Wednesday, March 28, 2012

Gastrointestinal Diseases





Diagnostic Procedures
Upper GI tract study (Barium swallow)
Pre procedure
examination of Upper GI under fluoroscopy after intake of barium sulfate
NPO after midnight prior to the day of the test

Post-Procedure
laxative (may be prescribed)
increase oral fluids
monitor passage of barium stools                           

Lower GI tract study (Barium enema)
    fluoroscopic and radiographic examination of large intestine after rectal instillation of barium sulfate.
PreOp:
low residue diet for 1-2 days before
clear liquid and laxative the evening before the test
NPO midnight prior to the day of the test
cleansing enemas on morning of test
PostOp:
same as Upper GI.
Notify Physician if no bowel movement within 2 days.

UGI Endoscopy
Direct visualization of esophagus , Stomach and duodenum
Obtain written consent
NPO for 6-8 Hours
Anticholinergic (ATSO4) as ordered ,To reduce Mucus secretions
Sedatives ,Narcotics,Tranquilizers, To relax the Client (diazepam, Meperidine HCL)
Remove dentures bridges, To prevent airway obstruction
Local spray anesthetic on the posterior pharynx-Instruct not to swallow saliva .

Colonoscopy
Fiberoptic endoscopic study of large intestine
patient side-lying / knee-chest position.
PreOp:
  Cleansing of colon
Clear liquid diet on noon day before the test
NPO midnight of test
Midazolam IV for sedation

PostOp:
Bed rest until alert.
Monitor for signs of perforation.
Report any bleeding.

Cholecystography, Cholangiography
Involves visualization of structures with use of a dye.
Always ask about allergies to iodine or seafood.

Fecal Analysis
Stool for Occult Blood  (guiac stool exam)
Detect GI bleeding
Increase fiber diet 48 to 72 hours
No red meats , poultry ,fish ,turnips ,horse radish

Stool for Ova and parasites
Send fresh warm stool specimen
Stool culture
Sterile test tube /cotton tipped applicator
Stool for lipids
Assess steatorrhea
Increase fat diet, No alcohol for 3 days
72 hour stool specimen (store on ice)

Measures secretion of HCL and pepsin
NPO for 12 hours
NGT is inserted , connected to suction
Gastric contents collected every 15 minutes to 1 hour
  
Stomatitis
An inflammation of the mucous lining in the mouth.
Can be caused by poor oral hygiene, poorly fitted dentures, immunocompromised, mouth burns from hot food or drinks, medications (especially chemotherapy), infections or allergic reactions, exposure to radiation.


Assessment
Burning sensation
Canker sores(small sores or ulcers  that are painful) = cold sores = virus
Excessive salivation
Halitosis (unpleasant odor of the breath) 
Xerostomia (abnormal dryness of the mouth due to insufficient secretions) – often with radiation
Erythema of the mucous membranes
White patches = thrush à candidiasis

Screening & Diagnosis:
Medical History – may disclose dietary deficiency, allergic reaction & systemic disease.
Physical examination – (+)apthous ulcers (well circumscribed oral lesions w/ white centers & reddish rings around the periphery.
Scraping of the lining of the mouth – (+) infectious causative agent

Treatment:
Antibiotics : tetracycline (Sumycin®) , chlorhexidine gluconate (PerioGard®, Peridex®)
Anti-fungal: nystatin suspension, clotrimazole (Mycelex Troches®)
Analgesics/topical anesthetics: lidocaine, benzocaine (Americaine®, Anbesol®), sulcrafate, orabase
Antiviral: acyclovir (Zovirax®)

Implementation
Instruct patient regarding good oral hygeine
Avoid foods that are irritating
Adequate fluid intake

Gastroesophageal Reflux

A condition in which stomach acid bile flows back into the esophagus.
It results from inability of the lower esophageal sphincter (LES) to close fully, thus allowing stomach contents to flow freely into the esophagus.

Assessment
Heartburn
Chest pain, especially at night while lying down
Dysphagia
Regurgitation of food or sour liquid
Cough, hoarseness, voice changes

Implementation
low-fat, high-fiber diet, avoid caffeine, tobacco, carbonated beverages.
avoid eating and drinking 2 hours before bedtime.
elevate head of bed
avoid cholinergics which delay stomach emptying
Instruct regarding meds: antacids, H2 receptor antagonists.

Esophagitis
(inflammation –esophagus)
Inflammation of the lining of esophagus.
Caused by an infection or irritation of the esophagus (due to backflow of acid fluid from the stomach/GERD, vomiting, surgery, medications).

Assessment
dysphagia (difficult/painful swallowing)
heartburn
esophageal pain
acid regurgitation
belching

Screening & Diagnosis:
Physical examination – reveals tachypnea, thrush in the oropharynx, & dental erosions
Upper GI x-ray w/ barium – esophageal motility abnormalities, esophageal strictures, gastric outlet obstruction.
Biopsy (sample of esophageal tissue is removed then sent to the lab. to be examined under the microscope)
Esophagogastroduodenoscopy (EGD) – reveals irritated, inflamed & eroded areas

Implementation
Small frequent meals
elevate head of bed 4 to 8 inches
no meals 2 hours before bedtime
Avoid irritating foods
Medications
Antacids
H2 recptor antagonist
Proton pump inhibitor

Hiatal Hernia
Sliding hernia: gastroesophageal junction and part of stomach slide upwards.
Paraesophageal hernia: part of stomach turns adjacent to esophagus
  Assessment
Heartburn
Belching
Substernal/epigastric pressure or pain after eating & when lying down
Hiccups
Dysphagia, feeling of fullness

Diagnosis: Chest X-ray or Barium swallow

                                                  Barium swallow images for hiatal hernia

Implementation:
If asymptomatic – no treatment necessary
Small frequent meals
Elevate head of bed to reduce acid reflux
Avoid activities that increase abdominal pressure:
(lifting heavy objects, bending over, etc)
  
Medications
Antacids
Antiemetics
Histamine receptor Antagonist
Gastric Acid secretion Inhibitors
  
AVOID
Anticholinergics
Xanthine derivatives
Ca-channel blockers
Diazepam

Implementation
Small frequent meals
Elevate head of the bed
Avoid factors that increases abdominal pressure

  
Surgery
NissenFundoplication (Gastric wrap Around)


Postop care
Facilitate airway clearnce
Semi-fowlers position
Reinforce DBCT exercise
Drainage from NG tube returns to yellowish green within first 8 to 12 hours post op
Oral fluids after peristalisis returns
Small frequent meals
Avoid gas forming food

Peptic ulcer disease
GASTRITIS
Diffuse or localized inflammation of the gastric mucosa

Acute gastritis
Short –term inflammatory process due to ingestion of chemical agents or food products that irritate and erode gastric mucosa

Chronic gastritis
Type A
Autoimmune in nature
Atrophic gastritis, gastric Ca , pernicious anemia
 Type B
Asociated with helicobacter pylori
  
Assessment
Anorexia
Heartburn
Nausea and vomitting
Sour taste in the mouth
Belching
Epigastric pain

Implementation
Assess for GI bleeding
Small frquent meals
Avoid irritating foods
Avoid smoking
  
Gastric Ulcer 
Normal or decreased acid production
Decreased mucosal resistance
Chronic NSAID use
Pain gets worse after meals
                                                              Gastric ulcer pics  
Duodenal Ulcer
May be asymptomatic
Pain ( midepigastric)

Meds for gastritis, GERD, PUD.
Antacids:
Aluminum hydroxide (Amphogel)
Bismuth subsalicylate (Pepto-Bismol)
Calcium carbonate (Tums)
Magnesium hydroxide (Milk of Magnesia)

GI protectors
Misoprostol (Cytotec)
Sucralfate (Carafate)

H2 Receptor Antagonists
Cimetidine (Tagamet)
Ranitidine (Zantac)
Famotidine (Pepcid)

Antimicrobials
Amoxicillin (Amoxil)
Clarithromycin (Biaxin)
Metronidazole (Flagyl)
Tetracycline (Achromycin

Proton Pump Inhibitors
Omeprazole (Prilosec)
Iansoprazole (Prevacid)


SURGERY
Vagotomy
Resection  of the vagus nerve
Decreased cholinergic stimulation
Pyloroplasty
Surgical dilation of the pyloric sphincter
Improves gastric emptying of the acidic chyme

Antrectomy
Removal of 50 % of the lower part of the stomach
Types
Billroth I   ( gastroduodenostomy)
Billroth II  ( Gastrojejunostomy  )
Subtotal gastrectomy with bilroth1/bilroth 2
Total gastrectomy

Potential complication following surgery
Respiratory ( Atelectasis)
Bleeding
Dumping syndrome

DUMPING SYNDROME
Early signs and symptoms ( 5 to 30 min p.c.)
Weakness
Tachycardia
Dizziness
Diaphoresis
Pallor
Feeling of fullness or discomfort
Nausea
Explosive diarrhea


Esophageal Varices
Elevated portal vein pressure
Tortous dillated thin walled veins

Assessment
Asymptomatic
If massive bleeding ( signs of shock)

Medication
Vassopressin ( pitressin)
Betablockers
Nitrates

Implementation
Assess vital signs
Assist patient to avoid straining and vomitting
Assess for bleeding
assist with Sengstaken tube

Sengstaken blakemoreTube

To compress esophageal varices

Liver Cirrhosis
Chronic, degenerative liver disease manifested by diffuse destruction & fibrotic regeneration of hepatic cells that leads to anatomic alteration & partial/complete occlusion of blood in the liver.

Types
Laennec’s cirrhosis
Biliary cirrhosis
Postnecrotic cirrhosis
Cardiac cirrhosis

Assessment

  • Fatigue
  •  nausea, vomiting
  •  itchy skin, jaundice
  •  spider angiomas
  • palmar erythema
  •  nosebleeds, GI bleeds, bruises
  •  ascites
  •   esophageal varices - CNS: lethargy

Analysis:
altered thought process
bleeding risk
Impaired skin integrity
Altered nutrition

Implementation
Check skin, gums and stool for bleeding
Avoid aspirin, NSAIDS, alcohol
Monitor weight
Monitor abdominal circumference
If ascites interferes with breathing- - high fowler’s



Hepatitis

A
Contaminated
Water/food/shellfish
-2-6 weeks incubation
- 0% become chronic
B
Blood transfusions
Sexual contact
Parenteral
-2-6 months incubation
-10% become chronic
C
Blood transfusions
Sexual contact
Parenteral
- 1-2 months incubation
D
Only in patients with hepatitis B
parenteral
incubation period: 21 to 140 days
E
Fecal oral
incubation period: 15 to 65 days




Assessment:

PREICTERIC:

nonspecific: fatigue, anorexia, malaise, weakness
low grade fever


ICTERIC
Jaundice
Pruritus
Brown-colored urine
Lighter-colored stools
Decrease in preicteric phase symptoms

POSTICTERIC
Energy level increase
GI symptoms are minimal to absent
Pain subsides
Serum bilirubin & enzyme levels return to normal

Treatment:
Diet therapy: high-calorie, moderate-protein, low fat
Activity – rest
Medications
Interferon alpha (IM or SC injection)
lamivudine (Ephivir HBV)
ribavirin  (Rebetol®)
Vitamins & minerals
Vaccines for preventive measures (only for hepa A  & B – 3 series shots)
Herbal medicines: licorice root


Implementation
Provide bed rest
Provide high-calorie diet
Monitor for signs of GI bleeding
Limit visitors/ isolation procedures if infectious

Cholecystitis
Inflammation of the gallbaldder
Associated with cholelithiasis

Assessment
Nausea and vomitting
Belching
Indigestion
+ murphy’s sign
Pain right upper quadrant

Dissolution therapy 
  •  Ursodiol(Actigall)
  •  Chenodiol (Chenix)


Analgesics: meperedinehydrochloride(Demerol)
Anti-emetics: promethazine (Phenergan, Prorex, Anergan)

Surgical
Cholecystectomy – removal of the gallbladder
Choledochotomy – incision of the common bile duct to remove the stone

Postoperative:
 Monitor T-tube drainage(up to 500 ml in 24 hours is normal) 


Pancreatitis
Acute or chronic inflammation of the pancreas wherein there is abnormal pancreatic enzyme activation in the pancreas


Acute Pancreatitis
Chronic Pancreatitis
         Pain midepigastric
         Left upper quadrant
         Tachycardia
         Increased temperature
         Abdominal distention & rigidity
         ↓ Bowel sounds
         Nausea & vomiting
         Cold clammy skin
         Mild jaundice
         Cullen’s sign – discoloration of the abdomen and periumbilical area
         Turner’s sign -  bluish discoloration of the flanks
         Reoccurring abdominal pain & tenderness
         steatorrhea & foul smelling stools
         Left upper quadrant mass
         Weight loss
         Muscle wasting
         Jaundice

Blood chemistry – reveal ↑ amylase, bilirubin, lipase, trypsinogen, alkaline phosphatase glucose, ↓ calcium

Medications
Analgesics: acetaminophen (Tylenol®), tramadol (Ultram®)
Antibiotics: imipenem and cilastatin (Primaxin®)
Pancreatic enzymes: pancrelipase (Lipancreatin®)
H2 blockers: cimetidine (Tagamet®), ranitide (Zantac®)

Diet therapy: low-fat, low-protein, high-carbohydrate, small frequent feedings with restricted

Implementation
Monitor vital signs, assess level of pain.
Maintain NPO and provide NG tube suction if vomiting in acute phase
Follow dietary recommendations & restrictions
Instruct patient about the importance of avoiding alcohol and smoking cessation.

APPENDICITIS (epityphlitis)
Inflammation of the appendix caused by an obstruction of the narrow appendiceal lumen secondary to impacted fecal material, kinking infectious swelling fibrous over growth or lymph node swelling.
Occurs in all age groups but rare in infants.

Types:
Simple appendicitis
Gangrenous appendicitis
Perforated appendicitis

Assessment
(+) Rebound tenderness
(+) Rovsing’s sign
(+) Psoas sign  
(+) Obturator sign
Low-grade fever
Nausea & vomiting
Loss of appetite
Inability to pass gas

Medication
Antibiotics : cefuroxime, metronidazole
Surgical
Appendectomy – surgical removal of the appendix to decrease the risk of perforation.
Laparoscopic surgery – remove appendix using a pencil-thin tube; provides less scarring & faster recovery.

Implementation
maintain bed rest
keep client NPO
semi-fowler’s position
monitor for signs of perforation and systemic infection
Postoperative:
monitor vital signs
monitor fluid intake and output
monitor bowel sounds
monitor dressing for drainage or signs of infection

 DIVERTICULOSIS
A condition when multiple diverticula exist without symptom or inflammation.
Diverticulitis
An inflammation of one or more diverticula

Assessment
Lower left side abdominal pain
Abdominal tenderness
Change in bowel
Vomiting
Bloating
Anorexia
Trace (occult) blood in the stool
Urinary frequency from pressure
Low grade-fever

Diagnosis
Physical examination & digital rectal exam
Hemooccult or guaiac testing Complete blood count - ↑ WBC, RBC loss
Abdominal x-ray/ CT scan
Barium enema
Colonoscopy or sigmoidoscopy

Medications
Opioid Analgesics: meperedine(Demerol®), pentazocine (Talwin ®)
Antispasmodics: propantheline bromide(Pro-Banthine®), oxyphencyclimine(Daricon®)
Antibiotics: metronidazole (Flagyl®), clindamycin (Cleocin®), cefoxitin (Mefoxin®)
Bulk preparation: psyllium(Metamucil)
Stool softener: docusate(colace)

Surgical
Bowel resection with primary anastomosis
Temporary or permanent colostomy
  
Implementation
Bed rest during acute phase
NPO during acute phase
Administer medications as ordered
Instruct to avoid straining
Increase fluid intake
Dietary modification
Provide colostomy care ( if present)

Inflammatory bowel diseases

Ulcerative colitis
Chron’s disease
Pathology
And location
         mucosal ulceration
         begins at rectum and progresses towards ileocecal junction
         Involves entire colon up to ileum
transmural thickening
granulomas
         Ileum, ileocolic colon
Assessment
         Abdominal cramping: left lower quadrant
         Abdominal distention
         Nausea & vomiting
         Fatigue
         Bloody purulent stool
         Fever
         Tenesmus
         Weight loss,
          anorexia
          
          
         Diarrhea
         Possible steatorhhea
         Weight loss + malabsorption à deficiencies
         Diffuse abdominal tenderness
         Abdominal pain & cramping
         Fever
          
          


Medication
Anti-inflammatory: sulfasalazine (Azulfidine),mesalamine (Asacol, Rowasa), olsalazine, salicylate
Corticosteroids: budesonide (Entocort EC), methylprednisolone, prednisone
Antibiotics: metronodazole (Flagyl),ciprofloxacin (Cipro)
Immune system suppresors : azathiophrine(Imuran), mercaptopurine (Purinethol), methotrexate, (rheumatrex)
Anti-diarrheals: psyllium powder (Metamucil), loperamide(Imodium)

Surgery
Total proctocolectomy/ Ileostomy
Kock ileostomy
  
Watch for dehydration
Monitor stool frequently and consistency
During acute phase NPO
Watch signs of gastrointestinal obstruction
Dietary modification

Colostomy
is a surgical procedure that involves connecting a part of the colon onto the anterior abdominal wall
-Cancer
-Ulcerative Colitis, Chrons
-Diverticulitis
Congenital conditions: Hirschprung's disease, rectal atresia, and megacolon
-Bowel Obstruction
-Traumatic Injury


Permanent Ostomy
Constructed when the rectum, colon, or the bladder have been removed
Temporary Ostomy
 Considered temporary if it is going to be reversed

An ileostomy is astoma that has been constructed by bringing the end of the small intestine (the ileum) out onto the surface of the skin..

Colostomy care:
Remove pouch when 1/3 full
Cleanse stoma with soft cloth and water or mild soap
Dry skin thoroughly before applying pouch
Use skin barrier powder or paste to protect from fecal drainage.
Irrigation of stoma: be gentle – never force catheter
Allow client to verbalize feelings about colostomy


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