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1. MANAGING PATIENTS WITH GASTROINTESTINAL SYSTEM DISORDER By: Amdehiwot A.

2.  Anatomy & Physiology overview of GIS  Anatomy of the Gastrointestinal System The GIT, is a hollow muscular tube that extends from the mouth to the anus . The GI tract is 7 m to 7.9 m long For simplicity and understanding, the digestive system can be dividing into four parts: The Upper GIT  Mouth, Oesophagus and Stomach. The Middle GIT  Small intestine. The Lower GIT  Large intestine. The 4 th part(accessory structures)  salivary glands, liver, gallbladder and pancreas. 2

3. Therefore, the GIT pathway extends from the mouth to the esophagus, stomach, small and large intestines, and rectum to the terminal structure, the anus. 3

4. Division of the abdominal region: In to four quadrants or nine regions. 4 Figure - Division of the abdominal region

5. Organs found in the 4 quadrants RUQ contains :- Duodenum, Pylorus, loops of SIs & Part of the colon Rt. adrenal gland, Portion of Rt. Kidney Liver, Gall bladder, head of pancreas RLQ contains :- Appendix, distended Bladder Loops of the SI, Cecum, portion of ascending colon Lower pole of the Rt. Kidney, Rt. Ureter, Enlarged uterus, Rt. Ovary, Rt. Salphinx & Rt. Spermatic cord 5  LUQ contains :- Lt. adrenal glands Portion of the colon, stomach & Loops of SI Portion of the Lt. Kidney Body of pancreas, Spleen  LLQ contains :- Loops of the SI, distended bladder, Sigmoid and portion of descending colon Lower pole of the pt Lt. kidney Lt. Ovary, Lt. Salpinx, Enlarged uterus Lt. spermatic cord, Lt. Ureter

6. Parts of GIT: 1. The esophagus Is located in the mediastinum anterior to the spine and posterior to the trachea and heart. Is approximately 25 cm (10 in) in length Passes through the diaphragmatic hiatus. 2. The stomach A hollow muscular organ, situated in the left upper portion of the abdomen; with a capacity of ~ 1500 mL The stomach stores food during eating, secretes digestive fluids, and propels the partially digested food/ chyme /, into the small intestine . The GEJ is the inlet to the stomach. The stomach has four anatomic regions : the cardiac (entrance), fundus, body, and pylorus (outlet) . The pyloric sphincter - controls the opening b/n the stomach & the SI. 6

7. 3. The small intestine Is the longest segment of the GI tract, accounting for about two thirds of the total length. Its functions are secretion and absorption It has three sections: The most proximal section is the duodenum, the middle section is the jejunum, and the distal section is the ileum. The ileum terminates at the ileocecal valve. This valve, or sphincter, controls the flow of digested material from the ileum into the cecal portion of the LI and prevents reflux of bacteria into the small intestine. Attached to the cecum is the vermiform appendix , an appendage that has little or no physiologic function. Emptying into the duodenum is the common bile duct, which allows for the passage of both bile and pancreatic secretions. 7

8. 4. The large intestine It consists of an ascending segment on the right side of the abdomen, a transverse segment that extends from right to left in the upper abdomen, and a descending segment on the left side of the abdomen. The sigmoid colon, the rectum, and the anus complete the terminal portion of the large intestine. A network of striated muscle that forms both the internal and the external anal sphincters regulates the anal outlet. 8

9. Blood supply & innervations of GIT Blood flow to the GI tract is about 20% of the total cardiac output and increases significantly after eating. Both the sympathetic and parasympathetic portions of the autonomic nervous system innervate the GI tract. Sympathetic nerves - exert an inhibitory effect on the GI tract, decreasing gastric secretion and motility and causing the sphincters and blood vessels to constrict. Parasympathetic nerve stimulation causes peristalsis and increases secretory activities. The sphincters relax under the influence of parasympathetic stimulation except for the sphincter of the upper esophagus and the external anal sphincter , which are under voluntary control. 9

10. The GIT is also composed of 4 layers; Mucosa (inner layer)  sub-mucosa  m uscularies and  Serosa Muscularies(longitudinal and circular) The largest serosa is peritoneum Most of abdominal organs are covered by peritoneum. Some are retroperitoneal organs. 10

11. Functions of the GIT; N.B: All cells of the body require nutrients These nutrients are derived from the intake of food that contains proteins, fats, carbohydrates, vitamins, minerals, and cellulose fibers and other vegetable matter, some of which has no nutritional value. These are: Secretion of electrolytes, hormones and enzymes to be used in the break down of the ingested materials. Movement of ingested products. Digestion of food and fluids. Absorption of products into the blood stream . Elimination of undigested/unabsorbed foodstuffs & other waste products 11

12. Assessment of Gastrointestinal System Health History A focused GI assessment begins with a complete Hx.  Common GIT disease symptoms includes ; Dysphagia and Odynophagia Heartburn, reflux & Indigestion Dyspepsia, Flatulence N ausea and vomiting Anorexia/ appetite loss Abdominal pain Diarrhea, constipation, fecal incontinence Alteration of bowel pattern Abdominal distension Weight loss Haematemesis Rectal bleeding Melaena Jaundice , Itching & previous GI disease is obtained. 12

13. Pain assessment Pain can be a major symptom of GI disease. The character, duration, pattern, frequency, location, distribution of referred pain Time of the pain greatly depending on the underlying cause. Other factors, such as meals, rest, defecation, and vascular disorders, may directly affect this pain . 13

14. P/E  proceeds in the ff steps  Inspection  auscultation  palpation  percussion 1. Inspection : - Inspect contour of the abdomen Is it flat, scaphoid, distention. 5 F’s that causes distention:- fluid, flatus, feces, fat, fetus Normally the flanks are concave but convex in distention Insp. umbilicus: it’s position, Sx of inflammation & hernia. Inspect abdominal skin : superficial veins, stretch marks, scar, rashes and lesions Look for prominent superficial veins  Caput medusae Inspect Scars:- it could be surgical or b/c of trauma. Finally the groins , uncover and inspect both groins for swelling, hernia (if hernia is present, ask pt to cough) Symmetry: Observe the abdomen for symmetry, checking for lumps, bulges or masses. Assess for visible peristaltic waves 14

15. 2. Auscultation:- Auscultation provides important information about bowel motility/ bowel sounds and vascular bruits/. Listen to the abdomen before performing percussion or palpation Normal- high-pitched, irregular gurgles with frequency of 5 to 35 times/mint, present equally in all four quadrants.  It is important to document the frequency of the sounds, using the terms Normal every 5 to 35/minutes), Hyperactive - in case of early onset of IOs. Hypoactive - in case of peritonitis Absent - incase of generalized peritonitis - bowel activity rapidly disappears & a state of paralytic ileus. 15

16. Auscultation cont’d Occasionally you may hear borborygmi —long prolonged gurgles of hyperperistalsis . Confirm bowel sounds in each quadrant, listen for up to 5mint to confirm the absence of bowel. Vascular Sounds : use the bell to auscultate vascular sounds. Normally there is no bruit. Abnormally- bruits heard over aorta, renal arteries A bruit in one of these areas strongly suggests renal/aorta artery stenosis as the cause of hypertension 16

17. 3. Percussion Helps you: To assess the amount & distribution of gas in the abdomen To identify possible masses that are solid or fluid filled. Estimating the size of the liver and spleen  Percuss all four quadrants to assess the distribution of tympany and dullness .  Tympany usually predominates b/c of gas in the GIT, but there are scattered areas of dullness due to fluid & feces. Percussion notes : normally- tympanic over bowels, Stomach, Empty bladder. Dull percussion note will be heard over liver, spleen, pancreas, kidney, uterus, distended bladder, fluid and tumor . 17

18. 4. Palpation:- Tell the patient to relax as best they can and to breathe quietly Types of palpation 1. Light Palpation - to detect tenderness , superficial masses and involuntary rigidity (muscular spasm) Using the finger tips, and compress to a depth of 1cm. Involuntary rigidity (muscular spasm) typically persists despite these maneuvers. It indicates peritoneal inflammation  Types of tenderness Murphy’s sign (inspiratory) Rebound tenderness Direct tenderness 2. Deep Palpation :- Compress to maximum depth 5 to 6cm , perform bimanual palpation if you encounter resistance or to assess deeper structures To detect masses and size of organs (organomegaly  liver, spleen). 18

19. General nursing interventions for the pt who is undergoing a GI diagnostic evaluation include: Establishing the nursing diagnosis Providing needed information about the test and the activities required of the patient Providing instructions about post procedure care and activity restrictions Providing health information and procedural teaching to patients and significant others Helping the patient cope with discomfort and alleviating anxiety Informing the primary care provider of known medical conditions or abnormal laboratory values that may affect the procedure Assessing for adequate hydration before, during, and immediately after the procedure, and providing education about maintenance of hydration 19

20. Diagnostic Evaluations in pts with GIS D/ors Diagnostic Tests Used to locate the nature and the level of the problem associated with GI diseases. GI diagnostic studies can confirm, rule out, stage, or diagnose disease. General methods of diagnosis include:-  L aboratory tests Complete Blood Count Red blood cells- 4.2 to 5.4 million/mm3 (women) 4.5 to 6.2 million /mm3 (men) Haemoglobin 12 to 16g/dl (Women) 14 to 18 g/dl (Men). Hematocrit- 38 to 46% (Women) , 42 to 54% (Men) Decreased value indicates possible anaemia or hemorrhage . Increased value indicates possible hemoconcentration , caused by dehydration. 20

21. Electrolytes Potassium 3.5 to 5 mg/d, decreased value indicates possible GI suction, diarrhoea, vomiting, intestinal fistula. Fecal Analysis - Stool for occult blood Normally- negative Presence indicates possible GI bleeding, peptic ulcer, cancer of the colon, ulcerative colitis. Stool for ova and parasites . Normally negative. Presence indicates infection. Stool cultures Normally no unusual growth. Presence of pathogens may indicate:- shigella , salmonella, staphylococcus aures , bacillus. Stool for lipids Normally 2 to 5gm/24h(Normal diet) Increased values indicate possible malabsorption of fecal fats ( steatorrhea ). Gastric analysis Is performed to measure secretions of HCL and pepsin in the stomach. it can aid in the diagnosis of duodenal ulcer, gastric carcinoma, pernicious anaemia. 21

22. Radiographic tests A flat plate of the abdomen is an X-ray study performed to visualize abdominal organs. This test can reveal abnormalities such as tumours, obstruction, abnormal gas collectives and strictures. Preparation For this procedure, the client should be dressed in a hospital gown with out any belts or jewellery . 22

23. Endoscopy Is the direct visualization of the GI system by means of a lighted, flexible tube. More accurate than radiologic examination because the physician can directly observe source of bleeding and surface lesions and determine the status of healing tissue. Anticholinergic medication- to decrease oropharyngeal secretion to prevent reflex bradycardia . sedatives- diazepam- to relax the client. Dentures- should be removed. A local anesthetic is sprayed on the posterior pharynx to ease the discomfort and prevent gagging when tube is inserted. Client should not swallow saliva. 23

24. Diagnostic Tests Procedure: After being medicated, a flexible, fiberoptic endoscopy tube is passed orally into esophagus stomach and pylorus and duodenum. Client should not swallow saliva. Some endoscopes are equipped with a camera. other endoscopic tubes have equipment for performing a biopsy (cytologic examinations). Single polyps are sometimes removed via an endoscopy . Follow-up-care vital signs are checked frequently. Client is also placed on one side to prevent aspiration. NPO until the gas reflex returns (2 to 4 hours). Assess for signs of perforation. 24

25. Lower gastrointestinal endoscopy (colon endoscopy) Colonoscopy This test is used to diagnose obstruction, bleeding, change in bowel habits, and colon cancer, among other conditions. cannot be performed if there is a suspected or documented colon perforation, acute severe diverticulitis. Sigmoidoscopy-25 to 30 cm (10 to 12 inch) To visualize the distal sigmoid colon and rectum. Protoscopy - 7cm (2 3/4inch) Visualize the lower rectum and anal canal Endoscopy, Proctoscopy, and Sigmoidoscopy Endoscopic examination of the anus, rectum, and sigmoid and descending colon is used to evaluate chronic diarrhea, fecal incontinence, ischemic colitis, and lower GI hemorrhage and to observe for ulceration, fissures, abscesses, tumors, polyps, or other pathologic processes. 25

26. DISEASES OF THE MOUTH AND RELATED STRUCTURES 1. Dental Plaque & Dental caries Def n :- Refers to localized, post eruptive, pathological process of external origin involving softening of the hard tooth tissue ( enamels ) & proceeding to the formation of a cavity. Also called tooth decay . It is a preventable d/s 26

27. ….Cont’d Therefore, tooth decay is an erosive process that begins with the action of bacteria on fermentable carbohydrates in the mouth , which produces acids that dissolve tooth enamel. Dental decay begins with a small hole, usually in a fissure (a break in the tooth’s enamel) or in an area that is hard to clean. If Left unchecked, the decay extends into the dentin . Because dentin is not as hard as enamel, decay progresses more rapidly and in time reaches the pulp of the tooth. 27

28. THE EXTENT OF DAMAGE TO THE TOOTH DEPENDS ON:- 1. The presence of dental plaque Dental plaque is a gluey, gelatin-like substance that adheres to the teeth. The initial action that causes damage to a tooth occurs under dental plaque. 2. The length of time acids are in contact with the teeth 3. The strength of acids & the ability of the saliva to neutralize them 5. The susceptibility of the teeth to decay – w/c is due to: Old age- demineralization Low/high florin intake Low mineral taking 28

29.  Causes & Contributing factors includes :- Poor oral hygiene Not brushing teeth on a regular basis to an improper diet Age - Older adults are subject to decay from drug-induced or age-related oral dryness Nutrition, soft drink consumption, and genetic predisposition. N.B : In general, dental decay can occur in anyone.  Clinical manifestations : - Soreness and pain - Usually accompanied by abscess As the infection progresses, the pt’s face may swell. 29

30. Diagnosis: is based on Sign & symptoms presentation and With x-ray studies Medical management: Depends on the extent of damage and; Treatment for dental caries includes fillings, dental implants, or extraction, if necessary. Nursing intervention Emphasis on preventive Mg't or measures 30

31. Prevention measures Measures to prevent /control dental caries includes: Practicing effective mouth care/ mechanical cleansing (brushing) on a daily basis, Normal mastication (chewing) and the normal flow of saliva also aid greatly in keeping the teeth clean Reducing the intake of starches & sugars (refined carbohydrates) Applying fluoride to the teeth or drinking fluoridated water Refraining from smoking Controlling diabetes Regular dental visits 31

32. N.B: Pts who snack should be encouraged to choose less carciogenic alternatives, such as F ruits, vegetables, nuts, cheeses, or plain yogurt. In addition, Frequent brushing, especially after meals, is necessary. Flossing should be performed daily. Fluoridation of public water supplies has been found to decrease dental caries. Some areas of the country have natural fluoridation; other communities have added fluoride to public water supplies. N.B:- Oral health is a very important component of a person’s physical and psychological sense of well-being. 32

33. 2. Periodontal disease Periodentium – is the tissue that surrounds and supports the teeth. Periodontal disease/pyorrhea /- is a condition affecting the gums (gingivae ) and other supporting structures (bone , cementum, and periodontal membrane ) Etiology & Predisposing factors: Malocclusion is a misalignment of the teeth of the upper and lower dental arcs when the jaws are closed  it can be inherited or acquired (from thumb-sucking, trauma, or some medical conditions. Poor fillings Usually extension of uncontrolled gingivitis Nutritional deficiency - Vitamin deficiency Poor cleaning & oral hygiene Food debris  dental plaque  Can be predisposed 2˚ to some chronic health problems like; Anemia, Leukemia & DM … 33

34. Pathophysiology Improper cleaning and poor mouth hygiene contribute to the problem Tartar or calculus that can not be brushed from the tooth tends to build up and requires professional removal twice yearly, If this is not done, gums become swollen and tender, infection progresses and pockets that collect pus & bacteria are formed b/n the gums & teeth. The protective layer that normally cover the gums is destroyed, exposing the blood vessels w/c bleed easily Bacteria thrive on the nutrients in the blood and tissues w/c fill and line the space. The bone supporting the teeth is destroyed, and the tooth becomes loose. 34

35. C/m – Inflammation of tissues surrounding teeth Bleeding Erythema Loosing of teeth Edema & tenderness to gums Mg’t: Mechanical cleansing of gums & teeth Regular and periodic dental examination Daily flossing Adequate & proper nutrition Incise to provide drainage if abscessed Root canal procedure / tooth extraction Use warm saline rinses Antibiotic for 2˚infections Analgesics. 35

36. 3. GINGIVITIS Def n : Gingivitis - is a form of periodontal disease, it is an inflammation of gums. Causes: Poor oral hygiene - food debris Nutritional problem Bacterial plaque Calculus ( tartar)- a hard calcified deposit/dental plaque C/Ms :- Painful, inflamed, swollen gum Bleeding in response to light contact 36

37. 4. PERIODENTITIS Def n : - Refers to the inflammation of tissues surrounding a tooth. Predisposing factors: Usually extension of uncontrolled gingivitis Nutritional deficiency Food debris   S/S:- has little discomfort at the beginning may be bleeding loosening of tooth foul smelling breath 37

38. Rx: - Anti pain Irrigation with saline Nutrition Antibacterial agents Preventive oral hygiene: Brush teeth using a soft tooth brush at least 2x/day ( gums and tongue surface should be brushed) Floss at least once a day Use anti-plaque mouth rinse Visit dentist when you have a chipper tooth, oral sore longer than 2 wks, or tooth ache Avoid alcohol and tobacco products Maintain adequate nutrition & avoid sweets. 38

39. 5. Periapical abscess  More commonly referred to as an abscessed tooth Def n : - Periapical abscess - refers to collection of pus in the apical dental periosteum (fibrous membrane supporting the tooth structure) and the alveolar process in the Periapical region (tissue surrounding the apex of the tooth) The abscess may be acute or chronic . Acute abscess - i s usually secondary to a suppurative pulpitis - that arises from an infection extending from dental caries. Chronic abscess - is a slowly progressive infectious process. 39

40. …. Cont’d Acute periapical abscess Is usually secondary to a suppurative pulpitis (a pus-producing inflammation of the dental pulp) that arises from an infection extending from dental caries. The infection of the dental pulp extends through the apical foramen of the tooth to form an abscess around the apex. Chronic dentoalveolar abscess Is a slowly progressive infectious process. In contrast to the acute form, a fully formed abscess may occur without the patient’s knowledge. 40

41. Cause: untreated dental carries Pathophysiology: Untreated dental carries  Pulpitis (a pus-producing inflammation of the dental pulp)  Spread of infection through apical foramen to the apex (alveolar process in the Periapical region)  Periapical abscess 41

42. Clinical Manifestations The abscess produces a dull, gnawing, continuous pain Mobility of the involved tooth , b/c of periodontal ligament abscess Surrounding cellulitis and edema of the adjacent facial structures There may also be a systemic reactions - fever and malaise in well developed abscess The gum apposite to the apex of the involved tooth is usually swollen on the chick side Swelling and cellulitis of the facial structures may make it difficult for the patient to open the mouth. It is often discovered on x-ray films 42

43. Medical Management Draining abscess/a needle aspiration - to relieve pressure and pain and to provide drainage Anti – pain medications Antibiotics Extraction- if severe After the inflammatory reaction has subsided, the tooth may be extracted. Nursing Management Assesses the patient for bleeding after treatment Instructs the patient to use a warm saline or warm water mouth rinse to keep the area clean. Instruct pt to take antibiotics and analgesics as prescribed, to advance from a liquid diet to a soft diet as tolerated & to keep follow-up appointments. 43

44. 6. Stomatitis  Stomatitis or mucositis  is an inflammation and breakdown of the mucous membranes of the mouth. Stomatitis may be a clinical manifestation of a systemic condition or the result of an infection in the oral cavity Stomatitis is often a side effect of chemotherapy or radiation therapy. Etiology Trauma & chemotherapy Irritants ( tobacco, alcohol) & acidic foods 2º to health problems like – renal, Liver diseases Hematological diseases Due to food & drug reactions Physical & emotional stress is suggested to be the factors for initiation. 44

45. C/m : Mild redness (erythema) and edema sores in vocal cavity Ulcers of mouth & lips causing extreme pain Speech, chewing food & swallowing may present problems. Excessive salivation bleeding and secondary infection Halitosis Mg’t : corticosteroids – systemic or topical Tetracycline oral suspension Oral hygiene with soothing solution Soft balanced diet 45

46. Nursing considerations: Prophylactic mouth care, including brushing, flossing, and rinsing, for any pt receiving chemotherapy or radiation therapy Teach pt about proper oral hygiene, such as saline rinses Apply topical anti-inflammatory, antibiotic, and anesthetic agents as prescribed N.B Many radiation therapy centers recommend the use of fluoride treatments for patients receiving radiation to the head and neck. 46

47. DISORDER OF ESOPHAGUS ACHALASIA Def n : Achalasia - is absent or ineffective peristalsis of the distal esophagus, accompanied by failure of the esophageal sphincter to relax in response to swallowing. OR It is an esophageal smooth muscle motility disorder in which the lower esophageal sphincter (LES) fails to relax. Narrowing of the esophagus just above the stomach results in a gradually increasing dilation of the esophagus in the upper chest. Achalasia may progress slowly and occurs most often in people 40 years of age or older . Cause: Unknown 47

48. Cause May be familial Unknown But; It is thought to result from a selective loss of inhibitory nitrinergic neurons (which contain nitric oxide synthase ) in the myenteric plexus, resulting in relatively unopposed excitation by the cholinergic system. 48

49. Clinical Manifestations Difficulty in swallowing ( dysphagia ) both liquids and solids  (primary symptom of Achalasia ) Sensation of food sticking in the lower portion of the esophagus. Food is commonly regurgitated (as the condition progresses) Either spontaneously or intentionally by the patient to relieve the discomfort produced by prolonged distention of the esophagus by food that will not pass into the stomach. The pt may also complain of chest pain & heartburn (pyrosis) Pain may or may not be associated with eating . Weight loss There may be secondary pulmonary complications from aspiration of gastric contents. 49

50. Diagnostic evaluations: X-ray studies show esophageal dilation above the narrowing at the gastroesophageal junction . Barium swallow, computed tomography (CT - scan) of the esophagus, and endoscopy may be used for diagnosis; however, The diagnosis is confirmed by esophageal manometry - is the measurement of muscular function of the esophagus or is a process in which the esophageal pressure is measured by a radiologist or gastroenterologist. 50

51. Management There is no cure for Achalasia. Treatment is focused on palliating symptoms by decreasing LES pressure to facilitate emptying of esophageal contents. Therefore the Mg't aspects includes; Pt instructed to eat slowly and to drink fluids with meals. As a temporary measure, calcium channel blockers and nitrates have been used to decrease esophageal pressure and improve swallowing. Injection of botulinum toxin (Botox) - to quadrants of the esophagus via endoscopy has been helpful  because it inhibits the contraction of smooth muscle. Periodic injections are required to maintain remission. 51

52. Mg’t cont’d…. If these/ the above methods are unsuccessful, 2 other methods will be done:- 1. Pneumatic (forceful) dilation- it is a conservative Mg't of Achalasia  to stretch the narrowed area of the esophagus Or 2. Surgical separation of the muscle fibers may be recommended. 52

53.  F orceful dilatation/ pneumatic dilation Is performed by passing a tube orally in to the esophagus A distensible bag at the end of the tube as positioned & inflated Pneumatic dilation has a high success rate. The procedure can be painful; therefore, moderate sedation in the form of an analgesic or tranquilizer, or both, is administered for the treatment. The patient is monitored for perforation . Complaints of abdominal tenderness and fever may be indications of perforation. 53 Mg't cont’d…

54. S urgical separation of the muscle Achalasia may be treated surgically by esophagomyotomy . The procedure usually is performed laparoscopically. The esophageal muscle fibers are separated to relieve the lower esophageal stricture. 54 Mg't cont’d…

55. 2. HIATAL HERNIA Defn:- It refers to a condition in which the upper part of the stomach protrude in to the lower thoracic cavity. Normally, the opening in the diaphragm encircles the esophagus tightly, and the stomach lies completely within the abdomen. In a condition known as Hiatal hernia, The opening in the diaphragm through w/c the esophagus passes becomes enlarged Esophagus enters the abdomen through an opening in the diaphragm & empties at its lower end into the upper part of the stomach and also; Part of the upper stomach tends to move up into the lower portion of the thorax. Hiatal hernia occurs more often in women than men. 55

56. There are two types of Hiatal hernias: 1. Type - I or sliding hernia The upper stomach & cardioesophageal junction have moved upward and slide in and out of the thorax. And 2. Type – II or Paraesophageal hernia All or part of the stomach pushes through the diaphragm next to the gastroesophageal junction. 56

57. Sliding esophageal and paraesophageal hernias FIG. (A) Sliding esophageal hernia. FIG. (B) Paraesophageal hernia. 57

58. Type I (sliding Hiatal hernia) Occurs when the upper stomach & the GEJ is displaced upward and slide in and out of the thorax. About 90% of pts with esophageal Hiatal hernia have a sliding hernia. C/Ms:- The pt with a sliding hernia may have; Heartburn, Regurgitation, and Dysphagia, dullness 50% of patients are asymptomatic. Sliding Hiatal hernia is often implicated in reflux . 58

59. Type II (rolling hernia/paraesophageal hernia ) Occurs when all or part of the stomach pushes through the diaphragm beside the esophagus/next to the gastroesophageal junction. Clinical Manifestations Many of the pts are asymptomatic Patients usually feels a sense of fullness after eating or may be asymptomatic. Reflux usually does not occur , because the gastroesophageal sphincter is intact. 59

60. Diagnostic evaluation – for both type Diagnosis is confirmed by x-ray studies, barium swallow, and fluoroscopy. Complications: The complications of hemorrhage, obstruction, and strangulation can occur with any type of hernia. 60

61. Management Management for an sliding hernia includes:- Frequent, small feedings that can pass easily through the esophagus. The patient is advised not to recline for 1 hour after eating, to prevent reflux or movement of the hernia, and Pt bed elevated at the head of the bed on 10 -20 cm  to prevent the hernia from sliding upward. Surgery is indicated in about 15% of patients. 61

62. Management for Rolling hernia may require Emergency surgery to correct torsion (twisting) of the stomach or other body organ that leads to restriction of blood flow to that area. F ixation of the prolapsed stomach in its normal position by suturing in to the abdominal wall And other Mg't aspects includes Frequent small feeding Reduce wt if pt is obese Should avoid heavy lifting & bending Eliminate gas forming foods Remaining in an upright position after a meal Anti acids If the hernia is big surgical treatment is necessary 62

63. Gastric disorders 1.Gastritis Gastritis (inflammation of the gastric or stomach mucosa) is a common GI problem. Gastritis may be Acute, lasting several hours to a few days, or Chronic , resulting from repeated exposure to irritating agents or recurring episodes of acute gastritis. 63

64. Causes of acute gastritis Acute gastritis is often caused by Eating foods that is irritating, or contaminated with disease-causing MOs. Overuse of aspirin and other NSAIDs Excessive alcohol intake Bile reflux, and radiation therapy It also may develop in acute illnesses, especially when the patient has had; Major traumatic injuries; Burns; Severe infection; Hepatic, renal, or respiratory failure; or Major surgery. 64

65. Causes cont’d… A more severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. Scarring can occur, resulting in pyloric stenosis or obstruction. N.B : Gastritis may be the first sign of an acute systemic infection. 65

66. Causes of chronic gastritis Chronic gastritis and prolonged inflammation of the stomach may be caused either by Benign or malignant ulcers of the stomach Helicobacter pylori bacteria Associated with autoimmune diseases such as pernicious anemia; Associated with dietary factors such as; caffeine; use of medications such as NSAIDs Alcohol, smoking chronic reflux of pancreatic secretions and bile into the stomach. 66

67. Pathophysiology In gastritis, the gastric mucous membrane becomes edematous and hyperemic (congested with fluid and blood) and undergoes superficial erosion. It secretes a scanty amount of gastric juice, containing very little acid but much mucus. Superficial ulceration may occur and can lead to hemorrhage. 67

68. Clinical Manifestations For acute gastritis: - Abdominal discomfort, severe epigastric pain Headache, lassitude(lack of energy) Nausea, anorexia, vomiting, and hiccupping - which can last from a few hours to a few days. Some Pt’s however, have no symptoms 68

69. C/Ms … For chronic gastritis:- Anorexia, Nausea & vomiting Heartburn after eating Belching (sudden escape of gas or potion of half- digested food from the stomach) A sour taste in the mouth Some patients may have only mild epigastric discomfort or report intolerance to spicy or fatty foods or slight pain that is relieved by eating. However, some patients with chronic gastritis have no symptoms. 69

70. Assessment & Diagnostic finding Gastritis is sometimes associated with hypochlorhydria (absence or low levels of HCl) or with hyperchlorhydria (high levels of HCl). Diagnosis can be determined by Upper GI radiographic studies/upper GI x-ray series or Endoscopy and Histologic examination of a tissue specimen obtained by biopsy. Diagnostic measures for detecting H. pylori infection may be used. 70

71. Medical Management For Acute gastritis Instruct the Pt to refrain from alcohol & food until symptoms subside Bed rest, parental fluid After the pt. can take nourishment by mouth, a nonirritating diet is recommended. If the symptoms persist, intravenous (IV) fluids may need to be administered. 71

72. Antacids – Al (OH)3 and MTS , 10 to 30 ml or 2-4 tablets b/n meals / PRN Mixture of magnesium Hydroxide and aluminum hydroxide , 10-30 ml or 2to4 chewable tablets between meals (PRN) If gastritis is caused by ingestion of strong acids or alkalis, emergency treatment consists of diluting and neutralizing the offending agent. To neutralize acids, common antacids (e.g., aluminum hydroxide) are used; To neutralize an alkali, diluted lemon juice or diluted vinegar is used. 72

73. If corrosion is extensive or severe, emetics and lavage are avoided because of the danger of perforation and damage to the esophagus. Therapy is supportive and may include Nasogastric (NG) intubation, Analgesic agents and sedatives, Antacids, and IV fluids. In extreme cases, emergency surgery may be required to remove gangrenous or perforated tissue. A gastric resection or a gastrojejunostomy ( anastomosis of jejunum to stomach to detour around the pylorus) may be necessary to treat pyloric obstruction, a narrowing of the pyloric orifice, which cannot be relieved by medical management. 73

74. Mg’t cont’d… For Chronic gastritis Modifying Pt’s diet Promoting rest, Reducing stress Recommending avoidance of alcohol and NSAIDs, and initiating pharmacotherapy Amoxicillin 500mg /po. TID + cimetidine 400mg /BID for 02 weeks 74

75. Nursing Management Reducing Anxiety The pt may be anxious because of pain and planned treatment modalities. It is important to explain all procedures and treatments based on the patient’s level of understanding. Relieving Pain By instructing the patient to avoid foods and beverages that may be irritating to the gastric mucosa and By instructing the patient about the correct use of medications to relieve chronic gastritis. Promoting Optimal Nutrition Provides Physical and emotional support Monitor fluid intake and output along with serum electrolyte values. 75

76. Promoting Optimal Nutrition For acute gastritis, the nurse Provides Physical and emotional support Helps the patient manage the symptoms, which may include nausea, vomiting, heartburn, and fatigue. Instruct the pt not to take foods or fluids by mouth - possibly for a few days; until the acute symptoms subside, thus allowing the gastric mucosa to heal. If IV therapy is necessary, the nurse monitors fluid intake and output along with serum electrolyte values. After the symptoms subside, the nurse may offer the patient ice chips followed by clear liquids. 76

77. Nsg Mg’t cont’d… N.B: Introducing solid food as soon as possible; May provide adequate oral nutrition, Decrease the need for IV therapy, and Minimize irritation to the gastric mucosa.. The nurse also instruct pt not to take caffeinated beverages, Because caffeine is a central nervous system stimulant that increases gastric activity and pepsin secretion. Instruct pt not to take alcohol & cigarette smoking B/c cigarette smoking contains nicotine, Nicotine reduces the secretion of pancreatic bicarbonate, and Nicotine inhibits the neutralization of gastric acid in the duodenum. 77

78. Promoting Fluid Balance Daily fluid intake and output are monitored to detect early signs of dehydration Minimal fluid intake of 1.5 L/day, minimal output of 30 - 60 ML/hr). If food and oral fluids are withheld, IV fluids (3 L/day) usually are prescribed A record of fluid intake plus caloric value (1 L of 5% dextrose in water need to be maintained. Electrolyte values (sodium, potassium, chloride) are assessed every 24 hours to detect any imbalance. The nurse must always be alert for any indicators of hemorrhagic gastritis , which include  Hematemesis, Tachycardia & Hypotension Patient’s vital signs are monitored as the pt’s condition warrants 78

79. 2. PEPTIC ULCER A peptic ulcer is frequently referred to as a gastric, duodenal, or esophageal ulcer , depending on its location. It is the erosion of the circumscribed area of the mucous membrane Peptic ulcers are more likely to be in the duodenum than in the stomach. It occurs with the greatest frequency in people between the ages of 40 and 60 yrs 79

80. Causes of peptic ulcer Infection with helicobacter pylori Excessive secretion of HCl - acid in the stomach associated with stress, caffeinated beverages, smoking and alcohol ingestion Chronic use of NSAIDs Familial tendency Zollinger – Ellison syndrome- gastrin secreting benign or malignant tumors of pancreas. 80