Nursing Management of Gastrointestinal Disorders

Objectives

  • Discuss presentation of patients with inflammatory & infectious GI disorders
  • Identify investigative procedures used for diagnosis
  • Explore surgical approaches to GI management
  • Examine medication therapies & nursing management

Anatomy of the Digestive System (Key Organs)

  • Oral cavity, salivary glands (parotid, sublingual, submandibular)
  • Pharynx → Oesophagus (posterior to trachea; passes through diaphragm)
  • Stomach, spleen, liver, gallbladder & common bile duct
  • Pancreas & pancreatic duct → Duodenum
  • Small intestine → Ascending, transverse, descending, sigmoid colon
  • Vermiform appendix → Rectum → Anus

Assessment & History Taking

  • Capture all GI-related information:
    • Abdominal pain, dyspepsia, gas
    • Nausea/vomiting, appetite, eating patterns
    • Dental & nutritional status; weight trends
    • Bowel habits: constipation, diarrhoea, continence, stool appearance
    • Jaundice, previous GI surgery, allergies, family history
  • Include psychosocial, spiritual, cultural factors
  • Evaluate knowledge gaps → targeted patient education

Abdominal Landmarks

  • Four Quadrants:
    1. \text{RUQ} 2. \text{RLQ} 3. \text{LUQ} 4. \text{LLQ}
  • Nine Regions: epigastric, umbilical, hypogastric/suprapubic, R/L hypochondriac, R/L lumbar, R/L inguinal

Common GI Signs & Symptoms

  • Often vague/non-specific
  • Pain: acute, chronic, spasmodic, referred
  • Nausea / Vomiting
  • Constipation / Diarrhoea
  • Guarding, rigid abdomen
  • Haematemesis → bright red, coffee-ground, streaked
  • Stool changes: melena, steatorrhoea

Diagnostic Studies

  • Stool specimens (occult blood, pathogens, fat)
  • Breath tests (e.g., ^{13}\text{C}-urea for H.\,pylori)
  • Imaging: abdominal US, CT, PET, MRI
  • Contrast studies: Upper & Lower GI series
  • Motility tests
  • Endoscopy (day-procedure, procedural sedation, prep):
    • Gastroscopy – oesophagus → stomach → duodenum (ulcers, tumours, infections)
    • Colonoscopy – rectum → entire colon (IBD, tumours)

Nursing Management for Endoscopy

  • Gastroscopy: fast \ge 6 h; expect sore throat, bloating, sedation drowsiness
  • Colonoscopy: bowel prep (picosulfate + Mg citrate), clear fluids, fasting
  • Monitor for rare complications: internal damage, bleeding, infection, perforation
  • Post-procedure monitoring: vital signs, abdominal pain, fever, dyspnoea, I&O

Upper GI Disorders

Gastro-Oesophageal Reflux Disease (GORD)

Clinical Manifestations
  • Heartburn (retrosternal burn), regurgitation, water-brash
  • Epigastric pain, dys/odynophagia
  • Oesophagitis (mild → erosive → severe)
  • Nocturnal cough, chronic laryngitis, reactive airway disease
  • Alarm features: anaemia, anorexia, bleeding, wt-loss, dental enamel erosion
Diagnostic Tests
  • Upper GI endoscopy + mucosal biopsy
  • 24-h ambulatory pH monitoring
  • Oesophageal manometry (pressure, coordination)
Complications
  • Oesophagitis → ulcerations; Barrett’s (metaplasia); strictures
  • Respiratory: aspiration, asthma exacerbation
Pharmacology
  • Antacids – short term
  • Acid suppression:
    • Proton Pump Inhibitors (PPIs): esomeprazole, rabeprazole
    • Histamine H_2 antagonists: ranitidine, famotidine
  • Prokinetics: metoclopramide, domperidone (↑ motility)
Lifestyle / Nursing Management
  • Avoid ↓LES pressure foods: caffeine, alcohol, chocolate, fatty/spicy meals, large meals, smoking
  • Trigger foods: citrus, onions, garlic, cinnamon, carbonated drinks, tomato
  • No food/drink 2{-}3 h before bed; elevate head of bed
  • Weight optimisation; review aggravating meds
Anti-Reflux Surgery (if refractory)
  • Indications: poor medical response, uncontrolled acid, aspiration risk, strictures
  • Fundoplication (lap/open):
    • Nissen (total wrap)
    • Toupet (partial)
  • Post-op issues: dysphagia & gas-bloat (~50\%)

Hiatus Hernia

  • Types: Sliding (common); Para-oesophageal/Rolling (emergency risk)
  • Symptoms: may be asymptomatic → fullness, heartburn, chest/upper-abd pain, acid taste, bloating, belching, nausea, dysphagia; large hernia → volvulus pain + vomiting
  • Management parallels GORD; surgical repair = fundoplication
  • Nursing: HOB ↑30^{\circ}, small frequent meals, avoid late eating, evaluate meds, stress reduction, weight ↓, no constrictive clothing, cease alcohol/smoking

Oesophageal Varices

  • Result of portal hypertension; lower oesophagus
  • High mortality if rupture (bleed accounts for (10{-}30)\% of upper GI bleeds)
  • Acute Management:
    • Resuscitate & treat hypovolaemic shock
    • Endoscopic sclerotherapy / band ligation (stops 90\%)
    • TIPS (shunt) if endoscopic ± drugs fail
    • Balloon tamponade – temporary, high re-bleed risk
    • Drugs: splanchnic vasoconstrictors – vasopressin, somatostatin; non-selective \beta-blockers (↓ portal pressure; \approx 70\% responders)

Gastritis

  • Inflammation of gastric mucosa; acute (hrs–days) or chronic
  • Acute S/Sx: heartburn post-meal, belching, sour taste, N/V, anorexia, epigastric tenderness, fullness, haemorrhage (esp. alcohol)
  • Chronic: similar; may be asymptomatic; loss of intrinsic factor → B_{12} malabsorption → megaloblastic anaemia & neuro issues
  • Diagnostics: history (ETOH/NSAIDs), endoscopy, UGI series, blood (H. pylori, anaemia), stool
  • Management: remove cause, NBM/IVF/antiemetics, NG in severe, monitor bleed; meds: PPIs, H_2 blockers; education re alcohol, smoking, diet

Peptic Ulcer Disease (PUD)

  • Gastric Ulcers: H. pylori (50{-}70)\%, NSAIDs, steroids, smoking; peak age 50{-}60, ↑ mortality
  • Duodenal Ulcers (>80\% PUD): H. pylori (90{-}95)\%, high HCl (COPD, cirrhosis, HPT, CKD), alcohol, smoking
Clinical Features
  • Gastric: epigastric burning/gaseous pain 1{-}2 h post-meal
  • Duodenal: mid-epigastric/back cramp pain during fasting/night; relieved by food/antacids
Complications
  • Bleed (anaemia/severe loss)
  • Perforation → peritonitis
  • Gastric outlet obstruction
  • Penetration into adjacent organs
  • Malnutrition (pain → ↓ intake)
Pharmacological Regimens
  • H. pylori eradication – 7-day Nexium Hp7: omeprazole 20\,mg\,bd, amoxicillin 1000\,mg\,bd, clarithromycin 500\,mg\,bd
  • PPIs (variable course)
  • H_2 antagonists (NSAID ulcers)
  • Cytoprotectives: sucralfate, misoprostol (barrier & prostaglandin)
  • Antacids (gelusil, mylanta) – buffer HCl
Nursing Care
  • Vitals, pain, meds
  • NPO, IV fluids ± blood, consider NGT suction
  • Strict fluid balance, mouth/nose care
  • Diet education & follow-up

Lower GI Disorders

Bowel Basics & Possible Insults

  • Aetiologies: inflammation, infection, vascular compromise, medications (opioids, NSAIDs, antibiotics), malignancy, diet, foreign bodies

Mechanical Problems

  • Obstruction, adhesions, diverticulitis, hernias, tumours, intussusception, volvulus

Diagnostic Endoscopy of Lower GI

  • Sigmoidoscopy: rectum + distal colon
  • Colonoscopy: rectum → entire colon + terminal ileum
  • Requires bowel prep (may start \le 10 days prior): picosulfate (stim) + Mg citrate (osmotic)
  • Nil orally per protocols; procedural sedation

Stool Investigations

  • FOBT annually >50 yrs (AUS screening); positive → colonoscopy
  • Stool for blood d/t polyps, cancer, haemorrhoids

Inflammatory Bowel Disease (IBD)

Symptoms
  • Crohn’s: diarrhoea, colicky pain, wt loss, rectal bleed, fever
  • Ulcerative colitis: bloody mucus diarrhoea up to 10{-}20\,/day, pain, fever, wt loss >10\%, anaemia, tachycardia, dehydration
Diagnostics
  • Hx & exam, stool cultures/FOBT, FBC, lytes, ESR, albumin
  • Sigmoid/colonoscopy + biopsy, capsule endoscopy, barium studies, genetic testing
Management
  • Medications for induction/maintenance of remission (5-ASA, steroids, immunomodulators, biologics)
  • Nutrition: adequate calories, protein, fluids/electrolytes
  • Rest & psychosocial support; smoking cessation
  • Surgery for emergencies or refractory disease
Nutritional Strategies
  • Food diary to ID triggers: milk, high-fat, cold, high-fibre
  • Enteral/parenteral feeds: high calorie, lactose-free, proximal absorption
  • Dietician referral

Colorectal Cancer

Epidemiology & Risk Factors
  • 2^{nd} most common cancer; ↑ in men; risk rises with age
  • Lifetime mortality risk by 85^{th} birthday: 1/45 men, 1/62 women
  • Family/personal hx of IBD, polyps, cancer; obesity, inactivity, smoking, high red/processed meat, ETOH
Clinical Presentation
  • Right colon: weight loss, anaemia, occult bleed, RIF mass
  • Left colon: colicky pain, rectal bleed, obstruction, tenesmus, LIF mass, bowel habit change
Diagnostics
  • DRE, FOBT, sigmoidoscopy, colonoscopy
  • Labs: FBC, coags, LFTs
  • Imaging: CT or MRI
Management
  • Surgery: polypectomy, resection + anastomosis, laparoscopic colectomy, abdo-perineal resection, stoma formation
  • Adjuncts: chemotherapy, radiotherapy, biologics
  • Follow-up: exams, colonoscopy, tumour markers

Stomas

  • Types: temporary/perm ileostomy (high output), colostomy (sigmoid, transverse, ascending/descending), urostomy, loop colostomy
Peri-Operative Nursing
  • Pre-op: body-image prep, counselling, stoma siting, bowel prep, antibiotics
  • Post-op: stoma assessment, pouch system (skin protection, drainage), record output (volume, colour, consistency), teaching for independence
Stomal Therapy Services
  • Home & outpatient follow-up; community stomal nurse
  • Written guides; pouch-change instructions; supplier list
  • Psychosocial support & support-groups
  • Allied health referrals (dietician, mental health, social work)

Ethical / Practical Considerations

  • Invasive diagnostics demand informed consent & respect for cultural/ spiritual values
  • Body image changes (e.g., stoma): holistic support & counselling critical
  • Resource allocation: timely access to endoscopy, imaging, medications vital for outcomes

Quick Reference of Key Percentages & Figures (LaTeX)

  • Variceal bleeding proportion of upper GI bleeds: (10\%-30\%)
  • Gastroscopy fasting: \ge 6\text{ h}
  • Colonoscopy stool actions in UC: 10{-}20 per day
  • Post-fundoplication dysphagia/gas-bloat: \approx 50\%
  • H. pylori prevalence: Gastric ulcer (50\%-70\%); Duodenal ulcer (90\%-95\%)