MEDICAL-SURGICAL NURSING (GASTROINTESTINAL SYSTEM) I. Introduction A. Anatomy 1. Mouth 2. Esophagus: passes through the diaphragmatic hiatus. 3.

Stomach: 1500 ml Gastroesophageal junction: inlet Chyme a. Cardia b. Fundus c. Body d. Pylorus Pyloric sphincter 4. Small intestine: secretion & absorption (primary function). Segmental contraction: mixing wave; churning motion Intestinal peristalsis: propel Villi (finger-like projections): produce digestive enzymes & absorbs nutrients a. Duodenum Sphincter of Oddi (confluence of common bile duct & duodenum): control bile flow. Ampulla of Vater Nutrients, Mg, PO4, K. b. Jejunum: process of absorption begins Fats, chon, cho, Na, Cl, Mg, PO4, K. c. Ileum Terminal ileum Ileocecal valve: prevents bacterial reflux into the s.i. B12, bile salts, Mg, PO4, K. 5. Large intestine Primary purpose: absorb water and electrolytes Bicarbonate: neutralize Mucus: protect from fecal adhesion Cecum o Appendix a. Ascending colon b. Transverse colon c. Descending colon d. Sigmoid colon e. Rectum f. Anus Internal sphincter: ANS External sphincter: cerebral cortex 6. Portal venous System a. Superior mesenteric vein (s.i., cecum, ascending & transverse colon) b. Inferior mesenteric vein c. Gastric splenic d. Cystic veins e. Vena portae (enters the liver) Gastric Artery Superior mesenteric artery Inferior mesenteric artery B. Physiology 1. Digestion Enzyme/Secretion Source Carbohydrates

Salivary glands Pancreas & intestinal mucosa Intestinal mucosa Intestinal mucosa Intestinal mucosa Protein Pepsin Gastric mucosa Trypsin Pancreas Aminopeptidase Intestinal mucosa Dipeptidase Intestinal mucosa Hydrochloric acid Gastric mucosa Fat (Triglycerides) Pharyngeal lipase Pharynx mucosa Steapsin Gastric mucosa Pancreatic lipase Pancreas Bile Liver & Gallbladder Medulla oblongata: swallowing center Intrinsic factor (from gastric mucosa): combine with vitamin B12 to be absorbed in the ileum. 2. Absorption 3. Elimination Brown feces: breakdown of bile by colonic bacteria Gases: methane, hydrogen sulfide, & ammonia C. Diagnostics 1. Stool tests Fecal Occult Blood Test (FOBT) 2. Breath tests Hydrogen Breath Test: cho absorption Urea Breath Test: carbon labeled urea, H. pylori presence 3. Abdominal Ultrasonography Endoscopic Ultrasonography (EUS): 8-12 hrs fasting; fat-free meal (gb studies); Ba studies after utz. 4. DNA Testing 5. Imaging Studies a. UGIT Study BaSO4: radiopaque Double-contrast studies: thick Ba suspension, give CO2 tabs in H2O after Enteroclysis: 500-1000ml of thin BaSO4 suspension into the s.i. through a duodenal tube, infuse methylcellulose in the tube after Clear liquids, NPO post mn, bowel prep b. LGIT Studiy Ba enema Double contrast/Air contrast: thicker Ba enema H2O soluble: H2O soluble iodinated contrast (gastrografin) Low residue diet 1-2 days before; clear liquids, laxatives, NPO post mn; cleansing enema @ am. c. Computed Tomography Check allergies to seafoods, serum crea, HCG levels. d. Magnetic Resonance Imaging No ferromagnetic objects, metals, jewelry; NPO 6-8 hrs;assess claustrophobia e. Positron Emission Tomography Carbon-11, fluorine-18, oxygen-15, nitrogen-13 f. Scintigraphy (Radionuclide testing) Radioactive isotopes g. Gastrointestinal Motility Studies

Ptyalin (Salivary amylase) Amylase Maltase Sucrase Lactase

6.

7.

8.

9.

Scintiscanner p.c.: measures rate of passage of radioactive substance. Colonic transit studies: capsule with 20 radionuclide markers Abd XR q 24 hrs until all markers are passed. Endoscopic procedures a. UGI Fibroscopy/Esophagogastroduodenoscopy (EGD) PillCam ESO: pill-sized instrument with 2 cameras Endoscopic Retrograde Cholangiopancreatography (ERCP): common bile, hepatic, and pancreatic ducts via ampulla of vater 8 hrs NPO; Midazolam (sedate); Atropine (reduce secretions); Glucagon (relax smooth muscles); Left lateral position b. Fiberoptic Colonoscopy Virtual colonoscopy/CT colonography Laxatives for 2 nights; fleets/saline enema @ am; polyethylene glycol electrolyte lavage; clear liquids starting noon before; oral lavage solutions @ intervals over 3-4 hrs; Midazolam, Glucagon; Left fetal position c. Anoscopy, Proctoscopy, Sigmoidoscopy Warm tap H2O/fleet enema; Comfortable in left side lying with right leg bent and placed anteriorly d. Small Bowel Enteroscopy Small-caliber transnasal endoscope Push & pull endoscope methods e. Endoscopy through Ostomy Manometry & Electrophysiologic Studies Changes in intraluminal pressure & coordination of muscle activity Esophageal Manometry: esophageal motility studies; 8-12 hrs NPO; No medications that affect motility 24-48 hrs Anorectal Manometry: phosphor-soda/saline cleansing enema 1 hr prior; prone/lateral position Rectal Sensory Function Studies Electrogastrography a. Defecography Anorectal function; very thick Ba paste; fluoroscopy Gastric analysis, Gastric acid Stimulation test, pH monitoring 8-12 hrs NPO; No medications that affect gastric secretions for 24-48 hrs; no smoking @ am; Gastric samples aspirated q 15 minutes for the next hour via NGT. Histamine/Pentagastrin subQ to stimulate gastric secretions Collect gastric specimen q 15 minutes for 1 hr. Ambulatory pH monitoring: 6 hrs NPO; no medications affecting gastric secretions 24-36 hrs; probe inserted via the nares and into position 5 in above lower esophageal sphincter connected to external recording device worn for 24 hrs; Dx GERD Bernstein test: HCL via feeding tube in esophagus; evaluate complaint of acid-related pain. Laparoscopy (Peritoneoscopy) Creation of pneumoperitoneum & incision lateral to the umbilicus.