DIGESTIVE

SYSTEM
Anatomy Review

■ Review glossary terms found at the beginning of chapters

■ Mouth  esophagus  stomach  small & large intestine  rectum  anus
■ How much surface area does the small intestine provide for absorption?
– 230 ft!!
■ Blood flow
– Arteries from the thoracic and abdominal aorta
– Portal venous system – superior mesenteric, inferior mesenteric, gastric,
splenic, and cystic veins
– 20% of CO goes to the GI tract
Sympathetic vs Parasympathetic

Sympathetic Parasympathetic
Inhibitory effect Excitatory effect
Decreases gastric secretions, motility, increases secretory activities,
blood vessel constriction peristalsis, sphincter relaxation
Functions of the digestive system

■ Breakdown of food particles into molecular form

■ Absorption of these particles into the blood stream
■ Elimination of undigested / unabsorbed food
■ Enzymes
– Amylase, maltase, sucrase, trypsin, HCl, bile (Chapter 55)
– Each have a digestive action
– GI chemistry!
Enzymes
REREFERRED
PAIN
Clinical manifestations
GI diagnostics
■ Labs
– CBC, CMP, Coags (INR), Lipid panel, LFTs
– Cancer: CEA (carcinoembryonic antigen)
■ Stool tests
– C. Diff, leukocytes, FOBT
■ Breath tests
– Detects bacteria overgrowth, H. Pylori
■ What does H. pylori cause??
■ Other
– US (ultrasound)
■ Enlarge gallbladder, stones, enlarged ovaries, appendicitis
– CT / MRI
– PET
■ PUD (Peptic ulcer disease)
Digestive and GI treatments

■ Feeding tubes & GI intubation

– When could a FT be indicated?
■ s/p MVA
■ CVA
■ Mechanical ventilation
■ ALS
■ HEENT malignancy
■ Partial or total gastrectomy
■ Aspiration risk
Feeding tubes and GI intubation

■ Inserted into the mouth, nose or abdominal wall

■ What is the indication?
– Decompress stomach
– Lavage
– Administer tube feedings, fluids and meds
– Aspirate GI contents
Tube feeding

What does enteral feeding mean?

– Feeding infused directly from a tube into the GI tract

We will compare this to parenteral in the coming slides

Osmolality

■ Ionic concentration of fluid

■ Normal body fluid osmolality 300Osm/kg
■ What can occur when a feeding is administered with high
osmolality is given to quickly or in large amounts?
■ Water moves rapidly into the intestines
– Leads to fullness, bloating, cramping, diaphoresis, osmotic
diarrhea
– What syndrome is this called?
Potential complications
Dumping syndrome
■ Leads to
– Dehydration
■ Dry mucous membranes
■ Thirst
■ Decreased UO
– Hypotension
– Tachycardia
Bowel elimination abnormalities

■ Malnutrition
■ Clostridium difficile (C. Diff)
■ Zinc deficiency
■ Dumping syndrome
■ Constipation
– Inadequate water intake
– Fiber free TFs
– Opioid use
Parenteral nutrition (PN)
■ Nutrition through an IV
– Given when it is not possible to get adequate nutrition through oral or enteral
routes
■ Very complex mixture
– Lipids, carbs, fats, vitamins, sterile water
■ Goals
– Nutritional status, establish a positive nitrogen balance, maintain muscle mass,
promote weight maintenance or gain, and enhance the healing process
■ PN can provide enough calories and nitrogen to meet nutritional needs and IV fluids
cannot
■ Indications
– Inability to ingest food or fluid for 7-10 days
Oral and esophageal disorders
Oral cancer
■ Risk factors (Chapter 56)
– Tobacco use (including smokeless)
– Alcohol use
– Infection with HPV (human papilloma virus)
– Poor oral hygiene
– History of head and neck cancer
■ Men are affected 2-4x more than woman and risk increases with age
■ May occur in any area but the lip is the most common
– Also commonly seen in the lateral tongue and floor of the mouth
Oral and esophageal
disorders
Manifestations of oral cancer
■ Early stage
– Few or no symptoms
– Painless sore or mass that does not heal;
indurated ulcer with raised edges
■ Late stages
– Complaints of tenderness
– Difficulty in chewing, swallowing or
speaking
– Cough up blood-tinged sputum
– Enlarged
 ORAL AND
ESOPHAGEAL
DISORDERS
Gastroesophageal reflux disease
(GERD)
■ Chronic disorder that describes a variety of clinical manifestations, with or
without tissue damage, cause by acid reflux from the stomach (or duodenum)
into the esophagus.
■ Reflux occurs when the LES (lower esophageal sphincter) is weak or relaxes
inappropriately.
■ Can be caused by a temporary or sustained decrease in LES competence.
 Incidence increases in:

• Aging patients
• Patients with irritable bowel
syndrome and obstructive airway
GERD disorders
• Asthma, COPD, cystic fibrosis
incidence and
risks Risks

• Tobacco use
• Coffee drinking
• Alcohol intake
• Gastric infection with H. Pylori
GERD management

■ Limit certain foods:

– Spicy/fatty, caffeine, chocolate, carbonated beverages, acidic foods,
peppermint
■ Avoid smoking and drinking alcohol
■ Maintain ideal body weight
■ Elevated HOB (head of bed) at least 30 degrees
■ Avoid eating and drinking 2 hours before bedtime
Gastric and duodenal disorders
Gastritis
Localized or patchy inflammation of the gastric mucosa
■ Acute
– Rapid onset of symptoms.
– Inflammatory process that might be accompanied by hemorrhage to the
mucosa
– Can be caused by dietary indiscretion, meds, alcohol, bile reflux, or
radiation therapy
■ Chronic
– Prolonged, persistent, or intermittent inflammation
– Due to ulcers (benign or malignant) or by H. pylori
– Might also be due to autoimmune disease, dietary factors, meds, alcohol,
smoking, or chronic reflux of pancreatic secretions or bile
EROSIVE
GASTRITIS
GASTRIC
AND
DUODENAL
DISORDERS
Gastric and duodenal disorders
Peptic Ulcer
■ A break in the lining of the mucosa
■ Associated with H. pylori
■ Risk factors (box 57.1):
– Excessive smoking and alcohol ingestion
– Chronic use of meds (such as NSAIDs)
– Family history
■ Treatment:
– Meds, lifestyle changes, and occasionally surgery
■ Clinical manifestations:
– Pain
o A dull gnawing feeling or burning in the midepigastrium
– Heart burn
– Vomiting
Gastric and duodenal disorders
Gastric and duodenal disorders

■ Pathophysiology of PUD (peptic ulcer disease)

■ Erosion caused by increased concentration of acid (pepsin) or decreased
resistant normal protective barrier
■ Mucosa can’t secrete enough mucous to act as a barrier
■ Mucosa is then exposed to HCl (and other irritating agents)  inflammation 
injury  erosion
■ NSAIDs can be a major contributing factor (inhibits prostaglandin synthesis)
which is associated with disruption of the normal protective barrier
Gastric and duodenal disorders

Stress Ulcer
■ Acute mucosal ulceration of the duodenal lor gastric area that occurs after
physiologically stressful events such as:
– Burns
– Shock
– Sepsis
– Multiple organ dysfunction syndrome (Clark et al., 2015)
■ Stress ulcers, which are clinically different from peptic ulcers, are most common
in patients who are ventilator-dependent after trauma or surgery
Gastric cancer
■ Highest rates in Hispanic, African, and Asian decent.
■ Overall incidence has declined over past 75 years
– Remains second leading cause of cancer mortality worldwide
■ Risk factors:
– Diet, gastric bacteria, H. pylori, smoking, alcohol consumption, family
history, chronic inflammation of the stomach.
■ Treatment:
– Surgical removal of the tumor
– Chemotherapy
– Palliative care if tumor is unresectable or has metastasized
Gastric cancer pathophysiology
■ Approximately 95% of gastric cancers are adenocarcinomas
■ 40% develop in lower stomach, 40% in middle, 15% in upper and 10% in more than one
area
Where does it begin?
■ Lesion involving cells on top of the layer of stomach mucosa, submucosa, and stomach
wall
■ The lesion will infiltrate the stomach wall and start extending (metastasizing) to nearby
structures and organs near the stomach
■ Lymph node involvement and mets tend to occur quickly due to abundant lymphatic and
vascular networks of the stomach
■ Most common met sites:
– Liver
– Peritoneum
– Lungs
– Brain
Gastric cancer clinical manifestations

■ Often asymptomatic until late in course and disease is advanced

■ Early:
– Gastric pain relieved with antacids
■ Advanced:
– Indigestion, anorexia, weight loss (often unintentional), vague epigastric
pain, vomiting, early satiety, abdominal pain above umbilicus, bloating,
blood loss
Gerontologic considerations

■ 6/10 patients diagnosed are 65 and older

■ 66.4% of deaths from gastric cancer are in patients 65 and older
■ Often geriatrics have atypical presentation
– Likely no symptoms until very advanced
■ Surgery is often hazardous with high risk of morbidity and mortality for the aging
population
Intestinal and rectal disorders

Constipation
■ Defined as fewer than 3 bowel movements weekly or bowel movements that are
hard, dry, small, or difficult to pass
■ Causes:
– Meds, chronic laxative use, weakness, immobility, fatigue, inability to
increase intra-abdominal pressure, diet, ignoring urge to defecate, and lack
of regular exercise
■ Perceived constipation:
– A subjective problem in which the person’s elimination pattern is not
consistent with what he or she believes is normal
Intestinal and rectal disorders

Constipation
■ Fewer than 3 BMs per week
■ Abdominal distention, pain, and bloating
■ A sensation of incomplete evacuation
■ Straining at stool
■ Elimination of small-volume, hard, dry stools
Intestinal and rectal disorders

Constipation complications
■ Decreased CO
■ Fecal impaction
■ Hemorrhoids
■ Fissures
■ Rectal prolapse
■ Megacolon
Irritable bowel syndrome

■ A functional disorder of the intestines of unknown etiology with no known cure

■ Characterized by abdominal pain and altered bowel habits
■ 10% to 15% of adults report symptoms of IBS in North America
■ More prevalent in females than males
■ Triggers:
– Chronic stress, sleep deprivation, surgery, infections, diverticulitis, and
some foods
IBS clinical manifestations

Diarrhea

Constipation

Abdominal pain

Flatus

Abdominal distention
Malabsorption
■ The inability of the digestive system to absorb one or more of the major vitamins,
minerals, or nutrients
■ Conditions
– Mucosal (transport) disorders
– Infectious disease
– Luminal disorders
– Postoperative malabsorption
– Disorders that cause malabsorption of specific nutrients
 Hallmark finding is diarrhea or
frequent, loose, bulky, foul-
smelling stools, high-fat content
and often grayish

Malabsorption
Symptoms similar to irritable
clinical bowel syndrome
manifestations

Manifested by weight loss and

vitamin and mineral deficiency
Celiac disease

■ A genetic autoimmune disorder that damages the small intestine

■ Related to eating foods containing gluten causing long-lasting problems,
particularly with malabsorption
■ Gluten is found in wheat, barley, and rye
■ Estimated prevalence of 1 in every 141 people in America
■ More common in females
■ More common in people with Down’s syndreom, Turner’s syndrome, and type 1
diabetes
Celiac disease clinical manifestations

■ Diarrhea (often foul smelling, light in color, and frothy)

■ Steatorrhea
■ Flatulence
■ Weight loss
■ Other signs of malabsorption
■ Abdominal pain
■ Abdominal distention
Appendicitis

■ Acute inflammation of the vermiform appendix

■ Most common reason for emergency abdominal surgery
■ May be a result of a fecalith or other foreign body blocking the opening
– Leading to inflammation and subsequent infection
■ The blockage causes increased intraluminal pressure and restricts blood flow,
causing edema and obstruction of the orifice
■ Gangrene can occur in as little as 24 to 36 hours and is life-threatening
■ Perforation can occur in as few as 24 hours
Diverticular disease

■ Diverticulum
– Sac-like herniation of the lining of the bowel that extends through a defect
in the muscle layer
■ May occur anywhere in the intestine but most common in the sigmoid colon
■ Diverticulosis
– Multiple diverticula without inflammation
■ Diverticulitis
– Infection and inflammation of diverticula
■ Diverticular disease increases with age and is associated with a low-fiber diet
■ Diagnosis is usually by colonoscopy
Intestinal obstruction
■ Occurs when the normal flow of contents through the gastrointestinal system
become blocked
– Occur in the small and large intestines
■ Mechanical obstruction:
– Intraluminal obstruction or mural obstruction from pressure on the intestinal
wall
■ Functional or paralytic obstructions:
– The intestinal musculature cannot propel the contents along the bowel
– The blockage also can be temporary and the result of the manipulation of
the bowel during surgery
Inflammatory
bowel disease

■ Chron’s disease (regional

enteritis)
■ Ulcerative colitis
■ Table 58.3