MS WK10

A&P REVIEW

GI system = mouth to anus

Functions: ingestion, digestion (mechanical and chemical), absorption (mainly small intestine), elimination

GI organs: oral cavity, esophagus, stomach, small intestine, large intestine, rectum and anus

Accessory organs: salivary glands, liver, gallbladder (stores/releases bile), pancreas (amylase/lipase/protease/insulin)

Age-related GI changes

• Decreased peristalsis (affects swallowing, increased aspiration risk, can lead to constipation)

• Gastric mucosa atrophy

• Dulled nerve impulses (ability to tell if you need to use restroom, thirsty, is reduced)

• Distention and dilation of pancreatic ducts

• Decreased size and number of hepatic cells (doses for older ppl is decreased to reduce risk of toxicity)

• Disruption of microbial balance (higher risk for GI infections ie c.diff)

Assessment

• History: general, health hx, changes in appetite, wt, stool (were these changes intentional?)

• Nutrition: special diet?, dysphagia, dyspepsia?

• Fhx of GI disorders

• Current problems: often s/s are vague, use PQRST for pain

Physical Assessment:

• Inspection

• RUQ, LUQ, LLQ, RLQ

• Auscultation (usuly high pitched clicking sounds q 5-15 seconds) (if absent, need to listen to ea quadrant for 5 min – absent is emergency), palpation

• Percussion (provider)

Diagnostic assessments: 

• Labs: LFT, Ammonia, cbc, CMP, amylase/lipase, CEA/CA19-9

• Stool tests: FOBT, regular stool sample (assess for infections)

• Imaging: xrays (looks for gas distribution present in poss perforation), CT/MRI (lesions)

• Other: 

  • Endoscopy: scope w camera inserted to visualize internal organs

    • Esophagogastroduodenoscopy (EGD) (helps for assessing GI bleed)

    • Endoscopic retrograde cholangiopancreatography (ERCP) (visualizes bile ducs and pancreatic)

    • Colonoscopy (entire colon and rectum)

    • Sigmoidoscopy (sigmoid and rectum)

    • Endoscopic US

  • US (assess structure)

  • Nuclear medicine (liver spleen scan or HIDA scan; more inclusive scan)

  • Non-invasive: CT, MRI, MRCP (mri for liver)

Liver, gallbladder (biliary system) and pancreas

CHOLESCYSTITIS - inflammation of gallbladder usually caused by gallstones (cholelithiasis) blocking cystic duct

• Blocked cystic duct impairs bile from leaving, irritating gallbladder wall. Leads to ischemia, infection, and poss perforation

• Stones mainly made from abnl breakdown of cholesterol or bile salts (biliary stasis and stone formation is the perfect envmt for cholescystitis)

• Types: acute (most common) vs chronic (recurrent gallstones)

Etiology/genetic risk

• family/genetics

• Pt most at risk for cholescystitis/gallstones: FEMALE, FORTY, FAT, FERTILE (FOUR F’s)

  • Estrogen increases cholesterol in bile and slows down motility

  • W age (aka 40) bile is more static w age

• Other risks: T2DM, Gastric bypass sx, rapid wt loss (<< all of these contribute to increased cholesterol), Crohn's disease, SCD (forms pigment stones)

Incidence and prevalence

• Usually occurs in wealthy countries:

  • High-fat, high-cholesterol diets

  • Low fiber intake

  • Sedentary lifestyle

  • Access to birth control (estrogen linked to increasing cholesterol and stasis)

• More common in women than men

Assessment

History

• Ask abt food intake ie fatty, greasy, fried foods

• Diet changes (high fat or rapid wt loss)

• Assess for prev hx of gallstones or biliary issues

• Ask abt birth control or estrogen

• Check RF: obesity, diabetes, fhx of gallbladder disease

Phys assmt and s/s

• Abd pain: RUQ, epigastric region

• Pain triggered by high fat/high volume

• Positive Murphy’s Sign: pain and sudden stop in inhalation when pressing under right rib cage

• n/v, fever

Signs of bile duct occlusion: jaundice, dark tea colored urine (bile leaks in urine), pale/clay colored stools (lack of bile), pruritus (bile salts can accumulate under skin and cause itching) ← these are all late signs or if bile duct was occluded

Diagnostics: 

• Labs: WBC, LFT (alt, ast), bilirubin (direct/conjugated)

  • (indirect/unconjugated = liver; direct/conjugated = gallbladder)

• US IS BEST INITIAL DX TEST for cholescystitis

• Xray

• Hepatobiliary iminodiacetic acid (HIDA scan)

• Endoscopic retrograde cholangiopancreatography (ERCP)

• Magnetic resonance cholangiopancreatography (MRCP)

Management

• Meds: ursodiol and chenodiol → given as long tern to dissolve/stabilize gallstones

  • Must meet criteria to take these meds

• Drain: percutaneous transhepatic biliary catheter-opens blocked duct so bile can flow (reserved for ppl who aren’t candidates)

• Surgical: CHOLECYSTECTOMY = GOLD STANDARD (laparascopic) (most ppl get this done)

  • Open cholecystectomy: used if the laparoscopic approach isn’t possible

ACUTE PANCREATITIS - acute inflammation of pancreas caused by premature activation of pancreatic enzymes that begin to digest organ itself (autodigestion of pancreas)

• Pancreas has 2 major endo/exocrine functions: 

  • Exocrine: digestion

  • Endocrine: blood sugar control

  • Amylase breaks down Carbs; lipase breaks down fats; protease breaks down proteins

• Complications: pancreatic necrosis, sepsis, ARDS (pulmo failure accnts for >½ of all deaths occuring in first week), hypovolemic shock (3rd spacing - shift from vascular to intersitial space - pt is dehydrated), altered coagulation (DIC - rare complication that depletes coagulation factors so pt just starts bleeding from everywhere), multi-organ failure

Etiology/incidence

• Gallstones (40%)

• Alcohol (30%)

• Other causes: trauma, meds, autoimmune; can be idiopathic

• Prognosis: good for pancreatitis asscdtd w biliary tract disease w early tx

  • Poor when related to alcohol use

• Incidence increasing: attacks more common during holidays/vacay when alco intake is high

Assessment: 

• History: collect hx after pain is controlled, ask abt alcohol usage and med problems

• Phys assmt and s/s: 

  • severe abd pain

  • usuly mid epigastric or LUQ

  • Jaundice (thinking abt bile duct occlusion [late sign])

  • Grey turners sign: flank area (purple dark blue discoloration. Indicates retroperitoneal bleeding)

  • Cullen’s sign: periumbilical area (indicates intraabdominal bleeding)

• Psychosocial assmt 

Diagnostic: 

• Labs:

  • amylase/lipase → impt for pancreatitis

  • Serum bilirubin and ALT (indicate biliary cause)

  • CBC w diff, ESR

• Diagnostic: 

  • Abd US, Xray, 

  • CT w Contrast (DIAGNOSIS - gold standard)

Management

• Nonsurgical (1st line)

  • NPO, IV fluids (hypovolemia and 3rd spacing), pain control, electrolyte replacement (mainstays for NI. fluid shifting from 3rd spacing plays part in why electrolytes are crazy), NG tube (when really sick w vomit or biliary obstruction for gastric decompression), Treat underlying cause, nutritional support as tol (clear liquids → low fat oral diet)

• Surgical: ERCP for gallstone removal

CHRONIC PANCREATITIS - progressive destructive disease of pancreas characterized by remissions and exacerbations

• Inflammation and fibrosis of tissue contribute to pancreatic insufficiency

• Leads to permanent damage of both exo/endo function

Types: 

• Chronic calcifying pancreatitis (CCP) - most common ← caused by alcoholism

• Chronic obstructive pancreatitis - from cholelithiasis ← gallstones

• Autoimmune pancreatitis

• idiopathic/hereditary

Assessment: abd pain, ascites (scarring of splenic vein tissue that backs up fluid into abd), steatorrhea (fat stools bc lipase isn’t breaking down fat so it just exits thru stool), wt loss (loss of nutrient absorption), jaundice, dark urine (bilirubin overspills in urine), polyuria, polydipsia, polyphagia (3 p’s related to DM, which we start to see since pancreas endocrine function is being lost), resp compromise

• Chronic pancreatitis can cause DM

Management: 

• Nonsurg: pain control ie tylenol, NSAIDs, opioids if needed

  • Pancreatic enzyme replacement therapy (PERT) → STANDARD OF CARE FOR CHRONIC PANCREATITIS. Most impt bc their pancreas isnt functioning right

  • Insulin (DM mgmt since they prbly developed it)

  • Nutritional support (high cal, low fat, fat soluble vits ADEK)

  • No alco or tobacco

• Surg:

  • Distal pancreatectomy: remove part of pancreas if theres localized damage/scarring in head or tail

  • Total pancreatectomy w islet cell autotransplantation (TPIAT) - entire pancreas is removed ← pt need to rely on insulin and lots of supplementations for all the pancreatic functions

Acute pancreatitis, we want to focus on underlying cause, pain mgmt, supportive care

Chronic pancreatitis, we want to focus on managing the disease

O B E S I T Y  &  M A L N U T R I T I O N

General nutrition recommendations for health promotion/disease prevention

• Current nutrition attention: health promotion/prevent disease

  • Dietary reference intake (DRIs): list of all Macro and micronutrients giving which is rec’d for men, women, age range, etc

  • Dietary guidlines for americans (MyPlate)

• Not specific common/typical diet

• Food allergy differs from food intolerance: allergy can cause anaphylaxis ie nuts shellfish latex 

• Food intolerance invlvs GI systems and occurs when system cant properly breakdown food

Nutrition Assessment

• Joint commission rqrs 24 hr nutrition assmt but those at high risk get a full comprehensive assmt (RDN gets invlvd) 

• Nutrition status reflects balance between nutrient rqrmts and intake.

• Evaluation of nutritional status impt. Includes: 

  • Review nutritional hx

  • food/fluid intake record

  • Notation of access to appropriate sources of nutrition

  • Lab data (needed along w hx to measure enteral feedings)

  • Food drug interaction

  • Health hx and physical assmt

  • Anthropometric measurements

  • Psychosocial assmt (to see if social worker should be involved)

ANTHROPOMETRIC MEASUREMENTS

• Noninvasive method of evaluating nutrition status

  • Ht & Wt (for wt-based meds)

  • BMI (based on ht and wt)

  • BSA (used in med dosing and burn degree)

UNDERNUTRITION - multinutrient problem (main one is protein)

• Protein-energy undernutrition (PEU); (used to be called protein-calorie malnutrition PCM). 

  • Two common forms: 

    • Marasmus: calorie malnutrition

    • Kwashiorkor: adequate calories, inadequate protein

  • Starvation: prolonged PEU

  • anorexia nervosa, bulimia nervosa, binge eating disorder

Prevalence: 1/3 of older adults are malnourished before hospital admission, advocate for clients nutrition status

Undernutrition: Assessment of Older Adult

• Chronic conditions/illnesses

• Constipation, Decreased appetite, Wt loss

• Drugs

• Dry mouth, Dentition

• FTT

• Impaired eyesight

• Pain thats acute/persistent, Depression, Decrease in enjmt of meals, Loneliness

• Inability to prepare meals bc of functional decline, fatigue, memory

• Income 

• Proximity to sources of nutrient-dense foods

• Transportation access

Assessment

• Hx: usual daily food intake, food preferences, eating behaviors/patterns, change in appetite, wt change, economic status

• Psychosocial: economic status, occupation, edu lvl, ethnicity/race, living/cooking arrangements, emotional status, financial resources

• Physical assessment & s/s

• Hair, eye, oral cavity, nails, skin (muscle wasting, dry skin, delayed wound healing, musculoskeletal, neuro (altered mental staus

• Anthropometric measurements

• food/fluid intake

• 3-day caloric intake (RDN) → done when pt is getting fed, but it seems like there is no change, 

Labs: cholesterol, H&H, albumin, Thyroxine binding prealbumin (PAB) (short term protein status accessor), transferrin

Total Enteral Nutrition (TEN)

• Nasoenteric tube (NET) - short term

  • NG tube = most common

  • Nasoduodenal (NDT) = small bore

  • Nasojejunal tube = used less often

  • Initial placement must be confirmed by xray prior to use

• Enterostomal feeding tubes - Long term

  • Percutaneous endoscopic gastrostomy (PEG)

  • Dual access gastrostomy-jejunostomy (PEG/J) ← bypass stomach for clear opening

  • Direct percutaneous endoscopic jejunostomy (DPEJ)

• Feeding can be bolus, continuous, or cyclical

Cyclical feeding: pt placed on pump, runs ofr certain 

Complications

• Safety !!! is priority

• Obstructed: most common cmplctn ← try using liquid meds, if crushing, makes sure youre bolusing before and after

• Tube misplacement, dislodgement (if peg tube comes out, don’t stick it into body–

• Abd distention, n/v (prolly bc of 

• Fluid and electrolyte imbalance

• Refeeding syndrome (change in fluids

PARENTERAL NUTRITION

• When pt cant cant use GI tract for nutrition

• IV nutrition. IV therapy carries all nutrients’

PPN: can be administered thru peripheral IV (lower osmolarity)

• Short term support

Can get phlebitis, fluid overload

Dont use for total nutritional 

TPN: administered Central line ie PICC sublavian ← must be ran on a central line. NOT peripheral 

• Long term support

• 100% for nutritional status 

• Worried abt REBOUND HYPOGLYCEMIA ← DONT SUD STOP TPN bc body has gotten used to and compensated for it, so hypo can result from 

• Monirot for techiniqe, hypoerglucemia, electrolyte imbalances 

OBESITY - dysregulation of hormones called adipokines → leads to chronic inflammation and metabolic disturbances. Work tgthr to affect appetite and fat metabolism

Classification:

• Overweight: BMI 25-29

• Obesity: BMI >30

• Class I: BMI 30-<35

• Class II: 35-<40

• Class III: BMI >40 (aka extreme or severe obesity) 

Etiology/Genetic

• Envtl, genetic, behavioral factors

• High fat, high cholesterol diet (High LDL, low HDL)

• Phys inactivity

• Drug therapy: corticosteroids, estrogens and some progestins, NSAIDs, antiHTN, antidepressants, psychoactive drugs, antiepileptic drugs, certain oral antidiabetic agents

• Drug therapies can affect hormones that affect appetite and metabolism

Incidence and prevalence: doubled since 1980

• 1/3 largest world population is classified as overweight or obese

• Leading cause of preventable death

• Healthy ppl 2030: reduce proportion of adults w obestiy (simple small goals)

Assessment: hx (RESPECT acronym)

• Appetite, attitude towards food, presence of any chronic disease

• Drugs taken, physical activity/funcional ability

• Fhx of obesity

• What forms of wt loss have been tried in past and results? 

Phys assmt and s/s:

• Ht, wt, anthropometric measurements

• Skin and skinforl areas (panniculus aka pannus →  abd apron)

Psychoscial assmt: circumstances, emotional factors, perception

Intervention:

• Nonsurg: 

  • Diet programs ie calorie deficit

  • Nutrition therapy

  • Exercise program increase activity

  • Drug therapy (52.4 tabel): orlistat, GLP 1, phentermine/topiiramate

  • Cryolipolysis: fat freezing more cosmetic for local fat areas

  • Behavioral management: support and ID triggers

  • Oral suprabsorbent hydrogel: capsule that expands in stomach, promotes satiety

  • complementary/integrative health- meditation, yoga

•  Surgical: 

  • Bariatrics: BMI >40, BMI >35 w comorbidities

  • Lots of pre op and post op, rqrs constant f/u to ensure routine assmt can help tx nutritional activities ← Pt must meet certain criteria to qualify for bariatrics

    • Gastric bypass (roux-en-y, most common), sleeve gastrectomy, adjustable gastric band