Gastrointestinal Disorders- Level 2

Gastrointestinal Disorders

Objectives

By the end of this lecture, students will be able to:

Explain the clinical manifestations, diagnostics, treatment, and nursing care of upper GI cancers.
Distinguish between the clinical manifestations, treatments, and complications of ulcerative colitis and Crohn’s disease.
Explain the relationship between polyps and colon cancer.
Describe patient teaching for an ostomy.
Define the following malabsorption syndromes: lactose intolerance, celiac disease, short bowel syndrome.

The Digestive System

The digestive system includes the mouth, salivary glands, esophagus, stomach, pancreas, liver, gallbladder, small intestine, large intestine, appendix, rectum, and anus.

Function of GI System

Main function is to supply nutrients to the body’s cells.
This is accomplished through:
- Ingestion
- Digestion
- Absorption
- Elimination

Tissue Layers of the GI Tract

The GI tract consists of the following layers:

Mucosa: Innermost layer including epithelium, lamina propria, and muscularis mucosae.
Submucosa: Contains glands and the submucosal plexus (plexus of Meissner).
Muscularis: Consists of circular and longitudinal muscle layers and the myenteric plexus.
Serosa: Outermost layer comprised of areolar connective tissue and epithelium.

Upper GI Problems

Upper GI problems include:

Oral Cancer
Esophageal Cancer
Stomach Cancer

Oral Cancer

Oral Cancer Types

Oral cavity cancer: Starts in the mouth.
Oropharyngeal cancer: Starts in the throat behind the mouth.
Risk Factors?
Prevention?

Oral Cancer - Common Manifestations

Common manifestations:

Chronic sore throat
Sore mouth
Voice changes
Leukoplakia
Hyperkeratosis
Erythroplakia
Asymptomatic neck mass (nonspecific)

Leukoplakia, Erythroplakia, Hyperkeratosis

These are precancerous lesions that can occur in the mouth.

Oral Cancer: Early Clinical Manifestations

Lip: Hard, painless ulcer.
Tongue:
- Ulcer or area of thickening.
- Soreness or pain.
- Sensitivity to spicy food.

Oral Cancer: Late Clinical Manifestations

Increased salivation
Slurred speech
Dysphagia
Toothache
Earache

Oral Cancer Diagnostics

Oral exfoliative cytology
Toluidine blue test
Biopsy with cytology
CT, MRI, PET scans

Oral Cancer Treatment: Surgical

Surgical excision of the tumor
- Partial mandibulectomy
- Hemiglossectomy
- Glossectomy
Radical neck dissection
- Excision of primary lesion with lymph nodes
- May also remove several muscle groups, veins, glands, and even parts of the thyroid and parathyroid.

Oral Surgery: Nursing Post-Op Management

Airway
Aspiration precautions
Nutrition
- PEG, NGT, TPN
- Daily weight
Pain management
Communication

Oral Cancer Treatment: Non-Surgical

Radiation
Chemotherapy
Palliative Care

NCLEX Practice

The nurse reviews the pre-op teaching plan for a client scheduled for a radical neck dissection. Which part of the nursing care plan should the nurse initially focus on?

The financial status of the client
Postoperative communication strategies
Information given to the client by the surgeon
The client’s support systems and coping behaviors

Esophageal Cancer

Esophageal Cancer Cause

Unknown
Smoking
Excessive alcohol intake
Barrett’s esophagus
Obesity
Injury
Achalasia
Risk factors

Esophageal Cancer: Clinical Manifestations

Progressive dysphagia
Pain
Weight loss
Sore Throat
Hoarseness
Choking

Esophageal Cancer: Diagnostics

Endoscopic biopsy
EUS (endoscopic ultrasonography)
Barium swallow (esophagram)

Esophageal Cancer: Treatment

Surgery
Radiation/Chemotherapy
Dilation
Stents
Palliative Care

The image illustrates esophageal stricture dilation using a balloon catheter and the placement of a stent to keep the esophagus open.

Esophageal Cancer: Treatment - Surgical

Esophagectomy
The image displays the process of removing the esophagus and tumor, then joining the remaining esophagus to the stomach (esophagogastrostomy).

Esophageal Cancer: Complications

Esophageal obstruction
Esophageal perforation
Hemorrhage
Metastasis

Case Study

TR: 68-year-old male dx with esophageal cancer, s/p esophagectomy
NGT to low wall intermittent suction s/p new PEG tube (feedings on hold due to new placement)

What assessment findings are you looking for with the NGT?
How does TR get nutrition since PEG feedings on hold?
What complications can occur?
TR pulls out his NGT. What should the nurse do?

Post-Op Day #1

TR’s surgeon has started tube feeding. His NGT was pulled out yesterday.

How do you manage the tube feedings?
12 hours later his RR is 32, he’s coughing and c/o abdominal pain. Temperature of 101.8^{\circ} F
What could be causing this?
What would you do first?

Stomach Cancer

Stomach Cancer Details

Risk increases with age
Men > women
No single causative agent:
- H. pylori
- Autoimmune related inflammation
- Repeated exposure to irritants

Stomach Cancer: Clinical Manifestations

Early signs:

Poor appetite
Unexplained weight loss
Anemia & pernicious anemia
Indigestion/pain
Early satiety
Advanced disease:
Obstruction (S/S: N/V, hematemesis)
Ascites
***Mets occurs early due to the large blood/lymph supply to the stomach

Stomach Cancer: Diagnostics

Upper GI endoscopy
Endoscopic ultrasound/CT/PET (to stage disease)
Labs:
CBC
Guaiac stool
Liver enzymes
Serum amylase
Tumor markers

Stages of stomach cancer

The image displays the stages of stomach cancer, from Stage 0 (tumor only in the stomach lining) to Stage IV (metastasis to other organs).

Stomach Cancer: Treatment

Surgery (treatment of choice)
Pre-Op Goals:

Correct any nutritional deficits
Correct anemia
Gastric decompression may be needed
Bowel prep

Stomach Anatomy

The image labels the fundus, pylorus, body, and antrum of the stomach, as well as the location of intrinsic factor production.

Billroth - Gastroduodenostomy

- 50%-75% of stomach removed.
Vagotomy is performed.
Remaining stomach is connected to the duodenum.

Billroth II - Gastrojejunostomy

-50% of stomach removed.
Vagotomy is performed.
Stomach is sutured to the jejunum.

Total Gastrectomy

The entire stomach is removed.

Stomach Surgery: Post-Op Nursing Care

Partial Gastrectomy (Billroth I & II)

NG tube
Drainage color
IV fluids
Pain management
Advance feedings
Total Gastrectomy
Possible chest tube
NG tube (less drainage)
Signs of leakage of fluids
IV fluids & PN
Slowly advance diet

Stomach Surgery: Complications

Nutritional deficiencies
Anemia/Pernicious anemia
Postprandial hypoglycemia
Dumping syndrome

Dumping Syndrome

Rapid emptying of the stomach contents into the small intestine
Why?
Occurs 15-30 Minutes After Eating

Epigastric Fullness
Weakness
Dizziness, vertigo
Diaphoresis
Tachycardia
Abdominal Cramping
Self-Limiting
Eat "No Fluids With Meals" or "No High Carbs", i.e., Bread, Potatoes.

Dumping Syndrome: Interventions

Diet:

6 small, dry meals daily
High protein
Low carbohydrates
Avoid simple sugars
Fluids between meals
Rest after meals

NCLEX Practice

A client is resuming a diet after a Billroth II Procedure. To minimize complications after eating, which actions should the nurse teach the client to do? Select all that apply.

Lay down after eating
Eat a diet high in protein
Drink liquids with meals
Eat six small meals per day
Eat concentrated sweets between meals only

Lower GI Problems

The following are considered lower GI problems:

Inflammatory Bowel Disease
- Ulcerative colitis
- Crohn's disease
Polyps
Colon Cancer
Malabsorption Syndromes
Parenteral Nutrition

Inflammatory Bowel Disease (IBD)

Inflammatory Bowel Disease (IBD) Cause

Unknown
Diagnosed by exclusion
Autoimmune disease
- Environmental factors
- Genetic predisposition
- Alterations in immune function

Inflammatory Bowel Disease (IBD) Classified

Classified as Crohn’s or ulcerative colitis based on clinical manifestations

Common in teenage years to early adulthood
2^{nd} peak in 6^{th} decade
More common in white, Jewish people
Ulcerative colitis – usually limited to the colon
Crohn’s – can involve any segment of the GI tract from mouth to anus (but most common in small intestine & proximal colon)

Inflammatory bowel disease (IBD)

The image compares Crohn's disease and Ulcerative colitis.

Extra-intestinal Manifestations of IBD

Systemic manifestations of IBD can affect:
Eye
Mouth
Liver and gallbladder
Kidney
Joints
Bones
Thromboembolism
Skin

Ulcerative Colitis (UC)

Chronic inflammatory process
Rectum to cecum
The image illustrates ulcerative colitis affecting the colon from the rectum to the cecum.

Ulcerative Colitis: Clinical Manifestations

Frequent, bloody stools (Severe cases: 10 - 20/day)
Abdominal pain
Anemia

Crohn’s Disease

Inflammation occurs anywhere along GI tract in characteristic skip lesions (cobblestone appearance)

Involves entire thickness of bowel wall
Obstructions
Fistulas

Crohn's Disease: Clinical Manifestations

Diarrhea
Abdominal pain (cramping)
Weight loss
Malabsorption (if small intestine is involved)

IBD: Diagnostics

Labs:

\downarrow H/H (UC)
\uparrow WBC
\downarrow Albumin
\downarrow Electrolytes: Na+, Cl-, K+
\uparrow Erythrocyte sedimentation rate (ESR)
\uparrow C-Reactive protein
Stool sample/culture
Colonoscopy

IBD: Drug Therapy

Aminosalicylates – sulfasalazine (Asultidine); mesalamine (Pentasa)
Antimicrobials – metronidazole (Flagyl); ciprofloxaxin (Cipro)
Corticosteroids – prednisone
Immunomodulators – azathioprine (Imuran); methotrexate
Biologic & Targeted – infliximab (Remicade); adalimumab (Humira)

UC Treatment - Surgical

Indications:

Failure to respond to conservative therapy
Massive hemorrhage
Perforation
Suspicion of cancer
Surgery:
Total proctocolectomy with ileoanal pouch/anal anastomosis
Total proctocolectomy with permanent ileostomy

Crohn’s Treatment - Surgical

Indications:

Strictures
Obstructions
Bleeding
Fistulas
Surgery:
Resection of diseased segments with re-anastomosis of remaining intestine

IBD: Complications

Crohn’s

Fistula
Strictures
Cancer of small intestine
Ulcerative colitis
Toxic megacolon
Colon cancer
Both
Extra-intestinal involvement

IBD: Treatment Goals

Improve quality of life
Provide adequate nutrition
Replace fluid & electrolyte losses
Prevent weight loss
How?
NPO
Tube feedings
Parenteral nutrition
Restart a regular diet gradually

NCLEX Practice

_ is most commonly found in the terminal ileum and beginning of the colon.

Ulcerative colitis
Crohn’s disease

_ affects the inner layer of the intestinal lining.

Ulcerative colitis
Crohn’s disease

NCLEX Practice

Select ALL the options below that are similarities between ulcerative colitis and Crohn’s disease.

Each cause inflammation.
Each are found from the mouth to the anus.
Both increase colon cancer risk.
The cause of both is unknown.
The cure for both diseases includes total proctocolectomy.

Polyps

SESSILE POLYP & PEDUNCULATED POLYP

Image of a sessile polyp and a pedunculated polyp.

Polyps: Clinical Manifestations

Rectal bleeding
Blood in stool
Asymptomatic

Polyps Types

Types:

Hyperplastic polyps (benign)
Adenomatous polyps (may lead to cancer)
- Sessile – flat
- Pedunculated – mushroom-shaped
Diagnosed via colonoscopy
Treatment: polypectomy

Colon Cancer

Image of a normal colon and a colon with cancer.

Colon Cancer Cause

Unknown
Age > 50
Men > women
Genetic/family history
Chronic IBD (esp. UC)
Abnormal KRAS gene
Lifestyle
Risk factors:

Colon Cancer Location and Symptoms

Ascending colon

Pain, mass, change in bowel habits, anemia
Transverse colon
Pain, obstruction, change in bowel habits, anemia
Descending colon
Pain, change in bowel habits, bright red blood in stool, obstruction
Rectum
Blood in stool, change in bowel habits, rectal discomfort

Colon Cancer: Clinical Manifestations

Early signs:

Fatigue
Weight loss
Advanced disease:
Abdominal tenderness
Palpable mass
Hepatomegaly
Ascites
Right-sided lesions vs. left-sided lesions
Anemia (right)
Obstruction; narrow stools (left)

Colon Cancer: Diagnostics

Fecal Occult Blood Test (FOBT) or Fecal Immunochemical Test (FIT)
Colonoscopy with biopsy
CBC, LFT
CEA (Carcinoembryonic antigen)
CT/MRI

Colon Cancer Stages

The image displays the stages of colon cancer, from Stage 0 to Stage IV, showing the extent of tumor spread.

Colon Cancer: Complications

Bowel obstruction
Bleeding
Fistula
Perforation
Peritonitis
Metastasis

Colon Cancer Treatment: Surgical

Depends on:

Stage and location
Ability to restore normal bowel function and continence
Examples:
Hemicolectomy
Abdominal-perineal resection
Low anterior resection

Ostomy

Definition:
A surgical procedure that creates an opening (stoma) to allow waste to exit the body
Reasons for:

Colon cancer
Trauma
Ulcerative colitis
Ruptured diverticulum
May be temporary or permanent

Types of Ostomies

Ileostomy
Ascending colostomy
Transverse colostomy (double-barreled)
Descending colostomy
Sigmoid colostomy (single-barreled)

Ostomy Surgery: Pre-op

Education?

NPO
Bowel prep for surgery
GOLYTELY INSTRUCTIONS:

Stoma Appearance

Dark pink or slightly red
Initial edema
Slight bleeding at first

Colostomy Care

Check skin around ostomy.
Protect skin. Keep clean and dry.
Change pouch as needed.
Don’t tape a leaking pouch.
Empty bag when 1/3 to 1/2 full.

Colostomy Teaching: Emptying the Bag

How to empty bag:

Open clip
Unfold cuff bottom
Squeeze or milk stool out
Clean tail/bottom of bag
Reclip the bag
Don’t wash bag out.

Ostomy Pouch Systems

Image depicting 1-piece and 2-piece ostomy systems.

Ostomy Teaching: Diet

After colostomy:

Can eat anything they did before
After ileostomy:
Avoid high fiber foods
Low fiber diet
Encourage fluids
Identify foods to avoid to reduce gas/diarrhea.
Avoid enteric-coated and capsule meds.
Tell HCP and pharmacist about ostomy.

NCLEX Practice

A client with a colostomy complains to the nurse of appliance odor. The nurse recommends that the client eat which deodorizing foods?

Eggs
Yogurt
Cucumbers
Mushrooms

NCLEX Practice

A client to be D/C’d with a temporary colostomy says to the nurse, “I know I’ve changed this thing once, but I just don’t know how I’ll do it by myself when I’m home alone. Can’t I stay here until the surgeon puts it back?” Which therapeutic response should the nurse make to the client?

“This is only temporary, but you need to hire a nurse companion until your surgery.”
“So you’re saying that although you’ve practiced changing your colostomy bag once, you don’t feel comfortable on your own yet?”
“Well, your insurance will not pay for a longer stay just to practice changing your colostomy, so you’ll have to fight it out with them.”
”Going home to care for yourself still feels pretty overwhelming? I will schedule you for home visits until you’re feeling more comfortable.”

Malabsorption Syndromes

Malabsorption Syndromes List

Lactose Intolerance
Celiac Disease
Short Bowel Syndrome

Lactose Intolerance

Lactase deficiency
Usually genetic
S/S:
Abdominal cramps
Bloating & gas
Pain
Diarrhea

Celiac Disease

Celiac sprue or gluten- sensitive enteropathy
Unable to tolerate and absorb gluten
Autoimmune disease
S/S:
Diarrhea
Flatulence
Steatorrhea
Abdominal distention
Malnutrition

Short Bowel Syndrome

Poor absorption of nutrients
Result of resections of the small bowel
Severity depends on the amount of bowel removed as well as the location of resection
S/S:
Chronic diarrhea
Steatorrhea
Malnutrition

Parenteral Nutrition

Total parenteral nutrition (TPN)
Partial parenteral nutrition (PPN)
Central parenteral nutrition (CPN)
Peripheral parenteral nutrition (PPN)

Parenteral Nutrition Details

Provides nutrients via the bloodstream

Hypertonic solution
Also contains vitamins and trace elements

Total Parenteral Nutrition

Central line
Daily orders
Administer at the same time each day
Blood sugar checks q 4-6 hours
Fluid balance and I & O’s

NCLEX Practice

The home care nurse visits a client who is receiving total parenteral nutrition and the client states: “I really miss eating dinner with my family.” How should the nurse respond in order to reply to the client therapeutically?

“What you are feeling is very common.”
“Tell me more about your family dinners.”
“In a few weeks, you may be allowed to eat.”
“You can sit down to dinner even if you do not eat.”