UNIT ONE

Disorders & Nursing responsibility of

Gastrointestinal system (GIS)

By Sewunet.A

1
 Review of anatomy & physiology of GIS
• Gastrointestinal system can be classified into two:-
1) Gastrointestinal tract (GIT)
2) Accessory Organs -Liver, Gallbladder, Pancreas
• The gastrointestinal (GI) tract is a pathway that
extends from the mouth through the esophagus,
stomach, & intestines to the anus.
 Esophagus: - is a collapsible tube, which is about
25cm in length & located in the thoracic cavity
posterior to the trachea & larynx at the level of C6 -
T11.
2
 Stomach: - is situated in the upper portion of the
abdomen to the left of the midline.
• Has a capacity of approximately 1500ml
• The inlet to the stomach is called esophago-
gastric junction.
• It is surrounded by a ring of smooth muscle, called
lower esophageal sphincter / or cardiac
sphincter/, which, on contraction, closes off the
stomach from the esophagus.

3
• It has three anatomical regions: - the cardiac /
entrance/, fundus /body/ & pylorus / outlet/.
• Circular smooth muscle in the wall of the pylorus forms
the pyloric sphincter & controls the opening between
stomach & small intestine.
• The epithelial lining of the stomach contains many
glands:-
– Cardiac glands secrete - mucus
– Peptic /chief cell/ secrete - mucus & pepsinogen
– Parietal cells secrete - Hcl & water
– Neck cells secrete - mucus

4
 Small intestine: - is the longest segment of the GI tract,
accounting for about two thirds of the total length of the
tract.
– It folds back & forth on itself allowing for approximately
7000cm of surface area for secretion & absorption.
– The small intestine is divided into three anatomic parts:
duodenum (upper part) about 25cm, jejunum about
2.5m.(middle part), and ileum about 3.6m. (lower part)
– The common bile duct, which allows for the passage of
both bile & pancreatic secretions, empties into
duodenum at the ampulla of vater.

5
• The junction between the small & large intestine is
located in the right lower portion of the abdomen.
It is called cecum.
• At that junction is the ileo-cecal valve, which
function to control the passage of intestinal
contents in to the large intestine & to prevent reflux
of bacteria into the small intestine.
• It is in this area that the vermiform appendix is
located.

6
 Large Intestine:-It has three parts - Colon, Sigmoid, &
Rectum
• The colon consists of an ascending segment on the
right side of abdomen, a transverse segment that
extends from right to left in the upper abdomen, &
a descending segment on the left side of abdomen.
• The terminal portion of the large intestine consists
of two parts: the sigmoid colon & the rectum.
• The rectum is continuous with the anus.
• The anal outlet is regulated by a network of muscle
that form both internal & external anal sphincter.
7
 Blood Supply of GIT

• From arteries which originate from thoracic &

abdominal aorta. These arteries are:-
• Gastric artery:- oxygen & nutrient supply to
stomach.
• Superior & inferior mesenteric arteries –
intestine.
• Portal vein drains blood & nutrient from
intestines to liver.

8
 Nerve supply of GIT

– It is innervated by both sympathetic &parasympathetic

portion of the autonomic nervous system.
• Sympathetic nerves exert an inhibitory effect on the
GI tract. ex:- decrease gastric secretion & motility.
• Parasympathetic nerve stimulation causes peristalsis
to occur & increases secratory activities.
• The only portions of the tract under voluntary control
are the upper esophagus & the external anal
sphincter.
•
9
 Digestive Process
• The four major activity of the GIT are:-
1. Secretion of electrolytes, hormones, & enzymes, to
be used in breakdown of the ingested materials
2. Movement of ingested products
3. Digestion of food & fluids
4. Absorption of end products into blood stream

10
 Accessory Organs

1. Liver
• It is the largest organ
• Located in the upper abdominal cavity below
diaphragm.
• It is highly vascularized. It receives blood from two
sources: -
a) Portal Vein
b) Hepatic artery
• Both sources leave the liver through hepatic vein.11
 Function of the liver
• Bile production & excretion. Bile consists of bile
pigment & bile salts.
• Metabolic function -Carbohydrates
-Protein
• Storages: - Glycogen
-Vit A.D.E & K.
-B12, iron
• Formation of certain Blood Compounds
– Heparin
– Blood protein
– Clotting factor 12
• Destruction of Erythrocytes
• Detoxification of harmful substances
• Heat production
2. Gall Bladder & Bile duct
• Function: - Store & concentrate bile salt.
3. Pancreas
• Function: - Exocrine & endocrine

13
14
 Nursing Assessment
1. Health History
• Begin by taking a complete history,
I) C/C: - F=ocllusing on symptoms common to
gastrointestinal dysfunction.
• Symptoms on which the assessment focuses include
pain, indigestion, intestinal gas, nausea & vomiting,
hematoemesis, & changes in bowel habits & stool
characteristics

15
*When conducting a symptom analysis of , ask the
client the following questions about the c/c &
present illness.
– Onset
– Duration
– Quality & characteristics
– Severity
– Location
– Precipitating factor
– Relieving factor
– Associated manifestation
16
Eg.
A. Pain: - duration, pattern, frequency, location,
distribution, aggravating & relieving factors
and severity.
B. Intestinal gas: - Belching expulsion of gas
from stomach through the mouth Or
flatulence ( the expulsion of gas from the
rectum.
C. Change in bowel habits:-
-Diarrhea
-Constipation
D. Characteristics of stool
-It can be brown, contain bright red
17
blood, black & tarry or pole yellow.
II) Past medical &surgical History
III) Family history
IV) Personal & social history

18
 2. Physical examination
• Stand on the right side of the patient.
• Place the client in a supine position,
elevate the head, arms should be at his
sides or folded a cross his chest.
• The room should be well illuminated
• Slightly flex at knee joint.
• Apply draping to expose the area from
the sternum to the pubis.

19
 The sequence of examination:

A. Inspection
– Size & shape of abdomen
– Scar, striae
– Abdominal movement
– Umbilical hernia
– Hernial sites
– Visible peristalsis
– Visible distended vein

20
B. Auscultation: - assess the sounds of peristalsis &
vascular abnormalities.
• Bowel sound: - frequency & intensity
- listen in all quadrants with
stethoscope.
C. Percussion: - Tympany is the normal percussion
note present throughout the abdomen except for
the area over liver & spleen.
• Estimate liver size:- normally in adult, it is 6 –
12cm.

21
D. Palpation
• Superficial palpation for tenderness &
mass over the four quadrants.
• Always start from pain free site
• Perform deep palpation for liver, kidney,
& spleen and to identify deep mass.

22
23
 Diagnosis tests, procedures and nursing
responsibilities.
• The entire GIT can be delineated by x-ray studies,
after the introduction of a contrast agent.
• A radi-opaque liquid (such as barium sulfate) is one
of the most commonly used media.
• Barium is insoluble substance & ingested for upper
GIT study but instilled rectally (barium enema) for
lower GIT studies

24
 A) Upper GIT studies / upper GI series/

• X-ray of upper GIT is taken after barium is ingested.

– This enables the examiner to detect any anatomic &
functional derangement of the upper GI organs Or
sphincters.
– It also aids in the diagnosis of ulcers, varices, tumors,
regional enteritis, & malabsorption syndromes.

25
• Patient preparation

–Keep the patient NPO after midnight

before the test.
–A laxative may be prescribed to clean
out the intestinal tract.
–Withheld all medications
–Patient should not smoke the morning
before the procedure because smoking
can stimulate gastric motility.

26
 • Procedure:-
» The patient is required to swallow barium
under direct fluoroscopic examination.
» As the barium descends in to stomach, the
position, patency, & caliber of the esophagus
are visualized.
» Fluoroscopic examination next extends to
stomach. The motility & thickness of the
gastric wall & mucosal pattern, & patency of
pylori.
•
•
27
• Post procedure
– Follow up care is needed after the procedure to
ensure that the ingested barium has been
completely eliminated.
– Stool must be monitored until they return to their
normal color /the barium will look like clay/
– A laxative or enema may be needed.

28
 B) Lower GI studies
• Barium enema is given before X-ray is taken
– The purpose of a barium enema is to detect the
presence of polyps, tumor, & other lesions of the large
intestine & to demonstrate any abnormal anatomy or
malfunction of the bowel.
• Nursing care for patient
– Instruct the patient to eat low - residue diet 1 to 2 days
before the test.
-Give laxatives/colon washout so that colon is
absolutely empty
29
 2. Laboratory test
a) Blood may be tested to determine:-
• Haemoglobin level
• Haematocrit
• Leucocyte count
• Serum electrolytes
• Bilirubin levels
• Blood glucose
• Pancreatic enzyme levels
30
b) Stool examination
• The stool is examined for its amount, consistency, &
colour, a screening test for occult blood is also
done.
– Melena / tarry black/  upper GI bleeding
– Bright red blood  lower GI bleeding
– Blood streaking on surface of stool  lower rectal
or anal bleeding

31
 Nursing Management
• Use spatula to place a small amount of stool in
a disposable waxed container.
• send specimen to laboratory

32
 3) Endoscopic Procedures
a. Upper Gastrointestinal Fibroscopy / Esophagogastro
duodenoscopy(EGD)
Purpose:
• For direct visualization of disease of the esophagus,
gastric, & duodenal mucosa / upper GI hemorrhage,
gastritis, PUD, motility can be evaluated.
• Esophageal & gastric motility can be evaluated.
• For collection of secretions & tissue specimens for
further analysis.
• Foreign body removal
• Cautery of bleeding point 33
–Side viewing flexible scopes are used to
visualize the common bile, & pancreatic &
hepatic duct through the ampulla of vater in
the duodenum.
–This procedure is helpful in evaluation
jaundice, pancreatitis, tumor of the pancreas,
common duct stones, & biliary tract disease
– This procedure is called endoscopic
retrograde cholangio pancreatography
(ERCP)
34
 Patient Preparation
»Instruct the patient to be NPO 6-12
hour before the examination.
»Spray or gargle with a local anesthesia,
along with IV diazepam before the
scope is introduced
»Atropine may be administered to
reduce secretions.
»Position the pt on left lateral position.

35
 Post procedure care

• After a gastroscopy the patient is instructed not

to eat or drink until the gas reflex returns (in 1 to
2 hour) to prevent aspiration of foods or fluids in
to the lungs.
• Assess the patient for the signs of perforation,
such as pain, bleeding, unusual difficulty
swallowing, & an elevated temperature.

36
 b) Lower GI fiberscopy
Colonoscopy
• Def.: - It is direct visual inspection of the colon to
the cecum by means of a flexible fiber optic
colonoscopy
1. Diagnostic colonoscopy
– lower GI bleeding
– colonic & ileo-cecal tuberculosis
– Inflammatory bowel disease & malignancy
2. Therapeutic colonoscopy
• Polyp-ectomy, foreign body removal, & control of bleeding
37
by electro coagulation
 Patient Preparation
• Patient should take only fluids / for 1 to 3 days
prior to the examination/ or
– 200cc of mannitol followed by plenty of water
after one hour initiates loose motions & clears
the bowel or
– Laxatives may be ordered for 2 nights prior to
the examination.
– Before the examination, a narcotic analgesic
may be administered.
– Position the patient on the left side with the
legs drawn up toward the chest.
38
–
 Post procedure care

• Observe for signs & symptoms of bowel

perforation (e.g, rectal bleeding, abdominal
pain or distention, fever, or focal peritoneal
signs)

39
 Anoscopy, Proctoscopy , & sigmoidscopy

• Anoscope: - is a rigid scope used to examine the

anal canal.
• Proctoscopes & sigmoidscopes: - are rigid or flexible
scopes used to inspect the rectum & sigmoid colon,
respectively, for evidence of ulceration, tumors,
polyps, or other pathologic processes.

40
 Patient Preparation

• A warm tape water enema is given until returns are

clear.
• Dietary restrictions are not usually necessary
• Sedation is not usually required.
Post procedure care
• Monitor the patient for rectal bleeding & signs of
intestinal perforation /e.g. fever, rectal drainage,
abdominal distention, & pain/
41
 Laparoscopy

• It is introduction of rigid laparoscope through a

nick in the anterior abdominal wall & insuflation of
peritoneum with room air or co make it possible to
look at the abdominal viscera & obtain biopsy.
• Indication:-
1. GI disease
• Evaluation of hepatic disease
• Differential diagnosis of jaundice
• Cancer
• Diagnosis of ascites
42
2. Miscellaneous
–Inspection of pelvic viscera
–Abdominal masses
–Abscure abdominal pain
–Evaluation of abdominal trauma.

43
 Assisting the patient in Gastric analysis
• Def: - Gastric fluid analysis involves examination of
gastric secretions, (hydrochloric acid and pepsin in
the stomach), & it may be performed by examining
a specimen vomitus or by testing a sample of the
gastric contents which have been aspirated via a
nasogastric tube.
• Two tests are performed in gastric analysis:
1) the basal cell secretion test

44
2)The gastric acid stimulation test (done for 1hr after
Sc injection of drug that stimulate gastric acid
secretion).
• Purpose: - To diagnose – Duodenal ulcer
- Zollinger Ellison syndrome
- Gastric carcinoma
- Pernicious anaemia

45
• Procedure: The client should be NPO for 12
hours before the test.
• The client’s naso-gastric tube is attached to suction,
and stomach contents are collected every 15
minutes for 1 hour
• The nurse must properly label the specimens with
the time & volume.

46
* Gastric analysis offers a means of estimating the
secretary activity of the gastric mucosa & of
determining the presence, or the degree, of gastric
retention in patients thought to have pyloric or
duodenal obstruction.
* A small NG tube /50cm/ is inserted through nose of
fasting patient & gastric content is aspirated.

47
 Gastrointestinal Intubation
Def: - It is the insertion of a short or a long flexible
rubber or plastic tube into the stomach or intestine
by way of the mouth or nose:
Purpose: - 1. To decompress the stomach &
remove gas and fluid.
2. To diagnose gastrointestinal motility
3. To administer medications & feeding
4. To treat an obstruction or bleeding
site.
5. To obtain gastric contents for analysis.
48
 Disease of the mouth & related structures

Periodontal Disease
• Periodentum is the tissue that surrounds &
supports the teeth.
• Periodontal disease includes :-
Gingivitis:-
• Defn: - It is an inflammation of gum
• It is the earliest form of periodontal disease.
• This is the most common infection of oral tissue.
49
Causes: - Poor oral hygiene: food debris, bacterial
plaque, & calculus / tartar/ accumulate.
C/M: - Painful, inflamed, swollen gums, usually the
gums bleed in response to light contact.
• Inflammation causes the gingival to separate from
the teeth surface & pockets formed in the gingival
that can collect bacteria, foods particles & pus.

50
 Nursing MX
• Brush teeth using a soft toothbrush at least 2
times daily
• Avoid alcohol & tobacco products
• Maintain adequate nutrition & avoid sweets
Medical MX
• Periodic professional dental cleaning

51
 Periodontitis

• Defn: -It is an inflammation of the tissue around

teeth.
Cause: - May result from untreated gingivitis
- Poor or inadequate dental hygiene
C/M: May have bleeding
• Infection
• Loosening of teeth
• Loss of teeth /late/
RX: - Instruction of patient in proper oral hygiene.
-antibiotic
-analgesics 52
 Periapical Abscess / Dento-alveolar
Abscess/
• Def.:-pus collection around the apex of the teeth.
• This is more commonly referred to as an
abscessed tooth, involves the collection of pus in
the apical dental periosteum & tissue
surrounding the apex of the tooth.
• It can be a cute or chronic

53
 Acute periapical abscess

• It is usually secondary to a suppurative pulpitis (a

pus producing inflammation of the dental pulp) that
arises from an infection extending from dental
caries.
• C/M: dull, gnawing / keep biting /, continuous
pain,
– Cellulites, edema of adjacent structures
– Swollen check
– Fever, malaise
• Mx:- Incision & drainage
- Antibiotic
54
 Chronic Periapical abscess

• It is slowly progressive infections process

• This can progress to a fully formed ‘’blind dental
abscess’’ without the patient’s knowing it.
• DX: - x – ray
• Mx: -Teeth extraction or root canal therapy,
with apicectomy / excision of the apex of the
tooth root.

55
 Stomatitis
• Def.:- It is the inflammation of the mucosa of the oral
cavity.
• Cause: - It is associated with emotional or mental stress,
fatigue, hormonal factors, minor trauma, and allergies.
• Associated with HIV infection / virus/, bacteria / such as,
syphilis & streptococcal/ and fungus moniliasis.
• C/M:  shallow ulcers with white gray center & red
border.
• Seen in the inner side of lip & cheek or on the tongue
• It begins with a burning sensations & slight swelling,
painful
56
•
 Necrotizing Ulcerative gingivitis or ‘’Trench
mouth, ‘’ or Vincent’s Angina
Defn: - It is pseudo membranous ulceration affecting
gum, mouth mucosa,tonsil & pharynx.
• It is an acute bacterial infection of the gingiva.
Etiology: - combination of a spirochete & a fusiform
bacillus.
Risk factors:-Poor oral hygiene, low tissue resistance,
& infection from complex micro- organisms, local
tissue damage & diabetes mellitus.

57
• C/M: - Foul breath, painful bleeding gums,
swallowing & talking are painful.
» Mild fever, swelling of neck lymph
nodes
• Treatment: - Antibiotic
» Teach the patient proper oral hygiene
» Irrigate with 2% to 3% hydrogen
peroxide or normal saline.

58
 Dental Caries
• Def: - A gradual pathologic disintegration &
dissolution of the tooth & dentin, with eventual
involvement of the pulp.
• Etiology: - It is the interaction of three factors.
These are:-
1. A susceptible tooth surface
2. proper microflora / streptococcus mutans,
Actinomyces Viscosus & lactobacillus/
3. a suitable substrate for the microflora /
carbohydrate/
59
Predisposing factors:-
• root exposure, lack of fluoride, inadequate
personal hygiene
Mx:-removal of decay.
• restoration
• tooth extraction

60
 Parotitis

• Parotitis (inflammation of the parotid gland) is

the most common inflammatory condition of
the salivary glands.
Cause: - Virus in children
• Staphylococcus aureus ( except in mumps)
Risk factors:- elderly, acutely ill & debilitated
people with decreased salivary flow due to
general dehydration or medication

61
C/M:  Fever
• Swelling, tenderness & tense gland
• Pain is felt in the ear & swelling gland interfere with
swallowing
• Overlying skin soon becomes red & shiny
Medical MX: - Antibiotic (cloxacillin 500Mg Po Qid for 7
days)
• Massage
• Analgesics
• Incision & drainage (I&D) of the glands if antibiotic
therapy is not effective.

62
Nursing Intervention
– Administer ordered medication
– Reassure the patient
– Tepid sponge bathes.

63
 Cancer of the mouth
• It may occur in any part of the mouth or throat
• It is curable if discovered early.
• This type of cancer is associated with the use of
alcohol & tobacco.
Predisposing factors
– Smoking & alcohol
– Old age
– Prolonged exposure to sun & wind

64
C/M
• It has no symptom during early stages
• Painless sore or mass that will not heal
• A typical lesion in oral cancer is painless indurated
(hardened) ulcer with raised edges.
• Any ulcer of the oral cavity that doesn’t heal in 2
weeks should be examined through biopsy.
• As the cancer progresses, the patient will complain
tenderness; difficulty in chewing, swallowing or
speaking, coughing of blood – tinged sputum; or
enlarged cervical lymph nodes.
65
 DX
– Clincal (History & P/E)
– Biopsy
Medical MX:
1. Resectional surgery or
2. Radiation therapy or
3. Chemotherapy or
4. combination of these therapies

66
 Nursing Process
Patient with conditions of the Oral cavity
1.Assessment
• History:  Normal brushing
– Awareness of any lesion in the mouth, lip, tongue, or
throat
– Recent history of sore throat
– Discomfort caused by certain foods
– Daily food intake
– Use of alcohol & tobacco

67
• P/E: - Inspect and palpate internal & external
structure of the mouth & throat.
• Lip: - Inspect for moisture, colour, symmetry,
fissures, & ulceration.
• Gums: - Inspect for inflammation, bleeding,
discolouration & note odor of breath
• Tongue: - Inspect for colour & lesion

68
 2. Nursing diagnosis
– Altered oral mucous membrane related to infection or
disease
– Altered nutrition, less than body requirement
– Pain related to oral lesion
– Body image disturbance related to a physical change in
appearance resulting from disease
– Anxiety
– Impaired verbal communication related to Rx
– Risk for infection
-Knowledge deficit
69
 3. Plan
• Improvement in the condition of oral mucous
membrane
• Improvement in nutritional in take
• Attainment of comfort
• To attain self image
• Absence of infection
• Understanding of disease process
• Alternative communication
70
 4. Nursing Intervention

• Promoting mouth care

• Advice to avoid smoking & alcohol
• Nutritional intake advice
• Give analgesics
• Provide paper & pen for communication by
writing
• Education the patient

71
 5. Expected outcomes

• Shows evidence of intact oral mucous

membrane
• Attains & maintains desirable body weight
• Free of anxiety
• Free of infection

72
 Trauma of the Mouth & Jaw

Fracture of the Jaw

• Fracture of the jaw area usually include injury to
the soft tissues
Causes: -
1. Trauma:-
• car accident
• Fall
• hit by a fist or a flying object
2. Patholgical: -
• osteomyelitis
73
• C/M: - Malocclusion, asymmetry, abnormal
mobility & crepitus (grating sound with movement)
and pain.
Immediate assessment; and Management
A. Determine obstruction to air way.
– Remove any obstruction from pharynx, such as broken
teeth, dentures, blood clots or broken bones
-Prepare for emergency tracheostomy
B. Control hemorrhage by direct pressure on vessels
supplying the area
74
C. Administer analgesics to relieve pain &
anxiety but not to depress respiration
D. Reassure the patient
E. Position the patient in prone position
F. Prepare the patient for reduction & fixation

75
 OESOPHAGEAL DIESASE
Achalasia

• Defn: - It is absent or ineffective peristalsis distal

esophagus accompanied by failure of the
esophageal sphincter to relax in response to
swallowing.
• Narrowing of the esophagus just above the stomach
results in a gradually increasing dilation of
esophagus in the upper chest.
• It may progress slowly.
• Affect mostly persons over 40 years of age.
76
C/M: - Difficulty in swallowing both liquids & solids
• Patient has a sensation of food ‘’ sticking’’ in lower
portion of the esophagus.
• Regurgitation
• Chest pain & heart burn
Diagnostic Evaluation
– X-ray – shows esophageal dilation above the narrowing
at the gastroesophageal junction.
– Barium swallow
-Endoscopy

77
Medical Mx
• Instruct the pt to eat slowly & drink fluids
with meals.
• Surgically by esophagomyotomy

78
 Hiatus Hernia

• The oesophagus enters the abdomen through an

opening in the diaphragm, & empties at its lower
end in to the upper part of the stomach.
• In hiatus hernia, the opening in the diaphragm
through which the oesophagus passes becomes
enlarged & parts of the upper stomach tends to
move up in to lower portion of the thorax
• It occurs more often in women than men.

79
C/M: - Heartburn
• regurgitation
• dysphagia
• 50 % of patients are a symptomatic
DX: - X - ray

80
 Medical Management

• Frequent, small feedings that can pass easily

through the oesophagus.
• Elevate head of the bed
• Surgery

81
 Oesophageal Diverticula

• Defn: - It is an out pouching of mucosa &

submucosa that protrudes through a weak portion
of the musculature.
• Diverticula may occur in one of three areas of the
oesophagus: -
1.Pharyngoesophageal or upper part of oesophagus
2. Mid-oesophageal
3. epiphrenic or lower part of the oesophagus

82
 C/M
• Difficulty in swallowing
• Fullness in the neck & then complain of
belching
• Regurgitation of undigested food
• Pouch, becomes filled with food & fluid
• sour taste in the mouth
• Chest pain

83
 Diagnostic Evaluation:-
• Barium swallow
• Esophagoscopy is contraindicated because of
danger of perforation
• Surgical removal of diverticula
Management: -
• Surgical removal (esophagectomy)
• Radiation
• Chemotherapy
Nursing intervention
• Post operatively feed the pt through NG tube
84
 Nursing Process
• Patients with conditions of the esophagus
1. Assessment:
• Complete history
• P/E
2. Nursing diagnosis may include:-
• Altered nutrition, less than body requirements,
related to difficulty swallowing
• Pain , related to a tumor,
• Knowledge deficity about the disease process
& Rx
85
3. NSg plan:
– To attain adequate nutritional intake
– To relief pain
– To increase knowledge level
4. Nursing Intervention
• Encourage the pt to eat slowly & to chiew all food
thoroughly
• Advice to eat small, frequent food
• Avoid very hot & cold beverages & spicy foods.
• Elevate the head of the bed
• Analgesics
• Educate the patient
86
5. Expected outcomes
–Achieve an adequate nutritional diet
–Free of pain
–Increased knowledge

87
 Gastric disorders
Acute gastritis
• It is an inflammation of the stomach mucosa.
• It is most often due to dietary indiscretion.
Cause:- Ingestion of strong acids or alkalies which
may cause the mucosa to become gangrenous or
to perforate.

88
 C/M
• Gastric mucous membrane becomes
oedematous & undergoes superficial erosion;
it secretes a scanty amount of gastric juice,
containing very little acid but much mucus.
• Abdominal discomfort, headache, nausea,
anorexia, & often accompanied by vomiting
• It will heal by itself
• Occasionally, hemorrhage may require surgical
intervention
89
 Chronic Gastritis
• Prolonged inflammation of the stomach may be
caused by either being or malignant ulcers of the
stomach, or by Helicobacter pylori ( H. pylori)
Cause: - H pylori
• Autoimmune (parietal cell changes, leading to
atrophy & cellular infiltration)
Risk factors: - Hot drinks & spices
• use of drugs & alcohol, smoking

90
C/M: - Anorexia, sour taste in the mouth
• heart burn
• belching, nausea & vomiting
Diagnostic Evaluation
–Endoscopy
–Upper GI x – ray series
–Histologic examination
–Serologic testing for antibodies for the H.
pylori antigens.

91
 MANAGEMENT

1. For Acute Gastritis:

– Instruct the pt to refrain from alcohol & food until
symptoms subside.
– Recommend non irritant diet
– If symptom persist administer fluids parenterally
– Aluminium hydroxide 2 tsp tid
– Nasogastric intubation
– sedatives

92
2. For chronic Gastritis
• Modify the pt’s diet
• Promote rest
• Reduce stress
• Treat H.pydori with (tetracycline or Amoxicillin)
and bismuth salt.

93
 Nursing Process

• The patient with Gastritis

A. Assessment
• Complete history (s/s of gastritis and Aggravating factors)
• P/E (abdominal tenderness, dehydration, any systemic
disorder)
B. Nursing diagnosis
– Anxiety
– Altered nutrition, less than body requirement
– Risk for fluid volume deficit
– Pain
– Knowledge deficit
94
C. Plan
• To reduce anxiety
• To maintain adequate nutritional intake
• To maintain fluid balance
• To increase awareness of dietary Mx.
• To relieve pain

95
D. Nursing Intervention
• Reassure the pt.
• Advice nutritional intake
• IV fluid administration
• Instruction to avoid coffee, smoking, alcohol, spicy
diets
• Educate the patient.

96
E. Expected out comes
– Anxiety & pain alleviated
– Maintained fluid balance
– Maintained nutritional status

97
 Peptic Ulcer Disease(PUD)
• It is an excavation (hollowed – out area)
formed in the mucosal wall of the stomach, the
pylorus, the duodenum, or the esophagus.
• It is frequently referred to as a gastric,
duodenal, or esophageal ulcer, depending on
its location

98
 Comparison of Duodenal & Gastric Ulcer

Duodenal Ulcer
• Age - Common b/n 30 - 60year
–Risk factors alcohol, smoking, B/d group o,
stress
–Male: Female: - 3: 1
–Stomach acid: - Hyper secretion
–Vomiting: - Uncommon
–Weight: - gain
99
–Pain: -occurs 2- 3 hour after meal &
relived by food ingestion
–Perforation: - more common
–Malignancy Possibility: -rare

100
 Gastric Ulcer
• Usually 50year & over
• Gastritis, alcohol, smoking, NSAID,A blood
group
• Male: Female: - 2: 1
• Normal to: - Hypo secretion
• Vomiting common
• Loss may occur
• Pain: ½ to 1hour after meal& relived by
vomiting
• Perforation: - Less common
• Malignancy Occasionally 101
 Etiology:-
• Etiology of PUD is poorly understood, but it is
associated with Gm negative H.Pylori
• PUD occurs only in the areas of GI tract that are
exposed to HCL & Pepsin.
Predisposition
• Stress or anger
• Familial tendency
• Use of NSAIDS, alcohol ingestion & excessive smoking.
• Bacterial infection (H. Pylori )
• 102
 PATHPHYSIOLOGY

• Peptic ulceration depends on the defensive

resistance of the mucosa relative to the aggressive
force of secretary activity. The defensive resistance
of the mucosa depends on the following factors:-
1. Mucosal integrity & regeneration
2. Presence of a protective mucus barrier
3. Adequate b/d flow to the mucosa
4. Ability of the duodenal inhibitory mechanism to
regulate secretion
103
• * The aggressive factors relate to the presence of
Helicobacter pylori & Volume of HCl & biliary acid.
• Ulceration occurs when aggressive factors exceeds
the defensive one.
C/M: - Pain (burning Sensation cramp like, gnawing
pain) in the mid-epigastrium or in the back
• Vomiting & Nausea
• Constipation & bleeding
• Abdominal distention, Bleeding

104
 Diagnostic Evaluation

• P/E
• Endoscopy
• X-ray
• Stool exam for occult blood
• Gastric Secretary studies ( achlorhydria )
• Biopsy & culture for H.pylori

105
 Management :(Non drug Mx.)

• Stress reduction & rest

• Smoking Cessation
• Dietary Modification ( advice the Pt. what ever
agrees with them)

106
 Medical Mx of PUD :-
• Medications are prescribed for clients with
PUD for 4 major reasons :-
a) To eliminate H. Pylori bacteria from the GIT
b) To reduce secretion (hypo-secretory drugs),
c) To neutralize acid (antacids)
d) To protect the mucosal barrier.
 Read the detail in your handout

107
 Surgical Treatment for PUD

Indication of Surgery: -
• Intractable ulcer (those who fail to heal after
12 to 16wks of medical Rx.)
• Life - Threatening Hemorrhage
• Perforation
• Obstruction of gastric out let.

108
 NURSING INTERVENTION
• Preoperative nursing care for the patient undergoing
surgery for peptic ulcer disease includes:-
1. Preparing the pt for diagnostic tests (Laboratory
analysis, x-ray, & general physical examination).
2. Attending to the pt's fluid & nutritional level & to
maintain an optimal fluid & electrolyte balance.
3. Clearing & emptying GIT.
_ Naso-gastric Suction often is required to empty the
stomach in Pt. with Pyloric obstruction
4. Limiting oral Intake
109
 Nursing Process
• The Patient with PUD
1. Assessment - History
-P/E
2. Nursing Diagnosis
• Pain related to the effect of gastric acid secretion.
• Anxiety related to an able to coping with an acute
disease
• Knowledge deficit about prevention & treatment.
• Altered nutrition, less than body requirement,
related to pain associated with eating.
110
3. Plan:-
• To relief pain.
• " " anxiety
• " Increase pts awareness
• " maintain adequate nutrition
4. Nursing Intervention
• Administer Medication
• Advise the pt to avoid foods that are irritant: -
Alcohol, caffeine & Cigarettes
• Reassure the pt.
• Teach necessary Information 111
 Evaluation:-
• Experiences less pain
• Free of anxiety
Complication
1. Perforation ( DU>GU)
C/F: - abrupt sever pain, tenderness, Rebound
tenderness, guarding
2. Gastric out late obstruction ( Pyloric Stenosis )
S/S: - Delayed gastric emptying
• Fullness
• Vomiting
• Weight loss 112
3. Hemorrhage
• PUD is the most common Cause of UGI
bleeding
• Occurs in 20% of PUD
• NSAID drugs intake increase risk of bleeding

113
 CANCER OF THE STOMACH

• It is most common in people over the age of 70

years
• It refers to the malignant neoplasms found in the
stomach.
Risk Factors :-
• Chronic inflammation of the stomach
• Pernicious anemia
• Gastric ulcer
• Heredity
• H.pylori bacteria
114
• smoking
Etiology- unknown
C/M: -are vague & indefinite
• Pain
• Indigestion
• Anorexia, nausea & vomiting.
• Dyspepsia
• Weight loss
• Constipation
• The commonest site is pyloric & antral region.

115
Diagnostic Evaluation :-
• Endoscopy for biopsy & cytology
• X-ray
Mx :- Surgical removal of the cancer,
chemotherapy, Radiation.

116
 THE PATIENT UNDERGOLNG GASTRIC SURGERY

Definition
1. Gastric Resection
• Total gastrectomy :- GI Continuity is restored by
anastmosis b/n end of esophagus & Jejunum.
• Subtotal gastrectomy: - Stump of stomach is an
astomosed to the jejunum.
2. Vagotomy: - Interruption of the impulses carried by
the vagus nerve by surgical interruption of its fibers.
117
3. Pyloroplasty: - A plastic operation for the repair
of a lesion of the pylorus, especially surgical
enlargement of the caliber of a stricture pylorus
by dividing the strictured portion longitudinally.
4. Gastroduodenostomy
- Surgical creation of an anastomosis between the
stomach & duodenum.
5. Gastrojejunostomy
- Surgical Creation of an anastomosis between the
stomach & Jejunum.
118
Preoperative Nursing Diagnosis:-
• Knowledge deficit regarding the surgical procedure
& postoperative Course
Plan: -
• To Provide information about the procedure &
Postoperative course
Nursing Intervention: -
• Teach the type of surgery that is planned
• Advise the patient that requests will be made to
breathe deeply & Cough, post Operatively.
119
• Advise the patient that a Nasogastric tube will be
placed postoperatively & fluid will be withheld until
peristalsis returns.
• Inform the patient that parentral fluids will be
given.
• Inform the patient that wound dressings may have
drainage.
• Informed Consent.

120
 POST OPERATIVE
A. Nursing Diagnosis :-
• Pain related to the surgical Incision
• Fluid Volume deficit, Related to shock or hemorrhage
• Risk for infection related to surgical incision.
B. Plan
• To relief pain
• To maintain normal fluid volume
• To maintain adequate nutrition
• To prevent infection
121
C. Nursing Interventions
• Administer analgesics as prescribed
• Withhold oral fluid until prescribed
• Monitor for signs of hemorrhage
-Observe Suture line for bleeding
-Evaluate B/P, pulse, & RR
-Observe gastric aspirate for evidence of
bleeding.
• Assess patient for signs of shock :
-Take B/P, PR, RR frequently
-Administer Fluids as prescribed. 122
• Administer oral & IV fluids as ordered.
• Increase fluids according to pt's tolerance.
• Assess wound for sign & symptom of infection
• Assess abdomen for signs of peritonitis
• Administer Prophylactic antibiotic

123
D. Nursing Evaluation
• Pain is relieved
• Remain NPO until physician allow intake of fluids.
• No hemorrhage
• Vital signs within normal ranges
• Bowel sounds audible
• Attains adequate caloric intake
• Absence of signs & symptoms of infection

124
 ACUTE APPENDCITIS
• It is an inflammation of the appendix.
• Etiology - not known
• Risk factors :- Sex (M>F)
• Age (most common b/n 10 & 30 Years)
• Economic status ( high & middle social class )
* Pathophysiology: - Appendix becomes inflamed &
edematous as a result of becoming either kicked
or occluded, possibly by a fecalith, tumor, or
foreign body. This cause ischemia & necrosis.
125
C/M: - Right lower quadrant pain
• Low grade fever
• Loss of appetite
• Local tenderness at McBurney's point when
pressure is applied
• Rebound tenderness (production of pain when
pressure is released)
• Constipation or diarrhea
• nausea

126
• Rovsing's sign may be elicited by palpating the
left lower quadrant, which paradoxically causes
pain to be felt in the right lower quadrant.
• Diffused pain if appendix is ruptured.

127
 Diagnostic Evaluation

• Complete Hx & P/E

• X-ray may reveal a right lower quadrant density or
localized air -flow levels.
• CBC……> Elevated WBC > 10,000/mm3 & neutrophil
count> 75%
• Ultrasound

128
 Management:-
• Secure IV fluid & administer antibiotics
• Analgesics can be given after diagnosis is made
• Appendectomy ( surgical removal of appendix )
Complications :-
-Perforation of appendix
- Peritonitis
-Appendial abscess

129
 Nursing Intervention:-
• Reliving pain by administering analgesics
• Preventing fluid volume deficit by giving IV fluids
• Reassure the pt & prevent infection
• Preoperative & postoperative nursing care is the
same as that of pt under going major surgery.

130
 Peritonitis

• Is an inflammation of the peritoneum (the thin

membrane that lines the abdominal wall & covers
most of the organs of the body.)
• There are two major types of peritonitis.
1. Primary peritonitis- caused by the spread of
infection /bacteria from the blood & lymph nodes
to the peritoneum. This type peritonitis is rare less
than 1% of all cases.

131
2. Secondary peritonitis- the more common type of
peritonitis caused during perforation or rupture of
abdominal organs allowing access to entry of
bacteria & irritant digestive juices to the
peritoneum.
Etiology – caused by bacterial or chemical
contamination of peritoneal cavity.
• The major source of inflammations are
From the diseases of GIT
From the external environment (gunshot wound,
stab wound)
132
Through the blood steam septicemia. A source of
infection (the most common organism E.coli,
streptococci, klebsiella, pseudomonas when they
enter the sterile peritoneal cavity.
Usually this is a result of
 Perforated appendix
 Perforated PUD
 Bowel perforation
 Septic abortion
 pancreatitis
 cholecytitis
133
• Peritonitis may also be associated with abdominal
surgical procedures & peritoneal dialysis.
C/M-
• Sharp abdominal pain w/c worsen with movement
• abdominal distention
• Fever & increased PR
• Abdomen becomes rigid(muscle guarding)
• Nausea & vomiting
• Decreased or absent bowel sound

134
• Tenderness
-Localized peritonitis= peritonitis confined to a
limited space e.g pelvis
-Generalized peritonitis= the whole peritoneal
cavity involved
• Respiration may be shallow & rapid
• Low B/P & sign of dehydration
Diagnosis
• Hx
• P/E
135
• Laboratory study- elevated WBC & to identify the
causative agent
• Abdominal X-ray – show dilation & edema of the
intestine or any perforated organ
-a free air or fluid in the
abdominal cavity
• Serum electrolyte studies- loss of electrolyte

136
 Medical mgt
• Fluid and electrolyte replacement
• IV antibiotics therapy(triple antibiotics) gentamycin,
clindamycin/metronidazole & ampicillin
• Analgesics for pain
• NGT- to reduce abdominal distention
• Oxygen therapy by nasal cannula or mask
Surgical mgt
• Drainage of the abscess /excess fluid
• Repair perforated/damaged tissue/organ
137
 Nursing mgt
• Regularly monitor vital signs, fluid intake & output
• Place the pt in fowlers position to promote
drainage
• Encourage and assist ambulation
• Watch closely for possible surgical complications
• Close follow up

138
 complication
• Generalized sepsis
• Shock- may result from septicemia or
hypovolemia
• Inflammatory process may cause intestinal
obstruction

139
 Disorders of the lower G.I.T.

Ulcerative Colitis
• It is a recurrent ulcerative & inflammatory disease
of the mucosal layer of the colon &rectum.
• It affects superficial mucosa of the colon & is
characterized by multiple ulcerations & diffuse
inflammations.
Etiology - unknown

140
Predisposing factors:-
• Anxiety, tobacco, radiation
• C/M: - Diarrhea (10 to 20 liquid stools daily)
• Abdominal pain
• Intermittent tenesmus
• Rectal bleeding
• Anorexia
• Weight loss
• Fever, Vomiting, dehydration
• Rebound tenderness may occur in the right lower
quadrant.

141
Diagnostic evaluation:-
• Careful stool exam :- to r/o amoeba
• Low hgb & Hct level
• Elevated WBC
• Sigmoidoscopy & barium enema

142
Mx: - Oral fluids & a low residual, high protein, high-
calorie diet with supplemental vitamin therapy &
iron supplement is given.
• Avoid any food which exacerbate diarrhea
• Treat dehydration
• Avoid cold foods & smoking
• Antibiotics can be given for secondary bacterial
infection.
• Partial or complete, with ileostomy or anastomosis.

143
Complication:-
• Perforation
• Hemorrhage
• Malignant neoplasm

144
 INTESTINAL OBSTRUCTION

• Intestinal Obstruction exists when blockage

prevents the normal flow of intestinal contents
through the intestinal tract.
• It can be classified as the following:-
A) Mechanical obstruction Vs Functional
Obstruction
B) Small bowel Obstruction Vs Large bowel
obstruction
C) Partial Obstruction Vs Complete Obstruction
145
 Causes of Intestinal Obstructions
1. Causes of Small bowel obstruction
Adhesion of intestinal wall due to:-
• Surgery
• Intestinal Tuberculosis
• Inflammatory Condition of intestine.
Paralytic ileus
Hernia
Gallstones ileus
Tumor
Ascaris bolus 146
Intusscusption: - It is the small bowel telescopes, as
if it were swallowing itself by invagination. It is the
commonest problem in infants.
C/M: - Sudden Colicky pain intermittent with 10 -20
minute Interval.
• Initial Vomiting
• Normal Stool may be passed or bloody.
• Restless, dehydration &cry
• Distention is late

147
2. Cause of large bowel Obstruction
Colorectal Cancer
Adhesion
Paralytic Ileus
Inflammatory bowel disease
Volvulus: - It is twisting of a mobile loop bowel on
its mesentery.
• It occurs mostly in sigmoid colon but it can affect
small intestine & caecum.

148
Cardinal S/S of large bowel Obstruction :-
• Colicky lower abdominal pain
• Absolute Constipation ( Flatus & Feces )
• Gross abdominal distention
• Nausea and Vomiting
• Abdominal x-ray reveals grossly distended 2 limbs of
sigmoid colon often with fluid - air level.

149
 Comparison of small bowel Vs large bowel
obstruction
 Small bowel Obstruction
• Abdominal Crampy
• Vomiting early S/S
• Constipation late sign
• Abdominal distention
• Diagnostic - Hx & P/E
• Evaluation - abdominal X-ray indicates abnormal
quantities of gas &/or air in the bowel.
150
• Mx: - Decompression of the bowel through NG
tube.
-IV fluid ( N/S or R/L ) administered
-Surgical Intervention

151
 Large bowel obstruction
• Abdominal Crampy
• Constipation is early S/S
• Grossly distended abdomen
• Fecal Vamiting
• Diagnostic - Hx & P/E
• Evaluation - Abdominal x-rays reveals distended
colon
• Mx -Colonoscopy may be performed to Untwist &
decompress the bowel in high colon obstn-
152
-In lower bowel obstruction rectal tube may be used
for decompression.
-Surgical Intervention
-Iv fluid administration

153
 Diagnostic evaluation of Intestinal Obstruction

1. Hx
2. P/E - pt is acutely sick looking
• V/S: - B/P - decrease due to fluid loss & sepsis
- PR - Tachycardia
-To - Increases if there is complication
• HEENT - dry buccal mucosa
• Abdomen: - Distended
-Mild tenderness on palpation
-visible loop but not always
-Tympanic on percussion
154
 -Bowel sound may be absent or increase
-PR - empty rectum or hard stool
3) Ix - CBC
-Hgb
-V/A
-Abdominal x-ray

155
 Medical Management

A.General Management :-
• Keep the patient NPO
• NG tube should be inserted for small bowel
obstruction to aspirate intestinal content.
• Secure IV line ( Normal Saline or ringer Lactate )
• Triple antibiotic ( Ampicillin, Gentamycin,& CAF )
• Sedation

156
B. Specific RX:
Sigmoid Volvulus :-
• Rectal tube is inserted for deflation but
contraindicated if gangrenous.

157
 HERNIAS
• Def.:-It is a protrusion of bowel through a weak
point in the musculature of the anterior abdominal
wall or an existing opening.
Etiology: - Powerful muscular effort or strain
-Weakness or defect to the wall of
abdominal cavity
Predisposing factors:-
• Constipation, ascites
• Previous abdominal surgery
• Lifting heavy load
• Chronic Cough 158
 Classn- Based on Sites of Hernias :

1. Inguinal Hernia
• The protrusion of bowel through the weak point is
the inguinal canal which contains the spermatic
cord in the male & the round ligament in the
female.
• It occurs more commonly in males than females.

159
• Inguinal Hernia Can be:-
A) Direct inguinal Hernia
• Push their way directly forward through
posterior wall of the inguinal canal, into a
defect in the abdominal wall.
• Less common (20%)
• Strangulate Rarely

160
B) Indirect inguinal Hernia
• Pass through the internal inguinal ring & then
through the external ring
• Common (80%)
• Can Strangulate
Distinguishing direct from indirect hernias.
• The best way is to reduce the hernia &
occlude the internal ring with 2 fingers. Ask
the pt. to cough - if the hernia is restrained it
is indirect; if it pops out it is direct.g
161
2. Femoral Hernia
• More Common in women than men.
• Bowel enters the femoral canal, presenting as a
mass in the upper middle thigh or above the
inguinal ligament where it points down the leg,
unlike an inguinal hernia which points to the
groin.
• It is frequently strangulate & irreducible

162
3. Para-umbilical Hernias:
• These occur just above or below the umbilicus.
4. Incisional Hernias:-
• These follow breakdown of muscle closure after
previous Surgery. If obese, repair is not easy.

163
5. Umbilical Hernia: - Results from failure of
umbilical orifice to close.
• Occur most often in obese women & children
& in patients with cirrhosis and ascites.
C/F:- Only abdominal mass if not complicated
- Bowel sound on auscultation

164
 Classification of hernia according to
Severity
1. Reducible Hernia :- The protruding mass can be
replaced in abdomen
2. Irreducible Hernia :- The protruding mass cannot
be moved back into abdomen
3. Incarcerated: - An irreducible hernia in which the
intestinal flow is completely obstructed.
4. Strangulated: - an irreducible hernia in which the
blood & intestinal flow is completely obstructed.

165
C/F of Strangulation:
• Pain, vomiting
• Swelling of hernial sac,fever
• Lower abdominal sign of peritoneal irritation
Management-repairing the weak abdomen part
of abdominal wall.

166
 Disorders of the rectum
Haemorrhoids
• It is an enlarged & congested patch of mucosa &
sub-mucosa at ano-rectal junction or
• Are dilated portions of veins in the anal canal.
• Hemorrhoid based on its site:-
1. Internal haemorrhoid (if it is above internal
sphincter.)
2. External haemorroid ( if it is outside external
sphincter)
167
C/F:- Bright red blood occurring at the end of defecation
(Late)
• Mass Per-rectum
• Peri-anal Discomfort
• Pruritus
• Mucosal Discharge
• Pain when complicated
 External hemorrhoids are associated with severe pain
due to inflammation & edema caused by thrombosis.
Clotting of blood (thrombosis) lead to necrosis &
ischemia.
 Internal Haemorrhoids are painless until they bleed.
168
 Classification of heamorhoids based on its stage(severity)

• 1st degree:- Bleed but no prolapsed

• 2nd degree :- Prolapsed but reduce spontaneously
• 3rd degree :- " but need manual replacement
• 4th degree :- " not returned.
Etiology: - idiopathic
Predisposing factor:-
• Chronic Constipation
• Pelvic masses ( Pregnancy )
• Portal HTN 169
Rx: - Regulating bowel by laxatives
-Avoid Constipation
-Advice high - residue diet that contain fruit.
-Sitz bath
Good personal hygiene & by avoiding excessive
straining during defecation haemorrhoid symptoms
& discomfort can be relieved.
According to DACA drug Rx- Bismuth subgallate
insert one suppository in the rectum bid for five
days.

170
 Conservative Surgical Rx of internal
Haemorrhoid:-
A. Rubber - band ligation procedure: - The
haemorrthoid is visualized through the anoscope,
& its proximal portion above the muco-cutaneous
lines is grasped with an instrument.
• A small rubber band is then slipped over the
hemorrhoid. Tissue distal to the rubber band
becomes necrotic after several days & sloughs off.
• It may cause infection, pain & hemorrhage

171
B. Cryosurgical Hemorrhoidectomy
• Involves freezing the tissue of the hemorrhoid for a
sufficient time to cause necrosis.
• Not used widely because the discharge is very foul-
smelling & wound healing is prolonged.
C. Hemorrhoidectomy, or surgical excision, can be
performed to remove all of the redundant tissue
involved in the process.

172
 Ano-rectal Abscess

• Is a pus filled cavity caused by bacteria invading a

mucus secreting gland in the anus & rectum.
Risk Factors: - Regional enteritis
• - Immunodefcient States (HIV/AIDS)
* Many of these abscesses will result in fistulas.

173
C/M: -
• Abscess may occur in a variety of spaces in &
around the rectum.
• Pain
• Foul - Smelling pus
• In Superficial abscess, (Swelling, redness &
tenderness).
• Deeper abscess ( Fever, abdominal Pain )
• Fistula
174
Mx :- 1) Palliative Rx:-
-Sitz Bath
-Analgesics
2) Surgical Rx:-
- Incision & drainage
3.medical RX- ANTIBIOTICS -A

175
 ANAL FISTULA
• It is a tiny, tubular, fibrous tract that extends into
the anal canal from an opening located beside the
anus.
Cause:
• Fistula usually results from an infection.
• Trauma
• Fissures
• Regional Enteritis

176
C/M
• Pus or stool may leak constantly from the
cutaneous opening
• Passage of flatus or feces from the vaginal or
bladder depending on the fistulas tract.
• Fever
Mx:- Surgery is always recommended
-Fistulectomy (excision of the fistulous tract)

177
 ANAL FISSURE
• It is a longitudinal tear or ulceration in the lining of
the anal canal
Cause: - Trauma of passing a large firm stool
- Persistent tightening of the anal canal
secondary to stress or anxiety (leading to
Constipation)
- Child birth
- Trauma

178
C/M: - Extremely Painful Defecation
- Burning
- Bleeding
Mx: -
• Increase water intake
• Sitz bath
• Emollient Suppositories
• Corticosteroid Suppositories Relieve Discomfort
• Surgery
*Most of the fissures will heal by conservative
measures.

179
 Cancer of the Large Intestine:
Colon & Rectum

• Tumors of the small intestine are rare; conversely tumors of

the colon & rectum are relatively common.
Cause: - Unknown
Risk factors:-
• Age: - incidence increases with age (most patients are over
age 55). It is the most common cancer in old age except for
prostates cancer in men.
• Family history of colon cancer
• Chronic inflammatory bowel disease, Polyp
• A diet high in fat, protein, & beef & low in fiber
180
C/M -It is determined by the location, stage of
cancer & Function of the intestinal segment.
• Unexplained anemia
• Anorexia
• Weight loss
• Fatigue
• Abdominal Pain
• Melena
• Crampy

181
• Constipation
• Distention
• Tenesmus ( ineffective, painful straining of
stool )
• Rectal Pain

• Feeling of incomplete evacuation after a

bowel movement
• Alternating Constipation & Diarrhea
• Bloody Stool
182
* Diagnostic Evaluation:-
• Fecal occult blood testing
• Barium enema
• Procto-sigmoidoscopy
• Colonoscopy
• Biopsy or cytology smears.

183
 Medical Mx:-

• The patient with symptoms of intestinal obstruction

is treated with IV fluids & nasogastric Suction.
• Treatment depends on the stage of the disease &
related complications. The most widely used staging
method is duke's classification:-
• Class A- tumor limited to mucosa & Sub-mucosa
• Class B- Penetration through bowel wall
• Class C- Invasion into regional draining lymph system.
• Class D- Advanced & widespread regional metastasis
184
* Surgery is indicated for most class A- lesions & all
class- B and C.
• Radiation Therapy
• Surgical Removal: - is primary treatment
• Segmental Resection with anastomosis
• Temporary Colostomy followed by segmental
resection & anastomosis
• Permanent Colostomy or ileostomy

185
Complications of Colorectal Cancer
• Partial or Complete bowel obstruction
• Hemorrhage
• Perforation

186
 Nursing Process

• The patient with cancer of the colon or rectum

1. Assessment
• Hx: - Feeling of fatigue
• Presence & Character of abdominal or rectal pain
( location, frequency, duration, association with
eating or defecation )
• Past & Present elimination pattern
• Description of color, odor, & consistency of stool
including presence of blood or mucus
• Hx. of chronic inflammatory bowel disease
• Family hx of colorectal cancer.
• P/E:- Auscultation
• Palpation for areas of tenderness, distention &
Solid masses
• Inspect the stool for presence of blood.

188
Nursing Diagnosis: - May include:-
• Constipation related to obstructing lesion
• Pain related to tissue compression 20 to obstruction
• Risk for fluid volume deficit related to vomiting &
dehydration
• Impaired skin integrity related to the surgical
incision
• Body image disturbance related to colostomy
• Altered nutrition, less than body requirements,
related to nausea & anorexia
• Anxiety
189
plan :-
• To alleviate pain
• To attain optimal level of nutrition
• To maintain normal fluid & electrolyte balance
• To maintain optimal tissue healing, and adequate
protection of perio-stomal skin.
• To attain adequate elimination of body waste
products.
• To relieve anxiety

190
Preoperative Nursing Intervention
• Administer laxative & enemas as prescribed.
• Analgesics administration
• Full liquid diet may be prescribed 24 hours
before surgery to decrease bulk
• Instruct NPO.
• Parenteral nutrition

191
 Nursing Care for Patient with
Colostomy

• Colostomy: - Is the surgical creation of an opening

(stoma) into the colon.
• It can be temporary or permanent divertion.
• It allows for the drainage or evacuation of colon
contents to the outside of the body.
Colostomy Irrigation
a. It is done to permit escape of feces when there is
an obstruction of the large bowel or a known lesion,
such as cancer, that will eventually cause an
obstruction. 192
b. It also may be done to permit healing of the bowel
distal to it after an infection, perforation or
traumatic injury since it diverts the fecal stream
from the affected area.
c. It may be done as a palliative measure in the
treatment of an obstruction caused by an
inoperable growth of the colon or if the rectum
must be removed to treat cancer.
d. It may be done to provide a permanent means of
bowel evacuation.

193
• Purpose of colostomy irrigation
1. To encourage a bowel motion in a recently
established colostomy and to ensure that the
opening is patent.
2. To relieve constipation in patients who has difficulty
managing their colostomy.
3. To teach the patient how to establish regularity of
evacuation through the colostomy.
4. To reduce distention before closure of colostomy
Assignment- read colostomy irrigation procedure in
your hand out.
194
 Disorders of the Accessory Organs (Liver,
gallbladder and pancreas)
Diseases of the liver
Patient with hepatitis
• It is an inflammation of the liver
• Pathophysiology: - Hepatocytes are damaged
& become inflamed & necrosed by the body's
immune response to the virus. This alters
cellular function.
• The degree of functional impairment depends
on the amount of hepatocellular damage.
195
.
• The hepatocytes generally heal in 3 to 4 months
Cause:- Virus
- Bacteria
- Toxic substance
Types of Hepatitis: -
• viral hepatitis
• Toxic hepatitis
• Chronic hepatitis
• Alcoholic hepatitis
196
 Viral hepatitis

• Hepatitis type A
• Hepatitis type B
• Hepatitis type C
• Hepatitis type D
• Hepatitis type E

197
 Hepatitis type A /Infectious hepatitis /

– It is endemic in some areas of the world,

especially with poor sanitation
Causative agent: - Infectious hepatitis virus
Mode of transmission: - The major route of
transmision is through
• Faecal – oral route (Contaminated food, milk,
polluted water)
– Spread of the disease is enhanced by crowding &
poor sanitation.
198
Incubation: - 3-7 weeks; average 4 weeks.
Occurrence: -
• Worldwide – sporadic or epidemic
• Autumn & winter months
• Usually in children & young adults

199
C/M: -
1. Pre-icteric (Prior to period of Jaundice)
Phase:-
-Headache -Pain over the liver
-Abdominal tenderness - Fever
- Muscle crampy - Anorexia
-Vomiting - Backache
-nausea

200
2. Icteric phase
• Urine-dark; stool often light for several days
• Liver-enlarged, often tender
• Nausea, vague Epigastric distress, heart burn,
flatulence, anorexia

201
 Hepatitis B

Causative agent: - Hepatitis B Virus

Mode of transmission: -
A. Parenteral route
– Blood transfusion from an infected person
– Contaminated needles, syringes
B. Skin puncture – medical equipments
C. Mucosal transmission; dental instruments

202
Incubation period: - 6 weeks to 6 months/ average
2.5 – 3 month
Occurrence: - world wide
• Diagnosis: - Count electrophoresis (CEP)
• “Sandwich” Count electrophoresis (SCEP)
• Radioimmunoassay
C/M – S/S similar to infections hepatitis, but usually
more insidious in onset
• Respiratory manifestations minimal or absent

203
Rx: & Nursing Mx: -
• Isolate patient to minimize contacts
• Wear gloves; wash hands thoroughly
• Assist with laboratory diagnostic studies
• Handle bed pan carefully & instruct pt. to ensure
meticulous personal hygiene habit.
• Use disposable syringe & needles
• Avoid alcohol consumption
• Recognize that recovery is slow & prolonged

204
 LIVER CIRRHOSIS
• It is a chronic disease in which there has been
diffuse destruction of parenchymal cells followed by
liver cell regeneration & an increase in connective
tissue.
• These processes result in disorganization of the
lobular architecture and obstruction of the hepatic
venous & sinusoidal channels, causing portal
hypertension.

205
 Classification
1. Alcoholic cirrhosis of the liver (micro nodular)
– Fibrosis – mainly around central veins & portal
area
– Most commonly due to chronic alcoholism.
2.Post necrotic (Macro nodular)
• Due to previous acute viral hepatitis or drug
induced massive hepatic necrosis.
3. Biliary cirrhosis
• Scarring around bile ducts & lobes of liver.
206
• Result from chronic biliary obstruction (With or
without infection)
• Much more rare than alcoholic & post necrotic
cirrhosis
4. Cardiac cirrhosis is secondary to congestive heart
failure with prolonged venous hepatic congestion

207
Causes
• Alcohol & Hepatitis virus (B & C).....> By far the
most common
• Drugs * Methyldopa
* Methotrexate
• Autoimmune chronic active hepatitis
• Chronic hepatic congestion

208
C/F:- Weight loss, muscle wastage
• Flatulence, pal mar erythema
• Jaundice, loss of body hair, gynecomastia
• Oedema , Bleeding
• Anaemia 20 to bleeding
• Abdominal distinction (Ascites)
• Hepatomegely + spleenomegally
• Oesophageal varices.
• Sign of hepatic encephalopathy.

209
Diagnosis
• Liver biopsy & Liver function test
• Oesophagoscopy
• Liver scan
• Paracentesis to examine ascetic fluid

210
 Management
A/ Nutrition
• Maintain caloric & vitamin diet intake give protein
as tolerated
• Avoid table salt, salty foods & canned foods
• Use ‘Salt’ substitutes such as lemon juice
• Offer small frequent meals
• Eliminate alcohol

211
B/ Medication
Multivitamins preparation
• Vit. K – if a tendency of bleeding is manifested such as
epistaxis, melena, hematoemesis
• Vit B12 – to correct anaemia
• Electrolyte fluid balance EX .Spirinolacton
• Electrolyte fluid balance

• Avoid toxic drugs: - barbiturates, diazepam

- Oral contraceptive
- Alcohol
212
C/ Rest & activity
If there is no ascites & sign of hepatic coma: -
• Limit amount of activity
In advanced liver impairment
• Bed rest
• Frequent change of position
• Special skin care & passive exercise.

213
Complication of liver cirrhosis
• Hepatic comma
• Bleeding & oesophageal varices.
• Portal hypertension
• Spontaneous peritonitis
• Asites
• Hepatic encephalopathy
• Anaemia

214
 Hepatic Encephalopathy & Hepatic coma

• Hepatic encephalopathy: - Results from the

accumulation of ammonia & other toxic metabolites
in the blood.
• Hepatic coma: - represents the most advanced
stage of hepatic encephalopathy.

215
 • Ammonia accumulates because damaged liver
cells fail to detoxify & convert to urea the
ammonia that is constantly entering the blood
stream as a result of its absorption from the
GIT & its liberation from kidney muscle cells.
• The increased ammonia concentration in the blood
causes brain dysfunction & damage, resulting in
hepatic encephalopathy.

216
C/M: -
• Early Stage: - Late Stage
• Euphoria * Drowsiness
• Depression * Insomnia
• Apathy * Agitation
• Irritability * Slow & slurred speech
• Memory loss * Hyperactive reflex
• Confusion * Slow deep respiration

217
• Impending coma:- Asterixa (flappng tremor of
hands)
• Fetor hepaticas (Breath odour like freshly mowed
grass, acetone, or old wine, may be noticed.
• Disorientation to PPT

218
MX:- Vital signs are measured & recorded every 4
hours
• Serum ammonia level is monitored daily.
• Avoid constipation
• Enema to reduce ammonia absorption
• Sterilization of intestine (Neomycin sulphate)
• Lactulose is administered to reduce blood ammonia
• If sign of impending hepatic encephalopathy occur,
reduce protein intake.

219
 CANCER OF THE LIVER
Classification:-
1) Primary
2) Metastatic tumor
Primary tumor:- It can be benign or malignant
• Origin Benign Malignant
• Hepatocytes - Adenoma - HCC
• Connective tissue -Fibroma -Sarcoma
• B/d vessels -Hemangoma -
Hemangioendothelioma
• Bile duct -Cholangioma -Carcinoma
220
• Primary liver tumors usually occur in patients with
chronic liver disease.
• Hepatocellular carcinoma (HCC) is by far the most
common type of primary liver cancer.
• HCC grows rapidly & metastasis elsewhere.
• Other types of primary liver cancer include
cholangiocellular carcinoma (CCC) and combined
HCC & CCC.

221
Metastatic carcinoma –
• It arise from GIT (particularly colon),breast & the
lung.
• is more common than primary tumors.
• Malignant tumour reaches the liver by way of portal
system or lymphatic channels or direct extension
from abdominal tumour
• Liver is a frequent site of metastasis.

222
Causes: -
• Cirrhosis
• Hepatitis B & C
• Exposure to certain chemicals toxins
• Cigarette smoking & alcohol.

223
C/M: - Early manifestations are s/s of impaired
nutrition:
Such as: - Recent loss of weight
• Loss of strength
• Anorexia
• Anaemia
• Abdominal pain
• Enlargement of liver
• Jaundice & Ascites some times

224
MX: - Surgery (hepatic lobectomy), following surgery
the patient should be observed closely for
haemorrhage.
• Chemotherapy , Radiation
Nursing Care: -
• Rest & Positioning
• Psychological support
• Mouth care
• Patient education
• Pre - & post operation care
225
 LIVER ABSCESS
Def: - Formation of pus in the liver.
• Two Categories of liver abscess have been identified
1. Amoebic liver abscesses: - most common.
• Cause: - Entamoeba histolytica
2. Pyrogenic liver abscesses
• Less common
• Cause: - Staphylococcus, streptococcus, E. Coli

226
• Mechanism: - GIT infection......>Liver ……>Abscess
cavity formation
C/M: - fever
• Chillness
• Dull abdominal pain
• Tenderness
• May develop: - Hepatomegally
- Jaundice
- Anaemia

227
RX – Intravenous antibiotic therapy (Depending on
the organism identified)
• Continuous supportive care
• Blood transfusion
• Nutrition & fluid
• Rest & positioning
• Psychological support

228
 Trauma of the Liver
Def: - It is injury to the liver
Cause: - Stab
• Bullet injury
• Accidental puncture
MX: - Blood transfusion
• Surgical repair
• Control bleeding
• The area may be sutured or packed
• A drainage tube into the abdominal cavity is attached.
Complication: - Peritonitis
-Impaired liver function 229
 Disease of the Gall - bladder

Cholecystitis
• It is an inflammation of the gall bladder wall.
• It may be acute or chronic
Acute Cholecystitis
• It is acute inflammation of gall-bladder wall.
• It can be:
1) Acute calculus Cholecystitis (infection with
stone):-is most common.
230
2) Acute acalculus Cholecystis (Infection without
stone)
Cause: -
1) Gall stones (Obstruction of a cyst duct by a stone is
the usual cause of acute Cholecystitis).
2) Colon bacilli – E. coli
- Streptococcus faecalis.
- Staphylococcus
- Salmonella or complication of
typhoid fever.
*In 50% of cases the cause is not known. 231
S/S: - Sudden onset
• Severe nausea & Vomiting
• Pain & tenderness in the RUQ of abdomen or mid
epigastrium
• Fever , Jaundice

232
DX: - Murphy's sign on physical examination.
- Ultrasonography – is the best investigation
• x-ray
• WBC count
MX: - Complete bed rest
-IV fluid
-Analgesics
-Antibiotics (Ampicillin , gentamycin,
cephalosporin)

233
* If the condition persists or worsen it may indicate
suppuration (Empyema) of the gallbladder.
- Surgery for Empyema: - Cholecystostomy
- Cholecystectomy
Chronic Cholecystitis
• It is almost always associated with gallstones
S/S – long history of vague digestive complaints
• Abdominal discomfort & flatulence after a large
meal or one high intake.
• A dull aching pain
• Nausea & vomiting
234
• It affects middle-aged & older obese women.
Female to male ratio is 3:1
• Chronic inflammation results in scaring & thickening
of the wall of the gall bladder & Cholestasis.
• Moderate fever, dyspepsia
• If calculi are present, they progressively increase in
size or number.
DX: - Ultrasonography

235
MX: - Surgery – Cholecystostomy
• Low fat diet, weight reduction
• sedatives
Complication:-abscess
-Pancreatitis
- Cholangitis (inflammation of bile duct)
-Rapture of the gall bladde
-Biliary cirrhosis

236
 Cholelithasis
• It is a formation of stone with in the gall bladder
• Consistency of the stone: - Cholesterol
- Bile pigment
Aetiology – Not well known
• The possible reason for stone formation can be as
follows:-
1) Change in bile composition (high concentration
cholesterol)
2) Bile stasis (total parenteral nutrition)
3) Infection 237
Incidence: - May occur in both sexes
- More often occurs in middle aged
female, higher in individual with regional enteritis
-Diabetes
-Cirrhosis of liver
-Obesity & genetic factors.
-Oestrogen administration.

238
S/S: - Gallstone causes no manifestation unless
complicated.
• Pain which starts in the upper midline area. It may
radiate to the back & right shoulder.
• The client is restless, changing position frequently
to relieve intensity of the pain.
• Digestive disturbance fallowing fat ingestion.
• Inflammation of gall bladder, nausea, vomiting,
dyspepsia.
• Cholestasis (stasis of the bile with in the liver
leading to impaired functioning of the organ)
239
• Obstructive jaundice
DX. :- Endoscopy & U/S
RX. & Nursing Intervention
a. Medical management
• Administration of parenteral analgesics.
b. Endoscopy
• For stone removal from common bile duct
c. Cholestrol dissolving agents
• Ursodeoxycholic acid

240
d) Dietary management
• Avoid eating a fatty meal, consumption of a large
meal after fasting
• In acute attack the patient should be NPO.
• IV fluid for maintaining fluid & electrolyte balance.
• NG tube insertion & aspiration if vomiting &
abdominal distension occurs.
• Observe for sign of jaundice
e) Surgical MX: - Cholecystolithotomy

241
 Complication of Cholelithiasis
• Cholangitis
• Biliary Cirrhosis
• Carcinoma & Peritonitis
• Choledocholithiasis (Stone in the common bile
duct)

242
 Nursing MX of Gallbladder disease
A) Relieve pain
• Giving medication before the pain becomes more
severe
• Observe for the side effect of drugs
B). Relieving nausea & vomiting
* If vomiting is severe – use gastric decompression
* NPO
* Frequent mouth care

243
C) Providing comfort & emotional support
D) Maintaining fluid
NURSING PROCESS
The patient undergoing Surgery for gallbladder
Disease
1. Assessment
- History
- Physical examination

244
2. Nursing diagnosis
- Pain & discomfort related to surgical incision
- Impaired gas exchange related to high abdominal
surgical incision
- Impaired skin integrity related to surgery
- Altered nutrition related to inadequate bile
secretion
- Knowledge deficit about self care

245
3. Plan & implementation: -
• relief pain, absence of respiratory complication.
-Improved nutritional intake, understanding care.
Postoperative Nursing Intervention
• Relieving Pain
• Improving Respiratory Status
-Early ambulation
-Deep breathing & coughing exercise
• Promote skin care & biliary drainage

246
• Improve nutritional status
- Low fat & high CHO & Protein
• Patient education
• Monitor & manage potential complication.

247
 Disorders of the pancreas
Pancreatitis
• It is an inflammation of the pancreas
• It may be acute or chronic
Acute Pancreatitis :-
• It is an inflammation of the pancreas that may
result in auto-digestion of the pancreas by its own
enzymes.
• Potentially serious disease
• If it is mild the pancreas becomes swollen &
oedematous with treatment the patient recovers
248
• If it is severe & persists – necrosis & haemorrhage.

-Blood & enzymes may scape into the

surrounding tissue & peritoneal cavity
- Peritonitis, Paralytic ileus, or ascites may
develop.

249
Aetiology & risk factors
*In 90% of the cases it is due to biliary disease &
excessive alcohol consumption
- gall Associated with blockage of ampulla of vater
by stone causing activation of pancreatic enzyme
• Alcoholism
• Infection & injury
• Drugs, pancreatic ischemia during episodes of
hypotensive shock
• Idiopathic

250
DX. Determination of serum: -
• Amylase increased
• Lipase increased
• CT scan

251
C/M: - Sudden onset
* Penetrating pain to the back (burning or
boring pain) on the upper abdomen is the first
presentation later on the pain is generalized.
• Nausea/Vomiting
• Constipation
• Abdominal distension & rigidity as a result of
peritonitis
• Peristalsis diminished

252
• Shock due to the pain & loss of blood
• The skin became pale & cold
• Vital sign = B/P decrease, P/R increase
• Confusion, coma, transient hyperglycaemia
• Jaundice

253
RX. & Nursing Intervention
1. Anti-pain :-usually treated with narcotic analgesics
2. Keep the patient NPO
3. IV- Plasma or whole blood
– Electrolyte & glucose solution
4. Gastric aspiration
5. Mouth care
6. Medication – Antibiotics
- Analgesics

254
Surgical Intervention
• Surgery is not usually undertaken during on
acute attack of Pancreatitis unless there is
increasing obstruction jaundice due to
impacted stone.
• Choledocholithotomy

255
Chronic Pancreatitis
• It is an inflammatory disorder characterized by
progressive anatomic & functional destruction of
the pancreas.
Patho-physiology:- Repeated attack of acute
pancreatitis causes scarring & calcification
pancreatic tissue & irreversible damage to the
endocrine & exocrine pancreatic function.

256
Cause: - Alcohol consumption (excessive & prolonged
consumption) (75%)
• Protein malnutrition
• Pancreatic trauma
C/M: - Recurring attacks of severe upper abdominal &
back pain accompanied by vomiting
• Anorexia, nausea, flatulence, constipation,
abdominal distension.
• Weight loss, steatorrhea (stool with high fat
content)
• Hyperglycaemia.
257
*Thus, the clinical group of manifestation that serves
as a classical presentation of chronic pancreatitis
is :-
• Abdominal pain
• Weight loss
• Diabetes
• steatorrhea

258
RX. & Nursing Intervention
• Analgesics
• Low fat diet
• Avoid alcohol consumption
• Surgery: - Surgical intervention may be used to
drain pseudo cysts or to relief interactable pain
partial pancreatectomy or anatomises of the
pancreatic duct with the jejunum, may be done.

259
 Cancer of the pancreas
• About 75% occur in the head.
• About 25% occur in body & the tail
* Incidence increase with the following conditions: -
- Cigarette smoking
- Old age
-Alcohol consumption
-Ingestion of high fat diet.
* The prognosis of a patient with cancer of the
pancreas is very poor
260
 C/M: - RUQ pain which radiates to the back
• Progressive weakness & loss of body weight
• Jaundice
DX: - Ultrasonography
• CT scan
• Blood study (SGOT, alkaline phosphatase,---)
RX :-
• Surgery:-whipples Operation
(pancreatoduodenectomy with removal of the distal
third of the stomach.
Nursing Intervention:- similar to patient undergoing
GI surgery. 261