LABORATORY ASSESSMENTS ✓ In the X-ray room, the person drinks the

BARIUM SWALLOW TEST barium liquid. It often has a chalky taste

A barium swallow test is a special type of imaging but can sometimes be flavored.
test that uses barium and X- rays to create images
of your upper gastrointestinal (GI) tract. Your upper
GI tract includes the back of your mouth and throat
(pharynx) and your esophagus.

✓ A person will lie on a tilting table for part

of the examination.
✓ In some cases, a person will be given an
injection to relax their stomach.
✓ A person will be standing for some parts
Why are barium swallow tests used? of the examination and lying down on a
A barium swallow can help a doctor identify tilting table for other parts. This allows
problems in the food pipe, stomach, or bowel. A the liquid to travel through the body, and
barium swallow test may be used if someone has for the radiologist and radiographer to
any of the following conditions: take a selection of images.
• frequent, painful heartburn ✓ People do not have to stay in the
• gastric reflux, where food or acid keeps hospital after the test and are free to go
coming back up the food pipe home as soon as it is complete. The
• difficulty eating, drinking, or swallowing results usually arrive within 1-2 weeks.
This test can give a doctor information about how
the person is swallowing. It can also reveal if BARIUM ENEMA TEST
someone has any of the following in their food A barium enema is an X-ray procedure used to
pipe, stomach, or the first part of the bowel: examine the rectum and colon, often used as a
• ulcers complement to lower gastrointestinal (GI)
• abnormal growths endoscopy.
• blockages
• narrowing
Procedure
✓ People who are undergoing a barium
swallow should not eat or drink for a few
hours before the test. In some cases, the
doctor may ask the person to stop taking
medication before the test.
✓ Some hospitals recommend not chewing
gum, eating mints, or smoking cigarettes It is a diagnostic tool for patients with:
after midnight the night before a barium • Lower GI bleeding
swallow test. • Altered bowel habit
✓ The test takes around 60 minutes and will • Abdominal pain
take place in the X-ray department of the • To screen for polyps and colorectal
hospital. A person will need to change into cancer
a hospital gown.
Contraindications include: ✓ Screening continues until the
• Acute colitis/diverticulitis, radiologist identifies the caecum, by
• Recent polypectomy or colonic seeing the appendix or by seeing
biopsy barium entering the small bowel.
• Older patients (>70 years old) ✓ Once the entire colon is filled further
• pregnancy. pictures are taken in individual
Patient Preparation positions to obtain complete views.
Bowel preparation: ✓ The radiographer ensures all pictures
• This varies but often involves a are valid.
period of low-residue diet and ✓ The rectum is emptied of barium
oral/laxative washout. and the catheter removed.
Preparation is vital for good views of the ✓ The patient passes barium for
bowel: several hours after the procedure.
✓ The patient should receive full Risks and Side Effects
instructions on preparation and the ✓ Patients may feel
procedure. • nauseous after a barium
Procedure swallow test or
✓ The patient is cannulated and may • become constipated.
be given intravenous antispasmodic Drinking lots of fluids can help to relieve
medication (for example hyoscine constipation.
butylbromide) to make the Symptoms of nausea should improve
procedure more comfortable and as the barium passes through the system.
to aid the passage of barium. ✓ It is normal for people to have white-
✓ The patient is positioned in a left colored stools the first few times they
lateral position on an X-ray table. use the toilet after having a barium
✓ A digital rectal examination is then swallow test.
performed. ✓ Some people might worry about
✓ A rectal catheter is lubricated and being exposed to radiation as part
inserted into the rectum. This has two of the X-ray process. However, the
connectors. One connector is for amount of radiation a person is
passing barium and the other is for exposed to is minimal.
insufflating air. ✓ Sometimes, the injection given to
✓ The patient is placed prone. relax the stomach can cause
✓ Liquid barium is passed via a giving temporary blurred vision.
set into the catheter. It is passed Special Considerations
slowly to prevent the patient from ✓ People should not have a barium
experiencing discomfort or an urge swallow test if they are pregnant.
to defecate. ✓ If someone has glaucoma or heart
✓ X-ray screening takes place as the problems and needs to have a
barium is passed so the radiologist barium swallow, the doctor may not
can observe filling. The amount give the stomach-relaxing injection.
instilled depends on the patient. The ✓ If someone has diabetes then the
radiologist stops once the rectum is doctor will schedule a morning
filled and the barium continues to appointment for the barium swallow.
pass around the colon. The ✓ People who use insulin will be asked
radiologist may change the to miss their morning dose and
patient’s position as necessary in maybe the previous evening’s dose.
order to aid filling. They should bring their insulin and
✓ Once the contrast reaches the some food to have after the test.
splenic flexure, the patient returns to However, those who take long-
the prone position, and the air is acting insulin should continue taking
insufflated. As air enters, the colon this.
inflates, and the images of the Minor Complications
mucosa become clearer. ✓ Constipation.
✓ Radiography staff may assist in ✓ Abdominal discomfort.
moving the patient to aid filling and ✓ Rectal bleeding.
to provide reassurance. ✓ Flatus.
Major Complications examined. Biopsies can be taken
✓ Colonic perforation. through the scope. Biopsies are
✓ Hemorrhage. tissue samples that are looked at
✓ Oversedation. under the microscope.
✓ Cardiac arrhythmia. ✓ Different treatments may be done,
such as stretching or widening a
ESOPHAGOGASTRODUODENOSCOPY (EGD) narrowed area of the esophagus.
a test to examine the lining of the ✓ After the test is finished, the client will
esophagus, stomach, and first part of the not be able to have food and liquid
small intestine (the duodenum). until their gag reflex returns (so you
do not choke).
✓ The test lasts about 30 to 60 minutes.
Minor Complications
✓ Constipation.
✓ Abdominal discomfort.
✓ Rectal bleeding.
✓ Flatus.
Major Complications
✓ Colonic perforation.
✓ Hemorrhage.
✓ Oversedation.
✓ Cardiac arrhythmia.

EGD is done in a hospital or medical DIGESTIVE SYSTEM

center. The procedure uses an endoscope. Every cell of the body requires nutrients,
This is a flexible tube with a light and yet most cells cannot leave their position in
camera at the end. the body and travel to a food source.
The procedure is done as follows: Therefore, the food must be converted
✓ During the procedure, breathing, to a usable form and then delivered to the
heart rate, blood pressure, and cells.
oxygen level are checked. Wires are The digestive system, with the assistance
attached to certain areas of the of the circulatory system, is a complex set
body and then to machines that of organs, glands, and ducts that work
monitor these vital signs. together to transform food into nutrients for
✓ The patient receives medicine into a cells.
vein to help you relax. The patient
should feel no pain and not
remember the procedure.
✓ A local anesthetic may be sprayed
into the mouth to prevent you from
coughing or gagging when the
scope is inserted.
✓ A mouth guard is used to protect
the teeth and the scope. Dentures
must be removed before the
procedure begins.
✓ The patient then lie on your left side.
✓ The scope is inserted through the
esophagus (food pipe) to the
stomach and duodenum. The
duodenum is the first part of the
small intestine.
✓ Air is put through the scope to make
it easier for the doctor to see.
✓ The lining of the esophagus,
stomach, and upper duodenum is
Functions of the Digestive System The organs of the digestive system can be
✓ Ingestion separated into two main groups:
✓ Propulsion ▪ Alimentary canal
✓ Food breakdown: mechanical ▪ Accessory digestive organs.
digestion and chemical digestion Organs of the Alimentary Canal
✓ Absorption The alimentary canal, also called
✓ Defecation/ elimination the gastrointestinal tract, is a continuous,
hollow muscular tube that winds through
INGESTION the ventral body cavity and is open at
Food must be placed into the mouth both ends. Its organs include the following:
before it can be acted on; this is an active, A. MOUTH
voluntary process called ingestion. B. PHARYNX
C. ESOPHAGUS
PROPULSION D. STOMACH
If foods are to be processed by E. SMALL INTESTINE
more than one digestive organ, they must F. LARGE INTESTINE
be propelled from one organ to the next,
swallowing is one example of food MOUTH
movement that depends largely on the Food enters the digestive tract
propulsive process called peristalsis through the mouth, or oral cavity, a
(involuntary, alternating waves of mucous membrane-lined cavity.
contraction and relaxation of the muscles ✓ LIPS
in the organ wall). ✓ CHEEKS
✓ PALATE
FOOD BREAKDOWN: MECHANICAL ✓ UVULA
DIGESTION ✓ VESTIBULE
Mechanical digestion prepares food ✓ ORAL CAVITY PROPER
for further degradation by enzymes by ✓ TONGUE
physically fragmenting the foods into ✓ LINGUAL FRENULUM
smaller pieces. Examples of mechanical ✓ PALATINE TONSILS
digestion are the mixing of food in the ✓ LINGUAL TONSIL
mouth by the tongue, churning of food in
the stomach, and segmentation in the
small intestine.

FOOD BREAKDOWN: CHEMICAL DIGESTION

The sequence of steps in which the
large food molecules are broken down into
their building blocks by enzymes is called
chemical digestion.

ABSORPTION
Transport of digested end products
from the lumen of the GI tract to the blood
or lymph is absorption, and for absorption
PHARYNX
to happen, the digested foods must first
From the mouth, food passes
enter the mucosal cells by active or passive
posteriorly into the oropharynx and
transport processes.
laryngopharynx.
DEFECATION/ELIMINATION
Defecation is the elimination of
indigestible residues from the GI tract via
the anus in the form of feces.

Anatomy and Physiology of the Digestive

System
Oropharynx
PHYSICAL BREAKDOWN
The oropharynx is posterior to the
oral cavity. First, the food is physically broken down
Laryngoparynx into smaller particles by chewing.
The laryngopharynx is continuous
with the esophagus below; both of which
are common passageways for food, fluids,
CHEMICAL BREAKDOWN
and air.
Then, as the food is mixed with saliva,
ESOPHAGUS salivary amylase begins the chemical
The esophagus or gullet, runs from digestion of starch, breaking it down into
the pharynx through the diaphragm to the
maltose.
stomach.

STIMULATION OF SALIVA

When food enters the mouth, much

larger amounts of saliva pour out;
however, the simple pressure of anything
put into the mouth and chewed will also
stimulate the release of saliva.

• MUCOSA PASSAGEWAYS
• SUBMUCOSA
• MUSCULARIS EXTERNA
The pharynx and the esophagus have no
• SEROSA digestive function; they simply provide
• INTRINSIC NERVE PLEXUSES passageways to carry food to the next
processing site, the stomach.

FOOD PROPULSION – SWALLOWING

AND PERISTALSIS
For food to be sent on its way to the
mouth, it must first be swallowed.
▪ SIZE AND FUNCTION - About 25 cm
(10 inches) long, it is essentially a
passageway that conducts food by DEGLUTITION
peristalsis to the stomach.
Deglutition, or swallowing, is a complex
▪ STRUCTURE - The walls of the
alimentary canal organs from the process that involves the coordinated
esophagus to the large intestine are activity of several structures (tongue, soft
made up of the same four basic palate, pharynx, and esophagus).
tissue layers or tunics.
ACTIVITIES OCCURRING IN THE MOUTH,
PHARYNX, AND ESOPHAGUS BUCCAL PHASE OF DEGLUTITION
The activities that occur in the
The first phase, the voluntary buccal
mouth, pharynx, and esophagus are food
ingestion, food breakdown, and food phase, occurs in the mouth; once the food
propulsion. has been chewed and well mixed with
Food Ingestion and Breakdown saliva, the bolus (food mass) is forced into
Once food is placed in the mouth, both the pharynx by the tongue.
mechanical and chemical digestion begin.
 STOMACH ENTRANCE
Once food reaches the distal end of the
esophagus, it presses against the cardio
esophageal sphincter (lower esophageal
sphincter (LES)), causing it to open, and
food enters the stomach.
STOMACH
Different regions of the stomach have
PHARYNGEAL-ESOPHAGEAL PHASE been named, and they include the
following:
The 2nd phase, the involuntary
✓ CARDIAC REGION
pharyngeal-esophageal phase,
✓ FUNDUS
transports food through the pharynx and ✓ BODY
esophagus; the parasympathetic division ✓ PYLORUS
of the autonomic nervous system ✓ RUGAE
controls this phase and promotes the ✓ GREATER CURVATURE
mobility of the digestive organs from this ✓ LESSER CURVATURE
point on.

FOOD ROUTES

All routes that the food may take, except

the desired route distal into the digestive
tract, are blocked off; the tongue blocks
off the mouth; the soft palate closes off
the nasal passages; the larynx rises so
that its opening is covered by the flaplike ✓ LESSER OMENTUM
epiglottis. ✓ GREATER OMENTUM

✓ STOMACH MUCOSA
✓ GASTRIC GLANDS
✓ INTRINSIC FACTOR
✓ CHIEF CELLS
✓ PARIETAL CELLS
✓ ENTEROENDOCRINE CELLS
 • LOCATION - The C-shaped stomach • GASTRIC JUICE - Secretion of gastric
is on the left side of the abdominal juice is regulated by both neural
cavity, nearly hidden by the liver and hormonal factors.
and the diaphragm. • GASTRIN - The presence of food and
• FUNCTION - The stomach acts as a a rising pH in the stomach stimulate
temporary “storage tank” for food the stomach cells to release the
as well as a site for food breakdown. hormone gastrin, which prods the
• SIZE - The stomach varies from 15 to stomach glands to produce still
25 cm in length, but its diameter and more of the protein- digesting
volume depend on how much food enzymes (pepsinogen), mucus, and
it contains; when it is full, it can hold hydrochloric acid.
about 4 liters (1 gallon) of food, but • PEPSINOGEN - The extremely acidic
when it is empty it collapses inward environment that hydrochloric acid
on itself. provides is necessary, because it
• STOMACH MUCOSA - The mucosa of activates pepsinogen to pepsin, the
the stomach is a simple columnar active protein-digesting enzyme.
epithelium composed entirely of • RENNIN - Rennin, the second
mucous cells that produce a protein-digesting enzyme produced
protective layer of bicarbonate-rich by the stomach, works primarily on
alkaline mucus that clings to the milk protein and converts it to a
stomach mucosa and protects the substance that looks like sour milk.
stomach wall from being damaged
by acid and digested by enzymes. FOOD ENTRY
• GASTRIC GLANDS – This otherwise
As food enters and fills the stomach, its
smooth lining is dotted with millions
of deep gastric pits, which lead into wall begins to stretch (at the same time
gastric glands that secrete the as the gastric juices are being secreted).
solution called gastric juice.\
• INTRINSIC FACTOR - Some stomach
cells produce intrinsic factor, a STOMACH WALL ACTIVATION
substance needed for the
absorption of vitamin b12 from the Then the three muscle layers of the
small intestine. stomach wall become active; they
• CHIEF CELLS - The chief cells compress and pummel the food,
produce protein-digesting enzymes, breaking it apart physically, all the while
mostly pepsinogens. continuously mixing the food with the
• PARIETAL CELLS - The parietal cells enzyme-containing gastric juice so that
produce corrosive hydrochloric the semifluid chyme is formed.
acid, which makes the stomach
contents acidic and activates the
enzymes. FOOD PROPULSION
• ENTEROENDOCRINE CELLS - The
enteroendocrine cells produce local Peristalsis is responsible for the
hormones such as gastrin, that are movement of food towards the digestive
important to the digestive activities site until the intestines.
of the stomach.
• CHYME - After food has been
processed, it resembles heavy
cream and is called chyme. PERISTALSIS
ACTIVITIES OF THE STOMACH
Once the food has been well mixed, a
The activities of the stomach involve
food breakdown and food propulsion.
rippling peristalsis begins in the upper
Food Breakdown half of the stomach, and the
The sight, smell, and taste of food contractions increase in force as the
stimulate parasympathetic nervous system food approaches the pyloric valve.
reflexes, which increase the secretion of
gastric juice by the stomach glands.
 • Circular folds
PYLORIC PASSAGE
The pylorus of the stomach, which holds
about 30 ml of chyme, acts like a meter
that allows only liquids and very small
particles to pass through the pyloric
sphincter; and because the pyloric
sphincter barely opens, each
contraction of the stomach muscle
squirts 3 ml or less of chyme into the
• Peyer’s patches
small intestine.

ENTEROGASTRIC REFLEX
When the duodenum is filled with
chyme and its wall is stretched, a
nervous reflex, the enterogastric reflex,
occurs; this reflex “puts the brakes on”
gastric activity and slows the emptying
of the stomach by inhibiting the vagus • Ileocecal valve
nerves and tightening the pyloric
sphincter, thus allowing time for
intestinal processing to catch up.
SMALL INTESTINE
The small intestine is the body’s
major digestive organ.
• Hepatopancreatic ampulla

• LOCATION - The small intestine is a

muscular tube extending from the
pyloric sphincter to the large
intestine.
• SIZE - It is the longest section of the
alimentary tube, with an average
• Duodenal papilla length of 2.5 to 7 m (8 to 20 feet) in a
• Circular folds living person.
• SUBDIVISIONS – The small intestine
has three subdivisions: the
duodenum, the jejunum, and the
ileum, which contribute 5 percent,
nearly 40 percent, and almost 60
percent of the small intestine,
respectively.
• ILEOCECAL VALVE - The ileum meets
the large intestine at the ileocecal
valve, which joins the large and
small intestine.
• HEPATOPANCREATIC AMPULLA - The
• Microvilli main pancreatic and bile ducts join
• Villi at the duodenum to form the flask
• Lacteal like hepatopancreatic ampulla,
 literally, the ” liver-pancreatic-
enlargement”. PANCREATIC JUICE
• DUODENAL PAPILLA - From there, the Foods entering the small intestine are
bile and pancreatic juice travel literally deluged with enzyme-rich
through the duodenal papilla and pancreatic juice ducted in from the
enter the duodenum together. pancreas, as well as bile from the liver;
• MICROVILLI - Microvilli are tiny pancreatic juice contains enzymes that,
projections of the plasma along with brush border enzymes,
membrane of the mucosa cells that complete the digestion of starch, carry
give the cell surface a fuzzy out about half of the protein digestion,
appearance, sometimes referred to
and are totally responsible for fat
as the brush border; The plasma
digestion and digestion of nucleic acids.
membranes bear enzymes (brush
border enzymes) that complete the
digestion of proteins and
carbohydrates in the small intestine. CHYME STIMULATION
• VILLI - Villi are fingerlike projections of When chyme enters the small intestine,
the mucosa that give it a velvety
it stimulates the mucosa cells to
appearance and feel, much like the
soft nap of a towel. produce several hormones; two of these
• LACTEAL - Within each villus is a rich are secretin and cholecystokinin which
capillary bed and a modified influence the release of pancreatic juice
lymphatic capillary called a lacteal.
and bile.
• CIRCULAR FOLDS - Circular folds,
also called plicae circulares, are
deep folds of both mucosa and
submucosa layers, and they do not ABSORPTION
disappear when food fills the small Absorption of water and of the end
intestine. products of digestion occurs all along
• PEYER’S PATCHES - In contrast, local the length of the small intestine; most
collections of lymphatic tissue found substances are absorbed through the
in the submucosa increase in intestinal cell plasma membranes by
number toward the end of the small the process of active transport.
intestine.
ACTIVITIES OF THE SMALL INTESTINE
The activities of the small intestine
DIFFUSION
are food breakdown and absorption and
food propulsion. Lipids or fats are absorbed passively by
FOOD BREAKDOWN AND ABSORPTION the process of diffusion.
Food reaching the small intestine is
only partially digested.
DEBRIS
DIGESTION At the end of the ileum, all that remains
carbohydrate and protein digestion has are some water, indigestible food
begun, but virtually no fats have been materials, and large amounts of
digested up to this point. bacteria; this debris enters the large
intestine through the ileocecal valve.

BRUSH BORDER ENZYMES

The microvilli of small intestine cells FOOD PROPULSION
bears a few important enzymes, the so- Peristalsis is the major means of
called brush border enzymes, that break propelling food through the digestive
down double sugars into simple sugars tract.
and complete protein digestion.
 • FUNCTIONS - Its major functions are
PERISTALSIS to dry out indigestible food residue
The net effect is that the food is moved by absorbing water and to eliminate
through the small intestine in much the these residues from the body as
same way that toothpaste is squeezed feces.
from the tube. • SUBDIVISIONS - It frames the small
intestines on three sides and has the
following subdivisions: cecum,
CONSTRICTIONS appendix, colon, rectum, and anal
Rhythmic segmental movements canal.
produce local constrictions of the • CECUM - The saclike cecum is the
first part of the large intestine.
intestine that mix the chyme with the
• APPENDIX - Hanging from the
digestive juices, and help to propel food cecum is the wormlike appendix, a
through the intestine. potential trouble spot because it is
LARGE INTESTINE an ideal location for bacteria to
The large intestine is much larger in accumulate and multiply.
diameter than the small intestine but • ASCENDING COLON - The
shorter in length. ascending colon travels up the right
✓ Cecum side of the abdominal cavity and
✓ Appendix makes a turn, the right colic (or
✓ Ascending colon hepatic) flexure, to travel across the
✓ Transverse colon abdominal cavity.
✓ Descending colon • TRANSVERSE COLON - The
✓ Sigmoid colon ascending colon makes a turn and
✓ Anal canal continuous to be the transverse
colon as it travels across the
abdominal cavity.
• DESCENDING COLON - It then turns
again at the left colic (or splenic)
flexure, and continues down the left
side as the descending colon.
• SIGMOID COLON - The intestine then
enters the pelvis, where it becomes
the S-shaped sigmoid colon.
• ANAL CANAL - The anal canal ends
at the anus which opens to the
exterior.
✓ External anal sphincter • EXTERNAL ANAL SPHINCTER - The
✓ Internal involuntary sphincter anal canal has an external voluntary
sphincter, the external anal
sphincter, composed of skeletal
muscle.
• INTERNAL INVOLUNTARY SPHINCTER -
The internal involuntary sphincter is
formed by smooth muscles.
ACTIVITIES OF THE LARGE INTESTINE
The activities of the large intestine
are food breakdown absorption and
defecation.
FOOD BREAKDOWN AND ABSORPTION
What is finally delivered to the large
• SIZE - About 1.5 m (5 feet) long, it intestine contains few nutrients, but that
extends from the ileocecal valve to residue still has 12 to 24 hours more to
the anus. spend there.
• METABOLISM - The “resident”
bacteria that live in its lumen
 metabolize some of the remaining open or be constricted to stop
nutrients, releasing gases (methane passage of feces.
and hydrogen sulfide) that • RELAXATION - Within a few seconds,
contribute to the odor of feces. the reflex contractions end and
• FLATUS - About 50 ml of gas (flatus) is rectal walls relax; with the next mass
produced each day, much more movement, the defecation reflex is
when certain carbohydrate-rich initiated again.
foods are eaten. ACCESSORY DIGESTIVE ORGANS
• ABSORPTION - Absorption by the Other than the intestines and the
large intestine is limited to the stomach, the following are also part of the
absorption of vitamin K, some B digestive system:
vitamins, some ions, and most of the ✓ TEETH
remaining water. ✓ SALIVARY GLANDS
• FECES - Feces, the more or less solid ✓ PANCREAS
product delivered to the rectum, ✓ LIVER
contains undigested food residues, ✓ GALLBLADDER
mucus, millions of bacteria, and just TEETH
enough water to allow their smooth ✓ Permanent teeth
passage. ✓ Incisors
• PROPULSION OF THE RESIDUE AND ✓ Canines
DEFECATION - When presented with ✓ Premolars and molars
residue, the colon becomes mobile, ✓ Crown
but its contractions are sluggish or ✓ Enamel
short- lived. ✓ Root
• HAUSTRAL CONTRACTIONS - The ✓ Dentin
movements most seen in the colon ✓ Pulp cavity
are haustral contractions, slow ✓ Root canal
segmenting movements lasting
about one minute that occur every
30 minutes or so.
• PROPULSION - As the haustrum fills
with food residue, the distension
stimulates its muscle to contract,
which propels the luminal contents
into the next haustrum.
• MASS MOVEMENTS - Mass
movements are long, slow-moving,
but powerful contractile waves that
move over large areas of the colon • FUNCTION - The teeth tear and grind
three or four times daily and force the food, breaking it down into
the contents toward the rectum. smaller fragments.
• RECTUM - The rectum is generally SALIVARY GLANDS
empty, but when feces are forced Three pairs of salivary glands empty
into it by mass movements and its their secretions into the mouth.
wall is stretched, the defecation ✓ PAROTID GLANDS - The large parotid
reflex is initiated. glands lie anterior to the ears and
• DEFECATION REFLEX - The empty their secretions into the
defecation reflex is a spinal (sacral mouth.
region) reflex that causes the walls ✓ SUBMANDIBULAR AND SUBLINGUAL
of the sigmoid colon and the rectum GLANDS - The submandibular and
to contract and anal sphincters to sublingual glands empty their
relax. secretions into the floor of the mouth
• IMPULSES - As the feces is forced into through tiny ducts.
the anal canal, messages reach the ✓ SALIVA - The product of the salivary
brain giving us time to make a glands, saliva, is a mixture of mucus
decision as to whether the external and serous fluids.
voluntary sphincter should remain
 ✓ SALIVARY AMYLASE - The clear phospholipids, and a variety of
serous portion contains an enzyme, electrolytes.
salivary amylase, in a bicarbonate- • BILE SALTS - Bile does not contain
rich juice that begins the process of enzymes but its bile salts emulsify fats
starch digestion in the mouth. by physically breaking large fat
PANCREAS globules into smaller ones, thus
Only the pancreas produces providing more surface area for the
enzymes that break down all categories of fat-digesting enzymes to work on.
digestible foods. GALLBLADDER
While in the gallbladder, bile is
concentrated by the removal of water.
• LOCATION - The gallbladder is a
small, thin-walled green sac that
snuggles in a shallow fossa in the
inferior surface of the liver.
• CYSTIC DUCT - When food digestion
is not occurring, bile backs up the
cystic duct and enters the
gallbladder to be stored.

DISEASES OF THE UPPER GASTROINTESTINAL

TRACT
• LOCATION -The pancreas is a soft, GASTROESOPHAGEAL REFLUX DISEASE
pink triangular gland that extends (GERD)
across the abdomen from the Some degree of gastroesophageal
spleen to the duodenum; but most reflux (backflow of gastric or duodenal
of the pancreas lies posterior to the contents into the esophagus) is normal in
parietal peritoneum, hence its both adults and children.
location is referred to as Excessive reflux may occur because of an
retroperitoneal. ✓ lower esophageal sphincter,
• PANCREATIC ENZYMES - The ✓ pyloric stenosis, or
pancreatic enzymes are secreted ✓ motility disorder.
into the duodenum in an alkaline The incidence of GERD seems to increase
fluid that neutralizes the acidic with aging.
chyme coming in from the stomach. Clinical Manifestations
• ENDOCRINE FUNCTION - The Symptoms may include:
pancreas also has an endocrine ❖ pyrosis (burning sensation in the
function; it produces hormones esophagus)
insulin and glucagon. ❖ dyspepsia (indigestion)
LIVER ❖ regurgitation, dysphagia or
The liver is the largest gland in the odynophagia (pain on swallowing),
body. ❖ hypersalivation, and
• LOCATION - Located under the ❖ esophagitis.
diaphragm, more to the right side of Assessment and Diagnostic Findings
the body, it overlies and almost ✓ Ambulatory 12 to 36 hour
completely covers the stomach. esophageal pH monitoring
• FALCIFORM LIGAMENT - The liver has (used to evaluate the degree of acid
four lobes and is suspended from the reflux)
diaphragm and abdominal wall by
a delicate mesentery cord, the
falciform ligament.
• FUNCTION - The liver’s digestive
function is to produce bile.
• BILE - Bile is a yellow-to-green,
watery solution containing bile salts,
bile pigments, cholesterol,
 ✓ Bilirubin monitoring (Bilitec) ✓ domperidone (Motilium), and
(used to measure bile reflux patterns) ✓ metoclopramide (Reglan).
Exposure to bile can cause mucosal Because metoclopramide can have
damage. extrapyramidal side effects that are
Diagnostic testing may include an increased in certain neuromuscular
✓ endoscopy or disorders, such as Parkinson’s disease, it
✓ barium swallow should be used only if no other option
to evaluate damage to the exists, and the patient should be monitored
esophageal mucosa. closely.
Management ❖ If medical management is
❖ Management begins with teaching unsuccessful, surgical intervention
the patient to avoid situations that may be necessary.
decrease Surgical management involves a
✓ lower esophageal sphincter pressure ✓ Nissen fundoplication (wrapping of
or a portion of the gastric fundus
✓ cause esophageal irritation. around the sphincter area of the
❖ The patient is instructed to eat esophagus).
✓ low-fat diet. A Nissen fundoplication can be performed
❖ The patient is instructed to avoid by the open method or by laparoscopy.
× caffeine,
× tobacco, GASTRITIS
× milk, Gastritis is inflammation of the stomach
× foods containing peppermint or mucosa.
× spearmint, and carbonated • Acute gastritis
beverages • Chronic gastritis
× eating or drinking 2 hours before ACUTE GASTRITIS
bedtime; lasts several hours to a few days and is
× tight-fitting clothes; often caused by dietary indiscretion
× to maintain (eating irritating food that is highly
× normal body weight seasoned or food that is infected).
❖ The patient is instructed Other causes include excessive use of
✓ to elevate the head of the bed on ✓ aspirin and other
6- to 8-inch (15 to 20cm) blocks; and ✓ nonsteroidal anti-inflammatory drugs
to elevate the upper body on (NSAIDs),
pillows. ✓ excessive alcohol intake,
❖ If reflux persists, antacids or H2 ✓ bile reflux, and
receptor antagonists, such as ✓ radiation therapy.
✓ famotidine (Pepcid), A more severe form of acute gastritis is
✓ nizatidine (Axid), or caused by strong acids or alkali, which
✓ ranitidine (Zantac), may be may cause the mucosa to become
prescribed. gangrenous or to perforate.
❖ Proton pump inhibitors (medications Gastritis may also be the first sign of acute
that decrease the release of gastric systemic infection.
acid), such as CHRONIC GASTRITIS
✓ lansoprazole [Prevacid], is a prolonged inflammation of the
✓ rabeprazole [AcipHex], stomach that may be caused either by
✓ esomeprazole [Nexium], ✓ benign or malignant ulcers of the
✓ omeprazole [Prilosec], and stomach or
✓ pantoprazole [Protonix]) ✓ by bacteria such as Helicobacter
may be used; however, these products pylori.
may increase intragastric bacterial growth Chronic gastritis may be associated with
and the risk of infection. ✓ autoimmune diseases such as
❖ In addition, the patient may receive pernicious anemia
prokinetic agents, which accelerate ✓ dietary factors such as caffeine
gastric emptying. ✓ the use of medications such as
These agents include NSAIDs or bisphosphonates (eg,
✓ bethanechol (Urecholine),
 alendronate [Fosamax], risedronate ✓ If gastritis is due to ingestion of strong
[Actonel], ibandronate [Boniva]) acids or alkali,
✓ alcohol, ❑ dilute and neutralize the acid with
✓ smoking, or common antacids (eg, aluminum
✓ chronic reflux of pancreatic hydroxide);
secretions and bile into the ❑ neutralize alkali with diluted lemon
stomach. juice or diluted vinegar.
Superficial ulceration may occur and can ✓ If corrosion is extensive or severe,
lead to hemorrhage. ❑ avoid emetics and lavage because
Clinical Manifestations of danger of perforation.
ACUTE GASTRITIS ❑ Supportive therapy may include
May have rapid onset of symptoms: nasogastric intubation,
✓ abdominal discomfort, ❑ analgesic agents and sedatives,
✓ headache ❑ antacids, and IV fluids.
✓ lassitude ✓ Fiberoptic endoscopy may be
✓ nausea necessary;
✓ anorexia ❑ emergency surgery may be required
✓ vomiting, and to remove gangrenous or
✓ hiccupping perforated tissue;
CHRONIC GASTRITIS ❑ gastric resection (gastrojejunostomy)
May be asymptomatic. may be necessary to treat pyloric
❖ Complaints of obstruction.
✓ anorexia Chronic Gastritis Diet modification
✓ heartburn after eating ✓ rest
✓ Belching/burping ✓ stress reduction
✓ a sour taste in the mouth, or ✓ avoidance of alcohol and NSAIDs
✓ nausea and vomiting. ✓ pharmacotherapy are key
✓ Patients with chronic gastritis from treatment measures.
vitamin deficiency usually have Nursing Management
evidence of malabsorption of Reducing Anxiety
vitamin B12. ✓ Carry out emergency measures for
Assessment and Diagnostic Findings ingestion of acids or alkalies.
✓ Gastritis is sometimes associated ✓ Offer supportive therapy to patient
with achlorhydria or hypochlorhydria and family during treatment and
(absence or low levels of after the ingested acid or alkali has
hydrochloric acid) or with high acid been neutralized or diluted.
levels. ✓ Prepare patient for additional
✓ Upper gastrointestinal (GI) x-ray diagnostic studies (endoscopy) or
series, surgery.
✓ endoscopy. ✓ Calmly listen to and answer
Medical Management questions as completely as possible;
ACUTE GASTRITIS explain all procedures and
✓ The gastric mucosa is capable of treatments.
repairing itself after an episode of Promoting Optimal Nutrition
gastritis. As a rule, the patient ✓ Provide physical and emotional
recovers in about 1 day, although support for patients with acute
the appetite may be diminished for gastritis.
an additional 2 or 3 days. ✓ Help patient manage symptoms
✓ The patient should refrain from (eg, nausea, vomiting, heartburn,
alcohol and eating until symptoms and fatigue).
subside. Then the patient can ✓ Avoid foods and fluids by mouth for
progress to a nonirritating diet. hours or days until acute symptoms
✓ If symptoms persist, intravenous fluids subside.
may be necessary. ✓ Discourage caffeinated beverages
✓ If bleeding is present, management (caffeine increases gastric activity
is similar to that of upper GI tract and pepsin secretion), alcohol, and
hemorrhage. cigarette smoking (nicotine inhibits
 neutralization of gastric acid in the ❖ Peptic ulcers are more likely to be in
duodenum). the duodenum than in the stomach.
✓ Refer patient for alcohol counseling They tend to occur singly, but there
and smoking cessation when may be several present at one time.
appropriate. ❖ Chronic ulcers usually occur in the
Promoting Fluid Balance lesser curvature of the stomach,
✓ Monitor daily intake and output for near the pylorus.
dehydration (minimal intake of 1.5 ❖ Peptic ulcer has been associated
L/day and urine output of 30 mL/h). with bacterial infection, such as
✓ Infuse intravenous fluids if Helicobacter pylori.
prescribed. ❖ The greatest frequency is noted in
✓ Assess electrolyte values every 24 people between the ages of 40 and
hours for fluid imbalance. 60 years.
✓ Be alert to indicators of hemorrhagic ❖ After menopause, the incidence
gastritis among women is almost equal to
❑ Hematemesis that in men.
❑ Tachycardia ❖ Predisposing factors include
❑ Hypotension ✓ family history of peptic ulcer,
NOTIFY PHYSICIAN!!! ✓ blood type O,
Relieving Pain ✓ chronic use of nonsteroidal anti-
✓ Instruct patients to avoid foods and inflammatory drugs (NSAIDs),
beverages that may be irritating to ✓ alcohol ingestion,
the gastric mucosa. ✓ excessive smoking, and,
✓ Instruct patients on the correct use ✓ Possibly high stress.
of medications to relieve chronic ❖ Esophageal ulcers result from the
gastritis. backward flow of hydrochloric acid
✓ Assess pain and attainment of from the stomach into the
comfort through the use of esophagus.
medications and avoidance of ❖ Zollinger–Ellison syndrome
irritating substances (gastrinoma) is suspected when a
patient has several peptic ulcers or
PEPTIC ULCER an ulcer that is resistant to standard
A peptic ulcer is an excavation medical therapy.
formed in the mucosal wall of the This syndrome involves
✓ esophagus ✓ extreme gastric hyperacidity
✓ stomach, (hypersecretion of gastric juice),
✓ pylorus, or ✓ duodenal ulcer, and
✓ Duodenum. ✓ gastrinomas (islet cell tumors). About
It is frequently referred to as a 90% of tumors are found in the
✓ Esophageal ulcer gastric triangle.
✓ Gastric ulcer ✓ About one third of gastrinomas are
✓ Duodenal ulcer malignant.
depending on its location. ✓ Diarrhea and steatorrhea
(unabsorbed fat in the stool) may be
evident.
✓ These patients may have coexistent
parathyroid adenomas or
hyperplasia and exhibit signs of
hypercalcemia.
✓ The most frequent complaint is
epigastric pain.
✓ The presence of H. pylori is not a risk
factor.
❖ It is caused by the erosion of a ❖ Stress ulcer (not to be confused with
circumscribed area of mucous Cushing’s or Curling’s ulcers) is a
membrane.
term given to acute mucosal
ulceration of the duodenal or gastric
 area that occurs after bloating; it is relieved by ejection of
physiologically stressful events, such the acid gastric contents.
as ❖ Constipation or diarrhea may result
✓ burns, from diet and medications.
✓ Shock, ❖ Bleeding (15% of patients with
✓ severe sepsis, and gastric ulcers) and tarry stools may
✓ multiple organ trauma. occur; a small portion of patients
✓ Fiberoptic endoscopy within 24 who bleed from an acute ulcer
hours of trauma or injury shows have only very mild symptoms or
shallow erosions of the stomach wall; none at all.
✓ by 72 hours, multiple gastric erosions Assessment and Diagnostic Methods
are observed, and as the stressful ❖ Physical examination (epigastric
condition continues, the ulcers tenderness, abdominal distention).
spread.
✓ When the patient recovers, the
lesions are reversed; this pattern is
typical of stress ulceration.
Clinical Manifestations
❖ Symptoms of an ulcer may
✓ last days,
✓ weeks, or
✓ months and may subside only to
reappear without cause.
Many patients have asymptomatic ulcers.
❖ Dull, gnawing pain and a burning
sensation in the mid epigastrium or in
the back are characteristic.
❖ Pain is relieved by eating or taking ❖ Endoscopy (preferred, but upper
alkali; once the stomach has gastrointestinal [GI] barium study
emptied or the alkali wears off, the may be done).
pain returns. ❖ Diagnostic tests include
✓ analysis of stool specimens for occult
blood,
✓ gastric secretory studies,
✓ biopsy and histology with culture to
detect H. pylori (serologic testing,
stool antigen tests, or a breath test
may also detect H. pylori)
Medical Management
❖ The goals of treatment are to
eradicate H. pylori and manage
gastric acidity.
Pharmacologic Therapy
❖ Sharply localized tenderness is ❖ Antibiotics combined with
elicited by gentle pressure on the ✓ proton pump inhibitors and
epigastrium or slightly right of the ✓ bismuth salts
midline. to suppress H. pylori.
❖ Other symptoms include ❖ H2-receptor antagonists (in high
✓ pyrosis (heartburn) and a burning doses in patients with Zollinger–Ellison
sensation in the esophagus and syndrome) to decrease stomach
stomach, which moves up to the acid secretion; maintenance doses
mouth, occasionally with sour of H2-receptor antagonists are
eructation (burping). usually recommended for 1 year.
❖ Vomiting is rare in uncomplicated Proton pump inhibitors may also be
duodenal ulcer; it may or may not prescribed.
be preceded by nausea and usually ❖ Cytoprotective agents (protect
follows a bout of severe pain and mucosal cells from acid or NSAIDs).
 ❖ Antacids in combination with ✓ obstruction.
✓ cimetidine (Tagamet) or ❖ Surgical procedures include
✓ ranitidine (Zantac) ✓ vagotomy,
for treatment of stress ulcer and for ✓ vagotomy with pyloroplasty, or
prophylactic use. ✓ Billroth I or II.
Lifestyle Changes Vagotomy
❖ Stress reduction and rest are priority
interventions.
❖ The patient needs to identify
situations that are stressful or
exhausting (eg, rushed lifestyle and
irregular schedules) and
implement changes, such as
✓ establishing regular rest periods
during the day in the acute phase of
the disease.
✓ Biofeedback,
✓ hypnosis,
✓ behavior modification, Pyloroplasty
✓ massage, or
✓ Acupuncture may also be useful.
❖ Smoking cessation is strongly
encouraged because smoking
raises duodenal acidity and
significantly inhibits ulcer repair.
✓ Support groups may be helpful.
❖ Dietary modification may be helpful.
✓ Patients should eat whatever agrees
with them; small, frequent meals are
not necessary if antacids or Billroth I or II
histamine blockers are part of
therapy.
❖ Over secretion and hypermotility of
the GI tract can be minimized by
avoiding extremes of temperature
and overstimulation by meat
extracts.
❖ Alcohol and caffeinated beverages
such as coffee (including
decaffeinated coffee, which
stimulates acid secretion) should be Assessment
avoided. ❖ Assess pain and methods used to
❖ Diets rich in milk and cream should relieve it; take a thorough history,
be avoided also because they are including a 72-hour food intake
potent acid stimulators. history.
❖ The patient is encouraged to eat ❖ If patient has vomited, determine
three regular meals a day. whether emesis is bright red or
Surgical Management coffee ground in appearance.
❖ With the advent of H2-receptor This helps identify source of the blood.
antagonists, surgical intervention is ❖ Ask patient about usual food habits,
less common. alcohol, smoking, medication use
❖ If recommended, surgery is usually (NSAIDs), and level of tension or
for nervousness.
✓ intractable ulcers (particularly with ❖ Ask how patient expresses anger
Zollinger–Ellison syndrome), (especially at work and with family),
✓ life threatening hemorrhage, and determine whether patient is
✓ perforation, or
 experiencing occupational stress or ✓ Encourage family to participate in
family problems. care, and give emotional support.
❖ Obtain a family history of ulcer Monitoring and Managing Complications
disease. If hemorrhage is a concern
❖ Assess vital signs for indicators of ❖ Assess for
anemia (tachycardia, hypotension). ✓ faintness or dizziness and nausea,
❖ Assess for blood in the stools with an before or with bleeding;
occult blood test. ✓ test stool for occult or gross blood;
❖ Palpate abdomen for localized ✓ monitor vital signs frequently
tenderness. (tachycardia, hypotension, and
Collaborative Problems/ Potential tachypnea).
Complications ❖ Insert an indwelling urinary catheter
❖ Hemorrhage: upper GI ✓ monitor intake and output;
❖ Perforation ✓ insert and maintain an IV line for
❖ Penetration infusing fluid and blood.
❖ Pyloric obstruction (gastric outlet ✓ Monitor laboratory values
obstruction) (hemoglobin and hematocrit).
Planning and Goals ❖ Insert and maintain a nasogastric
❖ The major goals of the patient may tube and monitor drainage; provide
include lavage as ordered.
✓ relief of pain, ❖ Monitor oxygen saturation and
✓ reduced anxiety, administering oxygen therapy.
✓ maintenance of nutritional ❖ Place the patient in the recumbent
requirements, position with the legs elevated to
✓ knowledge about management prevent hypotension or place the
and patient on the left side to prevent
✓ prevention of ulcer recurrence, and aspiration from vomiting.
✓ absence of complications. ❖ Treat hypovolemic shock as
Nursing Interventions indicated.
❖ Relieving Pain and Improving If perforation and penetration are
Nutrition concerns
✓ Administer prescribed medications. ❖ Note and report symptoms of
✓ Avoid aspirin, which is an penetration (back and epigastric
anticoagulant, and foods and pain not relieved by medications
beverages that contain acid- that were effective in the past).
enhancing caffeine (colas, tea, ❖ Note and report symptoms of
coffee, chocolate), along with perforation
decaffeinated coffee. ✓ sudden abdominal pain,
✓ Encourage the patients to eat ✓ referred pain to shoulders,
regularly spaced meals in a relaxed ✓ vomiting and collapse,
atmosphere; obtain regular weights ✓ extremely tender and rigid
and encourage dietary abdomen,
modifications. ✓ hypotension and tachycardia, or
✓ Encourage relaxation techniques. ✓ other signs of shock
❖ Reducing Anxiety
✓ Assess what the patient wants to CHRONIC INFLAMMATORY BOWEL
know about the disease and DISORDERS (CIBDs), APPENDICITIS,
evaluate the level of anxiety; INTESTINAL OBSTRUCTION, DIVERTICULITIS &
encourage the patient to express DIVERTICULUM, HEMORRHOIDS
fears openly and without criticism. The two types of CIBDs are:
✓ Explain diagnostic tests and ❑ Crohn's disease (regional enteritis)
administer medications on schedule. ❑ Ulcerative colitis
✓ Interact in a relaxing manner, help in
identifying stressors, and explain
effective coping techniques and
relaxation methods.
 ✓ Fistula formation. An abnormal
opening that connects the small
and large intestines. The content of
small intestines becomes
contaminated with feces from the
large intestines. Septicemia may
CROHN’S DISEASE (REGIONAL ENTERITIS) occur.
an idiopathic inflammatory disease
of the
✓ small intestine (60%), the
✓ colon (20%), or
✓ both terminal ileum

The characteristic clinical manifestations

are as follows:
✓ Abdominal pain, weight loss.
✓ Be aware NURSE!!! to detect clinical
manifestations of
✓ peritonitis,
Causes ✓ bowel obstruction &
✓ Unknown, thought to be ✓ nutritional & fluid imbalances
autoimmune Interprofessional collaborative
✓ M. paratuberculosis management are as follows:
✓ Genetic predisposition (1st degree & ✓ Low fiber diet. To rest the bowels.
identical twins) ✓ Total parenteral nutrition. If severe
✓ common among Jewish- Americans; malnutrition is present.
associated with environmental ✓ Steroid. To relieve inflammation.
factors. ✓ Azulfidine (Sulfisoxazole). It is a
Age Group Sulfonamide which has antibiotic
✓ Age groups commonly affected are and anti-inflammatory effects on the
20 to 30 years and 40 to 60 years of intestines.
age. ✓ Antibiotics like Flagyl
Clinical Manifestations (Metronidazole) and Cipro
✓ The primary problem is diarrhea (5 to (Ciprofloxacin) are prescribed to
6 soft stools per day). control secondary bowel
✓ Transmural inflammation (the entire inflammation and infection.
wall of the intestine is affected). ✓ Surgery: Ileostomy, Colectomy.
✓ Abdominal distention, masses, visible
peristalsis
✓ The ileum and ascending colon are
commonly affected. Inflammation is
discontinuous (regional). This
produces the "cobblestone" lesions.
✓ Stool is with pus and mucus.
✓ weight loss (80% of clients)
 ✓ Steroid (Hydrocortisone). To relieve
inflammation.
✓ Azulfidine. To relieve infection and
inflammation in the colon.
✓ Surgery: Ileostomy,
Proctocolectomy.
▪ Proctocolectomy is done
because there is 100% rectal
involvement.

ULCERATIVE COLITIS
Ulcerative and inflammatory
condition of affecting the mucosal lining of
the colon or rectum.

Comparison between Crohn's Disease and

Ulcerative Colitis
Causes
✓ Unknown
✓ Common among Jewish-
Americans; associated with
environmental factors.
Age Groups
✓ Age groups commonly affected are
15 to 40 years of age.
Clinical Manifestations
✓ The primary problem is diarrhea (20
to 30 watery tools per day).
✓ Mucous ulceration of the intestine.
✓ Inflammation starts from the rectum,
it ascends until the entire lower
colon is affected. The inflammation
is continuous.
✓ Stool is with pus, mucus and blood.
Bleeding is severe.
✓ Rectal involvement is 100%
✓ Abdominal Pain
✓ Anorexia
✓ Weight loss
✓ Fever
Interprofessional Collaborative
Management are as follows:
✓ Low fiber diet. To rest the bowels
during acute episodes. APPENDICITIS
✓ Total parenteral nutrition. To provide Is inflammation of the vermiform
nutritional support in severe appendix.
malnutrition.
 ✓ Anorexia, nausea, and vomiting. This
The most common cause of appendicitis is
is due to vagal stimulation.
obstruction of the appendix by:
✓ Rigid abdomen, guarding. This is a
✓ fecalith
protective mechanism to relieve the
✓ foreign bodies or
pain.
✓ infection.
✓ Rebound tenderness (Blumberg's
The other causes of appendicitis are
sign). Deep palpation of the viscera
✓ low fiber diet and high intake of
over the suspected inflamed
refined carbohydrates
appendix.
✓ kinking of the appendix
▪ Severe pain on abrupt release of
✓ swelling of the bowel wall.
steady pressure over the site is felt
(seen in peritonitis).
✓ Psoas sign (Cope's psoas test or
Obraztsova's sign) is right lower
quadrant pain that is produced with
the patient extending the hip.
This is due to inflammation of the
peritoneum overlying the psoas muscle
themselves.

Clinical Manifestations
✓ Acute abdominal pain that usually
starts in the epigastric or umbilical
region.
▪ The pain lasts for 2 to 3 hours,
▪ it subsides for the next 2 to 3 hours,
and then ▪ Straightening out the leg causes the
▪ it recurs and persists. pain because it stretches the
▪ This time, the pain becomes muscles, and
localized in the right lower ▪ flexing the hip into the “fetal
quadrant/ McBurney's point position” relieves the pain.
(halfway between the umbilicus and This is due to retrocecal inflammation of
the anterior spine of the ilium). appendix.
McBurney’s Point ✓ Obturator sign-pain on passive
internal and external rotation of the
flexed right thigh.
 ✓ Rovsing's sign - continuous deep flatus indicate return of
palpation starting from the left iliac peristalsis.
fossa upwards (anticlockwise along ▪ Ambulate the client after 24
the colon) may cause pain in the hours to prevent post-op
rights iliac fossa by pushing bowel complications.
contents towards the ileocecal ▪ If appendicitis ruptured, the
valve and thus increasing pressure client may experience
around the appendix. peritonitis. Penrose drain is
✓ Dunphy's sign - increased pain with inserted to drain exudates
coughing. from the area. The client
✓ Fever and leukocytosis. should be placed in semi-
(Temperature = 38 to 38.5 °C, WBC Fowler’s position to promote
level is above 10,000/cu.mm). drainage from the Penrose
These are due to inflammatory response of drain and to localize
the body. WBC level of 20,000/mm3 inflammation within the pelvic
indicates peritonitis due to rupture of area.
appendicitis. ▪ To prevent infection, cleanse
Normal: Leukocyte count (Neutrophils) the insertion site of penrose
Total: 4500 – 11,000/mm3 drain and the skin around
✓ Decreased or absent bowel sounds. separately.
The inflammatory process in the ▪ Mobilization of Penrose drain
area decreases peristalsis. involves pulling out 1 inch of
Interprofessional Collaborative the drain daily. A new sterile
management are as follows: safety pin is placed below the
✓ Bed rest. To reduce peristalsis and old safety pin before cutting
prevent rupture of appendicitis. the length of the drain.
✓ Maintain NPO. To observe pattern of
abdominal pain more accurately PERITONITIS
and this is also in preparation for Is inflammation of the peritoneum.
emergency appendectomy. ✓ It may be caused by
✓ Relieve pain by cold application ❑ ruptured appendicitis,
over the abdomen. ❑ perforated peptic ulcer,
✓ Avoid factors that increase ❑ diverticulitis,
peristalsis, thereby preventing ❑ pelvic inflammatory disease
rupture of the appendicitis: ❑ urinary tract infection or
▪ Heat application over the ❑ trauma,
abdomen ❑ bowel obstruction, and
▪ Laxative ❑ bacterial invasion.
▪ Enema
✓ Intravenous therapy. To maintain
fluid - electrolyte balance.
✓ Antibiotic therapy. To control
infection.
✓ Surgery: Appendectomy
▪ If the client received spinal
anesthesia, position during
immediate postop is flat on
bed for 6 to 8 hours. To
prevent spinal headache.
▪ Monitor for return of sensation
in the lower extremities. This
indicates recovery from spinal ✓ The inflammatory process may lead
anesthesia. to the following problems:
▪ Maintain NPO until peristalsis ❑ Adhesions,
returns. Return of bowel ❑ abscess formation, and
sounds and passing out of ❑ intestinal obstruction.
 ▪ Decreased peristalsis may cause the Jackson - Pratt). To drain exudates
following problems: from the area.
➢ Fluid shifting into the ✓ Fluids, electrolytes, and colloid
abdominal cavity (300 to 500 replacement as ordered.
ml/ hour) ✓ Antibiotics are ordered.
➢ Bowel distention with gas and ✓ Administration of TPN as ordered. To
fluid occurs. support nutritional requirements of
➢ Hypovolemia, electrolyte the client.
imbalances, dehydration and
shock are the dangerous INTESTINAL OBSTRUCTION
effects of peritonitis. A partial or complete block of the
Clinical Manifestations small or large intestine that keeps food,
✓ Abdominal pain and tenderness. This liquid, gas, and stool from moving through
is due to inflammatory process. the intestines in a normal way.
✓ Abdominal guarding and rigidity. An Mechanical intestinal obstruction
attempt to protect the painful area. ✓ Intussusception - Is telescoping of
✓ Abdominal distention. This is due to one portion of bowel (proximal) into
accumulation of gas and fluid in the another portion (distal). The
abdomen. condition results in an obstruction to
✓ Paralytic ileus. This is due to the passage of intestinal contents.
decreased peristalsis.
✓ Fever, elevated WBC
(20,000/cu.mm. of higher). These are
due to the inflammatory process.
✓ Nausea and vomiting. Due to vagal
stimulation.

✓ Volvulus - Is twisting of the intestines

due to impaired innervations. This
leads to intestinal obstruction.
Surgery is required to remove the
affected area and end-to-end
Interprofessional Collaborative anastomosis is done.
Management are as follows:
✓ Monitor vital signs, intake and
output. To assess for fluid balance.
✓ Nasogastric tube (NGT) insertion. To
relieve abdominal distention.
✓ Bed rest in semi Fowler's position. To
localize inflammatory process in
pelvic cavity.
✓ Encourage deep breathing to
prevent respiratory complications.
Abdominal distention and pain may
inhibit the client from deep
breathing.
✓ Peritoneal lavage with warm saline
to remove exudates, as ordered.
✓ Insertion of drainage tubes (e.g.,
penrose drain, hemovac, ep
 ✓ Inflammatory bowel disease ✓ Put in fowler’s position (alleviate
✓ Foreign bodies pressure on diaphragm)
✓ Strictures ✓ Encourage nasal breathing to
✓ Neoplasms minimize swallowing of air and
✓ Fecal impaction further abdominal distension
Non-mechanical intestinal obstruction: ✓ Institute comfort measures
✓ “paralytic”, “neurogenic” or associated with NG intubation and
“adynamic ileus” - brought about by intestinal decompression
interference with the nerve supply to ✓ Prevent complications
the intestine resulting in decreased • Measure abdominal girth daily to
or absent peristalsis. assess for increasing abdominal
Causes distension
• handling of the intestine during • Assess for S/Sx of peritonitis
abdominal surgery • Monitor urinary output
• Thoracic diseases (rib fracture, MI,
pneumonia) DIVERTICULITIS
• Hypokalemia Acute inflammation and infection
• Peritonitis caused by trapped fecal material and
• Shock bacteria.
• Vascular obstructions ✓ Diverticulum - is outpouching of the
• Interference with the blood supply mucosal lining of the GI tract
to a portion of the intestine, resulting commonly in the colon.
in intestinal ischemia and gangrene ✓ Diverticula/ Diverticulosis - are
of the bowel; caused by an multiple outpouchings.
embolus, atherosclerosis
Assessment Findings
✓ high-pitched bowel sounds above
the level of the obstruction
✓ decreased or absent bowel sound
below the obstruction

Causes
✓ Low fiber diet,
✓ Chronic constipation,
✓ Obesity
Assessment
✓ Dull, steady, cramp-like lower left
quadrant abdominal PAIN worsens
Nursing Interventions with movement, coughing or
✓ Monitor F&E balance, straining
✓ prevent further imbalance; ✓ Low–grade fever
✓ keep client NPO and ✓ Chronic constipation with episodes
✓ administer IV fluids as ordered of diarrhea
✓ Most clients w/ an obstruction have ✓ Nausea and vomiting
atleast an NGT. Accurately measure Diagnostic Test
the drainage from NG/intestinal ✓ Colonoscopy, sigmoidoscopy
tube ✓ visualization of diverticula
✓ CBC may reveal increased WBC
 ✓ Barium enema is NOT usually Assessment
ordered in cases of acute ✓ Constipation in an effort to prevent
inflammation because of possibility pain or bleeding associated with
of perforation defecation
Nursing Management ✓ Anal PAIN
✓ High fiber diet ✓ Rectal bleeding (usually bright red-
✓ Liberal fluid intake of 2,500 to 3,000 hematochezia)
ml/day. ✓ Anal itchiness
✓ Avoid nuts and seeds which can be ✓ Mucous secretion from the anus
trapped in the diverticula. ✓ Sensation of incomplete evacuation
✓ Bulk – forming laxatives are ordered of the rectum
to restore normal bowel pattern ✓ Internal hemorrhoids may prolapse,
✓ IVF and medications usually painless. External
✓ During an acute episode: hemorrhoids are usually painful
• Bed rest Nursing Management
• NPO, then clear liquids to rest the ✓ High fiber diet
bowel ✓ liberal fluid intake
• Avoid high fiber foods to prevent ✓ Bulk laxatives
further irritation of the mucosa ✓ Hot Sitz bath, warm compress, witch
• Gradually increase the fiber when hazel cream can be applied to
the infection/ inflammation subsides decrease size
✓ Local anesthetic application –
HEMORRHOIDS ▪ Nupercaine
Types Surgery
✓ External hemorrhoids – occur below ✓ Hemorrhoidectomy
the anal sphincter ✓ Sclerotherapy (5% phenol in oil)
✓ Internal hemorrhoids – occur above ✓ Cryosurgery
the anal sphincter ✓ Rubber band ligation (done only if
hemorrhoids are INTERNAL)
Pre-op Care
• Low residue diet to reduce the bulk
of stool
• Stool softeners
Post-op Care
• Promotion of comfort
o Analgesics as prescribed
o Post-op position: Side – lying
position or prone position
o Hot sitz bath 12 to 24 hrs. post-
op to promote comfort and
hasten healing
• Patient Teaching
o Clean rectal area thoroughly
after each defecation
o Sitz bath at home especially
after defecation
• Avoid constipation by adhering to
these practice :
o High–fiber diet, High fluid
Causes
intake, Regular exercise
✓ Chronic constipation
o Regular time for defecation,
✓ Pregnancy
Use stool softener until healing
✓ Obesity
is complete
✓ Prolonged sitting or standing
• Notify physician for the following:
✓ Wearing constricting clothing
o Rectal bleeding,
✓ Disease conditions like liver cirrhosis,
o Suppurative drainage,
RSCHF
 o Continued pain on ALCOHOLIC CIRRHOSIS
defecation, The scar tissue characteristically
o Continued constipation surrounds the portal areas.
This is most frequently caused by:
LIVER DISEASES: LIVER CIRRHOSIS, ✓ chronic alcoholism (the most
ESOPHAGEAL VARICES common type of cirrhosis)
GALLBLADDER DISEASES: Alcohol-associated cirrhosis
CHOLELITHIASIS, CHOLECYSTITIS, contributes to up to 50% of the overall
PANCREATITIS cirrhosis burden in the United States and
LIVER CIRRHOSIS worldwide (Lucey, 2019).
Cirrhosis is a chronic disease characterized
by replacement of normal liver tissue with POSTNECROTIC CIRRHOSIS
diffuse fibrosis that disrupts the Broad bands of scar tissue. This is a
✓ structure and late result of a previous bout of acute viral
✓ function of the liver. hepatitis.

BILIARY CIRRHOSIS
Scarring occurs in the liver around
the bile ducts. This type of cirrhosis usually
results from chronic biliary obstruction and
cholangitis (bile duct infection); it is much
less common.

Causes Clinical Manifestations

❑ Reduced protein intake Signs and symptoms of cirrhosis
❑ Excessive alcohol intake(major increase in severity as the disease
causative factor) progresses and severity is used to
❑ Exposure to certain categorize the disorder as
chemicals(carbon tetrachloride, ❑ compensated or
chlorinated naphthalene, arsenic, or ❑ decompensated cirrhosis.
phosphorus)
❑ Infectious schistosomiasis COMPENSATED CIRRHOSIS
Risk Factors Compensated cirrhosis, with its less
❑ Gender (twice as many men as severe, often vague symptoms, may be
women are affected, although, for discovered secondarily at a routine
unknown reasons, women are at physical examination.
greater risk for development of ✓ Abdominal pain
alcohol-induced liver disease) ✓ Ankle edema
❑ Age (Most patients are between 40 ✓ Firm, enlarged liver
and 60 years of age) ✓ Flatulent dyspepsia
❑ Diet (Reduced protein intake) ✓ Intermittent mild fever
Stages of Liver Damage ✓ Palmar erythema (reddened palms)
✓ Splenomegaly
✓ Unexplained epistaxis
✓ Vague morning indigestion
✓ Vascular spiders

DECOMPENSATED CIRRHOSIS
The hallmarks of decompensated
cirrhosis result from failure of the liver to
synthesize proteins, clotting factors, and
There are three types of cirrhosis or scarring other substances and manifestations of
of the liver: portal hypertension.
❑ ALCOHOLIC CIRRHOSIS ✓ Ascites
❑ POST-NECROTIC CIRRHOSIS ✓ Clubbing of fingers
❑ BILIARY CIRRHOSIS ✓ Continuous mild fever
✓ Epistaxis
 ✓ Gonadal atrophy ✓ Esophageal varices - 2° to
✓ Hypotension backpressure (major causes of
✓ Jaundice death in patients with cirrhosis)
✓ Muscle wasting ✓ Internal hemorrhoids,
✓ Purpura (due to decreased platelet ✓ Leg varicosities, and
count) ✓ Dependent edema (due to venous
✓ Sparse body hair stasis, increasing hydrostatic
✓ Spontaneous bruising pressure. This leads to shifting of
✓ Weakness plasma into interstitial space)
✓ Weight loss Consequences of Portal Hypertension:
✓ White nails ✓ Hepatomegaly - initially, then the
liver shrinks in size as fibrosis replaces
the liver parenchyma
✓ Splenomegaly - due to increased
backpressure of the blood
✓ Caput medusae (dilated veins over
the abdomen)

Clinical Manifestations
✓ Increased Bleeding tendencies -
(liver is unable to store Vit. K. There is
also impaired production of clotting
factors)
✓ Spider angioma - (telangiectasia /
✓ Portal HPN - (plasma shift into
dilated capillaries over the face and
interstitial spaces within the liver due
anterior trunk)
to the increase pressure. The
• due to increased estrogen
collection of fluids shifts out of the
Glisson’s capsule and accumulate in
the peritoneal cavity)

✓ Palmar erythema - This is also due to

elevated estrogen level in males.

PORTAL HYPERTENSION
✓ The liver is unable to excrete
adrenal cortex hormone, one of
which is aldosterone
(Hyperaldosteronism leads to
retention of sodium and water) ✓ Ascites - build-up of fluid in the
space between the lining of the
abdomen and abdominal organs
✓ Males (estrogen) will result to: ✓ HEPATIC ENCEPHALOPATHY -
❑ Decreased libido Accumulation of AMMONIA
❑ Impotence because the liver cannot convert
❑ Fall of body hair ammonia into urea that can lead to
❑ Atrophy of testicles hepatic coma (Ammonia is by
❑ Gynecomastia product of CHON (protein)
metabolism)
❑ Initial manifestations: BEHAVIORAL
changes and MENTAL changes
✓ Other findings in advanced stages
are:
❑ Asterixis – flapping tremors of the
hands
❑ Confusion/disorientation
❑ Delirium/hallucination
❑ Fetor hepaticus - disagreeable odor
from the mouth
✓ Females ( androgen) ❑ Coma
❑ Hirsutism Diagnostic Tests
✓ SGOT or AST, SGPT or ALT, LDH,
alkaline phosphatase increased
✓ Serum bilirubin increased
✓ PT prolonged
✓ Serum albumin decreased
✓ Hgb/Hct decreased
✓ BSP(Bromsulphthalein) increased
Nursing Interventions
❑ Provide sufficient rest and comfort
✓ Provide bed rest with bathroom
privileges.
✓ Encourage gradual, progressive,
increasing activity with planned rest
periods.
✓ Institute measures to relieve pruritus.
• Do not use soaps and
❑ Virilism (development or premature detergents
development of male secondary • Bathe in tepid water followed
sexual characteristics) by application of an
• Deepening of voice emollient lotion.
• Acne • Provide cool, light,
nonrestrictive clothing.
• Keep nails short to avoid skin
excoriation from scratching.
Apply cool, moist compresses to
pruritic areas
❑ Promote nutritional intake
✓ Encourage small frequent feedings.
✓ Promote a high-calorie, low to They are prone to rupture and
moderate- protein, high often are the source of massive
carbohydrate, low-fat diet, with hemorrhages from the upper GI
supplemental vitamin therapy tract and the rectum.
(vitamins A, B- complex, C, D, K, and In addition, abnormalities in
folic acid) blood clotting, often seen in patients
❑ Prevent infection with severe liver disease, increase
✓ Prevent skin breakdown by frequent the likelihood of bleeding with
turning and skin care. significant blood loss.
✓ Provide reverse isolation for clients Once esophageal varices
with severe leukopenia; pay special form, they increase in size over time
attention to hand-washing and may eventually bleed (Hammer
technique. & McPhee, 2019; Kovacs & Jensen,
✓ Monitor WBC. 2019; Simonetto et al., 2019).
❑ Monitor/prevent bleeding.
❑ Administer diuretics as ordered
❑ Provide client teaching & D/C
planning concerning:
✓ Avoidance of agents that may be
hepatotoxic (sedatives, opiates, or
OTC drugs detoxified by the liver)
✓ How to assess weight gain and
increased abdominal girth
✓ Avoidance of people with upper
respiratory infections
✓ Recognition and reporting of signs of
recurring illness (liver tenderness,
increased jaundice, increased Assessment and Diagnostic Findings
fatigue, anorexia) ✓ Endoscopy
✓ Avoidance of all alcohol ✓ Ultrasonography,
✓ Avoidance of straining at stool, ✓ CT scanning, and
vigorous blowing of nose and ✓ Angiography
coughing, to decrease the ✓ Endoscopic video capsule (can
incidence of bleeding detect esophageal varices but does
not substitute for endoscopy unless
ESOPHAGEAL VARICES this test cannot be performed)
Esophageal varices are ✓ Portal Hypertension Measurements -
present in 30% of patients with Portal venous pressure can be
compensated cirrhosis and 60% of measured
patients with decompensated ❑ Directly or
cirrhosis at the time of diagnosis ❑ Indirectly
(Hammer & McPhee, 2019; Kovacs & ✓ Indirect measurement of the
Jensen, 2019; Simonetto et al., 2019) hepatic vein pressure gradient is the
Varices are varicosities that most common procedure.
develop from elevated pressure in • The measurement requires
the veins that drain into the portal insertion of a catheter with a
system. balloon into the antecubital
or femoral vein. The catheter
is advanced under
fluoroscopy to a hepatic vein.
• A “wedged” pressure (similar
to pulmonary artery wedge
pressure) is obtained by
occluding the blood flow in
the blood vessel; pressure in
the unoccluded vessel is also
measured and the hepatic
 venous pressure gradient because of the poor physical
(HVPG) is obtained. condition that is typical of the
• An HVPG of over 10 mm Hg is patient with severe liver dysfunction.
indicative of clinically Pharmacologic Therapy
significant portal hypertension ✓ Octreotide (considered the
(Kovacs & Jensen, 2019). preferred treatment regimen for
Laboratory Tests immediate control of variceal
✓ Serum aminotransferases bleeding).
✓ Bilirubin ✓ Vasopressin (initial mode of therapy
✓ Alkaline phosphatase, and in urgent situations because it
✓ Serum proteins produces constriction of the
Splenoportography (which involves splanchnic arterial bed and
serial or segmental x-rays, is used to decreases portal pressure).
detect extensive collateral Monitoring of I&O and
✓ circulation in esophageal vessels, electrolyte(hyponatremia).
which would indicate varices) Contraindication:
✓ Hepatoportography and ✓ CAD (vasoconstriction is a side
✓ Celiac angiography effect that may precipitate
(these are usually performed in the myocardial infarction)
operating room or x-ray Therefore, vasopressin is used only in
department) urgent situations or when other agents such
as octreotide are not available.
Vasopressin must be given with close
monitoring.
✓ Beta-blocking agents such as
• propranolol,
• nadolol, or
• Carvedilol
❑ Decrease portal pressure
Medical Management ❑ Prevent a first bleeding episode
✓ Bleeding from esophageal varices is Effective prophylaxis against initial
an emergency that can quickly lead and recurrent bleeding episodes.
to hemorrhagic shock. ✓ Nitrates such as
✓ Close monitoring and • Isosorbide
management(ICU) ❑ Lower portal pressure
✓ The extent of bleeding is evaluated, ❑ Decreased cardiac output
and vital signs are monitored may be used in combination with
continuously if hematemesis and beta-blockers to reduce the risk of
melena are present. recurrent variceal bleeding.
✓ IV fluids Medical Management
✓ Electrolytes ✓ Balloon Tamponade
✓ Volume expanders
are provided to restore fluid
volume and replace electrolytes.
✓ Transfusion of blood components
also may be required.
✓ Caution must be taken with volume
resuscitation so that overhydration
does not occur, because this would
✓ Endoscopic Sclerotherapy (injection
raise portal pressure and increase
sclerotherapy)
bleeding.
o Sodium morrhuate,
✓ Monitoring of urine output. (FC)
o Ethanolamine oleate,
✓ Nonsurgical treatment of bleeding
o Sodium tetradecyl sulfate, or
esophageal varices is preferable
o Ethanol
because of the high mortality rate of
emergency surgery to control
bleeding esophageal varices and
✓ Endoscopic Variceal Ligation
(Esophageal Banding Therapy)

✓ Devascularization and Transection

✓ Transjugular Intrahepatic
Portosystemic Shunt
Additional Therapies
✓ Tissue adhesives and Nursing Management
✓ Monitoring the patient’s physical
condition and evaluating emotional
responses and cognitive status.
✓ Monitors and records vital signs and
assess the patient’s nutritional and
neurologic status.
This assessment assists in
identifying hepatic encephalopathy.
✓ If complete rest of the esophagus is
indicated because of bleeding,
✓ Fibrin glue parenteral nutrition is initiated.
✓ Gastric suction usually is initiated to
keep the stomach as empty as
possible and to prevent straining
and vomiting.
✓ The patient often complains of
✓ Coated expandable stents severe thirst, which may be relieved
✓ Portosystemic shunting by frequent oral hygiene and moist
sponges to the lips.
✓ Monitors the blood pressure.
✓ Vitamin K therapy and multiple
blood transfusions often are
indicated because of blood loss.
✓ A quiet environment and calm
reassurance may help to relieve the
✓ Balloon-Occluded Retrograde patient’s anxiety and reduce
Transvenous Obliteration (BRTO) agitation.
Surgical Management ✓ The nurse provides support and
Several surgical procedures explanations about medical and
have been developed to treat nursing interventions to prepare both
esophageal varices and to minimize the patient and the family, because
rebleeding, but these procedures these procedures can be difficult to
have SIGNIFICANT RISK. undergo and observe.
✓ Surgical Bypass Procedures
CHOLELITIASIS
 ✓ “gallstones” ✓ Vitamin Deficiency (fat-soluble
✓ FAT, FEMALE, FORTY, FERTILE vitamins A, D, E, and K)
▪ More common in women Diagnostic Tests
after age 40 (estrogen ✓ Direct bilirubin transaminase,
therapy), women taking oral alkaline phosphatase, WBC,
contraceptives, and in the amylase, lipase: all increased
obese. ✓ Abdominal X-Ray
✓ Ultrasonography
✓ Oral cholecystogram (gallbladder
series): positive for gallstone
✓ Radionuclide Imaging or
Cholescintigraphy
✓ Endoscopic Retrograde
Cholangiopancreatography

Gallstones are composed primarily

of
❑ Cholesterol (80%)
❑ Bile salts
❑ Ca++
❑ Bilirubin ✓ Percutaneous Transhepatic
❑ CHONs Cholangiography

Medical Management
✓ Supportive treatment: NPO with NG
intubation and IV fluids
✓ Diet modification with administration
of fat- soluble vitamins
Drug Therapy
Assessment Findings ✓ Narcotic analgesics (Demerol is the
✓ Most patients are asymptomatic. drug of choice) for pain
✓ When symptomatic; Excruciating ✓ Morphine sulfate is contraindicated
RUQ abdominal pain that radiates because it causes spasms of the
to the back or right shoulder and sphincter of Oddi
epigastric pain lasting ✓ Anticholinergics (atropine) may be
approximately 30 min used for pain
✓ Fever & leukocytosis (Elevated WBC) ✓ Antiemetics
✓ Charcot triad ✓ Ursodeoxycholic acid (UDCA) and
❑ Fever ✓ chenodeoxycholic acid
❑ Jaundice Nonsurgical Removal of Gallstones
❑ Pain in RUQ of abdomen ✓ Dissolving Gallstones
(ascending cholangitis) ✓ Stone Removal by Instrumentation
✓ Intolerance for fatty foods
(steatorrhea, Nausea & Vomiting,
sensation of fullness)
✓ Pruritus, easy bruising, dark amber
urine
✓ Grayish (like putty) or clay colored
stool (obstructive jaundice).
 ✓ Intracorporeal Lithotripsy • resume sexual activity as
✓ Extracorporeal Shock Wave desired unless ordered
Lithotripsy otherwise by physician
Surgical Management • clients having laparoscopy
✓ Laparoscopic Cholecystectomy cholecystectomy usually
✓ Cholecystectomy resume normal activity within
✓ Small-Incision Cholecystectomy two weeks
✓ Choledochostomy ✓ Recognition and reporting of signs of
✓ Surgical Cholecystostomy complications
✓ Percutaneous Cholecystostomy ❑ fever,
❑ jaundice,
❑ pain,
❑ dark urine,
❑ pale stools,
❑ pruritus
Gerontological Considerations
✓ Symptoms of biliary tract disease in
the older adult may be
Nursing Interventions accompanied or preceded by
✓ Administer pain medications as those of septic shock, which include
ordered and monitor for effects. ❑ oliguria,
✓ Administer IV fluids as ordered. ❑ hypotension,
✓ Provide small, frequent meals of ❑ changes in mental status,
modified diet, low fat (if oral intake ❑ tachycardia, and
allowed) ❑ tachypnea.
✓ Provide care to relieve pruritus
✓ Provide care for the client with a PANCREATITIS
cholecystectomy or ✓ An inflammatory process with
choledochotomy varying degrees of pancreatic
✓ Provide routine pre-op care edema, fat necrosis, or hemorrhage
✓ Provide routine post-op care ✓ Proteolytic and lipolytic pancreatic
✓ Position client in semi-Fowler’s or enzymes are activated in the
side-lying positions; reposition pancreas rather than in the
frequently. duodenum, resulting in tissue
✓ Splint incision when turning, damage and autodigestion of the
coughing, and deep breathing pancreas
✓ Maintain/monitor functioning of T- ✓ Occurs most often in the middle
tube aged
▪ Ensure that T-tube is Causes
connected to closed gravity ✓ Alcoholism/ alcohol abuse
drainage. ✓ Biliary tract disease/ biliary
▪ Avoid kinks, clamping, or obstruction
pulling of the tube. ✓ Trauma, viral infection, penetrating
✓ Measure and record drainage every duodenal ulcer, abscesses
shift ✓ Drugs (antihypertensives, steroids,
✓ Expect 300 – 500 ml bile-colored thiazide diuretics, antimicrobials,
drainage for the 1st 24° then 200 immunosuppressives, oral
ml/24° for 3 - 4 days contraceptives)
✓ Provide client teaching and Assessment Findings
discharge planning concerning ✓ Pain (LUQ radiating to back, flank, or
▪ Adherence to dietary restrictions substernal area) accompanied by
▪ Resumption of ADL DOB (shallow respiration with pain),
• avoid heavy lifting for at least aggravated by eating
6 weeks ✓ N&V, decreased/absent bowel
sounds,
✓ Abdominal tenderness w/ muscle-
guarding
 ✓ (+) Grey Turner’s spots (ecchymoses ✓ CT scan: enlargement of the
on flanks) pancreas
✓ (+) Cullen’s sign (ecchymoses of Drug therapy
periumbilical area) ✓ Analgesics (Demerol) to relieve pain.
MORPHINE is avoided because it
can cause spasm of the sphincter
aggravating pain
✓ Smooth-muscle relaxants to relieve
pain
• papaverine, nitroglycerin
✓ Anticholinergics to decrease
pancreatic stimulation
• Atropine, propantheline
bromide
✓ Antacids to decrease pancreatic
stimulation
✓ H2-antagonists, vasodilators,
calcium gluconate
Medical Maagement
✓ Diet modification
✓ NPO usually for a few days to
promote GIT rest
✓ Peritoneal lavage
✓ Dialysis if the condition is severe
Nursing Management
✓ Administer analgesics, antacids, and
anticholinergics as ordered, monitor
effects
✓ Withhold food/fluid and eliminate
odor and sight of food from
environment to decrease
pancreatic stimulations
✓ Maintain NGT and assess for
drainage.
✓ Institute Non-pharmacologic
measures to decrease pain.
✓ Assist client to positions of comfort
(knee chest, fetal position)
✓ Teach relaxation techniques and
provide a quiet, restful environment.
✓ Provide client teaching and
discharge planning concerning
• Dietary regimen when oral intake
permitted
▪ High CHO, high CHON, low-
fat diet
▪ Eating small, frequent meals
instead of three large ones
▪ Avoiding caffeine products
Diagnostic Tests ▪ Eliminating alcohol
✓ Elevated Serum amylase (>300 consumption
somogyi units) & lipase ▪ Maintaining relaxed
✓ Elevated urinary amylase atmosphere after meals
✓ Elevated blood sugar ✓ Provide client teaching & discharge
✓ Elevated lipid levels planning concerning
✓ Decreased Serum calcium • Recognition/reporting of signs of
complications
 ▪ Continued N&V
▪ Abdominal distension with
increasing fullness
▪ Persistent weight loss
▪ Severe epigastric or back
pain
▪ Frothy/foul-smelling bowel
movements
Irritability, confusion, persistent elevation of
temperature (2 days) ✓ The hypothalamus controls both the
anterior and posterior pituitary
ENDOCRINE SYSTEM glands. And therefore, it controls the
ANATOMIC AND PHYSIOLOGIC other endocrine glands.
OVERVIEW The anterior pituitary gland hormones and
The endocrine system and the their functions are as follows:
nervous system are two of the essential A. Growth hormone (GH) - It is also
communicating and coordinating systems known as somatotropin or
in the body. somatotropic hormone (STH) “
The nervous system communicates ▪ It is concerned with growth of cells,
through nerve impulses. bones and soft tissues.
The endocrine system ▪ It affects carbohydrate, protein and
communicates through chemical fat metabolism.
substances known as hormones, and it ▪ It increases blood glucose levels by
plays a role in reducing glucose utilization; an
✓ Reproduction, insulin antagonist.
✓ Growth and Development, and B. Prolactin (PRL) - Also called
✓ Regulation of energy. mammotropic hormone, lactotropic
GLANDS OF THE ENDOCRINE SYSTEM hormone, or luteotropic hormone.
The endocrine system is composed ▪ It is necessary for breast
of the development and lactation.
✓ PITUITARY GLAND ▪ It regulates reproductive function in
✓ THYROID GLAND males and females.
✓ PARATHYROID GLANDS C. Thyroid stimulating hormone [TSH)
✓ ADRENAL GLANDS ▪ It controls functions of the thyroid
✓ PANCREATIC ISLETS gland.
D. Gonadotropic hormones or
Gonadotropin
▪ The two gonadotropins are:
✓ follicle - stimulating hormone
(FSH), and
✓ luteinizing hormone (LH).
▪ They affect development of
secondary sex characteristics.
▪ They are necessary for
gametogenesis and sex steroid
production in males and females.
E. Adrenocorticotropic hormone
Pituitary Gland (Hypophysis) (ACTH) or Adrenocorticotropin
✓ It lies in the Sella turcica of the ▪ It controls functions of the adrenal
middle cranial fossa (the bony floor glands.
that supports the brain). F. Melanocyte - stimulating hormone
✓ It is composed of two parts: (MSH).
▪ The anterior pituitary gland ▪ It is necessary for pigmentation, e.g.
(adenohypophysis) skin, retina (melanin epithelial
▪ The posterior pituitary gland pigment layer).
(neurohypophysis).
The posterior pituitary gland hormones and ▪ Affect cardiac rate, force and
their functions are as follows: output.
A. Antidiuretic hormone (ADH) - It is ▪ Affect oxygen utilization.
also called vasopressin. ▪ Stimulate lipid turnover, free fatty
▪ It is the major control of osmolality acid release and cholesterol
(concentration) and body water synthesis.
volume. ▪ Stimulate sympathetic nervous
▪ It increases water reabsorption in the system (SNS) activity.
collecting ducts of the kidneys. ✓ Thyrocalcitonin (Calcitonin).
▪ It causes vasoconstriction. ▪ It lowers serum calcium levels.
B. Oxytocin ▪ It inhibits osteoclastic activity.
▪ It promotes milk "let - down" in a ▪ It lowers phosphate levels.
lactating breast. ▪ It decreases calcium and
▪ It causes increased uterine phosphorous absorption in the G.I.
contraction after labor has begun. tract.
▪ The relationship between
Thyrocalcitonin and calcium is
inverse:
Thyrocalcitonin is (↑) high, Calcium is (↓) low
Thyrocalcitonin is (↓) low, Calcium is (↑) high

Parathyroid Gland
▪ Produce Parathormone or
Parathyroid Hormone (PTH).
▪ PTH regulates calcium and
phosphorous balance.
▪ PTH elevates serum calcium levels
by withdrawal of calcium from the
bones. Low serum calcium levels
stimulate PTH release.
▪ The relationship of PTH and calcium
is direct proportion.
Hypersecretion of ↑ PTH: ↑ Hypercalcemia
Hyposecretion of ↓ PTH: ↓ Hypocalcemia
▪ The relationship between PTH and
Thyroid Gland
phosphorous is inverse.
The thyroid gland hormones are as
Hypersecretion of ↑ PTH: ↓
follows:
Hypophosphatemia
✓ Triiodothyronine (T3), Thyroxine (T4).
Hyposecretion of ↓ PTH: ↑
These two hormones:
Hyperphosphatemia
▪ Regulate metabolic rate of cells.
▪ PTH elevates serum calcium levels
▪ Regulate protein, fat and
and inversely, lowers phosphorous
carbohydrate metabolism.
levels
▪ Act as insulin antagonists.
Adrenal Glands
▪ The two divisions of the adrenal
glands are the adrenal cortex and
medulla.
▪ The adrenal cortex hormones
control the "3S:
✓ SUGAR,
✓ SALT AND
▪ Maintain growth hormone secretion ✓ SEX
and promote skeletal maturation.
▪ Affect central nervous systems (CNS)
development.
 stimulation on body organs are as
follows: (Concept "Every function is
high and fast, except G.I. and ler
G.U.")

1. Glucocorticoids (Cortisol)
▪ Maintain blood glucose levels
(Sugar).
▪ Enhance gluconeogenesis (protein
catabolism and fat
catabolism/lipolysis).
▪ Have anti-inflammatory effect.
▪ Decrease T-lymphocyte
participation in cell-mediated
immunity (immunosuppressant).
▪ Decrease new antibody release.
▪ Increase gastric acid and pepsin
production. This may cause G.I.
irritation.
▪ Maintain emotional stability.
2. Mineralocorticoids (e.g.,
Aldosterone)
▪ Maintain sodium and volume status
(Salt). PANCREAS
▪ Increase sodium reabsorption in ▪ The Islets of Langerhans perform the
distal tubules of the kidneys. endocrine functions of the
▪ Increase potassium and hydrogen pancreas. It has 2 types of cells, the
excretion in distal tubules. ✓ Alpha cells (Glucagon)
▪ Aldosterone is ✓ Beta cells. (Insulin)
✓ "pro- Sodium“ The alpha cells secrete glucagon;
✓ "anti- Potassium" while the beta cells secrete insulin.
(Aldosterone retains sodium,
excretes potassium).
Increased (↑) aldosterone level results to:
(↑) Hypernatremia
(↓) Hypokalemia
Decreased (↓) aldosterone level results to:
(↓) Hyponatremia
(↑) Hyperkalemia
3. Sex Hormones (Androgen and
Estrogen)
▪ Responsible for some secondary sex ▪ Glucagon
characteristics in females. In males, ✓ Enhances gluconeogenesis
these hormones work like gonadal (breakdown of fats and proteins into
steroids. glucose) and
▪ The adrenal medulla secretes ✓ Elevates blood glucose levels.
catecholamines (epinephrine and ▪ Insulin produces the following
norepinephrine) through stimulation effects:
of the SNS and medulla oblongata. ✓ Liver cells
▪ The effects of sympatho-adreno- a. Increase glycogenesis.
medullary response (SAMR) b. Increased fatty acid synthesis.
 c. Decreased glycogenolysis, T3 Resin Uptake
gluconeogenesis, and ketogenesis. Thyroid Binding Globulins
✓ Adipose tissues ↑: Hyperthyroidism
a. Increased fatty acid synthesis. ↓: Hypothyroidism
b. Increased glycerol synthesis and Thyroid Scan
formation. ▪ Radioactive iodine taken orally;
c. Decreased lipolysis. dose is harmless.
✓ Muscle ▪ Scanning done after 24 hours
a. Increased glycogenesis. ▪ Avoid iodine containing foods; dyes,
b. Increased amino acid uptake and medications.
protein synthesis. ▪ Cold nodules: cancer
c. Decreased protein catabolism. ▪ Hot nodules: benign
OVERALL EFFECT OF INSULIN: LOWER Ultrasound
GLUCOSE LEVELS ▪ No special preparation
Magnetic Resonance Imaging
DIAGNOSTIC TESTS OF THYROID DISORDERS ▪ Test cannot be done in clients with
Thyroid Function Tests metal implants (e.g., pacemakers,
✓ Thyroid - stimulating hormone assay arthroplasties, skull plates).
↑: Hypofunction of thyroid gland; ▪ Assess for allergy to contrast media.
primary hypothyroidism Computed Tomography
↓: Pituitary disorders; hyperthyroidism ▪ If contrast medium is used, note
✓ Radioactive Iodine Uptake (RAIU) allergy history.
↑: Hyperthyroidism; urine:
hypothyroidism DIAGNOSTIC TESTS OF PARATHYROID
↓: Hypothyroidism; urine: DISORDERS
hyperthyroidism. Total serum calcium
✓ Radioactive Iodine Uptake (RAIU) ▪ Venous blood is collected
↑: Hyperthyroidism; urine: ▪ ↑: Hyperparathyroidism
hypothyroidism ▪ ↓: Hypoparathyroidism
↓: Hypothyroidism; urine: Qualitative Urinary Calcium (Sulkowitch
hyperthyroidism. Test)
Patient teaching: ▪ Collect urine specimen.
❑ Radioactive dose is small and ▪ Fine white precipitate should form
harmless. when Sulkowitch reagent is added
❑ Contraindicated in to urine specimen.
pregnancy. ▪ Absent or decreased precipitate
❑ Seafoods may elevate results. indicates low serum calcium and
❑ Drugs that may elevate hypoparathyroidism.
results: barbiturates, estrogen, Quantitative Urinary Calcium (Calcium
lithium, phenothiazines. Deprivation Test)
❑ Drugs that may decrease ▪ Collect 24-hour urine specimen.
results: Lugol's solution, ▪ ↑: Hyperparathyroidism
saturated solution of ▪ ↓: Hypoparathyroidism
potassium iodide (SSKI), Tarot Serum Phosphorous
antithyroid, cortisone, aspirin, ▪ Collect venous blood specimen.
antihistamines. ▪ ↑: Hypoparathyroidism
❑ Collect 24-hour urine ▪ ↓: Hyperparathyroidism
specimen after oral tracer Serum Alkaline Phosphatase
dose given. ▪ Collect venous blood specimen.
❑ Thyroid is scanned after 24 ▪ ↑: Hyperparathyroidism
hours. ▪ ↓: Hypoparathyroidism
Thyroid antibodies Parathormone (PTH) Radioimmunoassay
↑: in Thyroiditis ▪ Collect venous blood
T3:T4 Radioimmunoassay ▪ ↑: Hyperparathyroidism
↑: Hyperthyroidism ▪ When elevated in conjunction with
↓: Hypothyroidism serum calcium levels, this is the most
Free Thyroxine Concentration specific test for hyperparathyroidism
DIAGNOSTIC TESTS OF ADRENOCORTICAL Clonidine Suppression Test
DISORDERS ▪ Clonidine (Catapress), a centrally
Cortisol level with dexamethasone acting adrenergic blocker
suppression test suppresses the release of
▪ Give dexamethasone before catecholamines.
phlebotomy to suppress diurnal ▪ In pheochromocytoma, clonidine
formation of ACTH does not suppress the release of
▪ ↑: Pituitary tumor, Cushing's catecholamines.
syndrome or disease. ▪ Normal Response: 2 to 3 hours after
▪ ↓: Addison's disease. a single oral dose of Clonidine, the
Cortisol plasma level total plasma catecholamine value
▪ Fasting is required; the patient decreases at least 40% from the
should be on bed rest for 2 hours client's baseline.
before the test because activity CT Scan, MRI and Ultrasound
increases cortisol level. ▪ To localize the pheochromocytoma.
▪ ↑: Cushing's disease.
▪ ↓: Addison's disease. DIAGNOSTIC TESTS OF PANCREATIC
17-hydroxysteroids DISORDERS (DIABETES MELLITUS)
▪ 24 hour urine collection to be kept FBS (Fasting Blood Sugar); FBG (Fasting
on ice. Blood Glucose):
▪ ↑: Cushing's disease. ▪ Normal: 70 - 110 mg/dL.
▪ ↓: Addison's disease. ▪ DM: ↑140 mg/dL for 2 readings.
17-ketosteroids 2- hour PPBS (2-hr. Postprandial Blood
▪ 24hour urine test; keep collection Sugar)
cold; may need preservative. ▪ Initial blood specimen is withdrawn.
▪ ↑: Cushing's disease. ▪ 100 g. of carbohydrate in diet is
▪ ↓: Hypofunction of adrenal gland taken by the client.
▪ 2 hours after meal, blood specimen
DIAGNOSTIC TESTS OF ADRENAL MEDULLARY is withdrawn: blood sugar returns to
DISORDERS normal level.
Vanillylmandelic Acid Test (VMA Test) OGTT / GTT (Oral Glucose Tolerance Test/
▪ VMA is a metabolite of epinephrine. Glucose Tolerance Test)
▪ 24-hour urine specimen is collected. ▪ Take a high carbohydrate diet (200
▪ Instruct the client to avoid the to 300 g.) for 3 days.
following medications and foods ▪ Avoid alcohol, coffee and smoking
which may alter the result: 36 hours before the test.
❑ Coffee ▪ NPO for 10 to 16 hours.
❑ Chocolate ▪ Initial blood and urine specimen are
❑ Tea collected.
❑ Bananas ▪ 150 to 300 g. of glucose per orem or
❑ Vanilla IV is given.
❑ Aspirin ▪ Series of blood specimen is
▪ Normal Value: 0.7-6.8 mg/ 24hr. collected after administration of
Total Plasma Catecholamine glucose (30 mins., 1 hour, 2 hours, if
Concentration required 3 hours, 4 hours, and 5
▪ The client should lie supine and rest hours after).
for 30 minutes. ▪ If glucose levels peak at higher than
▪ Butterfly needle is inserted 30 normal at 1, and 2 hours after
minutes before blood specimen is ingestion or injection of glucose, and
collected (to prevent elevation of are slower than normal to return to
catecholamine levels by the stress of fasting levels, then DM (diabetes
venipuncture). mellitus) is confirmed.
▪ Normal values: ▪ Done when results of FBS and 2- hour
❑ Epinephrine: 100 pg/ml (590 pmol/L) PPBS are borderline (high normal).
❑ Norepinephrine: 100 to 550 pd/ml Glycosylated Hgb (HbA1c)
(590-3240 pmol/L) ▪ Most accurate indicator of DM
(diabetes mellitus).
 ▪ Reflects serum glucose levels for the
past 3 to 4 months. Normal value is
4% to 6% (up to 7%) for nondiabetics.
▪ The goal for the client with DM is
7.5% or less

SOMNOLENCE

HYPERPITUITARISM
HYPOPITUITARISM
HYPERPITUITARISM
❑ Is hyperfunction of the anterior
pituitary hormones.
❑ It is frequently caused by benign
pituitary adenoma; may result also
from hyperplasia of pituitary tissues.
❑ Prolactinomas (prolactin secreting ✓ Signs and symptoms of increased
tumors) account for 60 to 80% of all intracranial pressure
pituitary tumors. ✓ Behavioral changes, seizures.
The characteristic manifestations of ✓ Disturbance in appetite, sleep,
hyperpituitarism are as follows: temperature regulation and
1. Overproduction of growth hormone emotional balance due to
results in acromegaly in adults; hypothalamic involvement.
gigantism in children. ✓ Diagnostic tests to confirm presence
2. Hormonal imbalances. of tumor: skull X-ray, CT scan, MRI.
ACROMEGALY 4. Endocrine manifestations:
✓ Irregular menses, anovulatory
periods, oligomenorrhea, (scanty
menstrual flow), amenorrhea
(absence of menstrual biguani flow).
✓ Infertility
✓ To Galactorrhea (excessive milk
production)
✓ Dyspareunia (painful sexual
GIGANTISM IN CHILDREN intercourse), vaginal mucosa
atrophy, decreased vaginal
lubrication, decreased libido due to
ovarian steroid effect.
✓ Decreased libido and impotence,
reduced sperm count, infertility and
gynecomastia in males.
Interprofessional collaborative
3. Neurologic manifestations:
management are as follows:
✓ Hemianopsia or scotomas (blind
1. Surgery: Transsphenoidal
spots in the visual field) or blindness.
hypophysectomy
✓ Headache
✓ Hypophysectomy is surgical removal
✓ Somnolence
of the pituitary gland.
HEMIANOPSIA
✓ The incision in transsphenoidal
hypophysectomy is made between
the upper lip and upper gum.
✓ The nursing interventions after
transsphenoidal hypophysectomy
are as follows:
 ▪ Keep head of bed elevated, at least ✓ Hormonal replacement therapy
for 2 weeks. To promote venous (HRT).
drainage and drainage from the
surgical site. SIMMOND'S DISEASE
▪ Maintain nasal packing in place and ❑ Is panhypopituitarism. It is total
reinforce as needed. absence of all pituitary hormones.
▪ Provide frequent oral care with
toothettes. To prevent trauma to the
incision.
▪ Instruct client to avoid blowing the
nose and activities that increase
intracranial pressure (ICP).
▪ Monitor the patient for any
postnasal drip or nasal drainage
which might indicate leakage of
cerebrospinal fluid (CSF). Check
nasal drainage for glucose. CSF is SHEEHAN'S SYNDROME
positive for glucose. ❑ Is hypopituitarism caused by
▪ Report to physician, outputs above postpartum pituitary necrosis.
900 mls/ 2 hours or urine specific ❑ It occurs in women with severe
gravity below 1.004. These indicate bleeding, resulting to hypovolemia
diabetes insipidus. and hypotension at the time of
▪ Administer glucocorticoids and delivery.
other hormone replacement as
prescribed. This may include
vasopressin, growth hormone
(somatotropin).
2. Radiation therapy as prescribed.
3. Pharmacotherapy.
▪ Parlodel (Bromocriptine) to lower GH
and prolactin levels.

HYPOPITUITARISM
❑ Is hypofunction of anterior pituitary
gland causing deficiencies in both
the pituitary hormones and the
hormones of the target glands.
❑ The causes are as follows: tumors,
trauma, encephalitis, polish
autoimmunity, stroke, surgery or
radiation of pituitary gland.
The clinical manifestations are as follows:
✓ Mild to moderate obesity (low GH,
TSH).
✓ Reduced cardiac output (low GH,
ADH).
✓ Infertility, sexual dysfunction (low
gonadotropins, ACTH).
✓ Fatigue, low BP.
✓ Headache, hemianopsia (due to
tumors of the pituitary gland; the
gland is located near the optic
nerve).
Interprofessional collaborative
management are as follows:
✓ Surgical removal of the tumor.
✓ Radiation therapy.