GASTROINTESINAL

SYSTEM
 Anatomy & Physiology
A. Upper gastrointestinal tract

1. Mouth: teeth and salivary glands

2. Esophagus
3. Stomach
A. Lower gastrointestinal tract
1. Small intestine - digests and absorbs,
mixes via peristalsis, receives
secretions from liver, gallbladder and
pancreas
a. duodenum - proximal section of
small intestine joins pylorus of the
stomach divided by the pyloric
sphincter is about ten inches long
b. jejunum - middle section, is about
eight feet long
c. illeum - lower section, is about 12
feet long
2. Colon - approximately six feet long, absorbs
water and sodium

a. ascending
b. transverse
c. descending
d. sigmoid
e. rectum - last seven - eight inches of
intestines
 Accessory digestive organs
1. Liver - largest gland of the body
a. lobes dived into lobules by blood
vessels and fibrous material
b. ducts - hepatic duct from liver; cystic
duct from gallbladder; common bile
duct formed by joining of hepatic duct
and cystic duct and drains into
duodenum
c. functions: Metabolism of fat,
carbohydrates and protein
i. converts glucose to glycogen for
storage
ii. converts glycogen to glucose and
releases into blood
iii. forms glucose from fats or proteins
iv. breaks down fatty acids into ketones
v. stores fat
vi. synthesizes triglycerides, phospholipids,
cholesterol, and choline (B complex factor)
vii. synthesizes various proteins
viii. converts amino acid to ammonia
ix. converts ammonia to urea

d.other functions
i. secretes bile, which is important in the
emulsifying of fats
ii. detoxifies substances such as drugs,
hormones
iii. metabolizes vitamins
iv. Pancreas
1.fish-shaped organ extending from
duodenal curve to the spleen
2.both an endocrine and exocrine gland

1.pancreatic cells - empty into duodenum at

the hepatopancreatic papilla; secrete
enzymes which digest fats, carbohydrates
and proteins
2.islet of Langerhans

1.alpha cells secrete glucagon to promote

liver glycogenolysis and gluconeogenesis
which ultimately increases blood glucose
level
2.beta cells secrete insulin
v. Gallbladder
1.similar size and shape as a pear
2.made up of smooth muscle and lined with
rugae-arranged mucosa
3.only purpose is to store bile
4.empties bile into duodenum when fat is
present there
D. Process of digestion
1.Purpose - converts foods into a form which
can be absorbed and used by the body
2.Digestive enzymes
3.Basic processes
a.absorption - accomplished by active
transport via intestinal cells. Water and
solutes move through the intestinal
mucosa in opposite direction expected in
osmosis and diffusion
b. metabolism - consists of the sum of all
physical and chemical changes that take
place within an organism
c. catabolism - series of chemical
reactions that take place within the cell;
breaks down food molecules to produce
energy
i.anabolism - synthesis of compounds from
simpler compounds
Disorders of Stomach and
Colon
Peptic ulcer diseases - include disorders
that ulcerate any part of stomach or
intestines.
1.Gastric ulcers
a.definition/etiology
i. incidence higher in the middle-aged and
elderly; most common in men ages 45-55
ii. risk factors: aspirin, NSAIDs, steroids,
caffeine, and alcohol intake; stress
iii. pathogen: H. pylori
b.pathophysiology
i. something disrupts mucosal layer and acid
diffuses back into mucosa
ii. commonest site: junction of fundus and
pylorus
iii. normal gastric acid secretion
c.findings
i. pain, burning or gas, worse with food
ii. pain in left upper epigastric area
iii. nausea/vomiting
iv. bleeding; hematemesis
d.diagnostic studies
i. endoscopy
ii. complete blood count (CBC)
iii. test stool for occult blood
e.complications
i. hemorrhage
• administer intra-arterial vasopressin
• administer intravenous fluids and blood
replacement
ii. perforation and peritonitis
• finding: severe abdominal pain
• finding: board-like abdomen
iii. paralytic ileus (obstruction): scarring may
obstruct pylorus
2. Duodenal ulcers
a.etiology/risk factors
i. excess production of hydrochloric acid
ii. more rapid gastric emptying
iii. familial tendency
iv. stress
v. more frequent in people with type O blood
vi. more common in men ages 25 to 50
b.pathophysiology
i. located 0.5 to 2 cm below pylorus
ii. arteriosclerotic changes in adjacent blood
vessels
iii. vagus nerve stimulation causes tissues to
release gastrin, which increases secretion
of hydrochloric acid
c.findings
i. pain, heartburn occur during night or when
stomach is empty
ii. pain relieved by food intake
iii. melena (tarry stool; black with digested
blood)
d.diagnostic studies
i. endoscopy -
esophagogastroduodenoscopy
ii. complete blood count (CBC)
iii. test stool for occult blood
complications
i. hemorrhage
• administer intra-arterial vasopressin
• administer intravenous fluids and blood
replacement
ii. perforation and peritonitis
• finding: severe abdominal pain
• finding: board-like abdomen
iii. paralytic ileus (obstruction): scarring may
obstruct pylorus
Management of peptic ulcer disease
a.NPO (nothing by mouth)
b.nasogastric tube
c.antibiotics: clarithromycin (Biaxin);
metronidazole (Flagyl)
d.H2 receptor antagonists
e.anticholinergics: dicyclomine hydrochloride
(Bentyl)
f. antacids; aluminum hydroxide (Amphogel);
aluminum-magnesium combinations
(Maalox, Mylanta, Gelusil); calcium
carbonate (Tums)
g.cytoprotective: sucrulfate (Carafate)
h.proton pump inhibitors:
i. anxiolytics
j. blood administration
k.surgical Intervention
i. vagotomy: eliminates stimulation of gastric
cells
ii. pyloroplasty: widening pylorus to improve
gastric emptying
iii. subtotal gastrectomy
iv. billroth I (gastroduodenostomy)
v. billroth II (gastrojejunostomy)
vi. total gastrectomy
billroth I (gastroduodenostomy
billroth II (gastrojejunostomy)
total gastrectomy
• Postoperative complications
a.dumping syndrome - from rapid emptying
of the stomach
i. tachycardia, palpitations, syncope,
diaphoresis, diarrhea, nausea, abdominal
distention
ii. more common with Billroth II
iii. subsides after several months
iv. decrease with slow eating, low-
carbohydrate, high-protein and fat diet
v. avoid liquids with meals
b.pernicious anemia secondary to loss of
intrinsic factor
Nursing interventions
a. pain relief
b. assess for bleeding
c. discuss life-style changes: stop smoking,
decrease stress
d. teaching - medications, diet
e. assess for post-operative complications -
infection, bleeding, respiratory complications
f. maintain patency of NG tube
g. observe drainage for signs of bleeding (drainage
should be dark red after 24 hours)
h. mouth care
Disorders of Intestines
A. Inflammatory intestinal diseases -
chronic, recurrent inflammation; etiology
unknown
1.ulcerative colitis
a.definition/etiology
i. affects young people ages 15 to 40
ulcerative colitis
b.pathophysiology
i. ulceration and inflammation entire length
of colon
ii. involves mucosa and submucosa
iii. begins in rectum and extends to distal
colon
iv.abscess and ulcers lead to bleeding and
diarrhea
v. colon cannot absorb, so fluids and
electrolytes go out of balance
vi. protein is lost in stools
vii. scarring produces narrowing,
thickening, and shortening of colon
viii. remissions and exacerbations
c.findings
i. bloody diarrhea ranging from two to three
per day to ten to 20 per day
ii. stools may also contain pus and mucus
iii. abdominal (tenderness and cramping)
pain
iv. fever, weight loss, anemia, tachycardia,
dehydration
v. impaired absorption of fat-soluble vitamins
such as E, K
vi. systemic manifestations
• skin lesions
• joint inflammation
• inflammation of the eyes - uveitis
• liver disease
Diagnosis
i. sigmoidoscopy
ii. colonoscopy
iii. barium enema
iv. complete blood count (CBC
BARIUM ENEMA
With a barium enema - bowel prep prior to
test, including cathartics, enemas; after
study use cathartic again to cleanse bowel
Increased fiber may cause flatulence
Increase fluid to 3000cc/day (unless
contraindicated)
management
i. rest
ii. fluid, electrolyte, and blood
replacement
iii. steroids as anti-inflammatories
iv. immunosuppressives
v. anti-infectives: sulfasalazine
(Azulfidine) primary drug of choice
vi. anticholinergics
vii. An tidiarrheals
viii. dietary restrictions - high calorie and
high protein
ix. surgical management
• total proctolectomy and ileostomy
• ileorectal anastomosis
• total proctolectomy with continent
ileostomy (Kock pouch)
• total colectomy with ileal pouch (reservoir)
complications
i. increased risk of colon cancer
ii. fluid and electrolyte imbalances
• nursing interventions
i. manage pain
ii. manage diarrhea
iii. teach weight loss and nutrition
iv. teach coping
v. remedy knowledge deficit
vi. reduce anxiety
Crohn's disease
a.definition/etiology
i. young people 15 to 30 years old
ii. inflammation of segments of bowel,
especially ileum, jejunum, and colon, with
areas of normal bowel between inflamed
bowel - cobblestone appearance
Crohn's disease
iii. inflammation involves all layers of bowel
wall - transmural
iv. ulceration, fissures, fistula, and abscess
formation
v. bowel wall thickens and narrows,
producing strictures
vi. slowly progressive
i. diarrhea with steatorrhea (fats not
processed)
ii. abdominal pain - right lower quadrant
iii. fatigue, weight loss, dehydration, fever
iv. systemic manifestations
• arthritis, clubbing of fingers
• skin inflammations
• nephrolithiasis
complications
i. obstruction from strictures
ii. fistula formation
iii. bowel may perforate and infect: peritonitis
iv. medical management
• rest
• nutritional support
• hyperalimentation
• diet high in calories and protein, low in
roughage and fat
• steroids as anti-inflammatories
• immunosuppressives
• anti-infectives: sulfasalazine (Azulfidine) primary
drug of choice
• anticholinergics
• antidiarrheals
• loperamide (Imodium) drug of choice
• balloon dilation of strictures
• surgery will not cure Crohn's disease; may limit
damage
o colectomy with ileostomy
o subtotal colectomy with ileostomy or ileorectal
anastomosis
nursing interventions
i. after surgery, monitor
• diarrhea
• fluid balance and nutrition
• skin integrity
• coping and self-care
• sexuality
• medications
Diverticular disease - outpouching of the
intestinal mucosa
1.Definition/etiology
a.most common in sigmoid colon
b.constipation, low fiber diet, obesity
c.colon wall thickens with increased
pressure in bowel
d.stool and bacteria retained in diverticulum
become inflamed and small perforations
occur
e.inflammation of surrounding tissue
2.Findings
a.frequently asymptomatic
b.crampy, lower, left abdominal pain
c.alternating constipation and diarrhea
d.low grade fever, chills, anorexia, nausea
e.leukocytosis
3.Diagnosis
a.barium enema
b.complete blood count, urinalysis, stool for
occult blood
c.colonoscopy
Management
a.diverticulosis (outpouching)
i. high fiber diet
ii. bulk laxatives
iii. stool softeners
iv. anticholinergics
b.diverticulitis (inflammation)
i. NPO
ii. rest bowel
iii. antibiotics
iv. surgery
• bowel resection
• temporary colostomy
Complications
a.abscess formation
b.perforation with peritonitis
c.fistula
d.bowel obstruction
• Nursing interventions
a.teach appropriate diet
b.avoid straining, coughing, lifting
c.avoid increased abdominal pressure
Bowel obstruction
1.Definition/etiology
a.mechanical: adhesions, hernias,
neoplasms, volvulus, intussusception
b.nonmechanical: paralytic ileus, occlusion
of vascular supply
c.distended abdomen from accumulation of
fluid, gas, intestinal contents
d.fluid shifts due to increased venous
pressure with hypotension and
hypovolemic shock
e.bacteria proliferate
volvulus
intussusception
2.Findings
a.abdominal pain
b.distention (more with large bowel
obstruction)
c.nausea/vomiting (more with small bowel
obstruction)
d.hypoxia
e.metabolic acidosis
f. bowel necrosis from impaired circulation
Complications
a.perforation and peritonitis
b.shock
c.strangulation of bowel
• Diagnosis
a.upper-GI and lower-GI series
b.abdominal X rays show air in bowel
c.low fluid volume increases white blood
cells, hemoglobin & hematocrit, BUN
Management
a.decompress the abdomen
b.nasointestinal tube
c.surgical bowel resection
Nursing interventions
a.manage pain, but avoid morphine or
codeine, which slow bowel motion
b.measure abdominal girth
c.with nasogastric or nasointestinal tubes,
provide oral care
d.nasogastric tubes: Salem sump (double
lumen), Levin (single lumen)
e.nasointestinal tubes
i. cantor tube - single lumen, mercury filled
weight on tip
ii. miller-Abbott - double lumen with mercury
weighted tip
iii.advance two inches per hour
f. maintain fluid and electrolyte balance
Colon cancer
1.Definition/etiology
a.may develop from adenomatous polyps
b.risk factors - low residue diet, high-fat diet,
refined foods
2.Pathophysiology
a.adenocarcinoma is the most common type
b.most common locations are sigmoid
rectum and ascending colon
c.often metastasizes to the liver
3.Findings
a.rectal bleeding
b.change in bowel habits - constipation,
diarrhea
c.change in shape of stool
d.anorexia and weight loss
e.abdominal pain, palpable mass
4.Diagnostics
a.colonoscopy
b.sigmoidoscopy
c.digital examination
d.stool for occult blood
e.barium enema
f. CT scan
g.carcinoembryonic antigen (CEA)
h.alkaline phosphatase and AST (aspartate
aminotransferase)
Complications - obstruction

• Management
a. radiation
b. chemotherapy
c. treatment of choice is surgery - bowel resection,
colostomy
i. right hemicolectomy - involves ascending colon
ii. left hemicolectomy - involves descending colon
iii.abdominal-perineal resection: removal of
sigmoid colon and rectum with formation of a
colostomy
Nursing interventions
a.manage pain
b.monitor for complications
i. wound infection
ii. atelectasis
iii. thrombophlebitis
c.maintain fluid and electrolyte balance
d.care of ostomy
 APPENDICITIS

 Description. Appendicitis is inflammation

of the vermiform appendix. It occurs in
about 7% of the population and affects
males more often than females. The peak
incidence is between ages 10 and 30.
 APPENDICITIS

Etiology. The precipitating event in

appendicitis is obstruction of the appendix
lumen, which can result from a fecalith,
kinking of the appendix, inflammation, or a
neoplasm.
 APPENDICITIS

Pathophysiology. Obstruction of the

appendix lumen causes increased
intraluminal pressure and triggers an
inflammatory process that can lead to
infection, necrosis, and perfortion.
Perforation and rupture can cause
peritonitis, a life-threatening condition
 APPENDICITIS

 Clinical manifestations
1. Acute abdominal pain, usually in the right
lower quadrant, rebound tebderness, or
both.
2. Nausea and vomiting
3. Low grade fever
4. Leukocytosis
 APPENDICITIS

 Nursing management
1. Provide general preoperative and
postoperative care
2. Provide discharge teaching.
Disorders of the Liver

A. Hepatitis
1.Definition/etiology - acute inflammatory
disease of the liver caused by viral,
bacterial, or toxic ingestion
2.Pathophysiology
a.inflammation of liver, enlargement of
Kupffer cells, bile stasis
b.regeneration of cells with no residual
damage
c.types
i. hepatitis A
• transmitted from infected food, water, milk,
shellfish
• fecal-oral route of infection common in
poor sanitation/overcrowding
• higher incidence in fall and winter
• new vaccine available
ii. hepatitis B
• blood-borne and sexually transmitted
• may become a carrier
iii.hepatitis C
• transmitted parenterally (post-transfusion
hepatitis) and possibly fecal-oral route
• may become a carrier
iv. hepatitis D
• blood borne
• coexists with hepatitis B
v. hepatitis E
• water borne
• contaminated food or water; rare in the
United States
Hepatitis B
1.Risk factors/infection route
a.homosexuality
b.iv drug use
c.health professionals
d.hemodialysis
e.transmission routes
i. sexual
ii. fecal-oral route: incubation 12 to 14 weeks
or longer
iii. contaminated body fluids
f. pathophysiology
i. hepatitis B has three distinct antigens
• HBsAg - surface antigen
• HBcAg - core antigen
• HBeAg - e antigen
ii. damage to the hepatocytes causes
inflammation and necrosis
iii. liver function decreased in proportion to
damage
iv. healing takes three - four months
• Findings
a.jaundice if liver fails to conjugate bilirubin
or excrete it
b.clay-colored stools from lack of urobilin
c.urine is dark from urobilin excreted in urine
rather than stool
d.urine foams when shaken
e.pruritus from bile salts excreted through
skin
f. right upper quadrant pain from edema and
inflammation of liver
g.anorexia, nausea, vomiting, malaise,
weight loss
h.prolonged bleeding from impaired
absorption of vitamin K
i. anemia from decreased RBC lifespan
Diagnostics - serologic markers of HBV
a.HBsAg - hepatitis B surface antigen
b.anti-Hbc - antibodies to B core antigens
c.elevated alanine aminotransferase (ALT
previously SGPT)
d.elevated bilirubin
e.elevated aspartate aminotransferase
(AST; previously SGOT)
f. elevated alkaline phosphatase
g.prolonged prothrombin time
Management - nonspecific and supportive
HEPATITIS

• Smokers who develop hepatitis often dislike

cigarettes; hepatitis may impair the sense of
smell.
• Hepatitis develops in three stages:
1. Pre-icteric (pre-jaundice) or prodromal when
general flu-like symptoms occur
2. Icteric or stage during which jaundice occurs
(not all patients with hepatitis develop jaundice)
3. Post-icteric (post-jaundice) or recovery stage:
patient continues to have fatigue and malaise
For the client with hepatitis:
• Provide a restful environment
• For clients with hepatitis or other severe
liver disease, use Acetaminophen
cautiously.
• Avoid over-the-counter medications that
contain aspirin or NSAIDs
• Steroids may mask signs of infections
• Monitor hydration status if NPO
• Monitor hemoglobin, hematocrit , and
electrolytes
• Monitor vital signs for shock
• If blood products given, monitor vital signs
for adverse effects
• Monitor drainage from nasogastric tube
• Assess for signs of perforation
• Monitor for signs of dumping syndrome
• Avoid foods and drinks that are spicy, hot,
or cold; avoid caffeine and alcohol
• Administer antacids after meals
• Do not give antacids at the same time as
H2 receptor antagonists (histamine
blockers)
• Maintain gastric pH >3.5
• After surgery, teach effective coughing
only if secretions are present. Coughing
increases pressure in the chest and
narrows airways. In clients with reactive
airways, it can cause bronchospasms and
wheezing.
a.symptomatic treatment of pain
b.antiemetics as needed
Nursing interventions
a.fatigue - provide rest periods; may require
bed rest initially
b.maintain skin integrity
c.client will tolerate less activity
d.nutrition needs:
i. increase carbohydrates and proteins;
decrease fat
ii. avoid alcohol
iii.eat frequent, small meals
Nursing interventions
a.fatigue - provide rest periods; may require
bed rest initially
b.maintain skin integrity
c.client will tolerate less activity
d.nutrition needs:
i. increase carbohydrates and proteins;
decrease fat
ii. avoid alcohol
iii.eat frequent, small meals
Prevention
a.hepatitis B vaccine provides active
immunity
b.hepatitis B immune globulin provides
passive immunity
c.observe Standard and Enteric Precautions
d.good handwashing
Cirrhosis
1.Definition/etiology - irreversible, chronic,
progressive degeneration of the liver, with
fibrosis and areas of nodular regeneration
Cirrhosis
a.types
i. Laennec's cirrhosis - related to alcohol
abuse
ii. post-necrotic - associated with viral
hepatitis or exposure to hepatotoxin
iii. biliary cirrhosis - associated with
inflammation or obstruction of gallbladder
or bile duct
iv. cardiac cirrhosis - associated with
congestive heart failure
2.Pathophysiology
a.nodular liver with fibrosis and scar tissue
b.destroys hepatocytes and kills tissue
(necrosis)
c.necrosis, nodules, and scar tissue obstruct
flow of blood, lymph, and bile
d.impaired bilirubin metabolism
Findings
a. weakness, fatigue, weight loss, hepatomegaly
b. right upper quadrant pain
c. jaundice, pruritus, steatorrhea (decreased
absorption of fat and fat-soluble vitamins)
d. clay-colored stools
e. increased bilirubin in urine, producing dark
colored urine
f. impaired aldosterone metabolism resulting in
edema
g. impaired estrogen metabolism: gynecomastia,
menstrual changes, changes in distribution of
body hair, vascular changes - spider angiomas,
palmar erythema
h.impaired metabolism of protein,
carbohydrate, and fat
i. produces less plasma protein, resulting in
edema and ascites
ii. produces less of proteins needed for
clotting (fibrinogen and prothrombin)
iii. absorbs less vitamin K, resulting in
prolonged bleeding
iv. liver fails to convert glycogen to glucose,
resulting in hypoglycemia
Diagnostics
a.liver function studies - ALT, AST, alkaline
phosphatase
b.prothrombin time, CBC
c.decreased cholesterol because liver
synthesis impaired
d.elevated serum bilirubin and urine bilirubin
e.ERCP to examine bile ducts
f. CT scan of liver
g.liver biopsy
• Management
a.steroids for post-necrotic cirrhosis
b.replace B vitamins and fat-soluble vitamins
c.diet
i. increased carbohydrates
ii. protein may be restricted, depending on
amount of damage and symptoms
iii.no alcohol
Nursing interventions
a.monitor for bleeding
b.alteration in nutrition
i. 2,000-3,000 calories daily
ii. low fat
c.provide rest periods; client will not tolerate
strenuous activities
d.remedy any knowledge deficit about
cirrhosis and its therapies
e.changes in LOC
i. confusion
ii. avoid sedation
f. impaired skin integrity, from edema and
pruritus
g.monitor fluid balance
h.measure abdominal girth daily
i. weigh daily
j. measure I & O
Complications
a.portal hypertension
b.ascites
c.hepatic encephalopathy
Portal hypertension
1.Definition/etiology - increased pressure in
portal circulation
2.Pathophysiology: normal blood flow is
altered producing an increased resistance
to flow through the liver. Congestion in the
portal system dilates veins, especially in
esophagus and rectum.
3.Findings
a.prominent abdominal-wall veins (caput
medusa)
b.hemorrhoids
c.enlarged spleen
d.anemia from increased destruction of
RBCs
e.esophageal varices and GI bleeding

4.Diagnostics: endoscopy
Management
a. Sclerotherapy - injection of a sclerosing
agent into varices
b. balloon tamponade
i. Sengstaken-Blakemore tube is inserted
into the stomach
ii. gastric balloon is inflated and presses on
lower esophagus while allowing suctioning
iii. esophageal balloon places pressure on
varices
iv. pressure is released as ordered to
prevent necrosis
Sengstaken-Blakemore tube
v. traction for increased pressure added by
attaching tube to football helmet
vi. assess for bleeding and signs of shock
vii. assess for respiratory distress -
aspiration or displacement of tube, suction
PRN
viii. keep head of bed elevated
c. medications
i. vasopressin
• constricts veins and decreases portal
blood flow
• given IV or into superior mesenteric artery
• side effects include hypothermia,
myocardial ischemia, acute renal failure
ii. nitroglycerin will decrease myocardial
effects
iii. beta-adrenergic neuron-blocking agents
may decrease risk of recurrent bleeding by
decreasing pressure in portal system
iv. cathartics to remove blood from GI tract
and decrease absorption of ammonia
d.surgical intervention
i. shunt to decrease blood flow to liver and
therefore pressure splenorenal shunt
• mesocaval shunt
• portacaval shunt
ii. TIPS (transjugular intrahepatic
portosytsemic shunt) - shunt placed
between hepatic and portal vein
Nursing interventions
a.prevent bleeding
b.avoid intake of alcohol, irritating or rough
food
c.avoid increased pressure in abdomen
d.if bleeding occurs - administer
transfusions, fresh frozen plasma, vitamin
K
e.monitor for infection
Ascites
1.Definition/etiology - accumulation of fluid in
the peritoneum
2.Pathophysiology
a.portal hypertension causes increased
plasma and lymphatic hydrostatic pressure
in portal system
b.hypoalbuminemia causes decreased
colloid osmotic pressure
Ascites
PARACENTESIS

• Paracentesis - aspiration of abdominal

ascites, usually 1000-1500cc removed
• Before paracentesis: empty client's
bladder
• During procedure: client sits upright
• After procedure: take frequent vital signs;
monitor urine output; and monitor for
drainage from puncture site
c.hyperaldosteronism due to liver's inability
to metabolize aldosterone causes body to
retain sodium and water
d.abdomen will have excess fluid, blood
vessels too little fluid
3.Findings
a.abdominal distention, protruding umbilicus,
dull sound on percussion of abdomen,
fluid wave
b.bulging flank
c.dyspnea
3.Findings
a.abdominal distention, protruding umbilicus,
dull sound on percussion of abdomen,
fluid wave
b.bulging flank
c.dyspnea
Medical management
a.diuretics - spirnolactone (Aldactone) -
aldosterone antagonist, spares potassium
b.iv albumin
c.paracentesis to remove fluid
d.diet low in sodium
e.peritoneal venous shunt - allows drainage
of fluid from the peritoneum to superior
vena cava
• Nursing interventions
a.measure I & O, daily weight, abdominal
girth, skin turgor
b.restrict fluids
c.monitor for ineffective breathing patterns
d.semi-Fowler's position
e.monitor for impaired skin integrity
f. remedy knowledge deficit
Hepatic encephalopathy - mental
dysfunction associated with severe liver
disease
1.Definition/etiology
a.impaired ammonia metabolism in liver
poisons brain tissue
b.ammonia produced in bowel from action of
bacteria on protein
2.Findings
a.changes in LOC from confusion to coma
b.changes in sleep pattern
c.memory loss
d.asterixis - flapping tremor
e.impaired handwriting
f. hyperventilation with respiratory alkalosis
g.fetor hepaticus - musty, sweet odor to
breath
3.Diagnostics - serum ammonia level

4.Management
a.neomycin sulfate (Mycifradin) - inhibits
action of intestinal bacteria
b.lactulose (Cephulac) - absorbs ammonia
and produces evacuation of the bowel
c.low protein diet
5.Nursing interventions
a.tremor, confusion can lead to injury:
maintain safety
b.ascites and low intake decrease fluid
volume
c.diarrhea from medications
Disorders of Pancreas and Gallbladder

A. Acute pancreatitis
1.Definition/etiology - inflammation of the
pancreas
a.alcohol ingestion
b.gall stones
c.drug ingestion
d.viral infections
e.trauma
2.Pathophysiology
a.autodigestion from premature activation of
pancreatic enzymes
b.proteases and lipases, normally active in
small intestine, are activated in the
pancreas
c.phospholipase A digests adipose and
parenchymal tissues
d.elastase digests elastic fibers of blood
vessels, producing bleeding
e.amylase digests carbohydrates
f. inflammation response occurs from
enzyme release
3.Findings
a.left upper quadrant abdominal pain
b.pain worsens after eating and when lying
flat
c.nausea and vomiting
d.fever, agitation, confusion
e.hypovolemia and shock
f. hemorrhage into retroperitoneal space
may produce ecchymosis in flank or
around umbilicus
g.tachypnea, pulmonary infiltrates,
atelectasis from circulating enzymes
h.Diagnostics
A. elevated enzymes: serum amylase,
serum lipase, and urinary amylase
B. elevated WBCs, decreased hemoglobin
and hematocrit
C. elevated LDH and AST (SGOT)
D. hyperglycemia
E. hypocalcemia
F. chest x- ray, CT scan, ultrasound, ERCP
Complications
a.respiratory problems - atelectasis,
pneumonia from the immobility imposed
by pain
b.tetany from decreased calcium levels
c.abscess or pseudocyst
Management
a.treat cause
b.pain relief - meperidine (Demerol)
c.fluid maintenance to prevent shock
d.insulin for hyperglycemia
e.calcium replacement
f. decrease stimulation of pancreas
i. NPO-TPN (nothing by mouth; total
parenteral nutrition)
ii. NG tube
iii. anticholinergics
iv. h2-receptor antagonists
Nursing interventions
a.manage pain
b.monitor alteration in breathing patterns
c.monitor nutritional status
d.oral care when NPO
e.if eating is allowed, diet high in proteins
and carbohydrates and low in fat
f. monitor fluid and electrolyte balances
Cholecystitis
1.Definition/etiology - inflammation of the
gallbladder
a.usually due to gallstones (Cholelithiasis)
b.types
i. cholesterol - most common
ii. pigment - unconjugated bilirubin
c.bile is blocked, and infects tissue
d.more common in women, especially those
over 40 and those who use birth control
pills
2.Pathophysiology
a.common bile duct is obstructed by a
gallstone
b.bile cannot be excreted, some is
reabsorbed
c.remaining bile distends and inflames gall
bladder
d.may scar gallbladder, resulting in less
storing of the bile from the liver
e.can perforate gall bladder
i. Findings
1.colicky pain in right upper quadrant with
possible radiation to right shoulder and
back
2.indigestion after eating fatty foods
3.nausea and vomiting
4.jaundice (if the liver is involved or inflamed
or the common duct obstructed)
5.low grade fever
ii. Diagnostics
1.endoscopic retrograde cholangiography
(ERCP)
2.endoscopic retrograde catheterization of
the gallbladder (ERCG)
3.ultrasound
Management
a.rest
b.low-fat diet
c.removal of stone in common duct by
endoscopy
d.to dissolve cholesterol stones
i. chenodeoxycholic acid (Chenodiol) - side
effects are diarrhea and hepatotoxicity
ii. ursodeoxycholic acid (UDCA)
e.control pain - meperidine (Demerol) is
drug of choice
f. replace vitamin K if bleeding time is
prolonged
g.extracorporeal shock wave lithotripsy -
may have hematuria after procedure, but
not longer than 24 hours
h.choledocholithotomy - to remove or break
up stones
i. laparoscopic laser cholecystectomy
j. cholecystectomy
Nursing interventions
a.monitor vital signs
b.monitor pain and medicate as needed
c.teach client - dietary restriction of fatty
foods
Situation- Mr. Maribojo was brought to the
emergency room complaining of pain
located in the upper abdomen. Diagnosis
is peptic ulcer.
1. Prescribed diet for him is:
 A. Full C. Soft
 B. Low Purine D. Bland
2. The purpose of dietary treatment of Mr.
Maribojo is to:
 A. Neutralize the free HCl in the
stomach
 B. Delay gastric emptying
 C. Prevent constipation
 D. Delay surgery
3. Antacids are administered to Mr.
Maribojo to:
 A. Tranquilize the intestine
 B. Decrease gastric motility
 C. Lower acidity of gastric secretions
 D. Aid in digestion
4. A patient is admitted to the hospital with
an exacerbation of his chronic gastritis.
When assessing his nutritional status, the
nurse should expect a deficiency in:
 A. Vitamin A C. Vitamin B6
 B. Vitamin B12 D. Vitamin C
Situation- Ms. Kim Anderson is scheduled
for stat total gastrectomy.
5. What is the involvement of this
surgery?
 A. Removal of stomach only
 B. Removal of the stomach, with
anastomosis of the esophagus to the
jejunum
 C. Removal of the ovary and fallopian
tube
 D. Removal of the stomach, with
anastomosis of the duodenum to the
jejunum
6. Which of the following is a postprandial
problem that may occur post gastric
reaction?
 A. Headache C. Dumping syndrome
 B. Nausea D. Vomiting
7. She is experiencing dumping
syndrome, what is the dietary
management needed?
 A. Full diet
 B. Bland diet and high protein
 C. High protein, high carbohydrate, low
fat
 D. High protein, low carbohydrate, high
fat and dry diet
 Situation- Jenny Lyn, 50 years of age, was
accompanied by her husband in the hospital.
She is complaining of severe sharp right
abdominal pain and frequently precipitated
after ingestion of fatty foods.
 8. The ingestion of fatty food usually
precipitated Jenny Lyn’s episode of upper
abdominal pain because:
 A. Fat in the stomach increases the rate of
peristaltic movements
 B. Fat in the duodenal contents initiates the
reaction that cause gallbladder
 reaction
 C. Fatty foods are likely to generate gas
 D. Fatty food contain higher amounts of
cholesterol than do proteins
9. Reasons why Jenny Lyn’s stool is clay-
colored:
 A. Increase in the red blood cell
breakdown
 B. Obstruction of bile flow to the bowel
 C. Absence of normal bacterial flora of
the bowel
 D. Interference with the absorption of
fats
10. Results of x-ray revealed presence of
stone in the gallbladder known as:
A. Cholelithiasis C. Cholecystitis
B. Choledocholithiasis D. Uterolithiasis
Situation- Ms. Sandara Park, a cook has
cholecystitis and cholelithiasis. She is
experiencing severe biliary colic.
11. The drug of choice during her attack is:
 A. Ponstan C. Morphine Sulfate
 B. Demerol D. Aspirin
12. Which of these drugs when given to
Ms. Park would produce spasm of
sphincter of Oddi and thereby increase
biliary pressure?
 A. Ponstan C. Demerol
 B. Benadryl D. Morphine
13. Usually you expect that the approach
used for her surgery is through a:
 A. Right Iliac incision
 B. Left subcostal incision
 C. Right subcostal incision
 D. Left Iliac incision
14. When teaching Mary Ann how to
control her symptoms of GERD, the nurse
provides her with many health promotion
modifications. Which modification is
correct when trying to control GERD?
 A. Only eat two to three meals per day.
B. Sleep flat in a left lying position.
C. Drink tea instead of coffee.
D. Avoid working in a bent-over position.
15. Which signs and symptoms would the
nurse expect to find when assessing a
client with esophagitis?
A. Mid-epigastric pain and tenderness
B. Abdominal distention and fever
C. Abdominal cramping and vomiting
D. Heartburn and dysphagia
16. When assessing a client admitted with a
bleeding gastric ulcer, the nurse would
expect to assess which type of stool?
A. Coffee-ground colored
B. Clay colored
C. Black, tarry
D. Bright red
17. When developing a teaching plan for a
client with GERD, the nurse should
include which discharge instruction?
A. “Elevate the foot of the bed by 6” to 8”.”
B. “Lie down immediately after a meal.”
C. “Take antidiarrheal medication after
each loose stool.”
D. “Avoid caffeine, tobacco, and pepper
mint.”
18. A 17-year-old patient with a temperature
of 100.7 oF comes into the emergency
department complaining of severe
abdominal pain in the RLQ and has had
nausea and vomiting in the last 6 hours.
Which condition would the nurse suspect?
A. Diverticulits
B. Appendicitis
C. Gastroenteritis
D. Irritable bowel syndrome (IRS)
19. Which would be an appropriate outcome
for the client experiencing constipation?
A. The client eats a high-fiber diet
B. The client avoids physical execise
C. The client drinks one to two glasses of
water daily
D. The client maintains a sedentary
lifestyle
20. A Billroth I procedure is a surgical
approach to ulcer management whereby:
A. A partial gastrectomy is done with
anastomosis of the stomach segment to
the duodenum.
B. A sectioned portion of the stomach is
joined to the jejunum.
C. The antral portion of the stomach is
removed and a vagotomy is performed.
D. The vagus nerve is cut and gastric
drainage is establishe.
END