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Diagnostic Evaluation

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					       Diagnostic Evaluation

• UGI- pass clay colored stools after test
• Lower GI
• Gastric Acid stimulation test-experience
  flushed feeling when med is injected
• Gastric PH
• Laparoscopy
• UGI
  Fiberoscopy/Esophagogastroduodenoscopy-
                                         1
                   Cont.

• With esophogogastroduodenoscopy-
  withhold food and fluids until gag reflux
  returns
• Sigmoidoscopy – lye on left side with rt leg
  flexed



                                                 2
            Cont. GI Tests
• Pre-op bowel prep with GoLightly –purpose
  is to decrease post-op sepsis
• Fiberoptic colonoscopy
• Abdominal ultrasonography
• Stool Test - False positive hematest may
  occur when taking Aspirin


                                          3
               Oral disorders
• Salivary glands- parotitis
• Cancer of the oral cavity –painless sore that has
  not healed
• …xerostomia – dryness of the mouth
• ….stomatitis- inflammation/breakdown of oral
  mucosa;side effect of chemotherapy
• Nsg Interventions –promote preventive mouth
  care- medicate if bacterial/fungal infection
• Promote adequate nutrition/hydration
                                                      4
     Disorders of the esophagus
• Mucus lined-muscular tube starts at base of
  pharynx ends 4cm below diaphragm.Two
  sphincters; upper and lower. Lower one, junction
  of stomach and esophagus allows for backward
  flow of stomach content.
• Dysphagia: most common symptom . Many patho
  conditions responsible( including motility
  disorders –achalasia, diffuse spasm), GERD
  (gastroesophageal reflux is an inflammatory
  response- AKA Reflux Esophagitis), hiatal
  hernias, perforation,cancer,chemical burns.
                                                     5
     Disorders of the Esophagus

• Achalasia- absent peristalsis of distal esophagus
• S&S= difficulty swallowing liquids and solids,
  regurgitate food to relieve pressure and to rid
  food that will not pass into stomach.Get pyrosis
  and chest pain
• Dx-manometry to measure increase pressure
• Tx= drink fluids with meals, eat slowly, ca
  channel blockers, nitrates, botulinum injection,
  surgery
                                                      6
                  Esophagus
• Diffuse spasm-motor disorder-stressful situations
  get contractions of the esophagus
• Clinical manifestations- dysphagia,chest pain
• Dx- manometry and barium swallow shows area
  of spasm
• Management:nitrates and sedatives to relieve
  pain,ca channel blockers to reduce spasms.small
  frequent feedings, soft diet,pneumatic dilation
• GERD- (backflow of gastric or duodenal contents
  into esophagus. Have incompetant lower
  sphincter,pyloric stenosis or motility disorder.  7
           Dumping Syndrome
• The term Dumping syndrome refers to GI
  symptoms that occur in some after a GI surgery or
  vagotomy.Foods high in CHO and electrolytes
  empty rapidly in the jejunum.The hypertonic
  intestinal contents draw extracellular fluid from
  the circulating blood into the jejunum to dilute the
  high concentration of electrolytes and sugars.
  Early symptoms, weakness, diaphoresis,
  palpitations, diarrhea, cramping, get rapid increase
  in blood glucose, followed by increased insulin
  secretion, get reactive hypoglycemia
                                                     8
     Cont. Dumping Syndrome
• Vasomotor symptoms occur 90 minutes
  after eating (headache, diaphoresis,
  dizziness, pallor.
• Tx- semirecumbant position during
  mealtime, after meal lye down 30 min to
  delay gastric emptying, fluids discouraged
  with meals.CHO intake should be low,
  glucose avoided.
                                               9
                     GERD
• S&S= pyrosis, indigestion,
  regurgitation,odynophagia, dysphagia- mimic
  heart attack
• Dx- endoscopy or barium swallow
• TX-avoid factors that cause irritation and decrease
  lower esophageal pressure. Low-fat, high fiber
  diet , avoid carbonated beverages, caffeine,
  tobacco, don’t eat/drink 2 hrs before sleep, , avoid
  tight clothes, normal wt, elavate HOB, meds
                                                     10
               Cont. GERD
• H2 blockers, antacids, gastric acid pump
  inhibitors, prokinetic agents, which accelerate
  gastric emptying ,Urecholine, Reglan, surgery
  (fundoplication)
• Hiatal Hernia – Normally the opening in the
  diaphragm encircles the esophagus tightly and the
  stomach is in the abd.With HH the opening in
  which the diaphragm through which the esophagus
  passes becomes enlarged and the stomach tends to
  move up into the thorax. Axial or sliding Hernia-
                                                 11
          HIATAL HERNIA
• Axial Hernia get difficulty in swallowing, heart
  burn because GE junction is displaced upward
  toward thorax.
• S&S= heartburn, indigestion or no symptoms.C/o
  include obstruction, hemorrhage, and strangulation
• Dx- barium swallow, fluoroscopy
• TX- frequent small feedings. Don’t recline for 1 hr
  after eating,elevate HOB, surgery, para-
  esophageal hernia may require emergency surgery.

                                                   12
                Diverticulum
• An outpouching of the sbmucosa or mucosa that
  protrudes through a weak portion of the
  musculature.
• Tx – dysphagia, fullness in the neck, regurgitation
  of undigested food, gurgling noises after eating.
  The pouch becomes full of food or fluid and
  halitosis occurs
• Dx- barium swallow. Avoid esophagoscopy
  because of perforation.
                                                    13
                       TPN
• Management_ surgical removal of diverticulum.
• For all patients with surgical intervention – TPN is
  ideal because it keeps nutritional balance and
  unlike a NG tube cannot cause aspiration
• TPN- start slowly to avoid hypertonic fluid intake,
  assess site for infection. Weigh daily, I&O, assess
  lab values.C/O include sepsis, air embolism,
  displaced cath, pneumothorax, fluid overload,
  hyper and hypoglycemia
                                                    14
                 Gastritis
• Inflammation of the gastric mucosa; acute
  or chronic
• NSAIDs. ASA,ETOH intake, food irritation
  or contamination, ingestion of strong alkali
  or acid may cause mucosa to perforate
  causing scarring and pyloric obstruction.
• Chronic gastritis cause by ulcers or bacteria
  H-Pylori

                                              15
                     Gastritis
• S&S – Acute (abd discomfort, headache, nausea,
  vomiting, some are asymptomatic)
• Chronic(may have vit B12 deficiency, anorexia,
  heartburn after eating, halitosis, nausea and
  vomiting)
Dx= UGI x-ray, H-pylori test
Tx – repairing itself in about two days. Avoid irritant
  causes, neutralize the offending agent
  (antacids)NG tube,analgesics,sedatives IV
  fluids,gastric resection may be necessary due to
  pyloric obstruction, antibiotics,Vit B              16
                 Peptic Ulcer
• Hollowed out area formed in the mucosal wall of
  the stomach, the pylorus, the duodenum or the
  esophagus.A peptic ulcer I referred as a gastric,
  duodenal, or esophageal or as peptic ulcer
  disease.Erosion of the mucosal or muscle layers or
  through the muscle to the peritoneum. More
  common in the duodenum. Zollinger-Ellison
  syndrome have extreme gastric acidity, peptic
  ulcers,gastrin secreting tumors of the pancreas is a
                                                     17
• Type of peptic ulcer- Stress ulcers are
  different because they are ulcerations of the
  mucosa that occur in the gastro- duodenal
  area.H-Pylori are in 70% of gastric ulcers
  and 95% with duodenal ulcers.Treated with
  antibiotics.Have increase hydrochloric acid
  production. Ingestion of milk, ETIOH,
  carbonated drinks, smoking increase acid.
                                              18
              Peptic Ulcer
• Familial tendency is a predisposing factor,
  Type O more susceptible to Peptic Ulcers.
  NSAIDS use, ETOH, excessive smoking.
  Stress ulcers may occur in those exposed to
  stressful situations ( burns, shock,sepsis,
  post op esophageal ulcers occur as a result
  of the backward flow of hydrochloric acid
  (GERD)
                                            19
                Peptic Ulcers
• S&S=last a few days – months. Disappear and
  may reappear.C/O of dull, gnawing pain or
  burning in midepigastrium or in the back.Pain
  relieved by eating because it neutralizes the acid
  once food or alkali is gone pain reoccurs. Sharp
  localized tenderness with light palpation. Some
  relief with pressure on epigastrium.Pyrosis,abd
  distention, vomiting, constipation, diarrhea, or
  bleeding.
• Dx- Endoscopy,stools for occult,pain relieved by
  food or arising suggest ulcer.
                                                       20
              Peptic Ulcer
• Tx- remission can occur, goal treat
  H_Pylori and/or mange gastric acidity. Life
  style changes, meds and surgery are part of
  the plan.
• Meds- Antibiotics, H2 antagonists, proton
  pump inhibitors, cytoprotective agents,
  antacids (pg 863), smoking cessation, rest
  and decrease stress, dietary modifications
                                            21
         Surgical Intervention
• Surgical management- those ulcers that do not
  heal after 12-16 weeks, hemorrhage, perforation,
  or obstruction or ZES not responding to meds.
  Vagaotomy, Billiroth I or II.Prophylactic use of
  H2 antagonist.If bleeding assess if fresh or coffee
  ground.Gastritis and hemorrhage from peptic ulcer
  are two most common causes of UGI bleed.The
  site of bleeding is usually distal portion of the
  duodenum, see hematemesis or melena.Assess for
  shock, treat blood loss, NG to suction/lavage,
  assess labs,PH gastric secretions,adm O2, IV’s
                                                   22
                  Perforation
• If bleeding,transendoscopic coagulation by laser,
  heat probe, medication, a sclerosing agent or
  combo ot therapies can halt the bleeding.
• Perforation is the erosion of the ulcer through the
  gastric serosa into the peritoneal cavity-
  EMERGENCY surgery. Penetration is the erosion
  of the gastric serosa into the pancreas, biliary tract
  or gasto-hepatic omentum. S&S- back and
  epigastric pain, not relieved by past med use.
                                                       23
            Perforation cont…
• S&S= sudden and severe abd pain, referred to the
  shoulder, especially to the rt side because of the
  phrenic nerve in the diaphragm, vomiting and
  collapse, rigid abd, hypotension and
  tachycardia.EMERGENCY surgery. Chemical
  peritonitisdevelops 2 hrs after perferation is
  followed by bacterial peritonitis, the perforation
  must be closed ASAP.Post-op = NG tube to
  suction, assess lytes and fluid balance, assess for
  peritonitis, Antibiotics.
                                                        24
        Monitoring for Pyloric
            Obstruction
• It is a narrowing of the opening between the
  stomach and duodenum.
• Area distal to pyloric shincter becomes scarred
  from spasm or edema. Have N/V, constipation,
  fullness, wt. Loss, anorexia. Insert NG to
  decompress the stomach.Assess how much is
  aspirated from the NG, a residual of more than
  200 is strongly suggestive of an
  obstruction.Managing the fluids and
  decompressing the bowel may help if not surgery
  (vagotomy and antrectomy)
                                                    25
Total Parenteral Nutrition- amino
      acid-dextrose /lipids
•   Negative Nitrogen Balance
•   TPN qualifiers:
•   Types of TPN
•   Central line method
•   Percutaneous cath:
•   PIC,Tunneled central catheters- Hickman
    broviac,groshong

                                              26
                Gastritis
• Inflammation of the gastric mucosa:
• Overuse of ASA,NSAIDS, etoh, bile
  reflux,ulcers, helicobacter pylori
• Clinical manifestations:
• Medical management:
• Nursing management:

                                        27
              Peptic Ulcer
• Excavation of the mucosal wall of the
  stomach
• Location: gastric, duodenal, esophageal
• Zollinger-Ellison Syndrome:
• Clinical manifestations:sharp abd pain if
  perforated ulcer occurs
• Medical management
• Nursing management
                                              28
  Intestinal and Rectal Disorders
• Watery stools associated with small bowel
  disease and loose, semisolid stools with
  disorders of the colon. Voluminous, grasy
  stools are assoc. with intestinal
  malabsorption, and the presence of mucus
  and pus in the stools suggest inflammatory
  enteritis or colitis.Oil droplets on the toilet
  water are diagnostic of pancreatic disorders.
                                                29
                       stool
• Dx = routine stool exam as well as stool for
  infectious or parasitic organisms, bacterial toxins,
  blood fat. Endoscopy or barium enema may assist
  with identifying the cause of diarrhea.
• Keep accurate record of I&), bedrest , foods low
  in bulk, Antidiarrheal meds (Lomotil)
• Fecal Incontinence- may result from trauma,
  stroke, dementia, diabetes, loss of muscle
  tone,fecal impaction
                                                     30
                    Stool
• Dx- rectal exam,endoscopic-sigmoidoscopy
  ( to R/O fissures, tumors..)
• Tx – treat the cause, bowel training, surgery
  includes sphincter repair, fecal diversion.




                                              31
       Irritable Bowel Syndrome
•   More common in women than in men.
•   Assoc. with hereditary, psychological stress,
•    diet high in rich and irritating foods, ETOH
•   Functional disorder of intestinal
    motility,neurologic regulating system may affect
    peristaltic waves to certain specific segments of
    the intestine and the intensity of propelling fecal
    matter.No inflammation of intestine or cellular
    changes.

                                                          32
                      Cont.

• S&S – constipation/diarrhea or both,
  pain,bloating, and abd. Distention.Abd. Pain
  precipitated by eating and relieved by defecation.
• Dx- stool studies, barium enema, colonoscopy-
  may revealspasm,mucus stimulation in the
  intestine.
• Tx- relieve pain,control diarrhea,
  constipation,reduce stress.Well balanced high
  fiber diet, antidepressants,anticholinergic and Ca
• Channel blockers to reduce spasms.
                                                       33
     Malabsorption Conditions
• Inability of the digestive system to absorb
  one or more nutrients-cho,fats,proteins.
• Mucosal disorders –Chrohn’s disease
• Post-op malabsorption (after gastric or
  intestinal resection)
• Disorders that cause it of specific
  nutrients(disaccharidase deficiency leading
  to lactose intolerance
                                                34
                   Cont..
• S&S- diarrhea or frequent,loose,bulky,foul-
  smelling stools with increased fat content
  often grayish. Abd distention,,flatus,
  weakness,wt loss.
• DX- lactose tolerance test,fecal fat analysis
• Tx- nutritional supplements, monitor fluid
  and electrolytes,antibiotics

                                              35
  Acute Inflammatory Intestinal
            Disorders
• Lower Gi prone to acute inflammation caused by
  bacterial, fungal and bacterial infection, two
  causes-appendicitis and diverticulitis. Can lead to
  peritonitis –inflammation within the abd.
• Appendicitis- rt lower abd, emergency surgery-
  low grade fever Rt quad. Pain,nausea,rebound
  tenderness,Rovsing’s sign, if ruptured, pain
  diffused.Never give a cathartic if suspect
  appendicitis- cause perforation of inflamed appen.
                                                    36
     Appendicitis -diverticulitis
• S&S- CBC, elevated WBC leukocyte count goes
  up,neutrophils go up
• Tx- surgery (appendectomy), pain management,
  IV fluids
• Diverticulitis- -food and bacteria are retained in
  the diverticulum produce infection and
  inflammation – impedes drainage and lead to
  perforation or abcess formation. 95% occur in
  sigmoid. Low dietary fiber intake could be a
  factor.
                                                       37
• S&S-chronic constipation, bowel irregularity
  (sudden diarrhea), abrupt onset of crampy pain in
  left lower quadrant, low grade fever., large bowel
  may narrow with fibroptic strictures, leading to
  cramps, narrow stools, increased constipation.If
  untreatred leads to septicemia.
• DX- barium enema shows narrowing of colon and
  thickened muscle layers.Lab test –elevated Sed
  rate and WBC.C/O – peritonitis,bleeding, abscess.
                                                   38
• Peritonitis get symptoms of hard,rigid,board like
  abd, loss of bowel sounds,shock
• TX- initially clear diet until inflammation leaves –
  high fiber, low fat helps increase stool volume,
  antibiotrics, bulk-forming laxative.Acute phase-
  NPO, IV fluids, NG to suction(distention or
  vomiting),Demerol not MS (causes increase
  intraluminal pressure) for
  pain,antispasmodica,stool softeners.
                                                     39
              Diverticulitis
• If perforation occurs- surgery(resection,
  end-to-end anastamosis, or double barrel
  colostomy.Treat peritonitis (antibiotics,
  fluid and electrolytes, colloids, isotonic IV
  fluids,analgesics




                                                  40
   Inflammatory Bowel Disease
• Regional enteritis (Crohn’s disease) and ulcerative
  colitis
• Environmental factors such as food additives,
  tobacco, pesticides, radiation can trigger attack.
• Crohn’s Disease –most common area is distal
  ileum and colon.Chronic inflammation extends
  through all layers of bowel wall from the intestinal
  mucosa. Fistulas, fissures and abscesses form as
  inflammation spreads into peritoneum.RLQ pain
                                                    41
               Cont. Crohn’s

• Hyperactive bowel sounds due to increase
  peristalsis.The lesions or ulcers are separated by
  normal tissue, advanced stages see granulomas
  and cobblestone appearance, bowel becomes
  thickened and fibrotic and intestinal lumen
  narrows.
• S&S- insidious onset,abd pain unrelieved by
  defecation, crampy abd pains occur after a meal,
  WT LOSS, ANEMIA.
                                                       42
• The ulcers in the membranes of the intestine
  get weeping, swollen intestine that
  continually empties an irritating discharge
  into the colon- causing chronic diarrhea and
  nutritional defecits. Can lead to
  perforation,get intraabdominal and anal
  abcesses.Fever leukocytosis. Abcesses and
  fissures are common.Someget periods of
  remission.
                                             43
              Cont. Crohns
• Dx- proctosigmoidoscopic, stool for occult
  and staetorrhea. Barium study of the UGI
  shows “string sign” of the terminal ileum,,
  indicating stricture of the intestine, see
  ulcerations abcess, cobblestone appearance
  and fissures/fistulas.CBC and
  WBCAlbumin and Sed rates.

                                                44
               Cont. Crohns
• C/O – fistula(between small bowel and skin(fluid
  accumulation and infection) Riskfor colon cancer.
• ULCERATIVE COLITIS- recurrent ulcerative
  and inflammatory disease of the mucosal layer of
  the colon and rectum.
• Patho: multiple ulcerations of the superficial
  mucosa of the colon,shedding of colonic
  epithelium,bleeding as a result of
  ulcerations.Lesions are continuous.Starts in
  rectum-bowel narrows,shortens and thickens.
                                                  45
           Ulcerative colitis
• S&S- exacerbations and remissions. ,bloody
  stools,diarrhea, abd pain,, cramping, feeling
  urgent need to defecate, pass 10 –20 stools
  /day.Hypocalcemia and anemia develop,
  rebound tenderness in RLQ
• DX- stool pos for blood, low
  HCT<HGB,Alb,electrolyte imbalance,wbcs

                                              46
• Barium enema shows mucosal irregularities,
  shortening of the colon, dilatation of bowel
  loops.Cathartics are not to be given when prepping
  for bowel studies, may exacerbate the
  condition.Test can cause perforation.
• C/O of UC ares toxic megacolon (ulcers go to
  muscularis –inhibiting the ability to contract get
  colonic distention – must respond to IV fluids,
  corticosteroids, antibiotics or surgery is necessary
  because of colonic perforation)Ileostomy is
  performed
                                                    47
    Management of Ulcerative
         Colitis (UC)
• For crohns and UC – oral fluids, low
  residue, high caloric diet with vitamin and
  iron supplement, Foods that cause diarrhea
  are avoided, cold foods and smoking are
  avoided. TPN may be necessary.
• Pharm- sedatives,
  antidiarrheal,antiperistalsis meds(to rest
  bowel)sulfonamides to reduce inflammation
                                            48
                      Cont.
• Antibiotics, corticosteroids (assess for long term
  side effects (htn, fluid retention cataracts),
  immunosuppressants
• Surgical Management- Strictureplasty(blocked
  section of bowel is widened, leaving bowel intact.
  Surgical removal of 50% of bowel cam be
  tolerated and the lesion can be resected and the
  remaining portions of the bowel are anastamosed

                                                   49
               Cont. surgical
• Total colectomy- excision of colon with ileostomy
• Segmental colectomy- removal of segment of
  colon with anastamosis of the remaining colon.
• subtotal colectomy- joing of ilieum and rectum
• Total colectomy with continent
  ileostomy(formation of internal pouch)
• Total colectomy with ileoanal anastamosis
  (formation of pouch with anal sphincter intact)

                                                  50
                  Ileostomy
• Surgical creation of opening into the small
  intestine, by an ileal stoma on the abd wall.
  Allows for fecal matter from ileum to outside of
  the body. Mushy drainage at frequent
  intervals,temporary or permanent.
• Continent ileal resevoir (Kock pouch) – no need
  fror external bag .GI effluent collects in a
  reconstructed reservoir. Nipple valve allows for
  pt. To catheterize for removal of feces.
                                                     51
• Ileoanal anastamosis – eliminates need for
  ileostomy, have fecal reservoir, and anal
  sphincter control of elimination. Decreases
  the number of BM to 7 –10/day
• Nsg- educate on diet, meds and support
  groups. Instruct to drink 2-3 L/fluid /day,
  Pre-op may get Neomycin to prevent post-
  op infection
                                                52