Gastro, Liver And Biliary System

CARE OF THE CLIENT WITH PROBLEMS RELATED TO THE GASTROINTESTINAL SYSTEM, LIVER AND BILIARY TREE Earl Francis R. Sumile, RN Instructor, College of Nursing University of Santo Tomas

Nursing Assessment •

Anorexia, nausea or vomiting

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Dysphagia

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Dyspepsia (indigestion)

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Pyrosis (heartburn)

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Diarrhea or constipation

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Regurgitation

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Bleeding- hematemesis, melena, hematochezia,

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flatulence, aerophagia, borborygmus

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Abdominal rigidity

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Hiccup

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Jaundice (obstructive)

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Acholic stools

Diagnostic Assessment: 2. Hematologic liver function studies a. To determine excretory function •

Serum bilurubin T=0.1-1 mg/dl

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Serum alkaline phosphatase 2-5 bodansky unit

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SGOT Serum Glutamic Oxalo Transaminase or AST Aspartate Aminotransferase N= 7-40 U

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SGPT Serum Glatamic Pyruvic Transaminase or ALT Alanine Aminotransferase N= 10-40 U

b. To determine metabolic function •

Serum protein- albumin, globulin

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Serum ammonia- N= 20-150 ug/ 100ml

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Serum amylase N= 4-25 u/ml

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Prothrombin time N=11-16 secs

c. To determine detoxifying function •

BSP- Bromosulphthalein- NPO- dye injected IV on one arm, after 45 mins. Blood extracted from other arm

1. Roentgenography or Fluoroscopy •

Barium swallow (UGIS)- x-ray of esophagus, stomach, and duodenum

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Barium enema (LGIS)- x-ray of small and large intestines Prep- light evening meal, catharties at bedtime, NPO x *hrs cleansing enema in am

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Oral Cholecystography- x-ray of visualization of the gall bladder after introduction of dye Telepaque tablets- to be taken one at a time at 5 minutes interval, with a total of 240 ml of water

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Cholangiography- x-ray visualization of common bile duct after giving of contrast medium (intravenous, operative and ttube) contrast medium- hypaque

1. Direct visualization- endoscopy and position during a. Esophagoscopy- recumbent with head and elevated shoulder b. Gastroscopy- right side lying c. Duodenoscopy- right side lying Prep- NPO x 6-8 hrs; anticholinergic, sedative, narcotic, topical anesthetic are given Post- NPO until gag reflex is back (x4hrs) d. Anoscopy e. Proctoscopy f. Sigmoidoscopy g. Colonoscopy Prep- cleansing enema; clear liquid diet; laxative; position

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Liver biopsy- done with a fine needle aspiration (FNAB); during the procedure- instruct patient to hold breath, position after- right sims with a small pillow or rolled towel at costal margin

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Analytic examination •

Gastric Analysis- to determine hydrochloric acid in the stomach Prep- NPO then NGT is inserted give gastric stimulant (histamine phophate to stimulatehydrochloric acid production) antidote histamine reaction- epinephrine or adrenalin

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Gastric Tubeless Analysis diagnex, blue or azuresin + 1g water no medications NPO 6-8 hrs urine saved after 2 hrs (n= blue color)

3. Cultures and stool specimens- hemoccult, hematest and guaiac

Alternative Feeding: •

Enteral hyperalimentation- delivery of nutrients directly to the GI tract. a. Short- term- esophagostomy; nasogastric tube b. Long- term- gastrostomy; jejunostomy

Indications of NGT: •

Gavage- to deliver nutrients; for feeding purposes

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Lavage- to irrigate the stomach

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Decompression- to remove stomach contents or air

Nursing Care in NGT: 2. Check placement of feeding tube •

Aspirate 10-20 ml of gastric secretions (measure gastric residual and return to stomach)

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Measure the pH of aspirated fluid

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Inject 10-30 ml of air into feeding tube and auscultate over the epigastric area with stethoscope

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Place patient on high fowler’s if permitted

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Hang or elevate the feeding bag or syringe about 18 inches above the patient’s head

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Flush tube with 30-50 ml of water in the end of the feeding

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Care of nares with NGT- apply water soluble lubricant to prevent irritation

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Reposition tube to insure patency

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If tube is for decompression, observe signs and symptoms for metabolic alkalosis

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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 Managements: •

Filter is used in the IV tubing to trap bacteria

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Solution and administration equipment should be changed every 24 hours

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Dressing changes every 48-72 hrs with antibiotic ointment to catheter insertion

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Medication is never administered in a TPN line

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Do not abruptly discontinue TPN

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Observe for complications •

Infection

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Venous thrombosis

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Hyperglycemia

Common Diseases: 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

Duodenal • 10x more frequent than gastric ulcer, occurs within 1.5cm of the pylorus • characterized by hypersecretion of acid due to increased rate of gastric emptying • more common among young men • smoking, alcohol, abuse, psychogenic stress

Signs and symptoms - gnawing, burning, cramping, epigastric pain (right side) 3-4 hrs after meals

Gastric • most common at antrum • gastric secretions and emptying normal • rapid diffusion of gastric acid to gastric mucosa • gnawing, burning, cramping, epigastric pain in epigastric (left side) 1 or 2 hrs p.c. • smoking, alcohol abuse, emotional stress, drugs • men with low socio- economic groups

Nursing Management • rest • bland diet- no caffeine, alcohol and spicy foods • stress nursing management • if with hemorrhage- gastric lavage

•Medications •Antacids-neutralizes hydrochloric acid and relieves pain; give 12 hrs after meals •Mucousal barrier fortifier- to protect mucousal barrier sucralfate; given 1 hr before meals (empty stomach) •Hyposecretory agents- reduce secretions • H2 (histamine) receptor antagonists- inhibits gastric secretions; given 1 hour a.c. •Anticholinergics- decreases motility and volume of gastric secretions; give 30 min a.c. •Prostaglandin analogs- cytotec •PPI- Proton Pump Inhibitor- losec

•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 of chyme

Complication: 1. Dumping Syndrome -rapid emptying of food especially concentrated carbohydrates int the duodenum; food draws fluid from the blood stream- hypovolemia

Signs and Symptoms

Nsg Management:

•faintness

a. Small frequent meals

•dizziness

b. Chew food thoroughly

•sweating

c. Avoid high carbohydrate diet

•nausea and vomiting

d. Avoid liquid within meals

•palpitations

e. Lying down after mealsflat for 5-30min p.c.

2. IBD- Inflammatory Bowel Disease

a. Regional enteritis (Crohn’s disease)- nonspecific inflammatory disease in any segment of the alimentary tract (usually ileum); thickening of intestinal wall with scar tissue formation; characterized by remissions and exacerbations

Signs and symptoms •3-5 large semisolid stools per day •stools contains mucus and possibly pus but rarely blood •steatorrhea if with small bowel affectation •right lower quadrant pain (mimics appendicitis)

B. Ulcerative colitis - chronic ascending inflammation of rectumand colon; may be psychophysiologic- related to personality traits of perfectionism, rigidity, insecurity, dependence on a mother figure

Signs and symptoms •profuse watery diarrhea (15-20 stools per day) •stool contains blood, mucus and possibly pus •abdominal cramping with BM (tenesmus) •loss of sodium, calcium, potassim, bicarbonate

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

C. 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

Management: 1. APR (Abdomino Perineal Resection)- Mile’s with colostomy site of permanent colostomy- lower descending colon Types of colostomy a. single barrel- usually permanent b. loop- with bowel inflammation; segment is brought to the abdomen for temporary colostomy held in place with rubber tubing connected to a glass rod and left until healed (10 days); usually temporary c. double barrel- if tumor at ascending or transverse colon (proximal stoma- evacuates feces, distal- mucus); usually temporary

Preop bowel prep: •reduce bacteria in the intestinal tract to prevent postop complications or infections •antibiotics- neomycin and kanamycin •reduce colon content- low residue diet, laxatives, enema •decompress gastrointestinal tract •cathartics•stimulants- increases motility •saline cathartics- contraction and movement of osmotic activity •lubricants- facilitates passage of stools •bulk forming

Colostomy Care: a. skin care- use of effective skin barriers or wafers to prevent skin irritation; cleanse with mild soap and water using cotton cloth b. odor control- avoid foods known to cause odor; lessen with yogurt, cranberry juice and buttermilk; use of pulvorized charcoal, sodium bicarbonate, spray disorders c. control of gas-avoid carbonated beverages and gas forming foods d. diet- avoid overeating; chew food thoroughly; prevent diarrhea or constipation e. colostomy irrigation- to stimulate peristalsis; to establish a regular pattern of evacuation

Nursing Consideration: •starts on 5th or 6th postop day •done at the same time everyday, preferably after a meal •patient sits on the commode •prime the stoma with little finger •hang the irrigating bag (use lukewarm solution) 18-20 inches above the stoma

D. Liver Cirrhosis -scaring of the liver

Causes: a. Laennec- alcohol ingestion or malnutrition b. Post hepatitis- fibrosis c. Biliary obstruction

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 ascitis; 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 ammoniahepatic encephalopathy

6. Detoxification of exogenous substances- decreased metabolism of drugs- altered effects, increased toxicity and side effects 7. Metabolism and storage of vitamins and minerals- decreased 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

Nursing Management: 1. Correct electrolyte imbalance 2. Reduction of ammonia formation- formed in intestines by intestinal bacteria in protein a. NGT suction b. Neomycin sulfate c. Lactulose d. Protein restriction e. Tap water enema f. Potassium g. Active ROM contraindicated since ammonia is formed during muscle contraction

3. Omission of all sedatives (detoxified by liver) 4. Butter ball diet- foods rich in carbohydrates are protein sparing nutrients- they are used by the body for energy in place of protein 5. 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

E. 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