GASTROINTESTINAL DISEASES

MOUTH: SIGNS AND SYMPTOMS

1. Bleeding gums – Vit. C deficiency
2. Glossitis, cheilosis – Vit. B2 deficiency
3. Smooth beefy red tongue – Vit. B12 deficiency
4. Strawberry tongue – scarlet fever
5. Koplik’s spots – measles
6. Thrush (white, removable plaques) – Candida albicans

GI BLEEDING

Hematemesis
➢ Vomiting bright red blood (rapid bleed)
➢ Vomiting “coffee-ground” (slow bleed)
Melena
➢ Black, tarry stool
➢ Source: upper GI, or small bowels
Hematochezia
➢ Bright red blood in stool
➢ Source: lower GI (or upper GI if massive)

MEDICAL CAUSES:
1. Upper GI
➢ Esophageal varices
➢ Gastritis
➢ Gastric ulcer
➢ Duodenal ulcer
2. Lower GI
➢ Hemorrohoids
➢ Anal fissure
➢ Diverticulosis
➢ Inflammatory bowel disease
➢ intussusception

UPPER ABDOMINAL PAIN

REFLUX ESOPHAGITIS
➢ Burning substernal pain
➢ After meals, at night
➢ May radiate to left arm

GASTRIC ULCER
➢ Steady, gnawing epigastric pain
➢ Worsened by food

DUODENAL ULCER
➢ Steady, gnawing epigastric pain
➢ Typically awakens patient around 1:00 am
➢ Relieved by food

PERFORATED PEPTIC ULCER

➢ Severe epigastric pain
➢ May radiate to back or shoulders
➢ Peritoneal signs
______________________________________________________________
 CHOLECYSTITIS
➢ Cramp-like epigastric pain
➢ May radiate to tip of right scapula
➢ Murphy’s sign-painful splinting of respiration during deep inspiration and
right upper quadrant palpation.

ACUTE PANCREATITIS
➢ Severe, boring abdominal pain
➢ Often radiates to back
➢ Peritoneal signs (rebound tenderness, abdominal rigidity)

HIATAL HERNIA
1. SLIDING HERNIA: gastroesophageal junction and part of stomach slide upwards
2. PARAESOPHAGEAL: part of stomach turns adjacent to esophagus

Assessment
1. Often asyptomatic
2. Heartburn
3. Regurgitation of food
4. Diagnosis: chest X-ray or barium swallow

Implementation
1. If asymptomatic: no treatment necessary
2. Small frequent meals
3. Elevate head of bed to reduce acid reflux
4. Avoid activities that increase abdominal pressure:
(lifting heavy objects, bending over etc.)
ESOPHAGEAL VARICES
Liver cirrhosis: elevated portal vein pressure> esophageal varices
Assessment
1. History of alcohol (liver cirrhosis)
2. Hematemesis = vomiting blood
3. Melena = black, tarry stools
4. Signs of shock if bleeding is severe

Implementation
1. Watch for hemorrhage, hypotension, signs of shock
2. Monitor vital signs if acute bleeding
3. Watch for signs of hepatic encephalopathy
4. Assist with Sengstaken tube
Sengstaken tube (to compress varices)
➢ Monitor bleeding in gastric drainage
➢ Watch for signs of asphyxiation
➢ Watch for tube displacement

GASTRITIS
Inflammation of gastric mucosa
ACUTE GASTRITIS (Erosive)
➢ Acute hemorrhagic lesions
➢ Stress ulcers
➢ Aspirin, NSAIDs
➢ Alcohol

CHRONIC GASTRITIS TYPE A (Non-erosive)

➢ Autoimmune gastritis
➢ Involves body and fundus

______________________________________________________________
 ➢ Pernicious anemia

CHRONIC GASTRITIS TYPE B (Non-erosive)

➢ Involves body and fundus
➢ H. pylori

Assessment
1. Nausea, anorexia
2. Sour taste in mouth
3. Belching
4. Cramping, pain

Implementation
1. Watch for signs of GI bleeding (“coffee-ground” vomit)
2. CBC if suspected pernicious anemia

Medications
1. Antacids
2. Antihistamine (to reduce acid secretion)
3. Antibiotics (to eradicate H. pylori)

PEPTIC ULCER DISEASE

GASTRIC ULCER
➢ Normal or decreased acid production
➢ Decreased mucosal resistance
➢ Chronic NSAID use
➢ Pain gets worse after meals

DUODENAL ULCER
➢ Increased acid production
➢ Pain typically relieved by meals

Assessment
1. Gnawing, burning epigastric pain
2. Vomiting
3. GI bleeding>anemia

Diagnosis
1. upper GI series or endoscopy
2. test for presence of Helicobacter pylori

Implementation
1. Watch for signs of bleeding- “coffee-ground” vomit, tarry stools
2. Avoid irritating food
3. Avoid cigarette smoking
4. Avoid aspirin, NSAIDs and steroids

Medications
1. Antihistamine
2. Antibiotics to eradicate H. pylori

Note: gastric resection is much common nowadays due to more effective drugs
including the use of antibiotics to eradicate H. pylori

LIVER: SIGNS & SYMPTOMS

______________________________________________________________
 Jaundice - diminished bilirubin secretion
Fetor hepaticus - sulfur compounds produced by intestinal bacteria, not cleared by liver
Spider angiomas palmar erythema gynecomastia - elevated estrogen levels
Ecchymoses(easy bruising) - decreased synthesis of clothing factors
Xanthomas(yellow skin plaques / nodules) - elevated cholesterol levels
Hypoglycemia –- decreased liver glycogen stores, decreased liver glucose production
Splenomegaly - portal hypertension
Encephalopathy asterixis (hand-flapping tremor) - portosystemic shunt (digestive
products bypass liver and are not detoxified)

INDIRECT BILIRUBIN (unconjugated) increased

➢ Hemolytic anemia
➢ Physiologic jaundice of the newborn
HBs-Ag
➢ Earliest marker of hepatitis B
➢ Indicates infective state (hepatitis B)
JAUNDICE
➢ Skin looks yellow if serum bilirubin > 2mg/dL
PREHEPATIC
➢ Hemolysis: sickle cell anemia, Hemolytic anemias (antibodies against RBC’s)
HEPATIC
➢ Hepatitis: impaired conjuction of bilirubin by liver cells
POSTHEPATIC
➢ Cholestasis: impaired excertion by liver cells (estrogens, some drugs), Bile duct
obstruction

DRUG INDUCED LIVER DISEASE

CHLORPROMAZINE
➢ Reversible cholestasis
ETHANOL
➢ Fatty liver, Cirrhosis
ACETAMINOPHEN/ CARBON TETRACHLORIDE
➢ Acute liver cell necrosis
ESTROGENS
➢ Hepatocellular adenoma (benign)
AFLATOXIN HEPATITIS B AND C
➢ Hepatocellular carcinoma

IMPLEMENTATION
1. Check skin, gums and stool for bleeding
2. Avoid aspirin
3. Monitor weight
4. Monitor abdominal cicumference
5. If ascites interferences with breathing > high Fowler’s

DIET:
1. High carbohydrate, high calorie, vitamins (low protein diet if client has hepatic
encephalopathy)
2. Provide counseling if client abuses alcohol

GALLBLADDER

CHOLELITHIASIS
➢ presence of gallstones in the gallbladder
➢ Usually asymptomatic (70%)
➢ May cause biliary colic (20%)

______________________________________________________________
 ➢ May cause cholecystitis (10%)

BILIARY COLIC
➢ Steady, cramplike pain in epigastrium
➢ Murphy’s sign (inspiratory arrest during palpation of liver margin)
➢ Pain does not subside spontaneously

Implementation
1. No oral food during acute cholecystitis

Diagnosis
1. X-ray, ultrasound, scan to visualize stones
2. ERCP to visualize ducts

Medications
1. Analgesics
2. Antibiotics
3. Ursodiol: (resolves small cholesterol stones, but does not help in acute attack)

Post Operative
1. Monitor T-tube drainage (up to 500ml in first 24h is normal)

Client Education
1. Reduce dietary fat and cholesterol intake

PANCREATITIS

ACUTE PANCREATITIS
➢ Causes – Alcohol abuse, cholelithiasis
➢ Features – Elevate lipase, amylase
➢ Mortality rate – 10%

CHRONIC PANCREATITIS
➢ Causes – Alcohol abuse, rarely due to cholelithiasis
➢ Features – pancreatic calcifications

Assessment
1. Nausea
2. Severe abdominal pain around umbilicus
3. Abdominal rigidity
4. Signs of shock
5. Dark urine, clay-colored stools if due to bile duct obstruction (stones)

Laboratory
1. Elevate amylase, lipase
2. If serum calcium low> poorer prognosis
Implementation
1. Keep client NPO
2. Assist with nasogastric tube
3. Monitor vital signs
4. Monitor input/output
5. Assess for respiratory difficulties and base of lungs
Client Education
1. Strict avoidance of alcohol

MALDIGESTION
Dysfunction of pancreas
➢ Chronic pancreatitis

______________________________________________________________
 ➢ Cystic fibrosis
Lack of specific enzymes
➢ Lactase deficiency
Lack of bile salts
➢ Biliary cirrhosis
➢ Resected terminal ileum
➢ Bacterial overgrowth

MALABSORPTION
Dysfunction of small bowel
➢ Short bowel syndrome
➢ Bacterial overgrowth
➢ Celiac disease
➢ Tropical sprue

Note: Diarrhea often leads to transients lactase deficiency: Teach client to avoid milk when
having diarrhea of any cause.

DIARRHEA
Secretory
➢ Large volume watery stools
➢ Persists with fasting
➢ (cholera, dysentery)

Osmotic
➢ Bulky, greasy stools
➢ Improves with fasting
➢ (lactase deficiency, pancreatic insufficiency, short bowel syndrome)

Inflammatory
➢ Frequent but small stools
➢ Blood and/or pus
➢ (inflammatory bowel disease, irradiation, shigella, amebiasis)

Dysmotility
➢ Diarrhea alternating with constipation
➢ (irritable bowel syndrome, diabetes mellitus)

LOWER ABDOMINAL PAIN

Appendicitis
➢ Vague periumbilical pain, nausea
➢ Later localizes to lower right quadrant
➢ Perforation: high fever and leukocytosis

Diverticulitis
➢ Elderly patients
➢ Steady pain
➢ Localized to lower left quadrant
➢ Left sided appendicitis

Inflammatory bowel disease

➢ Chronic, cramping pain
➢ Diarrhea, blood and pus in stool

Intestinal obstruction
➢ Hyperactive bowel sounds

______________________________________________________________
 Intestinal infraction
➢ Absent bowel sounds
➢ Gross or occult blood in stool

APPENDICITIS

Assessment
1. Nausea, anorexia
2. Initially periumbilical pain
3. Later localizes to McBurney’s point
4. Mild fever, elevated WBC count
5. Abdominal rigidity
6. Rebound tenderness

Implementation
1. Maintain bed rest
2. Keep client NPO if surgery is likely
3. Semi-Fowler’s position decreases pain
4. Monitor for signs of perforation and systemic infection

Post Operative
1. Monitor vital signs
2. Monitor fluid intake and output
3. Monitor bowel sounds
4. Monitor dressing for drainage or signs of infection

DIVERTICULITIS
Diverticula - bulging pouches of mucosa through sorrounding muscle
Diverticulosis - presence of diverticula
Diverticulitis - inflammation of diverticula
Assessment
1. Pain in lower left quadrant
2. May be relieved by bowel movement
3. Bowel irregularities
4. Rectal bleeding
5. Mild fever
6. Elevated WBC

Diagnosis:
1. Barium enema
2. Sigmoidoscopy
3. Colonoscopy

Implementation
1. NPO if peritonitis or massive bleeding
2. Liquid or soft diet during acute phase
3. High fiber and bulk-forming diet after pain subsides
4. Stool softeners
5. Temporary colostomy necessary: perforation, peritonitis or obstruction

Post Operative
1. Monitor vital signs
2. Monitor fluid intake and output
3. Watch for bleeding: hemoratic and hemoglobin
4. Watch for signs of infection: pus or foul odor
HEMORRHOIDS
➢ Varicosities of anal and rectal veins
Predisposing factors

______________________________________________________________
 1. Hereditary
2. Chronic constipation
3. Pregnancy
4. Liver cirrhosis

Assessment
➢ Rectal pain and itching
➢ Bleeding (bright red blood on stool)

Implementation
1. Warm sitz baths to ease pain and swelling
2. Stool softeners, high fiber diet
3. Avoid straining
4. Surgery: ligation, sclerotherapy or surgical excision

Topical Medications
1. Anti-inflammatory: hydrocortisone cream
2. Astringents: witch hazel cream

Post Operative
1. Watch for rectal bleeding
2. Good anal hygiene – keep dry

INFLAMMATORY BOWEL DISEASE

CROHN’S DISEASE(regional enteritis)

➢ Cramping abdominal pain
➢ Fever, anorexia, weight loss

Pathology
1. Transmural thickening
2. Granulomas
3. Usually involves ileum
4. Rectum often spared
5. Affects several bowel segments

Complications
1. Perianal disease
2. Fistulas
3. Perforation
Outcome
➢ Many patients will have disease recurrence a few years after surgery
ULCERATIVE COLITIS
➢ Less abdominal pain
➢ More bloody diarrhea
Pathology
1. Mucosal ulceration
2. Begins at rectum and progresses
3. Towards ileocecal junction
4. Limited to colon (but involve terminal ileum)

Complications
1. Increased risk for colon carcinoma

Outcome
➢ Surgery is curative

______________________________________________________________
Note: The cause of Crohn’s disease and ulcerative colitis are unknown. These patients often
have additional chronic inflammations such as sacroiliitis, iritis or conjunctivitis.

Assessment
1. Abdominal pain and cramping
2. Malaise, weakness
3. Anxiety
4. Chronic diarrhea with blood, pus or mucus
5. Fever , elevated WBC count
6. Weight loss

Diagnosis
1. Baruim enema
2. endoscopy with biopsy

Implementation
1. Watch for dehydration
2. Monitor stool frequency and consistency
3. Monitor hemoglobin and hematocrit
4. Watch for signs of gastrointestinal obstruction
5. Provide psychological support and counseling

Diet
1. Acute phase: bowel rest > NPO > low-residue diet
2. Low-fat diet for steatorrhea
3. Avoid milk (lactose deficiency of chronic diarrhea)
Medications
1. Sulfasalazine
2. Steroids
3. Analgesics
Surgery
➢ Indicated it perforation, obstruction or cancer develops

INTESTINAL OBSTRUCTION
MECHANICAL OBSTRUCTION
➢ Due to adhesions, tumors, vovulus (twisting)
➢ Increased bowel sounds

PARALYTIC ILEUS
➢ Due to toxins, infections or postoperative
➢ Absent bowel sounds
Assessment
1. Nausea
2. Colicky pain
3. Constipation
4. Vomiting (fecal vomiting in severe lower bowel obstruction)
Diagnosis
1. abdominal film: intestinal gas
2. endoscopy

Implementation
1. Maintain NPO
2. Monitor vital signs
3. Turn client supine to prone (helps passing flatus and relief abdominal pressure)
4. Monitor patency of decompression tube

Post Operative
➢ Encourage coughing, turning, deep breathing

______________________________________________________________
 ➢ Monitor bowel sounds (return of peristalsis)

PERITONITIS
➢ Acute inflammation of peritoneum

Bacterial
1. Perforated duodenal ulcer
2. Ruptured appendicitis
3. Volvulus (twisting of bowel , strangulation, obstruction)
4. Abdominal trauma

Chemical
1. Pancreatitis
2. Perforated gastric ulcer

Note: Mortality dramatically decreased with antibiotics!

Assessment
1. Constant, intense, diffuse abdominal pain
2. Nausea
3. Weakness
4. Abdominal rigidity
5. Absent bowel sounds
6. Signs and symptoms of shock
7. Diagnostic paracentesis: cytology, bacterial culture

Implementation
1. NPO to reduce peristalsis
2. Monitor vital signs
3. Maintain bed rest
4. Semi-Fowler’s position
5. IV electrolytes and antibiotics are ordered

COLORECTAL CANCER
➢ Second most common cancer in US
➢ 5 year mortality about 50%
➢ Early diagnosis significantly improves survival

Assessment
1. Vague abdominal discomfort
2. Nausea, loss of appetite
3. Weakness, fatigue
4. Family history of colorectal cancer
5. Ribbon – or pencil – shaped stools
6. Black of tarry stools
7. Anemia
8. Signs of intestinal obstruction

Diagnosis
1. sigmoidoscopy,
2. colonoscopy with boipsy
3. CEA blood test to detect recurrence after surgery

Implementation
1. Monitor intake and output
2. Monitor consistency and color of stool
3. Prepare client for surgery

______________________________________________________________
COLOSTOMY CARE
1. Remove pouch when 1/3 full
2. Cleanse stoma with soft cloth and water or mild soap
3. Dry skin thoroughly before applying pouch
4. Use skin barrier powder or paste to protect from fecal drainage
5. Irrigaton of stoma - never force catheter
6. Allow client to verbalize feelings about colostomy

______________________________________________________________