a priority when this tube is in place. At the bedside, scissors must always be present to allow for quick deflation and removal of the tube.
- Nursing Responsibilities: Deflate the balloon every 8 to 12 hours for at least 30 minutes.
Ascites
The excessive accumulation of fluid in the peritoneal cavity as a result of decreased oncotic pressure as a result of protein (albumin) depletion secondary to liver dysfunction.
- Signs and Symptoms: large abdomen
- Management:
- Administer: Loop Diuretics (and potassium supplementation).
- Diet: sodium restriction
- Paracentesis: the invasive removal of accumulated fluids through aspiration. In one withdrawal, not more than 500 mL of fluids may be removed to prevent sudden hypotension.
- Performed with sterile technique as it is an invasive procedure.
- Diagnostic Purpose: withdrawal of 3 to 5 liters of fluid to be used for diagnostic examination.
- Therapeutic Purpose: withdrawal of 5 to 6 liters of fluid as therapy, as long as client blood pressure is stable.
- Positioning: during the procedure, the patient is positioned in sitting or High fowler’s with a foot stool, and placed in a sitting position or based on client comfort after.
- Nursing Considerations: (a) empty the bladder, (b) monitor vital signs, specifically the blood pressure, (c) watch out for complications: infection, bleeding/leakage at the puncture site, F&E imbalance, and changes in mental status, and (d) measure abdominal girth in the morning.
Hiatal Hernia
The herniation of a part of the stomach through the diaphragmatic hiatus into the thorax due to an incompetent or abnormal opening of the diaphragm. There are two types:
- Sliding (Type I) Hiatal Hernia: the upper stomach and the gastroesophageal junction are displaced.
- Paraesophageal Hiatal Hernia: all parts of the stomach are displaced.
- Signs and Symptoms: (similar to the signs of GERD)
- Pyrosis when gastric contents are regurgitated into the esophagus.
- Dysphagia and odynophagia
- Feeling of fullness in the chest area
- Hemorrhaging, obstruction, and strangulation in severe cases
- Diagnostic Examination:
- X-ray studies are confirmatory for hiatal hernia.
- Barium swallow may also be used.
- Management:
- Diet: small, frequent meals
- Lifestyle:
- Avoid lying after eating for at least one hour to prevent reflux or reoccurrence of hernia.
- Elevate the head of the bed by four to eight inches.
- Surgery: Nissen Fundoplication (Gastric wrap-around), same as GERD.
Peptic Ulcer Disease
An excavation forms in mucosa of the stomach or upper gastrointestinal tract (esophageal, gastric, and duodenal). It may be caused by:
- Increased concentration of gastric acidity
- Decreased protective capability of the stomach mucosa
- Risk Factors: prolonged use of NSAIDs, old age, H. pylori infection, smoking and alcohol, family history, and chronic diseases (COPD, Liver Cirrhosis, CKD)
The type of the peptic ulcer disease is based on the location of the ulcer. Depending on their position, their cause and manifestations may vary:
- Esophageal Ulcer: the least common form; this may occur due to reflux damaging the esophagus.
- Gastric Ulcer: common in older patients, this appears on the greater curvature of the stomach and often leads into cellular aberrations— cancer of the stomach.
- Duodenal Ulcer: the most common type of ulcer
| Parameter | Gastric Ulcer | Duodenal Ulcer |
|---|---|---|
| Incidence | >50 years old | 30 - 60 years old |
| Portion of Cases | 15% | 80% |
| Hydrochloric Acid | Normal | Hypersecretion |
| Weight Changes | Often decreases; eating intensifies pain | Often increases; eating relieves pain |
| Bleeding | More bleeding | Less bleeding |
| Malignancy | Likely | Not likely |
Ulcers caused by Stress and Trauma
Parameter Curling’s Ulcer Cushing’s Ulcer Cause An ulcer that develops as the protective lining of the stomach thins after extensive burns from gastric cell hypoxia due to hypovolemia, often 72 hours after the burn. An ulcer that develops due to head trauma. Head trauma results in parasympathetic stimulation (“rest and digest”) which leads to acid hypersecretion.
- Signs and symptoms:
- Severe abdominal pain
- Pyrosis, Dyspesia
- Vomiting
- Coffee ground vomiting
- Hypotension and tachycardia (signs of shock)
- Diagnostic Examination:
- Physical examination
- Upper GIT endoscopy with biopsy
- H. pylori testing
- Blood studies: CBC and occult blood.
- Gastric secretory studies
- Complications:
- Vomiting which may also result in hypovolemic shock, fluid and electrolyte imbalance, and acid-base imbalance (metabolic alkalosis).
- Hemorrhage which may also result in hypovolemic shock.
- Peritonitis if a rupture or perforation occurs.
- Management:
- Goal of Therapy: eradicate H. pylori and to manage gastric activity
- Pharmacologic: a combination of antibiotics for H. pylori and drugs to reduce acidity:
- Proton pump inhibitors (omeprazole, esoprazole, etc.)
- Histamine 2 Receptor Blockers (-tidines)
- Bismuth Salts
- Lifestyle: cessation of smoking and alcohol use.
- Diet: small, frequent meals; avoid irritating foods such as hot, cold, spicy, highly seasoned foods, caffeine, and milk.
- Pain: manage pain but avoid NSAIDs, which are gastric irritants. Cox-2 Inhibitors may be used.
- Anxiety: reduce anxiety with therapeutic use of the self.
- Prevent complications.
- Surgery:
- Vagotomy to reduce vagal activity by cutting the vagus nerve
- Billroth Procedures: gastroduodenostomy (Billroth I) and gastrojujenostomy (Billroth II)
- Gastrectomy: removal of the entire stomach in cases of malignancy.
- Complications of Surgery:
- Dumping Syndrome: the loss of gastric regulation of gastric emptying results in the patient “dumping” consumed food quickly after eating.
- Pernicious Anemia: the loss of parietal cells results in intrinsic factor which is responsible for allowing vitamin B12 to be absorbed. Without it, red blood cells are unable to mature which results in megaloblastic anemia of the pernicious type.
Appendicitis
The inflammation of the appendix caused by a fecalith obstruction, kinking, or tumors, other foreign body obstructions of the appendix. This results in accumulation of fluids in the appendix which results in bacterial growth, rupture, and infection. This is common in 10 to 30 year olds.
- Signs and Symptoms:
- Anorexia, Abdominal Guarding
- Pain at McBurney’s Point, the region between the right anterior iliac crest and the umbilicus; McBurney’s Sign.
- Pyrexia, low-grade by nature.
- Examination reveals positive McBurney’s Sign
- Nausea and vomiting
- Decreased bowel sounds and peristaltic movement
- Increased WBC count on blood studies due to the infection.
- X-ray shows shadow of fecalith
- Signs:
- Obturator Sign: pain upon flexion and passive abduction of the right leg.
- Psoas Sign: pain at the right upon extension of the right leg.
- Jarrings Sign: pain when the patient stands on their toes and falls into a flat-footed stance.
- Rovsing’s Sign: referred tenderness
- Blumber’s Sign: rebound tenderness
- Diagnostic Examination:
- Physical Examination
- Complete Blood Count for WBC count.
- CT Scan: visualization of the appendix.
- Pregnancy Test: rule out the presence of an ectopic pregnancy.
- Urinalysis: rule out the presence of a urinary tract infection
- Complications:
- Ruptured Appendix, which leaks GIT contents into the peritoneal cavity, which can result in peritonitis. This relieves pain with the release of pressure.
- Abscess Formation
- Portal Phlebitis
- Management:
- Pain: while unconfirmed, no analgesics are given as these may mask complications of appendicitis. The sudden loss of pain indicates that the appendix has ruptured.
- No Warm or Hot Compress: a major contraindication; vasodilation produced by warmth will increase blood flow and worsen swelling of the appendix, which may result in rupture.
- No Laxatives or Enema: increases peristaltic movement, which can also result in rupture.
- Correct or Prevent Fluid and Electrolyte Imbalance, Dehydration, and Sepsis.
- Surgery: appendectomy. If the appendix has ruptured, a peritoneal lavage may also be required.
- Post-operative care: (a) Positioning: decrease tension on the incision site by placing the patient on high fowler’s, (b) Diet: start the patient on clear liquid diet.
Inflammatory Bowel Disease
A pair of chronic diseases that produce inflammation of the large intestine: regional enterocolitis (Chron’s disease) and ulcerative colitis.
| Parameter | R.E. | U.C. |
|---|---|---|
| Symptomatic Pattern | Prolonged | Exacerbations |
| Physiologic Change | Thickening of the membranes; narrowing of the colon | Ulcerations of the membranes |
| Commonly Affected | Ileum, Ascending Colon; Perianal | Descending Colon, Rectum; Rectal |
| Bleeding | Mild Bleeding | Severe Bleeding |
| Diarrhea | Less severe diarrhea | Severe Diarrhea |
| Level of Morbidity | Less severe | More severe |
| Cancer | N/A | Pre-malignant |
- Treatment: these are managed symptomatically— palliative therapy.
- Pharmacologic: management of inflammation is done with corticosteroids such as betamethasone or dexamethasone. These inhibit immune response in order to reduce inflammation.
- Pain is treated with COX-2 inhibitors.