Gastro Liver And Biliary System Bago 2

CARE OF THE CLIENT WITH PROBLEMS RELATED TO THE GASTROINTESTINAL SYSTEM, LIVER AND BILIARY TREE

ANATOMY AND PHYSIOLOGY  2. 3. 4.  7. 8.

Major Functions: Ingestion of food Digestion of food Elimination of waste products 2 Main Groups: Alimentary Canal Accessory Organs

Organs of the Alimentary Canal MOUTH

also known as ________ _______ protects its anterior opening _______ protects its lateral walls _______ forms its anterior roof _______ forms its posterior roof _______ fleshy fingerlike projection of the soft palate

_____ occupies the floor of the mouth _____ a pair of lymphatic tissue located at posterior

end of the oral cavity _____ lubricates the food for easy swallowing PHARYNX allows the passage of food from the mouth to the esophagus

ESOPHAGUS Hollow, muscular tube that propels the food from the pharynx down to the stomach STOMACH A dilated, saclike structure that lies on the left side of the abdominal cavity nearly hidden by the liver and diaphragm Contains 2 important sphincters The fundus is the expanded part of the stomach lateral to the cardiac region

 The body is the midportion and the funnel-shaped  3. 4. 5. 

pylorus is the terminal part of the stomach It has 3 major function such as: Stores food Mixes food with gastric juices Passes chyme An average meal can remain in the stomach for 3 to 4 hours

An accordion-like folds in the stomach lining, allows

the stomach to expand when large amount of foods and fluids are ingested Chemical breakdown of protein begins in the stomach SMALL INTESTINE Considered as the body’s major digestive organ Longest section of the GI tract and hangs in sausage like coils in the abdominal cavity

SMALL INTESTINE  It has 3 sections:

Duodenum 3. Jejunum 4. Ileum  Nearly all food absorption occurs in the small intestine 2.

LARGE INTESTINE  It frames the small intestine on three sides and has 2. 3. 4. 5. 6.

the following subdivisions: Cecum Appendix Colon Rectum Anal canal

3 Main functions: 1. Absorbs excess water and electrolytes 2. Stores food residue 3. Eliminate waste products in the form of feces

ACCESSORY ORGANS LIVER Heaviest organ in the body Located in the right upper quadrant and almost completely covers the stomach Has 2 major lobes divided by the falciform ligament The liver’s function includes M-etabolism of Carbohydrates, Fats and Proteins C-onverts ammonia to urea for excretion D-etoxify blood O-synthesizing plasma proteins, nonessential amino acids

acids, vitamin A and essential nutrients such as iron, and vitamins D,K, and B12 S-ecretes bile. A greenish fluid that helps digest fats and absorbs fatty acids, cholesterol, and other lipids. GALLBLADDER Small, pear-shaped organ that lies halfway under the right lobe of the liver Its main function is to store bile from the liver until it is emptied into the duodenum

PANCREAS Soft, pink, triangular gland that extends across the abdomen from the spleen to the duodenum Produces enzymes that digest carbohydrates fats and proteins (ALT) BILE DUCTS Provide the passageways for bile to travel from the liver to the intestines 2 hepatic ducts drain the liver and 1 cystic duct drains the gallbladder

METABOLISM It includes all chemical breakdown and building

reactions needed to maintain life Carbohydrates are the body’s major energy fuel Fats insulates the body, protects the organs, build some cell structure and provide reserve energy Proteins forms the bulk of the cell structure and most functional molecules The liver is the body’s key metabolic organ

 Diagnostic Assessment: 1. Hematologic liver function studies  To determine excretory function Serum bilurubin Serum alkaline phosphatase N=2-5 bodansky unit SGOT Serum Glutamic Oxalo Transaminase or AST Aspartate Aminotransferase N= 740 U SGPT Serum Glatamic Pyruvic Transaminase or ALT Alanine Aminotransferase N= 10-40 U

To

determine metabolic function Serum protein- albumin, globulin Serum ammonia- N= 20-150 ug/ 100ml Serum amylase N= 4-25 u/ml Prothrombin time N=11-16 secs



Barium swallow - identifies structural abnormalities of the esophagus, stomach, duodenum and jejunum as well as swallowing discoordination Pre-test prep: 2. Low-residue diet several days before the procedure 3. NPO for 8 to 12 hrs before the test 4. BaSO4 per orem is administered 5. X-rays are taken in standing and lying positon

 Post-test:

Laxative is administered 3. Increase fluid intake 4. Inform patient that the stool is white for 24-72 hours 5. Observe for Barium impaction: abdominal distention and constipation 2.

Barium Enema - identifies polyps, tumors, inflammation, strictures and other abnormalities of the colon Pre-test prep: 1. Low-residue diet 1 to 2 days before the test 2. Clear liquid diet the evening before the test 3. Laxative is given the evening before the test 4. NPO after midnight

5. Cleansing enemas the morning of the test ( if not contraindicated) 6. BaSO4 is administered per rectum Oral Cholecystography - identifies stones in the gallbladder or CBD and tumors or other obstructions Pre-test prep: Client swallows 6 dye tablets-one every 5 mins. after the evening meal with a total of 250 ml of water. Once the initial x-ray is taken, a fatty test meal is given to determine GB ability to empty.

Cholangiography Determines the patency of the ducts from the liver

and gallbladder. It is used when oral cholycystogram, vomiting interferes with the retention of the oral dye. - dye is usually instilled intraveneously (IV) or through the T-tube surgically placed in the CBD.

Pre-test prep:

1. Client must sign a consent form 2. Ask if the patient is allergic to iodine or shellfish. 3. Restrict food and fluids several hrs. before the examination.

Percutaneous Liver Biopsy Obtaining a small core of liver tissue by placing

needle (FNB) through the client’s lateral abdominal wall directly into the liver. Detects malignancies, infectious and inflammatory processes, liver damage and sign of rejection post liver transplant Pre-test prep: 1. CT scan or ultrasound is done to identify the appropriate site of the biopsy needle.

2. Position the patient in supine position with a rolled towel beneath the right lower ribs. 3. Instruct the patient to take a deep breath and hold it while the needle is being inserted.  Post-test: 4. Position patient on his right side with a small pillow under the costal margin for several hrs. 5. Ask the patient to prevent coughing or straining 6. Avoid heavy lifting or strenuous activity post procedure

Common Gastrointestinal Endoscopic Procedure Esophagogastroduodenoscopy (EGD)

- examination of the esophagus, stomach and duodenum through an endoscope - local spray anesthetic is given and anxiolytic agent to provide sedation and relieve anxiety. Post-test: Nurse monitors for any signs of complication especially signs of perforation - may not have food or fluids until the gag reflex returns. - Clear fluids are given first then progress to regular foods according to the client tolerance.

Colonoscopy Examination of the entire large intestine

with a flexible fiber optic colonoscope Air maybe instilled to promote visualization within the folds of the intestinal mucosa Clients are sedated briefly and monitored accordingly Position the patient in knee-chest/lateral position during the procedure

Proctosigmoidoscopy Examination of the rectum and sigmoid colon using

a rigid endoscope. Knee-chest position. Retrograde Endoscopic Cholangiopancreatography (ERCP) Combined endoscopic and radiographic examination using a contrast radiopaque medium instilled in the biliary tree and pancreatic ducts.

Periteneoscopy Examination of GI structures through an endoscope

inserted percutaneously through a small incision in the abdominal wall Patient can be given either local, spinal or general anesthesia

Panendoscopy Examination of both the upper and lower GI tracts

Stool Analysis Stools are collected to identify WBC

(inflammation and infection) RBC (blood loss) and fats (malabsorptions)  No red meat 3 days prior to collection of stool.

Gastointestinal Intubation for Feedings or Medications 

Different Types of GI Intubation Nasogastric ( nose-stomach via esophagus) Orogastric ( mouth-stomach) Nasoenteric ( nose-esophagus-stomach-small intestine) Gastrostomy (tube enters the stomach through a surgically created opening into the abdominal wall. Jejunostomy (enters jejunum or small intestine)

Alternative Feeding:  Enteral hyperalimentation- delivery of nutrients directly to the GI tract. 



Short- term- esophagostomy; nasogastric tube Long- term- gastrostomy; jejunostomy



Indications of NGT:



1. Gavage- to deliver nutrients; for feeding purposes 2. Lavage- to irrigate the stomach 3. Decompression- to remove stomach contents or air

Types of GI tube Levin tube – single lumen Salem-Sump tube - double lumen Miller-Abbot tube - double lumen intestinal tube Cantor-tube - single lumen intestinal tube Sengstaken-Blakemore tube - triple lumen tube used to treat bleeding esophageal varices

1. 2. 3. 4. 5.

Hang or elevate the feeding bag or syringe about 18 inches above the patient’s head Flush tube with 30-50 ml of water in the end of the feeding Care of nares with NGT- apply water soluble lubricant to prevent irritation Reposition tube to ensure patency If tube is for decompression, observe signs and symptoms for metabolic alkalosis

 Nursing Care in NGT: Check placement of feeding tube -Aspirate 10-20 ml of gastric secretions (measure gastric residual and return to stomach) - Measure the pH of aspirated fluid - Inject 10-30 ml of air into feeding tube and auscultate over the epigastric area with stethoscope

 Hyperalimentation (total parenteral

nutrition)- method of giving highly concentrated solutions intravenously to maintain a patient’s nutritional balance when oral or enteral nutrition is possible

 Nursing Management:  Filter is used in the IV tubing to trap bacteria  Solution and administration equipment should

be changed every 24 hours  Dressing changes every 48-72 hrs with antibiotic ointment to catheter insertion

Medication is never administered in a TPN line Do not abruptly discontinue TPN Observe for complications  Infection  Venous

thrombosis  Hyperglycemia

            

Nursing Assessment Anorexia, nausea or vomiting Dysphagia Dyspepsia (indigestion) Pyrosis (heartburn) Diarrhea or constipation Regurgitation Bleeding- hematemesis, melena, hematochezia, flatulence, aerophagia, borborygmus Abdominal rigidity Hiccup Jaundice (obstructive) Acholic stools

Common GI Diseases: Appendicitis  Inflammation of the verniform appendix  Predisposing factors: 3. 4. 5.  7. 8.

Microbial invasion Fecaliths – undigested food particles Intestinal obstruction Nursing Assessment: (+) rebound tenderness Low grade fever

3. anorexia 4. nausea and vomiting 5. pain at the McBurney’s point  Management: 5. Appendectomy within 24-48 hrs. 6. Medications: antibiotics, antipyretic, no analgesics 7. Avoid heat application, cleansing enema

Nursing Management:  Post AP 2. 3. 4. 5. 6. 7.

FOB for 6-8 hrs (spinal anesthesia) Monitor for return of sensation on lower extremities NPO until peristalsis returns Encourage ambulation Proper positioning Resume normal activities within 2 to 4 wks.

A. Peptic Ulcer Disease - break in the continuity of gastric mucosa that comes in contact with hydrochloric acid and pepsin  Predisposing Factors - emotional stress, irregular meals excessive smoking, drinking coffee or alcohol, drugs; genetics Incidence - more in men with emotional stress; type O blood

 Nursing Management 2. Rest 3. Bland diet- no caffeine, alcohol and spicy

foods 4. Stress nursing management 5. If with hemorrhage- gastric lavage

Gastric Ulcer

“Poor man’s ulcer” (50 y/o and above) Incidence: 20% Location: Antrum Pain: epigastric,30mins. a.c., not relieved by food and antacids Weight: loss Hemmorhage: hematemesis Complication: hemmorhage, CA

Duodenal Ulcer

“Executive ulcer” (25 to 50 y/o) - 80% - duodenal bulb - mid-epigastric, 3-4 hrs p.c. 12mn-3am, relieved by food - weight gain - melena - perforation

Medications:  Antacids-neutralizes hydrochloric acid and relieves pain; give 1-2 hrs after meals. Ex. Maalox, Kremil S, Amphogel, Milk of Magnesia  Anti- ulcer agent- protect ulcers from acid and pepsin. Given 1 hr before meals (empty stomach)  H2 (histamine) receptor antagonists- inhibits gastric secretions; given 1 hour a.c.

Ex. Cimetidine Ranitidine Famotidine













Anticholinergics- decreases motility and volume of gastric secretions; give 30 min a.c. Prostaglandin analogs – used to sustain the mucosal layer especially those on long treatment with aspirin. Ex. (Cytotec) PPI- Proton Pump Inhibitor- supresses gastric acid by blocking enzymes associated with the final step of acid production. Given before meals. Ex.(Losec, Nexium) Cytoprotective Drug- coats ulcer, taken on empty stomach. Ex.(Carafate) Helicobacter Pylori Drug- anti-microbials Ex. (Amoxicillin, Flagyl) Anticholinergics- reduce gastric motility and HCL secretion Ex. (AtSO4, Bentyl)

Surgery Gastrectomy- removal of stomach- anastomosis of esophagus and duodenum   



Billroth I- gastroduodenostomy Billroth II- gastrojejunostomy Vagotomy- resection of vagus nerve to inhibit vagal stimulation and decrease motility and gastric secretions Pyloroplasty- enlargement of pyloric sphincter to permit passage

Complication:

Dumping Syndrome - rapid emptying of food especially concentrated carbohydrates in the duodenum; food draws fluid from the blood stream- hypovolemia

Signs and Symptoms Nursing Management:  faintness a. Small frequent meals  dizziness b. Chew food thoroughly  sweating c. Avoid high carbohydrate diet  nausea and d. Avoid liquid within meals  palpitations e. Lying down after mealsflat for 5-30min p.c.

Chronic Inflammatory Bowel Disorders  Crohn’s Disease

 Ulcerative Colitis

- ileum/ascending colon - unknown, environmental - 20-30 years, 40-60 years

- rectum/lower colon - Unknown, emotional

- less, stool with pus and mucus - 5-6 stools/day Management: TPN, low fiber, Steroids, Ileostomy

stress - 15-40 years - Severe, stool with blood, pus and mucus - 20-30 watery stools/day - Management: Diet-low

fiber, Steroids, TPN, Ileostomy

Nursing Management of IBD: a. Pharmacotherapeutics- sulfonamide or

aspirin; corticosteroids; immunosuppressive drugs b. Diet- cannot cause IBD; for patient comfort      

high calorie and high protein diet bland low residue limit dairy products multivitamin and mineral supplement liberal fluid intake of 2.5-3 liters/ day TPN

c. Surgery- ileostomy

Colorectal Cancer  80%- distal portion from sigmoid to anus  Early detection:

a. digital rectal exam annually after age 40 b. occult blood test yearly after age 50 c. proctosigmoidoscopy every 5 years after age 50  Signs and symptoms

a. ascending colon- anemia and unexplained GI bleeding b. descending colon and sigmoid colon- change in bowel habits and rectal bleeding, tenesmus

Diverticular Disorders Diverticula – sac or pouches caused by

herniation of the mucosa through a weakened portion of the intestinal wall Diverticulosis – multiple outpouchings Diverticulitis – acute inflammation and infection caused by fecal material and bacteria

Management: 1. 2. 3. 4. 5. 6. 7.

High fiber diet/low fiber diet Avoid nuts and seeds Bulk-forming laxatives Bed rest Antibiotics, analgesics, anti-cholinergic NGT to relieve distention Weight loss to reduce intra-abdominal pressure

Accessory Organs

Normal and altered liver

function in cirrhosis:

1. Maintenance of normal size and drainage of

blood from gastrointestinal tract- gastrointestinal symptoms like nausea and vomiting 2. Metabolism of carbohydrates- decreased energy 3. Metabolism of fats- hepatomegaly (fatty liver); - decreased energy production; weight loss

 4. Protein metabolism- decreased albumin production-

edema and ascites - decreased production of clotting factors- bleeding; anemia  5. Detoxification of exogenous substances- decreased metabolism of sex hormones- loss of sex characteristics; - decreased metabolism of aldosterone- edema or ascites; - increased K or H2 excretion (hypokalemia or alkalosis); - decreased metabolism of ammonia- hepatic encephalopathy

6. Detoxification of exogenous substances- decreased

metabolism of drugs- altered effects, increased toxicity and side effects 7. Metabolism and storage of vitamins and mineralsdecreased stores of vitamins and minerals- anemia and decreased energy production 8. Bile production and excretion- obstruction of bile flow - decreased Vit. K absorption- decreased clotting factors- bleeding

9. Bilurubin metabolism- decreased uptake

from circulation- jaundice and pruritus; - decreased conjugation- increased urine bilurubin (dark urine); - decreased GI excretion- acholic stools

Liver Cirrhosis Degenerative liver disorder caused by generalized cellular damage  Types: Laennec’s or Alcoholic – results from chronic alcohol intake and is usually associated with malnutrition. Postnecrotic – results from destruction of liver cells secondary to infection, metabolic liver disease or exposure to industrial chemicals Biliary cirrhosis – scarring occurs around the bile ducts in the liver, usually related to chronic obstruction 

Nursing Assessment:  Early S/S 2. 3. 4. 5. 6. 7.

Weakness and fatigue Anorexia Tea-colored urine, clay-colored stool Loss of axillary and pubic hair Abdominal pain and shortness of breath Skin itching

 Late S/S 2. 3. 4. 5. 6.

Nosebleeding, anemia Spider angioma Palmar erythema Gynecomastia and testicular atrophy Ascites and jaundice

 Nursing Management: 2. Provide good nutrition. Vitamins and nutritional supplements promote healing of liver cells 3. Monitor vital signs for alcohol withdrawal 4. Weight patient daily. 5. Monitor intake and output 6. Give small frequent feedings rather than 3 full meals 7. Health teaching on abstinence from alcohol

7. Omission of all sedatives (detoxified by liver) 8. Butter ball diet- foods rich in carbohydrates are protein sparing nutrients- they are used by the body for energy in place of protein 9. Abdominal paracentesis

Complications: 1. Hepatic encephalopathy and coma 2. Portal hypertension- pressure >25-30 cm. of

saline 3. Bleeding esophagastric varices

Nursing Management: 1. IV fluids 2. Antiemetics 3.Blakemore- Sengstaken Tube (esophageal balloon

tamponade) Nursing Interventions: a. Keep a pair of scissors at bedside- in the event of acute respiratory distress cut across tubing to deflate balloon b. Deflate esophageal balloon for 5 minutes at 8-10 hrs interval to prevent necrosis

4. Porta- Systemic Shunting

a. Porta caval (portal vein to inferior vena cava) b. Splenorenal shunt (splenic to renal) 5. Diet high calorie, low to moderate protein, high

carbohydrate, low fat with vitamins ABCDK

Cholelithiasis- stone formation in the gall bladder Cholecystitis- inflammation of gall bladder usually

precipitated by gallstones Choledocholithiasis- stone formation at the common bile duct Incidence: (5 F’s) a. Female b. Forty (age- 40 years and above) c. Fair complexion d. Fertile e. Fat

Nursing Management: a. Pain control - Demerol (drug of choice) b. Anticholinergic - Atropine c. ESWL Extracorporeal Shock Wave Lithotripsy-

shock waves used to disintegrate gallstones

Pancreatitis  Inflammation brought about by the digestion of this

organ by the very enzymes it produces  Nursing Assessment: - extreme upper abdominal pain - persistent vomiting - abdominal distention - weight loss - steatorrhea - elevated serum amylase and lipase - ecchymosis around umbilicus - ecchymosis at flank area

Nursing Management: 1. 2. 3. 4. 5.

Administer anticholigernics, antacids, pancreatic extracts. Pancrealipase (Viokase) NPO with NGT in place, no ice chips or hard candies as these will stimulate the pancreas. IV fluids. May require TPN in moderate or severe cases Provide Demerol for pain relief Administer fat soluble vitamins

Hepatitis Inflammatory disease of the liver, usually caused by a virus, bacteria and toxic injury to the liver Types of Hepatitis 1. Toxic 2. Viral Viral Hepatitis Hepatitis A, B, C Prevention: - handwashing - enteric and blood, body fluids - do not recap needles - cannot donate blood - no intimate sexual contact during period of infection

Pre-icteric (prodromal phase)

- last for 1 week Assessment : 1. fever and chills 2. nausea and vomiting 3. anorexia 4. hepatomegaly

Icteric Phase

- starts with onset of jaundice - last from 4 to 6 weeks Assessment : - worsening anorexia - dyspnea - liver tenderness increases Post icteric - begins with disappearance of jaundice, normally lasts for several weeks up to 4 months

Management: Promote rest Maintenance of food and fluid intake Prevention of injury Provide comfort