Lecture #6: GI Disorders

GI system: components + overview

• Mouth: digestion begins, massication, break down food 

• Esophagus: transports food → stomach 

• Stomach: breakdown food 

• SI: primary absorption of nutrients 

• Liver: detoxification 

• Pancreas: enzymes produced, help breakdown food  

• Large intestine: absorption of water → form fecal material 

• Anus: expel feces

age-related changes in GI: tooth/gum, taste, saliva, enzymes, motility, sphincters

• Decreased taste: reduce appetite, add salt

  • Tooth/gum loss: hard to break down food: aspiration, dysphagia

  • Decreased saliva: difficult to swallow food  

• Decreased digestive enzymes: food intolerance —> avoid foods

  • Malabsorption: malnutrition risk 

• Decreased GI motility: constipation risk

  • Fiber: veggies, fruits - for constipation

  • Constipate: cheese/dairy/eggs - for diarrhea

• Weaker sphincters: fecal incontinence - physical (not functional)

factors affecting elimination: fiber/fluids, activity, medications, emotion, conditions, surgery

• Adequate fiber/fluids: maintain GI motility 

  • Food intolerances: can cause diarrhea/constipation 

• Activity/mobility: promotes peristalsis 

• Medications:

  • opioids: can cause constipation (need stool softener)

  • iron supplements: can cause constipation

  • antibiotics: can cause diarrhea

• Emotions: stress (diarrhea), depression, anxiety 

• Medical conditions: IBS, crohns, diverticulitis, neuro

• Surgery/anesthesia: decreased GI motility - if no motility + food → N/V

  • Ensure GI motility before PO: flatulence, active bowel sounds (hypoactive ok= need some)

    • Light amounts: start with water, small amounts of food - water/cracker

diagnostics for GI: labs

• Hemoccult (fecal occult blood, guaiac): look for microscopic blood 

  • Use: colon cancer detection, slow GI bleed

• Stool culture: look for bacteria (C Diff)/pathogens

  • O&P: ovum & parasites - eggs from pathogenic infections

diagnostics for GI: radiography - endoscopy & colonoscopy

• Endoscopy: camera - visualize structures, biopsy, treatment 

  • Upper: esophagus, stomach - through mouth 

    • Conscious sedation: pain med (fentanyl) + amnesic (versed/medazolam) → awake/respond/relaxed, but unable to remember 

      • Numb throat: relax esophagus 

    • Post op: make sure throat no longer numb - able to swallow before any PO

      • Sore: tylenol, ibuprofen, numb spray

  • Lower: colonoscopy (colon), sigmoidoscopy (sigmoid colon)  - through anus

    • Conscious sedation

      • Enema: clean out

      • Golightly: produce BM

        • Ensure drinking: 4 hrs to be effective

        • NPO expect for fluids 

        • Monitor BM: start to clear

      • Post op: sore - tylenol/ibuprofen

• Post op: safety after conscious sedation

dysphagia: definition, s/s, concerns

• Def: difficulty swallowing 

• S/S:

  • Coughing, choking, gag, regurgitation with/after food/liquids

  • Pocketing: avoid swallowing, long time to eat 

  • Drooling/wet/gurgly voice

    • Uncoordinated speech

    • Lip smacking/abnormal mouth movements

• Concerns:

  • Malnutrition: weight loss

  • Fluid deficiency

  • Aspiration → pneumonia (recurrent if small vol)

dysphagia: interventions - ST, diet, liquids, position, bites, chewing, oral care

• Speech therapy: swallow evaluation 

  • Dysphagia diet: puree, chopped, mechanical

    • If improvement: advocate for repeat swallow evaluation - upgrade diet to encourage adequate nutrition 

  • Thicken liquid: no straw, spooned liquids

• Position: high fowlers during & after meals- 30 mins

• Small bites: alternate food/drinks to ensure food passes

• Slow/deliberate chewing: counts with each bites

  • Check mouth after eating: check for pocketing 

  • Chin tuck: block airway during swallowing 

• Frequent oral care: prevent aspiration pneumonia

  • Can aspirate on own saliva (even in NPO)

  • Saliva: high bacteria count (oral care at least once per shift)

    • Suction at bedside

stomatitis: causes - sores, HSV, ulcers, pathogen (yeast/inhailer)

• Def: inflammation of the mouth

• Causes: 

  • Canker sores: nutritional deficiencies 

  • Herpes simplex virus: cold sores/blisters

  • Traumatic ulcers: biting/braces cut mouth 

  • Opportunistic pathogens: ↑ risk if immunocompromised (chemo, corticosteroids, radiation, HIV)

    • Thrush: candida infection - yeast (thrive in moist/dark environment) → can travel and inflame throat (dysphagia risk)

    • Not rising mouth after inhalers: corticosteroids - bacteria overgrowth

stomatitis: interventions - oral care, diet, medications (mouthwash, anethetics)

• Oral hygiene: frequent/gentle care - soft bristle, swab, avoid alcohol based mouth wash

  • Reduce inflammation 

  • Prevent secondary infection: skin breaks open → infection

• Diet: soft, bland foods - avoid spicy/acidic foods, alcohol

  • Prevent secondary trauma 

• Medications: read instructions - swish/spit, swish/swallow 

  • Magic mouthwash: contains 

    • Antipathogen: antifungal/bacterial/viral - based on organism

    • Antihistamines/corticosteroids: reduce inflammation/pain 

    • Antacids: coat mouth for other components to adhere

  • Topical anesthetics: stronger medications - when painful to eat

    • Benzocaine, viscous lidocaine

      • Numbness: risk for biting mouth 

gastritis: def, types, categories, s/s

• Def: inflammation of mucosal lining of stomach (not intestines)

• Types: 

  • Acute: rapid onset - mucosal changes revert back

  • Chronic: slow onset - mucosal changes do not return to normal

    • Higher risk of stomach cancer 

• Category: 

  • Ulcerative: ulcerations → bleeding risk 

    • S/s: hematemesis, melena (black tarry), smell of old blood, positive FOB

  • Non-ulcerative: no ulcerations

• S/S: 

  • Epigastric pain/burning

  • Loss of appetite, early satiety (feel full sooner than are full)

  • Nausea/vomiting

gastritis: causes

• H. pylori (#1 cause): can linger in stomach (even after abx) - recur

  • Risk factor for chronic gastritis → stomach cancer

    • MUST finish abx course 

• Medications: increase acid, decrease mucus/protection

  • NSAIDs

  • Corticosteroids:

• Irritants: bile reflux (GERD)

• Autoimmune gastritis: immune cells attach acid-producing cells in stomach —> low acid —> malabsorption of B12 deficiency → gastritis

  • Crohns 

• Lifestyle & dietary:

  • Caffeine/alcohol

  • Spicy/acidic foods

  • Smoking

• Medical conditions:

  • Chronic stress: high H production

  • Kidney/liver disease: inlammation

  • Radiation/chemotherapy: immunocompromised, stress

gastritis: diagnostics (CBC, endoscope, breath, fob) + interventions (diet, education, medications)

• Diagnostics:

  • CBC: Hb, hct, electrolytes → bleeding can cause fluid deficiency/electrolyte imbalances (severity of bleed)

  • Upper endoscopy: diagnose/cauterize bleed 

  • Urea breath test: H Pylori

  • FOB: bleeding

• Supportive care: based on severity of bleed- fluid/electrolyte status

  • IV fluids, blood transfusion, oxygen, monitor electrolytes, cardiac monitoring 

• Diet: bland - avoid spicy/citrusy foods 

• Patient education:

  • Avoid irritants: educate based on cause - alcohol, NSAID

  • Early s/s: corticosteroids, autoimmune

  • Importance of full antibiotic course: H pylori

• Medications: 

  • H2 blocker, PPIs (protonics), antacid: reduce acid → healing, prevent inflammation

  • Sucralfate: mucosal barrier fortifier - adhere to existing ulcers & shield/block acid from getting to ulcers (not preventative)

  • Antibiotics: finish full course - reduce cancer risk

diarrhea: def, cause, interventions

• Diarrhea: increase GI motility/BM - frequent, possibly watery/loose stools

  • Cause: pathogens (C Diff), impaction

    • Medications: lax/stool softeners - overuse

      • Elderly

      • Eating disorder

      • Athletes 

  • Risk: hypovolemic, electrolyte loss, skin integrity 

• Interventions:

  • Answer call lights promptly

    • Provide meticulous perianal skin care: barrier creams prevent breakdown 

  • Medications: antidiarrheals 

    • Hold antidiarrheals if impaction suspected: harden stool

    • Encourage constipating foods: eggs/cheese 

  • Rectal tubes: infectious cause (C Diff) - draining liquid stools (comfort, skin integrity)

  • Monitor: hydration, electrolytes, acid-base balance

C Diff

• C Diff: main bacterial culprit of diarrhea 

  • Cause: FO contact & abx 

    • Fecal oral contact: use hand hygiene (soap & water), alcohol based gels do not work

    • Overuse/use of antibiotics: abx kill good bacteria dies, bad bacteria overgrowth

fecal incontience: def, risk, intervention

• Fecal incontinence: loss of sphincter control - functional (forget)

  • Risk: skin breakdown

• Interventions: bowel traning

  • Encourage fluids, exercise (movement), nutrition (fiber)

  • Positioning: sitting upright, feet slightly elevated 

  • Warm beverage: relaxation/easier passage of stool

  • Schedule toileting based on normal pattern:

    • Note the general time of incontinence

    • Toilet at same time every day: prefer out of bed, bedpan next 

  • Allow time: do not rush

  • Maintain skin integrity: good hygiene

altered bowel function: constipation, hemorrhoids, impaction

• Constipation: slow GI movement/less BM - infrequent, hard stools, unable to evaluate bowel

  • Hemorrhoids: swollen vein - strain → pain, bleed (bright red)

    • Types: external/internal 

    • Risk: fluid imbalance 

    • Treat: hydrocortisone (inflam), topical, hemorrhoidectomy 

      • Rectal bleeding: can affect absorption of drugs given via suppository

• Impaction: hardened stool - no longer passing stool 

  • S/s: back up fluid, gas, fecal material- N/V, ruptures

    • Overflow diarrhea: leakage of diarrhea past impaction

      • Assessment: determine last BM, abdomen 

constipation & impaction: interventions - fiber, fluid, activity, meds, disimpaction

• Increase fiber intake: fruits, vegetables, whole grains

• Encourage adequate fluid intake

• Promote physical activity

• Stool softeners/laxatives: monitor stools for scheduled/PRN meds - determine need for them 

  • Assessment: confirm bowel movements - ask what is normal, when last BM

• Avoid excessive use of constipating medications (opioids-PRN softener)

  • Laxative overuse: rebound constipation - elderly, weight concerns, ED, athletes

• Fecal disimpaction: digital removal of stool 

  • Insertion in anus: vagus nerve stimulation - vasovagal response → drop in HR (faint)

    • HR monitor 

  • PPE/position: gas, loose stools

cleansing enema: def, positon, types, admin

• Def: solutions of fluid instilled into the colon - cleanse colon

• Position: sims position left lying with right leg up slightly

• Types:

  • Large volume

  • Small volume

  • Other

• Admin: 

  • If painful: slow instillation, relax muscles - encourage deep breathing (not hyperventilation)

    • Stop and let physician know

large volume enema

• Large volume: 500mL+

• Use: colonoscopy

• Types: 

  • Hypotonic (tap water): distends bowel, stimulates peristalsis 

    • Risks: fluid imbalance (hold in long)

    • Harsher: not for children/infants (fluid shifts)

  • Isotonic (NS): less distention → less effective 

    • Safest for infants/children

small volume enema

• Use: fluid overload, heart failure, sigmoidoscopy (cleanse upper)

  • Pts who cannot tolerate excess fluid

• Type:

  • Hypertonic (fleet): draws water into colon, softens stool → stimulates defecation

    • Risk: fluid deficiency

    • Contraindicated: dehydrated/renal patients

other enemas: oil, med, carmintive, anthelmintic

• Oil retention: constipation → soften stool/pass - retain for long

  • Not effective lack sphincter control

• Medicated: karyelate - hyperkalemia, antibiotics 

• Carminative: expel gas/bloating 

• Anthelmintic: intestinal parasite

small bowel obstruction: def, s/s intervention

• Blockage from a non-fecal source

  • Adhesions: crohns

  • Diverticula: diverticulitis

    • Back up of stool: pain, gas, fluid build up 

• S/S: N/V, emesis, overflow

• Intervention: need NG tube

NG tube: purpose

• Purpose: put something in (no suction), take something out (suction-on) - lasts for 30 days

  • Decompression of stomach: obstruction, impaction 

  • Diagnostic: diagnose upper GI bleed

  • Treatment: medications 

  • Feeding: enteral 

  • Irrigating: poison, alcohol overdose

NG insertion

• Assess for open nare: plug one nare, listen for open nare

• Measure: tip of nose —> earlobe —> xiphoid process - mark (tape/pen)

• Lubricate tip: prevent skin breakdown

• Instruct pt to open mouth (see it pass/prevent coiling), chin tuck

• Warn patient: insert tube

  • Resistance: twist to help pass

    • If high: move to other nare, do not force (notify doctor)

• Sip of water/ice chips to swallow tube down until reach marker 

  • Coughing a lot: tube in lung 

• In stomach: X-ray (gold standard- before feeding)

  • Check for placement: fluid will come out right away

    • Aspirate: check pH of secretions - expensive, more time 

      • Respiratory: alkalotic 

      • Stomach: acidic 

    • Insert 20 cc air: listen for sound - woosh

enteral nutrition: def, advatages (comp parenteral)

• Enteral: nutrition through GI - NG (30d)/ G/PEG (long-term) tube

  • Use: able to digest, not able to ingest

    • Dysphagia

    • Aspiration risk

    • Post stroke

    • Baby failure to thrive

    • Severe ED

  • Cost effective & safety: less potential for error

  • Preserve GI function & metab: fat metabolism & protein synthesis 

  • Support insulin-glucagon balance: risk for imbalance in parenteral

NG administration: bolus, continuous

• Bolus: intermittent feeding - several times a day by syringe/bag 

  • Mimic normal eating patterns 

  • Push or by gravity: usually push 

• Continuous: critically ill, unable to tolerate bolus - set amount on pump 

  • Start low, go slow: start around 10ml/hr, then check residual in 1hr

  • Check residual: after time passed, pause feeding, block it, withdrawal fluid to see if you can pull back fluid 

    • If nothing: increase feeding rate

    • If withdrawal same as set: put back in, check back in more time 

      • Reinstill amount, hold feeding: recheck time, ask physician 

NG tube: assessments

• Verify tube placement:

  • First time placing

  • Any time putting something in: q med admin/blous feeding

  • Standing: 1 per shift

    • May need to reposition pt/tube for suction

• Gastric residual volume: before putting things in, once a shift: standard

• Tolerance of formula/amount: can adjust formula with nutritionist 

  • Monitor BM: stools, constipation

• Response:

  • Hydration: need to give free water with tube feedings → imbalance fluid/electrolytes

  • Glucose: check regularly - once q day, more at beginning

  • Weight: I&O

  • Edema

• Infection: foreign body - increase infection risk 

NG aspiration

• Monitor for aspiration: risk of dislodging

  • Persistent coughing: dislodged into lung

  • Check placement regularly

  • Elevate HOB at least 30-45 degrees: risk of regurgitation of feeding

    • If flat: turn tube feed off 45 min before/after: prevent aspiration 

NG  tube: medications

• Before administration: confirm tube placement

• Flush:15–30 mL before/after each med

  • All meds separately: if some get in and then have to stop halfway through - dont know which meds get into patient 

• Crush meds/ liquid preferred

  • Dilute each med with 20 mL tap water: prevent build up - full dose gets to pt 

  • If tube occluded: pressure build spray on you 

    • Artificial enzymes: break build up in tube 

  • Flush every few hours: maintenance patency

• Administer by plunger/gravity (G tube)

• HOB ≥ 45° for 30 min after: prevent regurgitation → aspiration

• Clamp tube for 30-60 min following med admin, keep suction off 

  • If not able to have suction off: consult doctor 

• Reposition if N/V to promote suction

ostomy: types

• Ostomy: surgial opening(stoma) that redirect waste outside the body

  • Issue with intestines: not able to excrete via rectum 

• Types:

  • Gastrostomy tube: tube right into stomach - long term (over 30 d)

  • Jujenostomy: into jujenum - stomach canceecancer

  • Colostomy: solid output 

  • Ileostomy: liquid output on other side