GI disorders

• the GI system starts at the oral cavity (mouth) and ends at the anus
• the purpose of the GI tract is to absorb nutrients and fluids from the outside environment
• hiatal hernia: part of the stomach comes up through the sphincter into the thoracic cavity and on top of the diaphragm (hence chest pain)
• clinical manifestations of hiatal hernia: chest pain (RULE OUT CARDIAC FIRST), "heartburn", early satiety, difficulty breathing (especially after a large meal)
• what does a hiatal hernia mimic?

  heart attack
• medical treatment of a hiatal hernia?

  antacids, PPI (OMEPRAZOLE), H2 receptor antagonists (CIMETIDINE), surgical repair (nissen fundoplication)
• what is a nissen fundoplication?


  surgery where a hernia is brought back down under the diaphragm and the top of the stomach is wrapped around the esophagus
• when is a nissen fundoplication done?

  when 1/3 of the stomach is above the diaphragm
• complications of hiatal hernia: barretts esophagus
• what is barretts esophagus?

  a precancerous state; the lining of the esophagus becomes more resistant to acid
• physical assessment of hiatal hernia: dysphagia, clinical manifestations of GERD (acid reflux, heartburn, burping), nausea and vomiting, iron deficiency anemia (due to losing blood from the erosions), and eructation ("throwing up in your mouth")
• what is happening with eructation?


  the hiatal hernia pouch fills up and the sphincter cant close so when the pt burps the food comes back up
• labs for hiatal hernia: upper abdominal x-ray, endoscopy, barium swallow with fluoroscopy, and esophagogastroduodenoscopy (EGD)(scope to see whats going on)
• goal for hiatal hernia: pt will be free from complications such as acid reflux, barretts esophagus, and maintain a stable weight
• interventions for hiatal hernia: medication management (CIMETIDINE, OMEPRAZOLE, and antacid), position patient supine on right side (helps stomach empty quicker), and elevate head of bed after meals (keeps food/acid from coming back up; at least 30 degrees)
• teaching for hiatal hernia: limit foods (spicy, caffeine, chocolate, carbonated, acidic, peppermint, alcohol), eat meals 2 HOURS before laying supine, wear NONrestrictive clothing, maintain normal weight, proper positioning after eating, and post op education
• GERD: valve at top of stomach doesnt close correctly and acid comes back up
• clinical manifestations of GERD: heartburn and eructation
• medical treatment of GERD: antacids, H2 blockers (CIMETIDINE), prokinetic medication (encourges movement of GI), and PPI (OMEPRAZOLE)
• surgery for GERD: laparoscopic nissen fundoplication (SEVERE cases only)
• complications of GERD: barretts epithelium and esophageal strictures (causes difficulty in swallowing)
• GERD physical assessment: heartburn especially after a meal, eructation, dysphagia, regurgitation, halitosis (bad breath), dental cavities, nausea and vomiting, and asthma symptoms
• how does GERD cause halitosis (aka bad breath)?

  food is rotting in the esophagus
• labs/diagnostics for GERD: upper abdominal x-ray, endoscopy, EGD, CBC (looking for an infections or anemia/bleeding)
• interventions for GERD: same as hiatal hernia, administer medications as ordered, position patient on right side with head of bed elevated 6-12 inches, provide small frequent meals
• teaching for GERD: limit irritating foods (spicy, chocolate, peppermint, caffeine, alcohol), avoid smoking and alcohol, eat meals 2 hours BEFORE laying supine, wear nonrestrictive clothing, and maintain ideal body weight
• what are the problems with the esophagus?

  hiatal hernia and GERD
• peptic ulcer disease (PUD): damage to gastric mucosa of both the stomach and the small intestines; erosions due to corrosive action of gastric juice
• what is the pH of gastric juice?

  1.5-2
• clinical manifestations of PUD: pain triggered or worsened by eating
• medical treatment of PUD: antacids, H2 blockers (CIMETIDINE), PPI (OMEPRAZOLE), and sucralfate
• complications of PUD: GI hemorrhage (can erode into an artery), abdominal or intestinal infarction, perforation and penetration into attached structures (the acid "digs" holes into other organs), obstruction, peritonitis (EMERGENCY)
• gnawing pain that comes and goes?

  peptic ulcer disease
• physical assessment of PUD: abdominal, pain in RIGHT shoulder, nausea and vomiting, vital signs (blood pressure and HR), use of alcohol or other medications (NSAIDs and steroids cause GI bleeding), diet (what is usual for the patient; 24 hour recall), weight
• labs/diagnostic for PUD: upper GI endoscopy, CBC (WBC and H/H), serum electrolytes/BUN/Cr (K+, Na+), gastric pH, and blood culture (watching for sepsis)
• peritonitis/perforation symptoms (**BAD**):

  • abdominal rigidity (board like)
  • ABSENT bowel sounds (listen for 5 minutes in each quadrant)
  • fever
  • low urine output (bleeding and going into shock)
  • thirst (going into shock)
  • inability to pass stool or gas
• interventions for PUD: maintain IV infusions, administer medications as ordered, assist with gastric lavage (NG; suctioning off gastric secretions to rest the stomach and stop the raw areas from being burned more), prepare patient for endoscopy (NPO), limit food intake after evening meal, pain assessment
• teaching for PUD: take medications as prescribed, avoid eating within 2 HOURS of bedtime, advise patient to avoid risk factors (NSAIDs, ETOH, caffeine, spicy foods)
• why are NSAIDs a horrible culprit of PUD?

  they decrease Cox 1&2 and blocks mucus production which increases the risk of an ulcer
• GI Bleeding:

  • coffee ground emesis (digested stomach blood)
  • melena (black tarry stools)
  • hematochezia (bright red blood in the stool)