Anatomy of the Gastrointestinal Tract

Gastrointestinal tract (GI) is a 23- to 26 foot-long pathway that extends

from the mouth to the esophagus, stomach, small and large intestines, and
rectum, to the terminal structure, the anus
!tomach
is situated in the left upper portion of the a"domen under the left
lo"e of the li#er and the diaphragm o#erlaying the pancreas $
hollow muscular organ with a capacity of approximately %&'' ml
stores food during eating, secrete digesti#e fluids, and propels the
partially digested food, or chyme, into the small intestine
small intestine
is the longest segment of the GI tract, accounting for a"out two
thirds of the total length
It has three sections( duodenum, )e)unum and the ileum
large intestine
consists of an ascending segment, a trans#erse segment and
descending segment
*ompleting the terminal portion of the large intestine are the
sigmoid, the rectum, and the anus +egulating the anal outlet is a
networ, of striated muscle the forms "oth the internal and the
external sphincters
Functions of the Digestive System(
-he "rea,down of food particles into the molecular form for
digestion
-he a"sorption into the "loodstream of small nutrient molecules
produced "y digestion
-he elimination of undigested una"sor"ed foodstuffs and other
waste products
The Mechanical and Chemical Process involved in Digesting and
Absorbing foods and Eliminating waste roducts
!" Chewing and Swallowing
-he process of digestion "egins with the act of chewing, in which the food
is "ro,en down into small particles that can "e swallowed and mixed with
digesti#e en.ymes -he sali#ary glands secrete approximately %& / of sali#a
!ali#a contains ptyalin or sali#ary amylase, an en.yme that "egin digestion of
starches 0ater and mucus also present in the sali#a that help in lu"ricating the
food as it is chewed and facilitate swallowing
!wallowing "egins #oluntary act that is regulated "y the swallowing center
in the medulla o"langata of the central ner#ous system ( *1!)!wallowing
propels the "olus of food into the upper esophagus, thus ends as a reflex action
#" Gastric Function
Four ma$or functions%
short term storage reser#oir( allows large meal to "e consumed 2uic,ly,
"ut digested o#er extended period of time
en.ymatic digestion( especially of proteins
mix 3 grind foodstuffs( #igorous contractions of gastric smooth muscles
w4gastric secretions li2uefies food
slow release of li2uefied food (chyme
Gastric Surface%
5mpty( stomach is contracted 3 mucosa and su"mucosa ha#e distinct
folds - +ugae
o 6illed( rugae "ecome ironed out and flatten
a"rupt epithelial transition from stratified s2uamous (esophagus) to
columnar (gastric)
Gastric pits( extend from mucosa as straight or "ranched tu"ules to form
gastric glands
Secretory Cells%
7ucous cells( secrete 8*93-
o protect epithelium against shear stress 3 acid
:arietal cells( secrete hydrochloric acid 8*l 3 intrinsic factor
8ydrochloric $cid(
$cid causes hydrolysis, an initial step in the "rea,down
of the materials in the stomach It also functions to acti#ate the
.ymogen called pepsinogen as it lowers the p8 of the stomach
to an optimal range for en.yme acti#ationGastric acid also
facilitates the a"sorption of iron, calcium, and ;%2, and helps to
inhi"it infection and "acterial 4 fungi growth in the stomach and
small intestine
Intrinsic 6actor(
-his com"ines with dietary #itamin ;%2 so that the
#itamin can "e a"sor"ed in the ileum
*hief cells( secrete pepsin (proteyolytic en.yme)
G cells( secrete gastrin (hormone)
Stomach has a & layered defense against acid"
% :reepithelial layer *ontains mucus, "icar"onate, phospholipids -he p8
of mucus gel is < so this is protecti#e
2 5pithelial /ayer !urface epithelial cells pro#ide the next line of defense
through se#eral factors, including mucus production, epithelial cell ionic
transporters that maintain intracellular p8 and "icar"onate production, and
intracellular tight )unctions=
3 !u"epithelial /ayer 8as "lood flow and leu,ocytes
Motility%
Ingested food crushed, ground 3 mixed, li2uefied to form chyme
>pper stomach( acordian-li,e reser#oir applies constant pressure on
lumen
o low fre2uency, sustained contractions to generate "asal pressure
w4in stomach
o tonic contractions generate pressure gradient from stomach to
small intestine (responsi"le for gastric emptying)
o swallowing of food 3 gastric distention of this area inhi"its
contraction -? forms large reser#oir w4o significant pressure
(maintains /5! 3 pre#ents regurgitation)
/ower stomach( contractile grinder
o strong peristaltic wa#es, amplitude as they propagate towards
pylorus
o gastric distention strongly stimulates this type of contraction 3
accelerates li2uefaction and gastric emptying
&" Small 'ntestine Function
-hese secretions contain digesti#e en.ymes( amylase, lipase,
and "ile :ancreatic secretions ha#e an al,aline p8 due to their
high concentrations of "icar"onate -his al,alinity neutrali.es the
acid entering the duodenum from the stomach
Two tyes of Contractions%
% !egmentation *ontractions :roduce mixing wa#es that mo#e the
intestinal contents "ac, and forth in a churning motion
2 Intestinal :eristalsis :ropels the contents of the small intestine toward the
colon
*hyme stays in the small intestine for 3 to 6 hours, allowing
continued "rea,down and a"sorption of nutrients
!mall, finger li,e pro)ections called #illi are present throughout the
entire intestine and function to produce digesti#e en.ymes as well
as to a"sor" nutrients -he process of a"sorption "egins in the
)e)unum and is accomplished "y "oth acti#e transport and diffusion
across the intestinal wall into the circulation
(" Colonic Function
rea"sorption of water and electrolytes
-he waste materials from a meal e#entually reach and distend the
rectum, usually in a"out %2 hours $s much as one fourth of the
waste materials from a meal may still "e the rectum 3 days after
the meal was ingested
Physical Assessment
'nsection is performed first, noting s,in changes, nodules, lesions,
scarring, discolorations, inflammation, "ruising, or striae
Auscultation is used to determine the character, location, and fre2uency
of "owel sounds and to identify #ascular sounds -he fre2uency and character of
the sounds are usually heard as clic,s and gurgles that occur irregularly and
range from & to 3& per minute
1ormal( sounds heard a"out e#ery & to 2' seconds
8ypoacti#e( one or two sounds in two minutes
8yperacti#e( fi#e to six sounds heard in less than 3' seconds
$"sent( no sounds in 3 to & minutes
Percussion is used to assess the si.e and density of the a"dominal
organs and to detect the presence of air-filled, fluid-filled, or solid masses
-ympani is the predominant sound that results from the presence of air in the
stomach and small intestines @ dullness is heard o#er organs and solid masses
Petic )lcer Disease
$ peptic ulcer may "e referred to as a gastric, duodenal, or esophageal
ulcer, depending on its location(!melt.er etal 2''A)$ peptic ulcer is
an exca#ation ( hollowed-out area) that forms in the mucosal wall of
the stomach, in the pylorus, in the duodenum, or in the esophagus
Buodenal ulcers usually first occur "etween the ages of 3'-&' years and
are twice as common in men as in women
!tomach (or gastric) ulcers usually occur in people older than 6' years
and are more common in women
*is+ Factors%
% Helicobacter (H.) pylori
-he "acteria appear to trigger ulcers in the following way(
H. pylori's cor,screw shape ena"les it to penetrate the mucous layer of the
stomach or duodenum so it can attach itself to the lining
It sur#i#es in the highly acidic en#ironment "y producing urease, an
en.yme that generates ammonia to neutrali.e the acid
H. pylori then produce a num"er of toxins and factors that can cause
inflammation and damage to the lining, leading to ulcers in certain
indi#iduals
It also alters certain immune factors that allow it to e#ade detection and
cause persistent inflammation for a life -- e#en without in#ading the
mucous mem"rane
6actors that -rigger >lcers in 8 pylori *arriers8 pylori
Genetic 6actors
Immune $"normalities
/ifestyle 6actors
!hift 0or, and 9ther *auses of Interrupted !leep
2. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
3. Zollinger-Ellison Syndrome (ZES). The least ommon ma!or
ause of etic ulcer disease is Zollinger-Ellison syndrome
(ZES).
In this condition, tumors in the pancreas and duodenum
(gastrinomas) produce excessi#e amounts of gastrin, a hormone
that stimulates gastric acid formation -hese tumors are usually
malignant, so proper and prompt management of the disease is
essential
Clinical Manifestations
Dyspepsia. -he most common symptoms of peptic ulcer are ,nown collecti#ely
as dyspepsia :eptic ulcers can occur without dyspepsia or any other
gastrointestinal symptom, especially when caused "y 1!$IBs Byspepsia may
"e persistent or recurrent and can encompass a #ariety of symptoms in the upper
a"domen, including(
:ain or discomfort
;loating
$ feeling of fullness :eople with se#ere dyspepsia are una"le to drin, as
much fluid as people with mild or no dyspepsia
8unger and an empty feeling in the stomach, often % - 3 hours after a
meal
7ild nausea (Comiting, in fact, may relie#e symptoms)
+egurgitation (sensation of acid "ac,ing up into the throat)
;elching
>lcer Pain. -he pain of ulcers can "e either locali.ed in one place or diffuse -he
pain is descri"ed as a "urning, gnawing, or aching in the upper a"domen, or as a
sta""ing pain penetrating through the gut -he symptoms may #ary depending
on the location of the >lcer(
Buodenal ulcers often cause a gnawing pain in the upper stomach area
se#eral hours after a meal, and the pain is often relie#ed "y eating a meal
Gastric ulcers may cause a dull, aching pain, often right after a meal@
eating does not relie#e the pain and may e#en worsen it :ain may also
occur at night
>lcer pain may "e particularly confusing or disconcerting when it radiates to
the "ac, or to the chest "ehind the "reast"one In such cases it can "e confused
with other conditions such as heart attac,
!ymptoms of $nemia
;ecause ulcers can cause hidden "leeding, patients may experience the
symptoms of anemia, including fatigue and shortness of "reath
5mergency !ymptoms
$ sudden onset of se#ere symptoms may indicate intestinal o"struction,
perforation, or hemorrhage, all of which are emergencies !ymptoms may
include(
-arry, "lac,, or "loody stools
!e#ere #omiting, which may include "lood or a su"stance with the
appearance of coffee grounds (a sign of a serious hemorrhage) or entire
stomach contents (sign of intestinal o"struction)
!e#ere a"dominal pain with or without #omiting or e#idence of "lood
;leeding is sometimes the only symptom of an ulcer -his "leeding can "e
fast or slow
6ast "leeding re#eals itself in one of the following ways(
Comiting of "lood or dar, material that loo,s something li,e coffee
grounds( -his is an emergency and warrants an immediate #isit to an
emergency department
;lood in the stool or "lac,, tarry, stic,y-loo,ing stools
!low "leeding is often more difficult to detect, "ecause it has no dramatic
symptoms
-he usual result is low "lood cell count (anemia)
-he symptoms of anemia are ifatigue lethargy, wea,ness, and pallor
Diagnostic Findings
,oninvasive Tests for Gastrointestinal -G'. /leeding"
+ectal 5xam
*omplete ;lood *ount
6ecal 9ccult ;lood -est (69;-) -he 69;- tests for hidden
(occult) "lood in stools
7ultidetector *omputed -omography (7B*-) scans on
preoperati#e patients with pro#en GI perforations found the
technology to "e highly accurate in pinpointing the location of the
perforations
,oninvasive Screening Tests for 0" ylori

!pecific !creening -ests for 8 pylori -he following screening tests used or
under in#estigation for 8 pylori(
/reath Test
/lood Tests
Stool Test
Endoscoy
5ndoscopy is a procedure used to e#aluate the esophagus, stomach, and
duodenum using a long, thin tu"e tipped with a tiny #ideo camera (endoscope)
0hen com"ined with "iopsy, endoscopy is the most accurate procedure for
detecting the presence of peptic ulcers, "leeding, and stomach cancer, or for
confirming the presence of 8 pylori
Management
Petic )lcers Treatment
*hoice of treatment depends on whether the ulcer is caused "y infection
with H pylori *orrect diagnosis is the ,ey to whether a treatment wor,s or not If
the "acteria are the cause, treatment focuses on ,illing the infection +egardless
of whether the "acteria are the cause, reducing acid in the stomach is another
important focus of treatment
It is important that your health care pro#ider chec, with you during your
treatment to ma,e sure that your ulcer is healing
Medical Treatment
-he following treatments are recommended for ulcers(
/ifestyle changes - Duitting smo,ing, a#oiding alcohol, aspirin, and
1!$IBs
$cid-"loc,ing medications (
- $ntacids( neutrali.e acid
o 7ost include aluminum hydroxide com"ined with magnesium or
calcium 5xamples are 7aalox, 7ylanta, -ums, and +olaids
o -hey can cause constipation, although those containing
magnesium can cause diarrhea
o -hese effects are especially li,ely if the medications are ta,en
regularly
- 8istamine (82) "loc,ers( -hese are acid-"loc,ing medications widely
used in the treatment of peptic ulcers
o 82 "loc,ers include cimetidine (-agamet), ranitidine (Eantac),
famotidine (:epcid), and ni.atidine ($xid)
7edications that protect the lining of the stomach and duodenum
=-riple-therapy= or =dual-therapy= regimens for ulcers caused "y H
pylori
-reatment for "leeding ulcers depends on the se#erity of "lood loss
IC fluids
;owel rest( ;ed rest and clear fluids with no food at all for a few
days -his gi#es the ulcer a chance to start healing without "eing irritated
1asogastric tu"e( :lacement of a thin, flexi"le tu"e through your
nose and down into your stomach -his also relie#es pressure on the
stomach and helps it heal
>rgent endoscopy or surgery, if indicated( Bamaged, "leeding
"lood #essels can usually "e repaired with an endoscope -he endoscope
has a small heating de#ice on the end that is used to cauteri.e a small
wound
Surgery
!urgical operations often used in peptic ulcers include the following(
Cagotomy( *utting the #agus ner#e, which transmits messages from the
"rain to the stomach, can reduce acid secretion 8owe#er, this can also
interfere with other functions of the stomach $ newer operation cuts only
the part of the ner#e that affects acid secretion
$ntrectomy( -his is often done in con)unction with a #agotomy It in#ol#es
remo#ing the lower part of the stomach (the antrum) -his part of the
stomach produces a hormone that increases production of stomach acid
$d)acent parts of the stomach may also "e remo#ed
:yloroplasty( -his procedure also is sometimes done with #agotomy It
enlarges the opening "etween the stomach and duodenum (the pylorus)
to encourage passage of partially digested food 9nce the food has
passed, acid production normally stops
-ying off an artery( If "leeding is a pro"lem, cutting off the "lood supply
(artery) to the ulcer can stop the "leeding
,ursing Management
*elieving Pain
*educing An1iety
Maintaining 2timal ,utritional Status
Managing and Monitoring Potential Comlications
8emorrhage is the common complication with peptic ulcer -he nurse
assesses signs of "leeding or hemorrhage+elated nursing and colla"orati#e
inter#entions in the presence of "leeding include the following(
Inserting a peripheral IC line for the infusion of saline or lactated
+ingerFs solution and "lood products
7onitoring hemoglo"in and hematocrit to assist in e#aluating
"lood loss
Inserting 1G- to distinguish fresh "lood from Gcoffee groundsH
material, to aid in the remo#al of clots and acid, to pre#ent nausea and
#omiting, and to pro#ide means in monitoring further "leeding
$dministering 1G la#age of saline solution
Inserting indwelling catheter and monitoring urine output
7onitoring #ital signs and oxygen saturation and administering
oxygen theraphy
:lacing patient in dorsal recum"ent position with the legs ele#ated
to pre#ent hypotension, or placing the patient on the left side to pre#ent
aspiration from #omiting
-reating hemorrhagic shoc,
Teaching Patients self care and revention
Iou can pre#ent peptic ulcers "y a#oiding things that "rea, down the
stomachJs protecti#e "arrier and increase stomach acid secretion -hese include
alcohol, smo,ing, aspirin and nonsteroidal anti-inflammatory drugs, and caffeine
8ome care for peptic ulcers often centers on neutrali.ing the stomach acid
BonJt smo,e, and a#oid coffee and alcohol -hese ha"its increase gastric
acid production and wea,en the mucosal "arrier of the GI tract, thus
promoting ulcer formation and slowing ulcer healing
BonJt ta,e aspirin or nonsteroidal anti-inflammatory medications
$cetaminophen is a good su"stitute for some conditions If
acetaminophen doesnJt help, tal, to your health care pro#ider a"out
alternati#es
1o particular diet is helpful for people with peptic ulcers $#oid eating any
foods that aggra#ate your symptoms
:re#enting infection with H pylori is a matter of a#oiding contaminated
food and water and adhering to strict standards of personal hygiene
0ash your hands carefully with warm water and soap e#ery time you use
the "athroom, change a diaper, and "efore and after preparing food
!ome e#idence exists that exercise may help reduce the ris, for ulcers in
some people In one study, exercise was associated with a lower ris, for
duodenal, "ut not gastric, ulcers in men In this study, exercise appeared
to ha#e no effect on ulcer de#elopment in women
!tress relief programs ha#e not "een shown to promote ulcer healing, "ut
they may ha#e other health "enefits
Follow3u
6ollow the recommendations of your health care pro#ider
/ifestyle changes can relie#e your symptoms and help your ulcer heal
!top smo,ing, a#oid alcohol and caffeine, and a#oid aspirin and
nonsteroidal anti-inflammatory medications
-a,e your medications as prescri"ed
6ollow up as scheduled with your health care pro#ider to monitor your
progress and pre#ent complications

Parenteral ,utrition
In many patients, either the enteral route, the parenteral route, or a
com"ination of "oth routes (com"ination feeding) should "e used to meet
nutritional needs
Enteral nutrition
-he gastrointestinal tract is always the preferred route of support, ie, 4'f
the gut wor+s5 use it4 7ost would agree that 51 is safer, more cost effecti#e,
and more physiologic that :1 Impro#ements o#er the past few years ha#e
greatly expanded choices in enteral formulas, e2uipment, and techni2ues
6ong3term nutrition%
Gastrostomy
Ke)unostomy
Short3term nutrition%
1asogastric feeding
1asoduodenal feeding
1aso)e)unal feeding
:otential "enefits of enteral nutrition o#er :1 include(
% Physiologic
o 1utrients are meta"oli.ed and utili.ed more effecti#ely #ia
the enteral than the parenteral route
o -he gut and li#er process enteral nutrients "efore their
release into systemic circulation
o -he gut and li#er help maintain the homeostasis of the
amino acid pool as well as the s,eletal muscle tissue
2 'mmunologic
o Gut integrity is maintained "y enteral nutrients through the
pre#ention of "acterial translocation from the gut, sytemic
sepsis, and potential increased ris, of multiple organ failure
o /ac, of GI stimulation may promote "acterial translocation
from the gut without concurrent enteral nutrition
o :ro#ision of early enteral nutrition may minimi.e ris, of gut
related sepsis
3 Safety (a#oid complications related to intra#enous access)(
o *atheter sepsis
o :neumothorax
o *atheter em"olism
o $rterial laceration
L Cost
o *ost of 51 formula is less than :1
o *ost of e2uipment and personnel for preparation and
administration is less
8owe#er, there are contraindications to enteral nutrition support(
5xpected need less than &-%' days
!e#ere acute pancreatitis
8igh-output proximal fistulas
Ina"ility to gain access
Intracta"le #omitting or diarrhea
Formula selection
!election of an enteral formula must "e patient specific -he functioning
and capacity of the GI tract, underlying disease states and patient tolerance must
"e assessed to determine which formula should "e selected 7any formulas are
#ery similar in composition, #arying only slightly in nutrient content It is important
to "e familar with the properties of commonly used enteral formulas
Parenteral nutrition
:arenteral nutrition is the pro#ision of nutrients intra#enously It is used in
patients who cannot meet their nutritional goals "y the oral or enteral route
0hen the gut is not wor,ing, :1 is also used for long-term nutrition support in the
home setting -he principle forms of :1 are peripheral and central (-:1)
Parenteral nutrition -P,.
:eripheral :arenteral 1utrition (::1)
-otal :arenteral 1utrition (-:1)
:1 should only "e initiated in patients who are hemodynamically sta"le
and who are a"le to tolerate the fluid #olume, protein, car"ohydrate, and lipid
doses necessary to pro#ide ade2uate nutrients
*onditions warranting cautious use of :1(
$.otemia
*ongesti#e heart failure
Bia"etes 7ellitus
5lectrolyte disorders
:ulmonary disease
*entral :1 (-:1) is a concentrated formula which is hyperosmolar and
must "e deli#ered into a central #ein -:1 pro#ides(
*ar"ohydrates in the form of glucose
:rotein in the form of amino acids
/ipids in the form of triglycerides
5lectrolytes
Citamins and trace minerals
:eripheral :1 has similar nutrient components as -:1 "ut in a lower
concentration so it may "e deli#ered "y peripheral #ein /arge fluid #olumes must
"e administered to pro#ide compara"le nutrients ::1 is typically used for short
periods (up to two wee,s) "ecause of limited tolerance
Combination Feeding
*om"ination feeding can "e used as a "ridge "etween parenteral and enteral
(or oral) nutrition in patients whose clinical status does not warrant full enteral
nutrition, "ut whose nutritional status is "est managed with some form of
enteral nutrition -hus, patients following a com"ination feeding regimen
recei#e parenteral and enteral nutrition simultaneously 5#en a small amount
of enteral nutrition will preser#e the entero-hepatic circulation and "arrier
function of the GI tract