gi lectures notes

7/28/2019 GI Lectures Notes

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GI Test 4/25/2011 2:11:00 PM

GI

Terminologies

y Visceral pain; dull poorly localized painy Somatic pain; sharp pain, well localizedy Referred pain; pain experience at a distance from disease processy Fetor hepaticus; sweet fecal odor caused by hepatic failurey Feculent breath; foul fecal odor caused by severe bowel obstructiony Severe halitosis; foul breath odor can be caused by poor dental

hygience or neoplasms or esophagus and stomach

y Jaundice; yellowish discoloration of skin caused by high bilirubinlevel associated with liver disease, biliary obstruction, excessive

hemolysis

y Grey turners sign; ecchymosis to flanks indicative ofretroperitoneal bleeding

y Ascitis; intraperitoneal fluid infrequently associated withy Anasarca; entire body edema seen in end stage renal diseasey Diastasis recti abdominis; abnormal separation of two abdominal

muscles by raising his or her head from bed

y Ballottment; technique of examining a fluid filled part of body todetect floating object.

y Cullens sig; ecchymosis around umbilicus indicative inintraparanteal bleeding

y Mcburney's sign: is a sign of acute appendicitisy Rovsing

Salivary glands

y 1000-1500 ml/dayy Enzymes pityalin (amylase) and lysozymey Initiates carb metabolism, destroy bacterial protects muscus

membrane, and tooth decay

Stomach 2500 ml/day

y Enzyme pesiny Converts proteins into proteoses and peptones

Liver bile 500-100 ml/day

y No enzymesy Emulsifies fat

Pancrease 1000-1500 ml/day


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y Enzymes trypsin , amylase, mylasey Digest major components of chime

Differntation of abd pain

y Gastritis; epigastric or slightly left midline, maybe described asindigestion, nausea vomiting, hematamesis, abd tenderness

y Peptic ulcer, epigastric or RUQ, gnawing or burning, abdtenderness, hematemesis or melena

y Pancreatitis; epigastric or LUQ may radiate to back, flanks or leftshoulder, boring worsen by lying down, nausea or vomiting,

jaundice maybe present if common bile duct is obstructed.

y Cholecystitis; epigastric PRRUQ area, cramping, maybe referred tobelow right scapula, murphys sign; nausea vomiting, abd

tenderness in RUQ

y Appendicitis; epigastric or periumbilical pain, later localizes in RLQ,mcburneys sign, rovsing sing, dull to sharp pain, anorexia, fever,

diarrhea, leukocytosis, rebound tenderness, indicates peritoneal

irriation

y Intestinal obstruction, epigastric or umbilical, spastic to dull, changein bowel habits, melena or hematochezia, hyperactive to hypoactive

bowel sounds

y Stepso Inspection

Inspection; Landmarks General survey Mouth Skin Contour of abd Abd girth Weakness of abd wall Movement of abd

o Auscultation Put pillow under knees to relax abd muscle Bowel sounds Succussion splash Vascular sounds; use bell


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Peritoneal friction rub; presence of peritoneal fluido Percussion

Percussion tones normally heard are Dull liver, full sigmoid colon, full bladder, flute tone,

tympani gastric bulle (drum like sound) When testing for ascitis (fluid like, shifting dullness,

midline dullness)

Organ borders (spleen, liver, stomach, bladder,intestine)

o Palpation Method Light palpation 1-2 cm Deep palpation 4-5 cm only physician Ballottement

Laboratory and Diagnostic exams

y Upper GI studyy series of radiographys of lower esophagus, stomach, duodenum,

using barium sulfate as contrast medium

y Detects any abnormal conditions of GI tracty Tumorsy Other ulcerative lesionsy Prep

o NPO post midnighto No smoking night before studyo Explain importance of expelling barium solutiono Stools will be whitish or light in color until all solution expelled

out (72) hrs

o Eventual absorption of fecal water may cause hardenedbarium impaction

o Advice increase fluid intakeo Administer MOM after exam to promote expulsion of solution

unless contraindicated

y Tube Gastric analysiso Stomach contents aspirated to determine amount of acid

produced by parietal cells in stomach


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o Analysis helps determine completeness of vagotomy, confirmhypersecretions of achlohydria, estimate acid secretory

capacity or test for intrinsic factor.(vitamin B12)

o Nursing interventions No anti cholinergic for 24 hrs prior to test NPO after midnight No smoking Label specimens properly and send to lab asap Remove NG tube as soon as specimens collected.

y EGDo Evaluates esophagus, stomach and duodenum.o Nursing careo NPO PMNo Consento Pre op check listo Pt usually given midazolam IVo Spraying of pharynx with lidocaine hydrochlorideo NPO until further order or until gag reflex returnedo Assess for any S/S of perforation; abd pain, tenderness,

guarding, oral bleeding, melena (black stool), hypovolemic

shock.

y Capsule Endoscopyo Pt swallows capsule with camerao Collect about 57000 imageso Visualizes small intestineo Use to diagnose Chrons diseaseo Celiac diseaseo Malabsorptiono Helps identify possible sources of GI bleedingo Capsule relays images to a data recorder that pt wears on

belt.

o Nursing intervention Diet prep is similar to colonoscopy Pt swallows video capsule and kept 4-6 hrs later Device is removed after 8 hrs Peristalsis causes capsule to pass in bowel movement.


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y Barium swallowo More thorough barium contrast study of esophagus provided

by most UGI exam

o Defects in luminal filling and narrowing of barium columnindicate tumors, scarred stricture or esophageal varices

o Allows easy recognition of anatomical abnormalitieso Left atrial dilation, aortic aneurysm, and para-esophageal

tumor may cause extrinsic compression of barium column

within esophagus.

o If barium leaks from GI tract, its not absorbed and can causecomplications.

y Gastrografin studieso Gastrografin:

water soluble and rapidly absorbedo Preferable when perforation is suspectedo It facilitates imaging through radiographso If product escapes from GI tract it is absorbed by the

surrounding tissue

y Diatrizoateo Use in place of bariumo Interventions

Maintain NPO after midnight Explain importance of rectally expelling barium Stools will be light colored until complete expelling

occurs

Increase fluid intake Give MOM after barium swallow exam unless

contraindicated.

y Esophageal function testo Acid perfusion test, attempt to reproduce symptoms of

gastroesophageal reflux

o Helps differentiate esophageal pain from angina pectoriso If pt suffers pain within instillation of hydrochloric acid into

esophagus, test is positive and indicates reflux esophagitis

o Interventions Avoid sedating pt


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NPO for 8 hrs prior exam Withhold antacid and analgesics

y Stool for occult blood, guaiac, hemoccult, hematest!o Stool specimen free from tissue and urineo Diet free from organ mean 24-48 hrs before test

y Sigmoidoscopyo Lower segment of large intestine!o Nursing care

NPO Admin enema night before Consent Observe for signs of bowel perforation

Abd pain Bleeding Tenderness Distention

y Barium enema studyo AKA lower GI serieso Consists of series of xrays of colono Used to diagnose presence of :

polyps , tumors, diverticula, positional abnormalitieso Can be used to detect intussusceptions in childreno Nursing care

Administer cathartics such as magnesium citrate Cleansing enema evening before MOM evacuation of barium NPO Retained barium equals hard stools!

y Colonoscopyo Requires sedationo Camera to view entire colono GOLYTELY night beforeo More accurateo Requires bowel preparation night before

y Virtual colonoscopyo Uses MRI or CT to take pictures of entire colon


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o Needs sedation but no consent less invasiveo Same prep as conventional colono Needs GOLYTELY night beforeo GOLYTELY bowel prep (pg 183 box 5-2 AHN)

y Stool cultureo Exam of stool for presence of bacteria, ova, parasiteso Many physicians may order stool for ova and parasites (o&P)o Usually done to detect enteropathogens aka, shigella, c diff.o Usually 3 stool series are collected on subsequent days.o Nursing interventions

If enema ordered use only saline or tap water Soap suds enema could affect viability of organisms

collected

Stool samples obtained before barium exam instruct ptnot to mix specimen with feces

Don gloves , make sure specimen taken to lab within 30min

y Obstruction serieso AKA flat plate abd

y Group of xray series performed on abdomen for pts who havesuspected bowel obstruction , perforated viscus, paralytic ilius, or

abdabcessy Consists of at least 2 radiographic studiesy First shot is erect abdxray that allows visualization of diaphragmy Radiographs are examined for evidence of free air under the

diaphragm- which is pathognomonic sign of obstruction

y Detects air fluid levels within intestiney Nursing care

o Ensure study is scheduled before barium studies for adequatevisualization.


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GI Pharm. 4/25/2011 2:11:00 PM

Pharmacology Notes 4/15/11-For Test 4 Pharmacology

Hydrochloric acid production

Stomach-acid production

Rugae-big folds in the stomach

Gastric pits-smaller folds in the stomach where we find the parietal cellsParietal cells

Hydrochloric acid

Parietal cells--> HCL

Potassium goes out, Hydrogen goes in produces Hydrochloric acid

H2 Blockers (dine)

y Ranitidine (Zantac) works in less than 1 hour (Long acting)y Cimetidine (Tagament)y Decrease acid in stomach

PPI Proton Pump Inhibitors -(ZOLE)

y Reduce acid secretions of the stomachy Esomeprazole (Nexium)y Omeprazole -Long acting (Starts in 1-3 hours but lasts 24 hours)

Short Acting- Antacids

y Aluminum Hydroxide (Amphojel)y Side effects fecal impaction, intestinal obstructiony Maalox-short acting

Vomiting

y Nausea and vomiting-defense of the GI system and are signs ofaltered body function

y Nausea-unpleasant sensation of the need to vomity Vomiting-(emesis) the forcing of the stomach contents up through

the espophagus and out to the mouth

y Phases of vomitingo Nauseao Retches (gagging)o Vomiting

y Vestibular system-when balance is or sense of position is upset,vomiting occurs


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y Receptors in the GI tract mechanoreceptors and chemoreceptorso Mechanoreceptors-distention and contraction in bowel

obstruction, vomiting occurs

o Chemoreceptor-sensory verve cells in response to chemicalstimuli such as poisonous substances in the intestines

y Vomiting Center of the brain-located in the medulla is responsiblefor initiating the vomiting reflex.

y It combines the input from the GI tract, vestibular apparatus andhigher brain pressure centers for activation.

y Once activated, the vomiting center causes vomiting by stimulatingthe salivary and respiratory centers and the throat (pharyngeal), GI

and abdominal muscles

y Causes of nausea and vomitingo Unpleasant sights, smells, memories, side effects of

chemotherapy, medical disorders

o Drug or treatment induced---agents antibiotics, cancerchemo, opiate drugs, radiation therapy

o Labyrinth disorders-----menier's disease, motiono Endocrine system infection---pregnancy, gastroenteritis, viral

laybrinthitis

o Increased intracranial pressure-hemorrhage, meningitiso Postoperative-analgesics, anesthetics, proceduralo Central Nervous System---Anticipatory, bulimia nervosa,

migraine

Antiemetic Drugs -

y Intended responses for antiemetic agents:y -vomiting reflex inhibitedy -vomiting reflex pathways are interruptedy -Pt is sedatedy -Nausea is relievedy -Vomiting is preventedy Nursing Diagnosis:

o Risk for fluid & electrolyte imbalanceo Nausea r/t distention & contraction in the intestinal tracto Nausea r/t poisonous substance in the stomach


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y Common side effects of antiemetic drugs vary with the prescribeddrug.

Anticholinergics-

y Primary antimuscarinic (anti-parkinson) agents that act by bindingto and blocking acetylcholine receptors

o thus, preventing the nauseous stimuli from being transmittedy -limits the stimulation of the emetic center from the vestibular

system.

y -has minimal effect on vestibular stimulation (vestibular andserotonin)

y Scopolamine Hcl (transderm-Scop, scopace, maldemar)Antihistamines-

y it inhibits the same pathways as anticholinergic drugs and depressinner ear excitability, reducing vestibular stimulation

y -Decreases allergic response by blocking histaminey -also acts on chemoreceptor trigger zone to decrease vomitingy -increases CNS stimulation, has anticholinergic responsey -because of this it inhibits one or more of the vomiting reflex

pathways

y -sedating effects help control the sensation of nauseaPromethazine (phenergan)

Dipenhydramine (benadryl)

Meclizine (bonamine, antivert)

Cyclizine (Marezine)

5HT3-Receptor Antagonist/serotonin blockers-

y Blocks serotonin receptors in the GI tract and the chemotriggerzone in the brain

y -by blocking the receptors in both of these sites at least twopathways of the v omiting reflex are interrupted

y - most commonly used agents to prevent and treat nausea andvomiting associated with chemotherapy

Serotonin Blockers


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y Dolasetronmesylatey Granisetron HCLy Ordansetron HCLy Palonosetron HCL

Dopamine receptor antagonist or neuroleptic agents-

y Directly block dopamine from binding to the receptors in thechemotrigger zone and the intestinal tract

y -foods in the intestinal tract moves along more quickly and is lesslikely to stimulate responses that trigger the vomiting reflex, used

after surgery to promote peristalsis, prevents nausea and vomiting

Dopamine Receptor Antagonist Agents

y Metoclopromide (Reglan, Emex, Maxeran)y Chlorpromazine (Thorazine)y Perphenaziney Prochlorperazine (Compazine)y Trimethobenzamide (Tigan)

Drugs Common Side Effects

y Cyclizineo drowsiness, dry mouth, hypotension-Antihistamine

y Meclizine (Antivert)o Drowsiness-Antihistamine

y Prochlorperazineo blurred vision, constipation, dizziness, involuntary msucle

spasms, jitteriness, mouth puckering-Domamine receptor

y Metochlopromide (reglan)o drowsiness, fatigue, increased depression, restlessness-

antiemetic, (dopamine receptor antagonist)

y Promethazine (phenergan)o confusion, disorientation, dizziness, dry mouth, nausea,

vomiting rash, sedation-antihistamine

y Ondansetrono abdominal pain, constipation, fatigue, headache-Serotonin

y Granisetron


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o headache, constipation loss of energy-Serotoniny Scopolamine (L-Hyoscine)

o Blurred vision, constipation, dilated pupils, dizziness,drowsiness, dry mouth, light-headedness, rash, urinary

retention-anticholinergicy Trimethobenzamide (Tigan)

o blurred vision, diarrhea, drowsiness, muscle cramps,headache, hypotension, rectal irritation-Dopamine Receptor

Antagonist

Adverse Effects

y Also varies with the prescribed drugsy Prochlorperaziney promethazine (phenergen)y Metochlopromide (reglan)-cause tardive dyskinesiay Neuroleptic malignant syndrome-rare and life threatening side

effects in which dangerously high body temperature

y Trimethobenzamide-may cause coma, seizure


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GASTROINTESTINAL DISORDERS4/25/2011 2:11:00 PM

GASTROESOPHAGEAL REFLUXDISEASE (GERD)

y DESCRIPTIONo The backflow of gastric and duodenal contents into the

esophagus

y Caused by an incompetent lower esophageal sphincter, pyloricstenosis, or a motility disorder

y Symptoms may mimic those of a heart attacky ASSESSMENT

o Pyrosiso Dyspepsiao Regurgitationo Pain and difficulty with swallowingo Hypersalivation

y IMPLEMENTATIONo Instruct the client to avoid factors that decrease lower

esophageal sphincter pressure or cause esophageal irritation

o Instruct the client to eat a low-fat, high-fiber diet; avoidcaffeine, tobacco, and carbonated beverages; avoid eating

and drinking 2 hours before bedtime; avoid wearing tight

clothes; and to elevate the head of the bed on 6- to 8- inch

blocks

o Avoid the use of anticholinergics, which delay stomachemptying

o Instruct the client regarding prescribed medications, such asantacids, histamine H2-receptor antagonists, or gastric acid

pump inhibitors

o Instruct the client regarding the administration of prokineticmedications if prescribed, which accelerate gastric emptying

o If medical management is unsuccessful, surgery may berequired and involves a fundoplication (wrapping a portion of

the gastric fundus around the sphincter area of the

esophagus); may be performed by laparoscopy

HIATAL HERNIA

y DESCRIPTIONo Also known as esophageal or diaphragmatic hernia


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o A portion of the stomach herniates through the diaphragmand into the thorax

y It results from weakening of the muscles of the diaphragm and isaggravated by factors that increase abdominal pressure such as

pregnancy, ascites, obesity, tumors, and heavy liftingy Complications include:

o ulceration, hemorrhage, regurgitation and aspiration ofstomach contents, strangulation, and incarceration of the

stomach in the chest with possible necrosis, peritonitis, and

mediastinitis

y ASSESSMENTo Heartburno Regurgitation or vomitingo Dysphagiao Feeling of fullness

y IMPLEMENTATIONo Medical and surgical management is similar to that for GERo Provide small, frequent meals and minimize the amount of

liquids

o Advise the client not to recline for 1 hour after eatingo Avoid anticholinergics, which delay stomach emptying

GASTRITISy DESCRIPTION

o Inflammation of the stomach or gastric mucosay Can be acute or chronicy ACUTE

o Caused by the ingestion of food contaminated with disease-causing microorganisms or food that is irritating or too highly

seasoned, the overuse of aspirin or other

nonsteroidalantiinflammatory drugs (NSAIDs), excessive

alcohol intake, bile reflux, or radiation therapy

o ASSESSMENT Abdominal discomfort Headache Anorexia, nausea, and vomiting Hiccuping


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y CHRONICo Caused by benign or malignant ulcers, or by the bacteria

Helicobacter pylori; may also be caused by autoimmune

diseases, dietary factors, medications, alcohol, smoking, or

refluxo ASSESSMENT

Anorexia, nausea, and vomiting Heartburn after eating Belching Sour taste in the mouth Vitamin B12 deficiency ACUTEEROSIVE GASTRITIS

o IMPLEMENTATION Acute: Food and fluids may be withheld until symptoms

subside; then ice chips followed by clear liquids and

then solid food is introduced

Monitor for signs of hemorrhagic gastritis such ashematemesis, tachycardia, and hypotension, and notify

the physician if these signs occur

Instruct the client to avoid irritating foods, fluids, andother substances such as spicy and highly seasoned

foods, caffeine, alcohol, and nicotine Instruct the client in the use of prescribed medications,

such as antibiotics and bismuth salts (Pepto-Bismol)

Provide the client with information about theimportance of vitamin B12 injections, if a deficiency is

present

PEPTICULCERDISEASE

y DESCRIPTIONo An ulceration in the mucosal wall of the stomach, pylorus,

duodenum, or esophagus, in portions that are accessible to

gastric secretions; erosion may extend through the muscle

y May be referred to as gastric, duodenal, or esophageal ulcerdepending on location

y The most common peptic ulcers are gastric ulcers and duodenalulcers


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GASTRICULCERS

y DESCRIPTIONo Involves ulceration of the mucosal lining that extends to the

submucosal layer of the stomach

y Predisposing factors include stress, smoking, the use ofcorticosteroids, nonsteroidalantiinflammatory drugs (NSAIDs),

alcohol, a history of gastritis, a family history of gastric ulcers, or

infection with Helicobacter pylori

y Complications include:o hemorrhage, perforation, and pyloric obstruction

y ASSESSMENTo Gnawing, sharp pain in or left of the midepigastric region 1 to

2 hours after eating

o Nausea and vomitingo Hematemesis

y IMPLEMENTATIONo Monitor vital signs and for signs of bleedingo Administer small, frequent, bland feedings during the active

phase

o Administer histamine H2-receptor antagonists as prescribed todecrease the secretion of gastric acid

o Administer antacids as prescribed to neutralize gastricsecretions

o Administer anticholinergics as prescribed to reduce gastricmotility

o Administer mucosal barrier protectants as prescribed 1 hourbefore each meal

o Administer prostaglandins as prescribed for their protectiveand antisecretory actions

y CLIENT EDUCATIONo Avoid consuming alcohol and substances that contain caffeine

or chocolate

o Avoid smokingo Avoid aspirin or NSAIDso Obtain adequate rest and reduce stress

y IMPLEMENTATION: ACTIVEBLEEDING


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o Monitor vital signs closelyo Assess for signs of dehydration, hypovolemic shock, sepsis,

and respiratory insufficiency

o Maintain NPO status and administer IV fluid replacement asprescribed; monitor I&O

o Monitor hemoglobin and hematocritGASTRICULCERS

y IMPLEMENTATION: ACTIVEBLEEDINGo Administer blood transfusions as prescribedo Assist with the insertion of a nasogastric (NG) tube for

decompression and for lavage access

o Assist with normal saline or tap water lavage at roomtemperature to reduce active bleeding

o Prepare to assist with administering vasopressin (Pitressin) byIV as prescribed to induce vasoconstriction and reduce

bleeding

y SURGICAL IMPLEMENTATIONo TOTAL GASTRECTOMY

Also called esophagojejunostomy Removal of the stomach with attachment of the

esophagus to the jejunum or duodenum

o VAGOTOMY Surgical division of the vagus nerve to eliminate the

vagal impulses that stimulate hydrochloric acid

secretion in the stomach

GASTRICRESECTION

Also called antrectomy

Involves removal of the lower half of the stomach and usually includes a

vagotomy

GASTRICULCERS

SURGICAL IMPLEMENTATION

BILLROTH I

Also called gastroduodenostomy; partial gastrectomy, with remaining

segment anastomosed to duodenum

BILLROTH II


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Also called gastrojejunostomy; partial gastrectomy, with remaining segment

anastomosed to jejunum

PYLOROPLASTY

Enlarges the pylorus to prevent or decrease pyloric obstruction, thereby

enhancing gastric emptyingTOTAL GASTRECTOMY

TYPESOFVAGOTOMIES

BILLROTH I

BILLROTH II

PYLOROPLASTY

GASTRICULCERS

POSTOPERATIVE IMPLEMENTATION

Monitor vital signs

Position in Fowler's for comfort and to promote drainage

Administer fluids and electrolyte replacements by IV as prescribed; monitor

I&O

Assess bowel sounds

Monitor NG suction as prescribed

GASTRICULCERS

POSTOPERATIVE IMPLEMENTATION

Do not irrigate or remove the NG tube; assist the physician with irrigation or

removalMaintain NPO status as prescribed for 1 to 3 days until peristalsis returns

Progress the diet from NPO to sips of clear water to 6 small, bland meals a

day as prescribed when bowel sounds return

Monitor for postoperative complications of hemorrhage, dumping syndrome,

diarrhea, hypoglycemia, and vitamin B12 deficiency

DUODENAL ULCERS

DESCRIPTION

A break in the mucosa of the duodenum

Risk factors and causes include alcohol intake, smoking, stress, caffeine, the

use of aspirin, corticosteroids, and NSAIDs, and infection with Helicobacter

pylori

Complications include bleeding, perforation, gastric outlet obstruction, and

intractable disease


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Surgery is performed only if the ulcer is unresponsive to medications or if

hemorrhage, obstruction, or perforation occurs

DEVELOPMENT OFADUODENAL ULCER

DUODENAL ULCERS

PERFORATIONOFADUODENAL ULCERDUODENAL ULCERS

ASSESSMENT

Burning pain in the midepigastric area 2 to 4 hours after eating and during

the night

Pain that is often relieved by eating

Melena

DUODENAL ULCERS

IMPLEMENTATION

Monitor vital signs

Perform abdominal assessment

Instruct the client in a bland diet with small, frequent meals

Provide for adequate rest

Encourage the cessation of smoking

DUODENAL ULCERS

IMPLEMENTATION

Instruct the client to avoid alcohol intake, caffeine, the use of aspirin,

corticosteroids, and NSAIDsAdminister antacids as prescribed to neutralize acid secretions

Administer histamine H2-receptor antagonists as prescribed to block the

secretion of acid

DUMPING SYNDROME

DESCRIPTION

Rapid emptying of the gastric contents into the small intestine

Occurs following gastric resection

DUMPING SYNDROME

ASSESSMENT

Symptoms occurring 30 minutes after eating

Nausea and vomiting

Feelings of abdominal fullness and abdominal cramping

Diarrhea

Palpitations and tachycardia


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Perspiration

Weakness and dizziness

Borborygmi

DUMPING SYNDROME

CLIENT EDUCATIONEat a high-protein, high-fat, low-carbohydrate diet

Eat small meals and avoid consuming fluids with meals

Avoid sugar and salt

Lie down after meals

Take antispasmodic medications as prescribed to delay gastric emptying

VITAMINB12DEFICIENCY

DESCRIPTION

Results from either an inadequate intake of vitamin B12 or a lack of

absorption of ingested vitamin B12 from the intestinal tract

Pernicious anemia results from a deficiency of intrinsic factor, which is

necessary for intestinal absorption of vitamin B12


ASSESSMENT

Severe pallor

Fatigue

Weight loss

Smooth, beefy, red tongueSlight jaundice

Paresthesias of the hands and feet

Disturbances with gait and balance


IMPLEMENTATION

Increase dietary intake of foods rich in vitamin B12 if the anemia is the result

of a dietary deficiency

Administer vitamin B12 injections as prescribed on a weekly basis initially,

and then monthly for maintenance (lifelong) if the anemia is the result of a

deficiency of the intrinsic factor

ESOPHAGEAL VARICES

DESCRIPTION

Dilated and tortuous veins in the submucosa of the esophagus


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Caused by portal hypertension, often associated with liver cirrhosis, and high

risk for rupture if portal circulation pressure rises

Bleeding varices is an emergency

The goal of treatment is to control bleeding, prevent complications, and

prevent the reoccurrence of bleedingESOPHAGEAL VARICES

ESOPHAGEAL VARICES

ASSESSMENT

Hematemesis

Tarry stools, melena

Ascites

Jaundice

Hepatomegaly and splenomegaly

Dilated abdominal veins

Hemorrhoids

Signs of shock

ESOPHAGEAL VARICES

IMPLEMENTATION

Monitor vital signs

Elevate the head of the bed

Monitor for orthostatic hypotension

Monitor lung sounds and for the presence of respiratory distressAdminister oxygen as prescribed to prevent tissue hypoxia

Monitor level of consciousness (LOC)

ESOPHAGEAL VARICES

IMPLEMENTATION

Maintain NPO status

Administer IV fluids as prescribed to restore fluid volume and correct

electrolyte imbalances; monitor I&O

Monitor hemoglobin, hematocrit, and coagulation factors

Administer blood transfusions or clotting factors as prescribed

ESOPHAGEAL VARICES

IMPLEMENTATION

Assist in inserting an NG tube or a balloon tamponade as prescribed

Assist with the administration of iced saline irrigations to achieve

vasoconstriction of the varices


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Prepare to assist with administering vasopressin (Pitressin) by IV or intra-

arterial infusion as prescribed to induce vasoconstriction and reduce bleeding

ESOPHAGEAL VARICES

IMPLEMENTATION

Prepare to assist with administering nitroglycerin (Tridil) with vasopressin(Pitressin) to prevent vasoconstriction of the coronary arteries

Instruct the client to avoid activities that will initiate vasovagal responses

Prepare the client for endoscopic procedures or surgical procedures as

prescribed

ESOPHAGEAL VARICES

ENDOSCOPIC INJECTION (SCLEROTHERAPY)

Injection of a sclerosing agent into and around bleeding varices

Complications include chest pain, pleural effusion, aspiration pneumonia,

esophageal stricture, and perforation of the esophagus

INJECTIONSCLEROTHERAPY

ESOPHAGEAL VARICES

ENDOSCOPICVARICEAL LIGATION

Ligation of the varices with an elastic rubber band

Sloughing, followed by superficial ulceration, occurs in the area of ligation

within 3 to 7 days

ESOPHAGEAL VARICES

SURGICAL SHUNT PROCEDURESSPLENORENAL

Involves splenectomy, with anastomosis of the splenic vein to the left renal

vein

PORTACAVAL

Shunting of the blood from the portal vein to the inferior vena cava

MESOCAVAL

Involves a side anastomosis of the superior mesenteric vein to the proximal

end of the inferior vena cava

SHUNTING PROCEDURES

ESOPHAGEAL VARICES

SURGICAL SHUNT PROCEDURES

TRANSJUGULAR INTRAHEPATIC PORTAL/SYSTEMIC

Uses the normal vascular anatomy of the liver to create a shunt with the use

of a metallic stent


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The shunt is between the portal and systemic venous system within the liver

and is aimed at relieving portal hypertension

ULCERATIVECOLITIS

DESCRIPTION

Ulcerative and inflammatory disease of the bowel that results in poorabsorption of nutrients

Commonly begins in the rectum and spreads upward toward the cecum

Characterized by various periods of remissions and exacerbations

The colon becomes edematous and may develop bleeding lesions and ulcers;

the ulcers may lead to perforation

ULCERATIVECOLITIS

DESCRIPTION

Scar tissue develops and causes loss of elasticity and loss of ability to absorb

nutrients

Acute ulcerative colitis results in vascular congestion, hemorrhage, edema,

and ulceration of the bowel mucosa

Chronic ulcerative colitis causes muscular hypertrophy; fat deposits; and

fibrous tissue with bowel thickening, shortening, and narrowing

ULCERATIVECOLITIS

DESCRIPTION

Surgical intervention involves creation of an ostomy; the ostomy can be

created within the ileum or at various sites within the large bowelAn ileostomy is the surgical creation of an opening into the ileum or small

intestine that allows for drainage of fecal matter from the ileum to the

outside of the body

A colostomy is the surgical creation of an opening into the colon that allows

for drainage of fecal matter from the colon to the outside of the body

ULCERATIVECOLITIS

ACUTEULCERATIVECOLITIS

ULCERATIVECOLITIS

ASSESSMENT

Anorexia

Weight loss

Malaise

Abdominal tenderness and cramping

Severe diarrhea that may contain blood and mucus


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Dehydration and electrolyte imbalances

Anemia

Vitamin K deficiency

ULCERATIVECOLITIS

IMPLEMENTATIONAcute phase: Maintain NPO status, administer IVs and electrolytes, or total

parenteral nutrition (TPN) as prescribed

Restrict the clients activity to reduce intestinal activity

Monitor bowel sounds and for abdominal tenderness and cramping

Monitor stools, noting color, consistency, and the presence or absence of

blood

ULCERATIVECOLITIS

IMPLEMENTATION

Monitor for perforation, peritonitis, and hemorrhage

Following the acute phase, the diet progresses from clear liquids to low-

residue as tolerated

Instruct client to consume a low-residue, high-protein diet; vitamins and iron

supplements may be prescribed

Instruct client to avoid gas-forming foods and milk products and foods such

as whole-wheat breads, nuts, raw fruits and vegetables, pepper, alcohol,

and caffeine-containing products

ULCERATIVECOLITISIMPLEMENTATION

Instruct the client to avoid smoking

Administer bulk-forming agents such as bran, psyllium, or methylcellulose,

to decrease diarrhea and relieve symptoms

Administer antimicrobial, corticosteroids, and immunosuppressants as

prescribed to prevent infection and reduce inflammation

ULCERATIVECOLITIS


TOTAL PROCTOCOLECTOMY WITH PERMANENT ILEOSTOMY

Curative and involves the removal of the entire colon (colon, rectum, and

anus with anal closure)

The end of the terminal ileum forms the stoma, which is located in the right

lower quadrant

TOTAL PROCTOCOLECTOMY WITH PERMANENT ILEOSTOMY


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ULCERATIVECOLITIS


KOCK ILEOSTOMY (CONTINENT ILEOSTOMY)

An intra-abdominal pouch (stores the feces) is constructed from the terminal

ileumThe pouch is connected to the stoma with a nipple-like valve constructed

from a portion of the ileum; the stoma is flush with the skin

A catheter is used to empty the pouch, and a small dressing or adhesive

bandage is worn over the stoma between emptyings

KOCK ILEOSTOMY (CONTINENT ILEOSTOMY)

ULCERATIVECOLITIS


ILEOANAL RESERVOIR

A two-stage procedure that involves the excision of the rectal mucosa, an

abdominal colectomy, construction of a reservoir to the anal canal, and a

temporary loop ileostomy

The ileostomy is closed in approximately 3 to 4 months after the capacity of

the reservoir is increased

CREATIONOFAN ILEOANAL RESERVOIR

ULCERATIVECOLITIS


ILEOANAL ANASTOMOSIS (ILEORECTOSTOMY)Does not require an ileostomy

A 12- to 15-cm rectal stump is left after the colon is removed and the small

intestine is inserted into this rectal sleeve and anastomosed

Requires a large, compliant rectum

ILEOANAL ANASTOMOSIS

ULCERATIVECOLITIS

PREOPERATIVECOLOSTOMY AND ILEOSTOMY

Consult with enterostomal therapist to assist in identifying optimal

placement of the ostomy

Instruct the client to eat a low-residue diet for a day or two prior to surgery

as prescribed

Administer intestinal antiseptics and antibiotics as prescribed to cleanse the

bowel and to decrease the bacterial content of the colon

Administer laxatives and enemas as prescribed


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POSTOPERATIVECOLOSTOMY

Place a petrolatum gauze over the stoma as prescribed to keep it moist,

followed by a dry sterile dressing if a pouch (external) system is not in place

Place a pouch system on the stoma as soon as possibleMonitor the stoma for size, unusual bleeding, or necrotic tissue

ULCERATIVECOLITIS


Monitor for color changes in the stoma

The normal stoma color is pink to bright red and shiny, indicating high

vascularity

A pale pink stoma indicates low hemoglobin and hematocrit levels

A purple-black stoma indicates compromised circulation, requiring physician

notification

ULCERATIVECOLITIS


Assess the functioning of the colostomy

Expect that stool is liquid in the immediate postoperative period, but

becomes more solid depending on the area of the colostomy

Ascending colon - liquid

Transverse colon - loose to semi-formed

Descending colon - close to normalLOCATIONSOFCOLOSTOMIES

ULCERATIVECOLITIS


Monitor the pouch system for proper fit and signs of leakage

Empty the pouch when it is one-third full

Fecal matter should not be allowed to remain on the skin

Administer analgesics and antibiotics as prescribed

gi lectures notes

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