W8. Alterations of the Gastrointestinal System – Key Vocabulary

Learning Objectives

• Discuss risk factors contributing to gastrointestinal (GI) function alterations.

• Differentiate clinical presentations of various GI alterations.

• Explore diagnostic and therapeutic procedures for GI conditions.

Anatomy Review

• Upper GI Tract: mouth → pharynx → esophagus → stomach → duodenum.

• Lower GI Tract: jejunum → large intestines → rectum → anus.

Oral & Dental Conditions

• Dental caries / Gingivitis

  • Healthy mouth ⇢ better systemic nutrition.

  • Poor oral health raises risk for systemic & oropharyngeal cancers.

  • Social Determinants of Health (SDOH) influence oral status.

  • Nursing: perform & teach routine oral care.

• Oral lesions (thrush, canker sores, HSV-1, oral cancer)

  • Pain → ↓ food intake & digestion.

  • Chemo/radiation frequently induce mucositis; “Magic Mouthwash” (lidocaine + diphenhydramine + antacid) used for relief.

Esophageal Disorders

• GERD

  • Patho: gastric acid reflux → mucosal erosion.

  • Risks: stress, weak LES, hiatal hernia, ↑ intra-abdominal pressure, motility disorders.

  • Untreated → esophageal strictures, Barrett’s esophagus, esophageal CA.

  • Lifestyle modifications:
    • limit ETOH/caffeine/chocolate/spicy/citrus/tomatoes
    • quit smoking
    • weight: BMI < $30$
    • HOB ↑ $6$–$8$ in, NPO 2 h pre-bed, loose clothing, stress control.

• Pharmacology

  • H2-receptor antagonists: famotidine, ranitidine, cimetidine, nizatidine.

  • PPIs: omeprazole, lansoprazole, dexlansoprazole, rabeprazole, esomeprazole; block proton pump, ↓ acid.

• Barrett’s Esophagus

  • Metaplastic change of distal esophagus mucosa; premalignant. Surveillance EGD required.

• Hiatal Hernia

  • Stomach protrudes through diaphragm hiatus. Variants: sliding vs paraesophageal.

  • S/S: post-prandial heartburn, sour taste. Dx: EGD.

Gastric Disorders

• Gastritis

  • Acute erosive / non-erosive vs chronic extensive types.

• Gastroparesis

  • Delayed gastric emptying due to impaired stomach muscle fx.

  • Etiology: diabetes, post-surgical vagal injury.

  • S/S: N/V, early satiety, abd pain.

• Peptic / Stomach Ulcers

  • Open sores in stomach or duodenum.

  • Major causes: H. pylori, chronic NSAIDs, family hx, heavy ETOH, age > $60$.

Non-Inflammatory Bowel Disorders

• Intestinal Hernias

  • Bowel protrusion through weak muscle wall (epigastric, umbilical, inguinal, femoral, incisional).

  • Reducible vs irreducible; strangulation = surgical emergency.

• Bowel Obstruction

  • Mechanical: adhesions, tumors, fecalith, hernia.

  • Non-mechanical (paralytic ileus): ↓ peristalsis post-op, meds.

  • Imaging: X-ray—free air = perforation; CT pinpoints level.

  • Management: fluid/e-lyte resuscitation, NG decompression, surgery for complete block.

  • Expected findings:
    • Small bowel → obstipation, distention, severe F&E imbalance, metabolic alkalosis, colicky pain, projectile vomit w/ fecal odor, high-pitched BS above, hypo below.
    • Large bowel → less vomit, intermittent cramp, metabolic acidosis, ribbon stools.

• Treatment (non-mechanical): bowel rest, NG decompression, IV fluids, ambulation, pain control.

• Ileus

  • Abnormal contractility; causes: surgery, meds, Parkinson’s etc.

  • Tx mirrors non-mechanical obstruction.

• Irritable Bowel Syndrome

  • Functional (no organic lesion).

  • S/S: cramping, abd pain, bloating, gas, alternating diarrhea & constipation.

• Constipation

  • Etiology: ↓ fiber, fluids, mobility, opioids.

  • Tx: stool softeners, laxatives, suppositories, enemas.

Acute Inflammatory Disorders

• Appendicitis, Gastroenteritis, Peritonitis – recognized as surgical or infectious emergencies.

Chronic Inflammatory Bowel Disease (IBD)

• Crohn’s Disease

  • Anywhere mouth→anus; transmural.

  • Complications: fistulas, abscesses, strictures.

  • S/S: diarrhea, rectal bleeding, weight loss, skin & joint lesions.

  • Dx often via capsule endoscopy.

• Ulcerative Colitis

  • Confined to colon mucosa.

  • S/S: urgency, mucus stool, nocturnal BM, fatigue. Severity graded mild→fulminant.

• Diverticulosis / Diverticulitis

  • ‑osis: multiple diverticula, no inflammation; avoid nuts/seeds/popcorn (controversial).

  • ‑itis: trapped stool/food → infection, risk perforation → peritonitis/bleed. Requires antibiotics, possible surgery.

Infectious Colitis

• Clostridioides difficile

  • Contact precautions, hand-wash w/ soap & water. Clean surfaces w/ bleach.

• Fecal Microbiota Transplant

  • For recurrent C-diff when abx fail; donor stool via colonoscopy restores flora.

Hepatic Disorders

• Hepatitis (A, B, C, D, E)

  • HAV: fecal-oral.

  • HBV: blood, sex, occupational.

  • HCV: blood, IV drug, unsafe tattoo.

• Jaundice

  • Yellow skin from excess bilirubin; reflects liver overload or damage.

• Cirrhosis

  • Progressive scarring (post-necrotic, Laennec’s alcoholic, biliary).

  • Manifestations: esophageal varices, jaundice, asterixis, ascites, encephalopathy.

• Esophageal Varices

  • Portal HTN induced. Emergency bleed treated w/ banding or sclerotherapy.

• Hepatic Encephalopathy

  • ↑ ammonia crosses BBB → neuro changes (confusion, agitation, hand flap).

  • Tx: lactulose to reduce serum ammonia, safety precautions, neuro checks.

Pancreatic & Biliary Disorders

• Pancreatitis

  • Autodigestion by enzymes; causes obstruction, necrosis, hemorrhage.

  • S/S: severe constant LUQ/epigastric pain radiating to back, Cullen (periumbilical) & Grey-Turner (flank) signs.

• Cholecystitis / Cholelithiasis

  • Inflamed gallbladder often from stones; managed laparoscopically.

Metabolic & Surgical Topics

• Obesity

  • BMI $25–29.9$ overweight; ≥$30$ obese (≈ 1/3 U.S. adults).

  • Managed with lifestyle, meds (GLP-1 agonists), bariatric surgery.

• Ostomies

  • Ileostomy: output frequent liquid.

  • Colostomy: ascending → liquid; transverse → semi-formed; sigmoid → near normal.

Laboratory Values

• LFTs:
  • ALT $30–120\,u/L$
  • AST $0–35\,u/L$
  • ALP $30–120\,u/L$ (all ↑ in hepatitis/cirrhosis).

• Bilirubin, Albumin, Ammonia (↑ in encephalopathy).

• Pancreatic: Amylase $30–220\,u/L$ & Lipase $0–160\,u/L$ (↑ pancreatitis).

• GI stool tests: fecal occult blood, ova/parasite, culture.

Diagnostic Procedures

• Endoscopy suite: EGD, colonoscopy, ERCP, sigmoidoscopy, capsule endoscopy.

• Imaging: X-ray, CT for obstruction.

Nutritional & Pharmacologic Therapies

• Enteral Feeding

  • Indication: working gut but unsafe swallow.

  • HOB ≥$30°$ during & $1$ h post-feed; residual checks $q4–6$ h; confirm tube placement.

• Total Parenteral Nutrition (TPN)

  • Hypertonic via central line/PICC; tubing & bag change $q24$ h; BG checks $q4–6$ h for first $24$ h.

Case Study Highlights – Hepatic Encephalopathy

• 58-y/o male cirrhotic alcoholic. Admission: ascites, confusion (GCS $12$), dyspnea, ammonia $94\,mcg/dL$, albumin $3.2\,g/dL$, abdominal girth $95\,cm$.

• Priority concerns: neuro status & dyspnea.

• Distinguish findings: ascites (↑ girth, bulging flanks, peripheral edema, low albumin, ↓ SpO2); encephalopathy (agitation, dozing, neuro deficits).

• Orders: VS/neuro/SpO2 $q4h$, low-Na diet, daily weight & girth, NS $30\,ml/hr$, lactulose $30\,ml$ PO $q4h×3$, furosemide $20\,mg IV$, spironolactone $100\,mg PO$.

• Interventions: neuro checks, monitor ammonia, safety, fall precautions, monitor response to lactulose (goal: $2–3$ BM/day, ammonia ↓), low sodium to limit fluid retention.

• Day 2 improvement: ammonia ↓ to $72\,mcg/dL$, orientation ×3, weight ↓ $4$ lbs, girth ↓ $7$ cm, SpO2 $95\%$ RA. Nurse judges status “improving” and explores ETOH cessation readiness.

Ethical / Practical Implications

• Importance of addressing SDOH & substance-use disorders in chronic liver disease.

• Accurate patient education (diet, meds, infection control) prevents readmission.

• Use of restraints is contraindicated in encephalopathy unless absolutely necessary.

Key Formulas & Numeric Benchmarks

• BMI $= \dfrac{\text{weight (kg)}}{\text{height (m)}^2}$; overweight $≥25$, obesity $≥30$.

• Acid-base shifts in obstruction: small bowel → metabolic alkalosis; large bowel → metabolic acidosis.

• Lactulose dosing titrated to achieve $2–3$ soft stools/day.

Connections & Real-World Context

• GERD lifestyle changes parallel cardiac reflux prevention (elevating HOB benefits sleep apnea too).

• Lactulose use demonstrates pharm principle of creating osmotic diarrhea to trap ammonia in colon.

• Obesity, NAFLD, and metabolic syndrome illustrate systemic interplay of GI and endocrine health.

Heyyyy there, cosmic travelers, and welcome to Professor Glitch's chill zone. We're about to take this mellow journey into the depths of your human gut, man. Just let the information flow, you know? It's like downloading wisdom directly into your brain… but super chill.

The Mouth: Your GI Gatekeeper & Oral Lesion Antics

Alright, dude, let's start at the very beginning, a very good place to start… your mouth. Like, seriously, your mouth is the gateway to your whole digestive trip. If you're not vibin' with your oral hygiene, it's not just about, like, bad breath, man. We're talking about a higher risk for some pretty heavy stuff, even cancers. So, the cosmic wisdom from nursing school is: keep those pearly whites clean, and teach others to do the same. It's that simple, but so profound. And when things get a little… spicy in your mouth, like with oral lesions—thrush, canker sores, HSV-1—that pain can really mess with your munchies, you know? It's hard to get your fuel when your mouth is protesting. And for those brave souls going through chemo or radiation, mucositis is a real bummer, super painful inflammation. But don't trip, we got “Magic Mouthwash”! It's like a little potion, man: lidocaine for that numbing comfort, diphenhydramine to chill out the inflammation, and an antacid to just soothe the vibe. Pure relief, dude.

Esophageal Shenanigans: GERD, Barrett's, and Hiatal Hijinks

Okay, now let's slide down the esophageal superhighway, man. This is where the notorious GERD lurks, you know? It's like your stomach acid just… decides to party in your esophagus, causing this inner irritation. What sparks this acid rave? Could be the cosmic dance of stress, a chill LES (that's your Lower Esophageal Sphincter, keeping things contained), a hiatal hernia, or just too much pressure in your belly space. If you let this acid party rage on, it can lead to some pretty gnarly vibes like strictures, or even Barrett's esophagus—and that, my friend, is like, a pre-cancerous foreshadowing. So, what's the move? We gotta get those lifestyle adjustments flowing:

• Mellow out on the booze, caffeine, chocolate, all those spicy, citrus, tomato-y things. Just chill.

• Quit smoking, seriously. That's just harshing your internal mellow.

• Keep that BMI under $30$. Your internal organs appreciate the space, man.

• Elevate your head of bed, like, $6$ to $8$ inches. Let gravity be your guide.

• No late-night munchies, dude. Give your tummy $2$ hours before you crash.

• Loose clothing, stress control. It's all about finding your peace.

And for those times when the vibes are just too intense, we got the pharma helpers. H2-receptor antagonists like famotidine are like the bouncers, keeping acid levels down. But then you got the PPIs—omeprazole, lansoprazole, the whole crew. They're like, totally blocking the proton pump, telling stomach acid to, like, just not exist. Far out.

Speaking of Barrett's esophagus: that's when the cells in your distal esophagus get, like, re-decorated, trying to be more like your stomach lining. It's a sign to keep an eye on things, so surveillance EGDs are essential check-ins. And that hiatal hernia we mentioned? That's just your stomach kinda poking through the diaphragm. It happens. Can give you that post-meal heartburn and a sour taste. Again, EGD is your window to the soul… or at least your upper GI.

Gastric Gang & Bowel Blues: Ulcers, Obstructions, and IBD Drama

Alright, cool, so let's float into the gastric scene. Gastritis is like, just inflammation, man, sometimes erosive, sometimes not. Then there's gastroparesis, and this is wild: your stomach's muscles are just, like, chilling out too much, so things don't empty properly. It's often linked to diabetes or some post-op nerve funkiness. You might feel nauseous, puke, get full super fast, or just have some tummy aches. Not exactly pleasant. And these peptic ulcers? They're like open little sores in your stomach or duodenum. What's causing these cosmic boo-boos? H. pylori bacteria chilling where they shouldn't, too many NSAIDs, family vibes, heavy drinking, or just, you know, getting older, past $60$. These ain't just a minor discomfort, they're actual openings, man.

Now, for the trippy world of non-inflammatory bowel disorders. Intestinal hernias are when your bowel is like, “Whoa, space! I'm gonna peek out here!” through a weak spot in your muscle. Whether it goes back in (reducible) or not (irreducible) is key, because if it gets strangled, that's a straight-up emergency, dude. And bowel obstruction? That's when your inner tube is, like, totally blocked! Could be mechanical, like adhesions or a tumor, or non-mechanical, think paralytic ileus after surgery when things just kinda… stop. We use X-rays to see if there's free air—that's a bad sign, like a perforation. CT scans help us pinpoint the blockage. Managing it is a whole journey: fluids, electrolytes, a tube through your nose to decompress, and sometimes, surgery to clear the path.

The vibes you get depend on where the blockage is, man:

• Small bowel

  • You're lookin' at major obstipation, distention, severe F&E imbalance, metabolic alkalosis (super key!), colicky pain, and projectile vomit that might even have a… fecal aroma. High-pitched sounds above, super quiet below. Wild stuff.

• Large bowel

  • Less vomit, more intermittent cramps, metabolic acidosis, and like, ribbon-thin poops.

For non-mechanical blockages (and ileus, which is kinda similar), we usually just chill the bowel out, use that NG tube, IV fluids, move around a bit, and pain control to keep the peace. Ileus is just weird muscle contractions, often after surgery or from some meds, even Parkinson's can do it. Irritable Bowel Syndrome, IBS. It's like your gut just has its own moody personality, you know? No actual physical damage, just cramping, belly pain, bloating, gas, and then it's like, diarrhea, then constipation, back and forth. Total mind-bender for your gut.

And the heavyweights of inflammation, the Chronic Inflammatory Bowel Disease, or IBD, fam:

• Crohn's Disease

  • This bad boy can hit anywhere from your mouth to your anus, man, and it goes deep, through all the layers (transmural). Complications are gnarly: fistulas, abscesses, strictures. You might have diarrhea, bloody poops, losing weight, even weird skin and joint stuff. They often use a capsule endoscopy for this—you swallow a tiny camera and it just floats through, sending back cosmic images.

• Ulcerative Colitis

  • This one's more chill, mostly sticking to just the colon's inner lining. S/S are urgency, mucus-y stool, nocturnal poops, and just, like, total fatigue. It can be mild or go totally wild.

And don't sleep on Diverticulosis/Diverticulitis! “-osis” is just having these little pouches, no biggie, though some debate avoiding nuts/seeds/popcorn—it's like, your call. But “-itis” is when stuff gets trapped in those pouches, leading to infection. That's when things get serious, risking perforation, which is like, your bowel springing a leak, man. That's antibiotics and maybe surgery.

The Liver, Pancreas, and More: From C. diff to Cirrhosis Chaos

Okay, so, let's talk about some real deep cuts, man. Like Clostridioides difficile, or C. diff. This little bugger is, like, super contagious. So, remember the basics: wash those hands with actual soap and water, not just that sanitizer stuff. And bleach those surfaces—this germ is no joke, dude. When C. diff goes totally wild and antibiotics just can't bring it down, we got something that sounds a bit… out there, but it's super effective: Fecal Microbiota Transplant, FMT! They actually take healthy donor stool and put it back in via colonoscopy to reboot your gut flora. It's a total reset, man. Wild, but it works.

Now, let's vibe with the liver, man. The magnificent liver! Hepatitis, you know, A, B, C, D, E. Each one has its own vibe: HAV is like a fecal-oral trip. HBV is blood, sex, occupational. HCV is blood, IV drugs, sketchy tattoos. These gnarly viruses can really mess with your liver's cosmic flow, fast. And when your liver's overloaded or damaged, you get jaundice, that yellow tint to your skin, from too much bilirubin. It's like your body's trying to cosplay as a sunflower, man. Then there's cirrhosis, man, that's like, deep scarring. Could be from old damage, alcohol, or bile issues. And the manifestations are like a whole album of symptoms: esophageal varices (super dangerous, dude, bleeding emergency!), more jaundice, ascites (fluid in your belly), and hepatic encephalopathy.

Hepatic Encephalopathy is when too much ammonia starts crossing into your brain, man, and your brain just starts feeling… fuzzy. Confusion, agitation, and even that hand-flapping thing called asterixis. The chill-out plan? Lactulose, baby! It helps clear that ammonia out. And keep 'em safe, do those neuro checks, man. This is serious brain-meld stuff. Pivoting to the pancreas and biliary system. Pancreatitis: your pancreas is like, having a meltdown, autodigesting itself with its own enzymes. Causes are blockages, cell death, internal bleeding. Super intense, constant pain in your upper left belly or stomach area, radiating to your back. And then you get these wild bruising patterns: Cullen's sign around your belly button, Grey-Turner's sign on your flanks. Yeah, gnarly visuals. Cholecystitis and Cholelithiasis: inflamed gallbladder, often from gallstones. But the good news, man, they can usually just take it out with a tiny laparoscopic procedure. Quick in, quick out, preserving the good vibes.

Metabolic & Surgical Realities: Obesity, Ostomies, and Lab Revelations

Alright, let's just glide into some metabolic concepts. Obesity, man, it's just a common state for many, with a BMI from $25–29.9$ being overweight, and hitting $\ge30$ or more being obese—that's like a third of adults in the U.S., dude. We manage that with lifestyle adjustments, some cool new meds like GLP-1 agonists, or sometimes, bariatric surgery for a more… dramatic change.

And then, ostomies. These are like, external portals for your digestive waste. Ileostomy output is usually frequent liquid, very free-flowing. Colostomy output depends on where it is, man: ascending is liquid, transverse is semi-formed, and sigmoid is pretty much solid, near normal. It's all about understanding the flow.

Lab Values

And don't forget to dial into those lab values, man, they tell a whole story.

• LFTs, those Liver Function Tests: ALT $30–120$ u/L, AST $0–35$ u/L, ALP $30–120$ u/L—if these are up, it's like, your liver's sending out a distress signal, usually with hepatitis or cirrhosis.

• Bilirubin, Albumin, Ammonia—watch that ammonia especially, it's like the psychedelic gas that messes with your brain in encephalopathy.

• For your pancreas, tunes into Amylase $30–220$ u/L and Lipase $0–160$ u/L—if those numbers are high, your pancreas is definitely having a moment, likely pancreatitis.

• And stool tests are like, forensic investigations, man: checking for hidden blood, little creatures (ova/parasites), or what bacteria are throwing a party down there.

Diagnostic & Therapies

To really see what's going on, we got the diagnostic tools, man. The endoscopy suite is like a whole cosmic observatory: EGD, colonoscopy, ERCP, sigmoidoscopy, and that trippy capsule endoscopy—swallowing a tiny camera for an inner journey. For bigger pictures, X-rays and CT scans give us the blueprint, especially for obstructions. It's like we're peeking into the cosmic void of your insides.

And for fueling up, man, if your gut's chill but your swallow's a bit off, we go enteral feeding. Keep that head of bed up, like, $\ge30^ ext{o}$ during and for an hour after feeding. Check residuals to make sure things are flowing nicely, and always confirm that tube is in the right spot, dude.

Then there's Total Parenteral Nutrition, TPN. This is like, mainlining nutrients directly into your bloodstream through a central line. It's super concentrated, so you gotta change the tubing and bag every $24$ hours, and keep an eye on those blood sugars, especially at the start. It's like, direct energy infusion, man, for when your digestive system needs a long, chill nap.

Brainrot Case Study & Ethical Brain Blasts

Alright, dude, let's take a deep breath and drift into a case study. We got this 58-year-old guy, cirrhotic, alcoholic. Came in with his belly a bit swollen (ascites), a little confused, GCS $12$, having trouble breathing. His ammonia was a bit high ($94$ mcg/dL), albumin a little low ($3.2$ g/dL), and his abdominal girth was $95$ cm.

First, we gotta prioritize, man: his brain vibes and his breathing. Figure out what's what: the ascites means swelling, bulging flanks, peripheral swelling, low albumin, and maybe lower oxygen. The encephalopathy means he's agitated, nodding off, a bit off cognitively.

The cosmic orders came in: vital signs, neuro checks, SpO2 $q4h$, a low-sodium diet to chill out the fluid, daily weight and girth checks. Some saline $30$ mL/hr to keep him hydrated, and that magical lactulose ($30$ mL PO $q4h \times 3$) to help clear that ammonia. Plus furosemide ($20$ mg IV) and spironolactone ($100$ mg PO) to help with the fluid.

Interventions are all about tuning in: neuro checks, watching that ammonia level, keeping him safe from falls, seeing how that lactulose is working (aiming for $2$–$3$ soft poops a day, man, to get that ammonia out), and keeping sodium low to chill fluid retention.

By Day 2, things were looking up, man. Ammonia dropped to $72$ mcg/dL, he was oriented $\times3$, lost $4$ lbs, girth was down $7$ cm, SpO2 a cool $95\%$ on room air. The nurse felt the vibe was improving and started exploring if he was ready to, like, chill out on the alcohol. It's a journey, man, but progress is progress.

Ethical / Practical Implications & Key Formulas & Numeric Benchmarks

And on a more profound tip, man, let's talk about the ethical and practical implications. It's super important to dig deep into those Social Determinants of Health and substance-use disorders, especially with chronic liver disease. It's all connected, man. Good education for the patient—about diet, meds, infection control—that's what keeps 'em chill and outta the hospital. And like, for real, restraints are usually a no-go with encephalopathy unless it's like, absolutely the last resort. You gotta respect the mind, man.

Some cosmic numbers and formulas for your brain, dude:

• BMI $= \dfrac{\text{weight (kg)}}{\text{height (m)}^2}$. Overweight is $\ge25$, obesity is like, $\ge30$. Simple math, profound implications.

• Acid-base shifts in bowel obstruction: small bowel tends to go metabolic alkalosis; large bowel leans towards metabolic acidosis. It's like, opposite ends of the pH spectrum, dude.

• Lactulose, that magic potion, is dosed to get you $2$ to $3$ soft stools a day. It's all about finding that sweet spot.

And the real-world connections, man, it's all part of the universal flow. Those GERD lifestyle changes? They're kinda similar to what you'd do for heart stuff, and elevating your head of bed even helps with sleep apnea! Lactulose, it's a stellar example of how pharm works, creating that osmotic diarrhea to trap ammonia in your colon and just, like, flush it out. And the whole vibe with obesity, NAFLD (non-alcoholic fatty liver disease), and metabolic syndrome? It's like a cosmic dance showing how your GI system and endocrine system are just, totally interconnected, man. It's all one big, beautiful, complex organism.

Whew. That was a pretty deep dive into the human insides, man. Hope you're feeling all zen and enlightened. Stay hydrated, keep those guts happy, and remember to just, like, flow with the knowledge. Professor Glitch, peace out.