clinical management of GI, GU, endocrine, and metabolic conditions

RUQ organs

liver, gallbladder, colon, kidney and adrenal gland, duodenum with head of pancreas, small intestine

LUQ organs

stomach, spleen, pancreas, kidney and adrenal gland, colon (splenic flexure and transverse), small intestine (jejunum)

RLQ organs

ascending colon, caecum, appendix, small intestine

LLQ organs

descending colon, sigmoid colon, small intestine

oral cavity function

entrance to GI system, mechanical and chemical digestion begins

pharynx function

involved in swallowing and mechanical movement of food to esophagus

esophagus function

connect mouth to stomach, transport and disperse food

stomach function

mechanical: storage, mixing, grinding of food and regulation of outflow to small intestine
exocrine: secretion hydrochloric acid, intrinsic factor, pepsinogen, mucus necessary for digestion
endocrine: secretion of hormones that trigger release digestive enzymes from pancreas, liver, gallbladder into duodenum

small intestine function

duodenum: neutralizes acid in food transported from the stomach and mixes pancreatic and biliary secretions with food
jejunum: absorbs nutrients, water, electrolytes
ileum: absorbs bile acids and intrinsic factors to be recycled in body, necessary to prevent B12 deficiency

large intestine function

absorb water and electrolytes, store and eliminate indigestible material as feces

teeth function

breakdown food to combine with saliva

tongue function

provide taste sensation, keep food between teeth to maintain efficient chewing action for food to mix with saliva

salivary glands function

produce saliva

liver function

regulate serum levels of fats, protein, carbs
produce bile for absorption of lipids and lipid-soluble substances
assist with drug metabolism, RBC and vitamin K production

gallbladder function

store and release bile into duodenum via hepatic duct when food enters stomach

pancreas function

bicarbonate and digestive enzymes secreted by exocrine portion into duodenum
insulin, glucagon, and other hormones secreted by endocrine portion for regulating blood glucose levels

spleen function

filters out foreign substances and degenerates blood cells from bloodstream, stores lymphocytes

murphy’s sign

examine for cholecystitis, deep palpation of RUQ along subcostal margin and ask pt to take a deep breath
positive: sharp, sudden pain and/or cessation of inspiration d/t inflamed gallbladder being pushed against your hand

McBurney’s point/sign

examine for appendicitis, anatomical landmark located 1/3 of the way between right ASIS and umbilicus
positive: pain/tenderness present and may be increased by direct palpation

Kehr’s sign

examine for splenic rupture (usually d/t trauma)
positive: palpation of LUQ elicits left shoulder pain
may also indicate diaphragm or other peritoneal patho

aortic aneurysm

abnormal dilatation or outpouching of vessel wall d/t degeneration or weakening of the elastin and protein fibers
palpate left of umbilicus for enlarged, pulsating mass > 3 cm

thoracic aortic aneurysm

above diaphragm, tend to be more life threatening

abdominal aortic aneurysm

more common, significant familial risk

aortic aneurysm dissection/rupture

intimal tear creates false lumen between layers of vessel wall, most likely to occur with aneurysms > 5 cm
medical emergency

aortic aneurysm rupture s/s

sudden and excruciating chest or upper back pain that migrates sup or inf based on path of dissection, cardiogenic or hypovolemic shock, syncope, HTN, reduced or absent pulses, murmur or aortic regurgitation, pleural effusion, neuro compromise

aneurysm mgmt

nonsurgical: antihypertensives, anticoagulants
surgical: resection, graft, or repair via endovascular access or open incision

GI diagnostic procedures

xray, CT, MRI, US, endoscopy, colonoscopy

appendectomy

appendix removal

cholecystectomy

gallbladder removal

colectomy

resection of portion of colon, name generally includes section removed, may also have associated colostomy or ileostomy

colostomy

procedure to divert stool from a portion of the diseased colon to the exterior

fundoplication

fundus wrapped around esophagus and junction with stomach to help reinforce esophageal sphincter with hernia or GERD

ileostomy

similar to colostomy, performed in areas of the ileum (distal portion small intestine)

resection and reanastomosis

removal of nonfunctioning portion of GI tract and reconnection of proximal and distal GI portions that are functional, name includes sections that are resected and reanastomosed

GI transplantation

for irreversible intestinal failure

abdominal surgical precautions

no lifting, pushing, pulling > 10 lbs
avoid mvmt that require overactivation or stretch of ab muscles, log roll for bed mobility, no bearing down/holding breath, splint with pillow for coughing
avoid low seated surface, abdominal binder may be indicated
pillow under knees or sidelying may be most comfortable
encourage 3-5 walks/day, mobility = motility

pneumoperitoneum

free air or gas in peritoneal cavity, common after laparoscopic surgery d/t use of CO2 to inflate abdomen leaving residual air bubbles behind
irritation on phrenic nerve causes referred pain to shoulders - more common R because heart blocks air traveling L

antiemetics

ondansetron (zofran), metoclopramide (reglan)

antidiarrheal

atropine (lomitil), loperamide (imodium)

H2RAs

famotidine (pepcid)
decreased irritation in GI lining

laxatives

psyllium (metamucil), docusate (colace), mineral oil (fleet enema), fleet glycerin suppositories, lactulose, miralax, dulcolax, senokot
surgery and opioids decrease motility and water absorption

proton pump inhibitors

omeprazole (prilosec), esomeprazole (nexium), lansoprazole (prevacid), pantoprazole (protonix)

dysphagia

difficulty swallowing, oropharyngeal or esophageal, neuromuscular or structural
airway protection and nutrition maintenance is priority - may need alternative means of nutrition, modified diet consistency

dysphagia diagnostic procedures

barium swallow study, manometry, EGD, upper GI xray series, FEES

dysphagia PT considerations

caloric deficit impacting activity tolerance, fluid and electrolyte imbalance, positioning to reduce risk of aspiration

alternative means of nutrition

when safe oral route cannot be established or supplemental needs indicated
specialized liquid feedings containing protein, carbs, fats, vitamins, minerals, other nutrients

enteral nutrition

PEG, PEJ, NG (temp - high risk dislodgement)
directly into GI system

parenteral nutrition

IV access, if long term CVC
medical mixture of nutrients

central venous catheters

terminate in heart for direct administration of nutrition
PICC often in upper arm, also Groshong, Hickman, port
used for meds and therapeutic procedures as well as nutrition

varices

dilated blood vessels in lower 1/3 esophagus
strong association with portal HTN, alcohol abuse, liver disease
risk for hemorrhage, eventual need for banding/resection

varices PT considerations

monitor for S/S of bleeding
hematemesis, down trending RBC/Hb → pallor, fatigue, dec activity tolerance

esophageal cancer

esophagectomy is only primary tx following chemo and/or radiation
invasive, intense procedure with open incisions and thoracotomy
restricted oral intake until safe airway established and diagnostics reveal no leaks

PT considerations post esophagectomy for CA

airway clearance, safe positioning to reduce aspiration risk, often have chest tube and surgical drains, standard postop effects

UGIB

esophagus, stomach, duodenum
from ulcers, erosion, varices
hematemesis: fresh, bright blood in vomit
coffee ground emesis: dark, gastric-acid exposed blood
melena: black, tarry feces from blood moving through whole GI tract, rotten iron-like odor

peptic ulcer disease

most commonly caused by H pylori infection or chronic NSAID use, leads to UGIB

UGIB interventions and PT considerations

blood transfusions, surgery to resect or cauterize source
immediate notification LIP, monitor CBC, dietary restrictions

stomach cancer

adenocarcinoma is most common malignant tumor, rare for benign tumors
gastrectomy and anastomosis following chemo and/or radiotherapy
PT considerations: diet restrictions, standard postop effects

LGIB

colon or anorectum, dx with endoscopy or colonoscopy
from inflammatory disease, ischemia, colitis, lesions (hemorrhoids), polyps, CA
hematochezie: fresh bright blood in feces, BRBPR

LGIB interventions and PT considerations

blood transfusions, surgery to resect or cauterize source
monitor CBC, watch for s/s during bowel movement, diet restrictions

diverticulitis

inflammation and infection of large colon outpocketing associated with perforation, obstruction, abscess, fistula, hemorrhage
LLQ pain and tenderness, fever, N/V, constipation, bloody stools, fever, inc WBC

IBS

3 days/mo for 3 mo of pain-relieving BM, changes BM frequency, changes in form/appearance stool caused by emotions, food, neurohormonal agents, toxins, prostaglandins, bacterial overgrowth
diffuse pain, bloating, constipation, diarrhea, mucus in feces, lack weight loss

Crohn’s disease

idiopathic inflammatory bowel disease affecting primarily the small intestine caused by genetic predisposition, autoimmune mechanisms, infection, psych issues, diet, smoking, environ factors
constant cramping pain often in RLQ not relieved by BM, diarrhea, weight loss, fatigue, low grade fever

ulcerative colitis

same etiology and causes as Crohn’s with rectum affected
crampy lower ab pain relieved by BM, bloody stool, diarrhea, incontinence, nocturnal defection, fatigue, anorexia, weight loss, dehydration, tachycardia

inflammatory intestinal disease management

nonsurgical: pharm agents to treat bowel symptoms and source inflammation/infection, dietary and activity modification, psychotherapy
surgical: resection with/without ostomy creation - parastomal hernia occurrence nearly 50%, ostomy may be permanent or reversed later

inflammatory intestinal disease PT considerations

identify lines/drains, communicate with nursing to manage colostomy bag contents, monitor fluid/nutritional intake, electrolyte panel, standard postop effects

abdominal hernia

inguinal, femoral, ventral, incisional, umbilical
reducible, irreducible or incarcerated, strangulated (compromised circulation, potentially fatal)

abdominal hernia s/s

distension, N/V, observable or palpable bulge, paresthesia with nerve compression, pain

abdominal hernia mgmt

if asymptomatic, nonsurgical
surgery: reduction with reinforcement using mesh, wiring, fascia, or muscle flap

abdominal hernia PT consideration

strict adherence abdominal precautions, consider muscle flap source to avoid overuse, commonly use abdominal binder for external cueing and surgical site reinforcement

hiatal hernia

upward protrusion through esophageal hiatus of diaphragm into thoracic cavity
mimics GERD, dysphagia, epigastric or chest pain, dyspnea, hoarseness
nonsurgically managed with lifestyle modification and acid-reducers, surgically reduced and repaired

hiatal hernia PT considerations

mixture of esophageal positions and abdominal precautions, do not teach diaphragmatic breathing - will be painful

intestinal obstruction

mechanical: adhesions, tumor, herniation, inflammation
ileus: functional inhibition of normal bowel propulsion and motility most commonly from surgery, hypokalemia, peritonitis, trauma, spinal fx, narcotics

intestinal obstruction s/s

sudden onset crampy pain, distension, N/V, lack gas or BM, high-pitched or absent bowel sounds

intestinal obstruction mgmt and PT considerations

NG or OG tube suction, resection of blockage
drain mgmt, mobility = motility, monitor fluid and electrolytes d/t quick shifts in fluid balance

intestinal tumors

benign, malignant, or metastatic neoplasms that can affect GI motility and function
colorectal CA 3rd most common worldwide, rise in people < 40 yrs
screen with colonoscopy/Cologuard

intestinal tumor mgmt and PT considerations

resection with or without ostomy creation with chemo and/or radiation
same as other surgeries

anorectal conditions

similar etiologies and mgmt as intestinal conditions
inflammation, obstruction, perforations, fistula, fissure, hemorrhage, tumor
most common sign is painful BM and bloody stool
for transanal surgical approach may have restricted ability to sit and/or type sitting surface

liver function, hepatic panel lab values

measures liver’s ability to synthesize and clear toxins from the body
significant correlation to BP, cognition, and neuro function

model for end stage liver disease

calculation of bilirubin, creatinine, and INR
MELD-Na includes sodium
mortality predictor for pts with advanced liver disease, utilized in allocation for transplantation

serum albumin reference range/critical value

3.5-5
critical value: < 1.5

serum prealbumin reference range/critical value

15-36 in adults
critical value: < 10.7

albumin/prealbumin trending downward presentation

non-healing wound, peripheral edema and ascites, hypotension

serum bilirubin ranges/critical values

0.3-1
critical values: > 12

bilirubin trending upward presentation

jaundice (usually progressing in cephalocaudal direction), darker urine, pale stool, abdominal pain and bloating, confusion, sleep disturbances, muscle tremors, hyperreactive reflexes, asterixis

ammonia (NH3) ranges

10-80

ammonia trending upward presentation

hepatic encephalopathy, speech impairment, daytime sleepiness, breakdown fine motor skills, peripheral nerve impairment

transaminases (serum enzymes)

if trending upward liver is getting worse, no ranges

hepatitis

acute or chronic inflammation due to virus, autoimmune disease, alcohol abuse, med use, Wilson’s disease
viral hepatitis most common cause: B and C most common types with transmission via blood or bodily fluid, hep C leading cause liver CA

hepatitis s/s

malaise, weakness, jaundice, anorexia, weight loss, HA, dark colored urine

hepatitis mgmt and PT considerations

vaccines, antivirals, lifestyle modifications
protect self through universal precautions and vaccination

metabolic dysfunction-associated steatohepatitis (MASH)

aka non-alcoholic steatohepatitis, fatty liver disease, without tx can lead to cirrhosis and liver CA
chronic inflammatory process associated with buildup of fat
from overweight, type 2 DM, high cholesterol and triglycerides, high BP, insulin resistance

cirrhosis

chronic liver destruction and necrosis from chronic hepatitis, autoimmune disease, toxins, alcohol, drug use, metabolic comorbidities
complications include ascites, jaundice, portal HTN, variceal bleeding, impaired clotting, hepatic encephalopathy

cirrhosis s/s

fatigue, recent weight loss or gain, muscle wasting, jaundice, ascites, N/V, anorexia, fever, decreased urine output, bowel changes, AMS, asterixis, cachectic

cirrhosis mgmt and PT considerations

lifestyle modifications, parecentesis to drain ascites, supportive care
hepatectomy or liver transplant
multisystem involvement and cascade of sx and clinical presentations

encephalopathy

acute, global disruption of normal cerebral function in absence of structural brain disease
metabolic: from metabolic disruption, illness and typically reversible but can lead to long term deficits
hepatic: neuropsychotic manifestation due to ammonia intoxication, dec cerebral blood flow, altered NTs, metabolic and fluid disruption

encephalopathy clinical presentation

altered mental status: impaired attention, dec alertness, hypervigilance, hallucinations, impaired memory, disorientation, anxiety, agitation, stupor, coma
seizures: tonic-clonic
CN function: intact but may see ocular mvmt deviations and impaired brainstem reflexes in severe conditions
motor impairments: tremor, asterixis, multifocal myoclonus, reflexes
cardiopulm abnormalities

encephalopathy mgmt

lactulose to stimulate BM to excrete ammonia, fluid-balance correction

seizure

transient occurrence of s/s due to abnormal excessive or synchronous neuronal activity in brain
focal or generalized, monitored through EEG
from neuro etiologies and metabolic derangement, altered homeostasis, organ failure, toxin exposure

cholecystitis

acute or chronic gallbladder inflammation commonly associated with cholelithiasis (gallstones) that can lead to advanced infection

cholecystitis s/s

RUQ pain with interscapular or right shoulder referral pain, rebound tenderness, jaundice, anorexia, N/V, murphy’s sign