Upper GI

• Concept of Metabolism: Part II Exemplars: Stomach and Intestinal Disorders
• Major issues in GI disorders

  • Bleeding

  Hypovolemia

  Infection/Sepsis

  The need for surgical intervention
• GI Bleeding


  Characterization of bleeding that is associated with the amount/location and speed of bleeding
• GI Bleeding Clinical Terminology

  • Hematemesis – Vomiting of blood that can be red but is more often use for coffee ground emesis

  Melena – Dark tarry stool – As blood passes through digestive process, it changes from red to black, although sometimes used when there is a mix of stool and blood = "mahogony"

  Hematochezia – Actual term for red blood passing from anus

  Frank bleeding (Upper or Lower)
• GI Bleeding Management


  Determine the significance based on the character and frequency of episodes. Minor to hemorrhage

  Regardless, all episodes require collaboration with the HCP. Any can become life threatening as the affect of blood loss impacts the hemodynamic status of the patient

  Isotonic IV fluid use to sustain or resuscitate = Initial treatment consideration

  Preparation for possible replacement of blood – Type and screen or type and cross. What is the difference and factors in decision?

  Small amounts to support intravascular volume

  Fluid challenges or boluses (250, 500, 1000 ml)

  Minor or infrequent episodes

  Major or frequent episodes
• GI Bleeding Management


  Frequent and vigilant assessment:

  Level of consciousness and orientation

  Vital signs: Elevated heart rate (and rate of respiration) and risk for hypotension

  Hgb/Hct: Decrease as blood is lost. Can be a slow decline or rapid drop to critical levels. Evaluation of coagulation status? Platelets, PT/INR & PTT

  Oxygen saturation: Application of oxygen due to decreased oxygen carrying capacity to support homeostasis and avoid hypoxia or cardiac ischemia

  First signs of bleeding include tachycardia, tachypnea and change in mental status

  Should patient be made NPO?

  Should an NGT be inserted?
• Gastritis


  A localized or patchy inflammation of the gastric mucosa

  May be acute (lasting several hours to a few days) or chronic, resulting from repeated exposures to irritating agents or recurring episodes of acute gastritis

  Most common cause of chronic gastritis is the bacterium Helicobacter pylori (H pylori)

  Other agents include aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), ethyl alcohol, or bile salts

  All lead to disruption of the protective barrier which can lead to edema, ulceration of the stomach's lining and GI hemorrhage
• Gastritis: Clinical Manifestations


  Epigastric pain, nausea and vomiting, weight loss, decreased appetite, and changes in color of the stool (black to red blood depending on speed and amount of bleeding)

  Pain may be exacerbated with the ingestion of spicy foods

  In patients with acute gastritis or exacerbations of chronic gastritis, there may be evidence of dehydration or upper GI bleeding

  With significant fluid or blood loss, the patient may develop signs of hypovolemic shock including pallor, tachycardia, and hypotension

  Active infection with H pylori can be detected with urea breath testing

  Endoscopic visualization is required for accurate diagnosis of damage and presence of ulcerations
• H Pylori Medication Treatment

  Variety of treatment approaches for eradicating disease attributable to H pylori

  Success depends on the type and duration of therapy, patient compliance, and factors such as antibiotic resistance

  Most include the combination of a PPI with two antibiotics for 7 to 14 days

  Triple therapies recommended as first-line treatments and quadruple therapy is recommended as second-line treatment when triple therapies fail

  Can include antibiotics like Clarithromycin, Amoxicillin, Metronidazole, Levofloxacin, etc.
• Peptic Ulcer Disease (PUD)


  Duodenal or Gastric

  Most common manifestation is pain

  Duodenal – empty stomach relieved by antacids or eating

  Gastric – triggered by eating

  Most common causes include H Pylori and NSAIDS

  Also associated with the acute period during or after physiological illness/crisis

  Huge consideration in critical care - PUD prophylactic treatment (With PPI) has become standard of care due to high risk for mortality with associated GI bleeding
• Antacids


  Widely used (and overused) - available OTC

  Aluminum hydroxide (Mylanta or Maalox)

  Neutralize or reduce the acidity of gastric acid and stimulation of prostaglandins that promote mucosal protection

  Most common side effect is constipation although excessive use can lead to hypophosphatemia or toxicity in patients with renal impairment

  Calcium compounds like Tums can lead to hypercalcemia

  Mucosal protectant – Sucralfate: Acidic environment of the stomach and duodenum changes sucralfate into a protective barrier that adheres to ulcer. This protects the ulcer from further injury from acid and pepsin

  Compliance with antacids is difficult due to the frequency of administration

  Important dosing issues

  1 hour before or 2-3 hours after meals

  Take medications at least 1 hour before or after medications to avoid interactions or decreasing effect of medications
• Histamine 2-receptor antagonists (H2 blockers)

  Famotidine (Pepcid)

  Others: Ranitidine (Zantac) and Cimetidine (Tagamet)

  Block H2 receptors to suppress secretion of gastric acid and lower the concentration of hydrogen ions in the stomach

  Side effects can include general reports of headache, constipation, diarrhea, nausea

  While not noted in readings, H2 blockers have been associated with thrombocytopenia – reason they are now used less frequently than PPI

  Availability of these medications OTC can discourage patients from seeking appropriate health care
• Proton Pump Inhibitors (PPI)

  Omeprazole (Prilosec)

  Others: Pantoprazole (Protonix), Lansoprazole (Prevacid) and Esomeprazole (Nexium)

  Blocks basal and stimulated acid production when treating conditions

  Also widely used for prevention of physiological stress ulcers in at-risk clients experiencing acute events

  Side effects can include general reports of headache, constipation, diarrhea, nausea

  Long term use is associated with osteoporosis, hypomagnesemia and Clostridium difficile-associated diarrhea
• PPI Administration Issues


  Pantoprazole is the only form available for intravenous use and requires reconstitution prior to administration

  Do not crush, chew, or break any sustained-release capsules

  Omeprazole, esomeprazole, and lansoprazole are available as delayed-release capsules containing enteric-coated granules

  Capsules with "granules" are the only form appropriate for use in NGT/PEG and specific directions from the pharmacy must be followed

  Example: Lansoprazole – Open capsule, mix intact granules into 40 mL of apple juice (no other liquids) and inject through the enteral tube. Flush with additional apple juice to clear the tube
• Complications of Ulcers


  • Penetration – Leading to significant bleeding and/or nonhealing state

  Perforation – Leading to possible peritonitis and need for surgery

  Obstruction – Leading to need for surgery
• Nasogastric Tube (NGT)


  NGT are frequently used in the management of GI disorders

  They can be used for decompression or enteral feeding

  Decompression is the removal of fluids and air from the stomach

  Type of tube varies on method of decompression ordered:

  Straight, non-vented tube (Levin tube) low intermittent wall suction (LIWS) or to gravity drainage

  Vented (Salem sump-type) for patients requiring low continuous wall suction (LCWS)

  Make sure to watch Davis Skill Video: Inserting nasogastric / nasoenteric tubes and read Davis Vol 2 Procedures 39 A-D for managing gastric suction
• NGT Irrigation


  What is the typical approach used with most NGT irrigation (to maintain patency of the tube and avoid blockages and distention of the stomach?

  30-60 ml of normal saline using a bulb syringe from irrigation kit. Then reconnecting to suction system to allow it to be suctioned into the container
• General Approaches


  • Dietary: Bland, non-spicy diets and smaller frequent meals

  Avoid medications associated with problems (ASA, NSAIDS, etc.)

  Pharmacological management – See exemplar medications

  Focus on collaborative and nursing management when there is bleeding

  Surgical: Usually reserved for nonhealing ulcers or persistent / significant bleeding

  Endoscopic cauterization of area

  Vagotomy (Sever nerve to reduce acid production)

  Massive, uncontrolled bleeding or perforation may require partial/total gastrectomy
• Gastrectomy Active Learning Case


  Several weeks after surgery the patient comes to the office reporting that 15 – 30 minutes after eating they are experiencing dizziness, tachycardia, sweating and diarrhea. Based on the situation and the manifestations, the nurse would consider that the patient is experiencing Dumping Syndrome caused by only partially digested food entering the small intestine

  What patient teaching does this situation require?
• Appendicitis


  Acute inflammation of the appendix

  Surgical Emergency

  Signs and Symptoms

  Abdominal pain in RLQ

  Nausea/vomiting

  Anorexia

  Temperature

  Risk for perforation that can lead to peritonitis (as ANY GI perforation can)
• Peritonitis


  Local or generalized inflammation of the peritoneum, usually associated with perforation of GI organ: Inflammation and internal contamination from bacteria and intestinal contents spilling into the peritoneum

  Signs and symptoms

  Fever

  Elevated WBC

  Nausea and vomiting

  Tachycardia

  Pain

  Board like abdomen and/or Rebound Tenderness
• Inflammatory Bowel Disease (IBD)


  IBD is an umbrella term for two very similar chronic diseases of the gastrointestinal tract: Crohn's disease and ulcerative colitis

  Exact cause is unknown, but has been linked to genetic predisposition, environmental conditions, and defects in immune regulation

  Exacerbations and remissions with significant potential outcomes

  Adhesions

  Fistulas

  Toxic Megacolon

  Multiple surgeries including colostomy

  Hypovolemia

  Septic shock
• Fistula


  Extremely difficult to treat abnormal opening between organ and skin or between two organs

  Enterocutaneous fistula (between skin and intestine)

  Enteroenteral fistula (between intestine and intestine)

  Enterovesicular fistula (between bowel and bladder)

  Enterovaginal fistula (between bowel and vagina)
• Similarities and Differences


  • Crohn's disease (CD)

  Loose, semi formed stool: 5 – 6 per day

  Fistulas often occur

  Need for surgery is common with likely reoccurrence

  Ulcerative colitis (UC)

  Frequent, watery, with blood
• WBC


  White blood cells
• Symptoms of inflammatory bowel disease

  • Nausea and vomiting
  • Tachycardia
  • Pain
  • Board like abdomen and/or Rebound Tenderness
• Inflammatory Bowel Disease (IBD)

  Umbrella term for two very similar chronic diseases of the gastrointestinal tract: Crohn's disease and ulcerative colitis
• Inflammatory Bowel Disease (IBD)


  • Exact cause is unknown, but has been linked to genetic predisposition, environmental conditions, and defects in immune regulation
  • Exacerbations and remissions with significant potential outcomes
• Potential outcomes of IBD

  • Adhesions
  • Fistulas
  • Toxic Megacolon
  • Multiple surgeries including colostomy
  • Hypovolemia
  • Septic shock
• Fistula


  Extremely difficult to treat abnormal opening between organ and skin or between two organs
• Types of fistulas


  • Enterocutaneous fistula (between skin and intestine)
  • Enteroenteral fistula (between intestine and intestine)
  • Enterovesicular fistula (between bowel and bladder)
  • Enterovaginal fistula (between bowel and vagina)
• IBD: Management


  1. Aggressive fluid replacement and electrolyte management

  2. Bowel rest: NPO and need for parenteral nutrition

  3. Medication management may include antibiotics, antidiarrheals and
• Exemplars of IBD medications

  • 5 Aminosalicylates – Sulfasalazine
  • Glucocorticoid
  • Steroids
  • Immunomodulators
  • Azathioprine
• 5 Aminosalicylates


  Block production of prostaglandins and leukotrienes to decrease inflammation – Primary use is in UC
• Steroids


  Used in exacerbations but should be given for short periods of time and tapered because of long-term side effects
• Immunomodulators


  Modifies the activity of the immune system to decrease inflammation; may be used for long-term therapy
• Azathioprine


  • Contraindicated with ASA or sulfa allergies
  • Immune issues and can cause decreased healing of fistulas and abscesses
  • Rarely leads to bone marrow suppression causing pancytopenia – monitor CBC
  • Side effects: Blood disorders – agranulocytosis and anemia
  • Side effects: Nausea and vomiting – take with meals. Can cause liver toxicity
• Diverticular disease


  • Diverticulum: sac-like herniation of the lining of the bowel that extend through a defect in the muscle layer
  • Diverticular disease increases with age and is associated with a low-fiber diet, obesity, chronic constipation
  • Diagnosis is usually by colonoscopy
  • Diverticulosis: multiple diverticula without inflammation
  • Diverticulitis: infection and inflammation of diverticula
• Potential complications of diverticular disease

  • Perforation
  • Peritonitis
  • Abscess formation
  • Bleeding
• Acute management of diverticular disease


  Similar to IBD