Management of Patients With Gastrointestinal Disorders

Management of Patients With Gastrointestinal Disorders
By:Bonnie Curry

Content Overview
* Overview of GI System
* Assessment
* Diagnostic Evaluation/Nursing Responsibilities
* Pathophysiology of GI Disorders
* Gerontologic Considerations
* Peptic ulcer disease
* GI Bleeding

Overview of GI Tract
* Anatomy
* Physiology
* Parasympathetic Nerve
* Sympathetic Nerve
* Voluntary control
* Functions

Assessment
* Health history
* Clinical manifestations
* Pain
* Indigestion
* Intestinal Gas
* Nausea/Vomiting
* Changes in bowel status

Gerontological Considerations
* Age-related changes in the mouth
* Changes in the esophagus
* Decrease gastric motility
* Decrease absorption of nutrients

Diagnostic Exams/Nursing Considerations
* Nursing Responsibilities
* Provide
* Instruct
* Alleviate
* Help
* Encourage
* Assess

Diagnostic Exams/Nursing Considerations
Endoscopic Studies
* EGD (Esophago-duodenoscopy)
* Lumen of esophagus, stomach, and duodenum
* COLONOSCOPY
* Entire large bowel
* SIGMOIDOSCOPY
* visualizes lower portion of colon-rectum and sigmoid colon

Diagnostic Exams/Nursing Considerations
Endoscopic Studies
* EGD (Esophago-duodenoscopy)
* Lumen of esophagus, stomach, and duodenum

Diagnostic Exams/Nursing Considerations
Endoscopic Studies
* COLONOSCOPY
* Entire large bowel

Diagnostic Exams/Nursing Considerations
Endoscopic Studies
* SIGMOIDOSCOPY
* visualizes lower portion of colon-rectum and sigmoid colon

Diagnostic Exams/Nursing Considerations
Endoscopic Studies
* EGD
* Indications
* Nursing interventions
* Sigmoidoscopy
* Indications
* Nursing interventions
* Colonoscopy
* Indications
* Nursing interventions
* Colon prep

Diagnostic Exams/Nursing Considerations
Radiological Studies
* Upper Gastrointestinal Tract Study (UGI)
* Aids in diagnosis of ulcers, varices, tumors, regional enteritis, and malabsorption syndromes
* Nursing Interventions
* Post Procedure
* Small Bowel Follow Through
* Aids in diagnosis of obstructions, ileitis, and diverticula
* Nursing Interventions
* Post Procedure

Diagnostic Exams/Nursing Considerations
Radiological Studies
* Lower GI Tract Study: Barium Enema (BE)
* Aids in diagnosis of polyps, tumors, other lesions, abnormal anatomy
* Contraindication
* Nursing Interventions
* Post procedure
* Gastric Analysis
* Aids in detection of pyloric or duodenal obstructions, diagnosis of Zollinger-Ellison Syndrome (ZES).
* Nursing Interventions
Diagnostic Exams/Nursing Considerations
Radiological Studies
* Gastric Stimulation Test
* Procedure
* Nursing considerations
* Information obtained
* pH Monitoring
* Procedure
* Nursing considerations
* Information obtained
* Gastric Analysis
* Fluid
* pH
* Basal acid output
* Maximum acid output

Diagnostic Exams/Nursing Considerations
Other Studies
* Ultrasound
* Nursing Interventions
* Computed Tomography (CT Scan)
* Nursing Interventions
* Magnetic Resonance Imaging (MRI)
* Nursing Interventions
* Stool Studies

Peptic Ulcer Disease
* Crater like disruption to GI tract mucosa
* Esophageal
* Gastric
* Small intestine
* Duodenal most common (closest to the stomach)
* Zollinger-Ellison syndrome (ZES)
* Several ulcers
* Extreme gastric hyperacidity
* Tumors of the pancreas
* Resistant to standard medical therapy
* Stress ulcers

Peptic Ulcer Disease
* Clinical Manifestations
* Pain
* burning, gnawing, dull
* midepigastrium or back
* relieved by eating or antacids
* Pyrosis
* Vomiting
* Change in bowel status
* Bleeding
* Gastric Ulcer
* Age 50 & over
* Male:Fem 1:1
* 15% incidence
* Norm. to hyper acid
* Weight loss
* Pain I/2-1hr. After meal
* Pain not relieved by eating
* Vomiting common
* Hemorrhage more likely
* Hematemesis more common
* Duodenal Ulcer
* Age 30-60
* Male:Fem- 2 to 3:1
* 80% incidence
* Hyper acid secretion
* May have wt. Gain
* Pain 2-3 hrs.after meal
* Pain relieved by eating
* Vomiting uncommon
* Hemorrhage less likely
* Melena more common
* Early 1900’s: key variables stress and diet
* Treatment: BR, bland food, hospitalization
* Decades later: primary cause excess gastric acid
* Treatment: antacids, drugs that protect mucosa (Pepto Bismol)
* 1970’s: Histamine receptor acts as key regulator of stomach acid secretion.
* Treatment: H2 blockers -- gastric acid neutralized and secretion reduced (tagamet, zantac, pepcid, axid)
* Newer drug class-- proton pump inhibitors -- longer & more complete blocking of acid formation (prilosec, prevacid, protonix)
* 1980’s: Discovery of Bacterium Helicobacter pylori (H. pylori)
Combination of antibiotics and acid suppressors Antacids,tranquilizers, lifestyle and dietary changes, surgery

Treatment ...
Peptic Ulcer Disease:
Advances in understanding of PUD
* Cure was short-lived
* Relapse rate 95% over two years until discovery of h. pylori bacteria factor
* National Institute of Health statement
* Currently a decrease in incidence of ulcers due to h. pylori in the U. S. but increase in incidence due to use of ASA and NSAIDS.
* Disruption of the production of hormone-like substances (prostaglandins)
Peptic Ulcer Disease: H.pylori
* Infects over half of the world’s population and is transmitted from person to person.
* Poor food handling and sanitation practices are thought to be common routes of transmission
* Thrives amid overcrowding and poor living conditions

Peptic Ulcer Disease: H.pylori
* Contributing factors:
* Many people in household
* Sharing of beds
* Limited hot water supply
* Inadequate bathroom facilities
* Decrease noted in U. S. due to:
* Improvements in socioeconomic status and sanitation
* Widespread use of antibiotics in children

Peptic Ulcer Disease: H.pylori
* Two out of three individuals that harbor H. pylori in GI tract have no symptoms
* DX tests for h. pylori:
* Stool antigen
* Biopsy of site
* Breath test
* Antibiotic drug regimen increases resistance to antibiotics
* Research – h. pylori vaccine
* Advantages: cost effective and reduce the progression of antibiotic resistant strains due to widespread use of them in treating h. pylori infection

Peptic Ulcer Disease Theurapeutic Management
* Rest and stress reduction
* Dietary Interventions
* Smoking cessation
* Pharmacologic therapy
* Surgical Management
* Long term follow-up care

Peptic Ulcer Disease:Drug Therapy
* Conventional drugs and a triple drug regimen (Amoxicillin, Flagyl, and Pepto-Bismol)
* FDA Approved in 1996 2 drug combination (newer recommendation) : Prilosec(Proton Pump Inhibitor) and Biaxin(Antibiotic) for 14 days followed by only Prilosec for additional 13 days)
* Patient compliance is a major factor in the success of treatment with drug combination therapy
* Benefits of drug combination treatment
* quick relief from symptoms
* healing of ulcer without recurrence
* savings of time and money spent on treatment
* Antibiotics & Bismuth Salts
* Tetracycline, Amoxicillin, Biaxin, Pepto-Bismol
* Histamine (H2) Receptor Antagonists
* Tagamet, Zantac, Pepcid, Axid
* Proton Pump Inhibitor
* Prilosec, Prevacid, Protonix
* Cytoprotective Medications
* Cytotec, Carafate

Peptic Ulcer Disease:Drug Therapy
* Prevacid (Lansoporazole)
* inhibits proton pumps which are responsible for acid production in the stomach
* may have some anti-bacterial action against H. pylori (bacteria involved in ulcer formation)
* absorption delayed by carafate and theophylline levels affected (lowered) by prevacid
* Prilosec (omeprazole)
* Long-term uses may cause gastric tumors & bacterial invasion
* Tagamet (cimetidine)
* Least expensive
* May cause confusion, agitation or coma in elderly or those with HI and RI
* Long-term use may cause impotence and diarrhea
* Zantac (ranitidine)
* Fewer side effects than Tagamet
* Prolonged half-life in patients with RI & HI
* Axid (nizantidine)
* Used for duodenal ulcers
* Prolonged half-life in patients with RI
* Rarely, causes sweating, increased liver enzymes, nausea, urticaria
* Pepcid
* Prolonged half life inpatients with RI
* Short-term relief for GERD
* Dilute before IV injection
* Least interaction with drugs
* Carafate
* anti-ulcer drug that has local effect and coats the stomach
* Give 1 hour before meals
* Approved for duodenal ulcers, not gastric
* Cytotec (misoprostol)
* Used as preventive method in patients using NSAIDs
* Administer with foodMay cause diarrhea & cramping
* Tetracycline (with Bismuth salts)
* May cause photosensitivity
* Effectiveness reduced if taken with milk or dairy products
* Use with caution in renal or hepatic pts.
* Amoxicillin (with Bismuth salts or high dose of Proton Pump Inhibitor)
* May cause diarrhea
* Cross-sensitivity to penicillin
* Biaxin (Clarithromycin)
* Use with proton pump inhibitor or H2 receptor antagonist
* May cause GI upset
* Pepto-Bismol (Bismuth salicylate)
* Use with antibiotics to cure H. Pylori
* Should be taken on an empty stomach

Peptic Ulcer Disease: Surgical Management
* Vagotomy- severing vagus nerve to reduce gastric secretion.
* Pyloroplasty- longitudinal incision with transverse suturing to enlarge the gastric outlet and relax the muscle.
* Antrectomy- Removal of antral portion of the stomach and portion of duodenum and pylorus. (Billroth I, Billroth II, Subtotal)
* Post op care
* Routine post surgical care
* Maintain tubes and drains
* Pain management
* Psychological support
* Fluid and blood replacement
* Assess for complications

Research
* CURE (Center for Ulcer Research and Education) UCLA
* AHCPR (Agency for Health Care Policy and Research) ahcpr.gov
* NIH (National Institute of Health) nih.gov

Acute GI Bleeding: Risk Factors
* Lower GI Bleeding
* Malignant tumors
* Polyps
* Ulcerative Colitis
* Crohns Disease
* Diverticula
* Hemorrhoids
* Rectal Fistulas
* Massive GI Bleed
* Upper GI Bleeding
* Esophageal varices
* Ulcers and tumors
* Gastric
* Ulcers and gastritis
* Tumors
* Small Intestine
* Peptic ulcers
* Crohns Disease
* Meckel’s diverticulum

Acute GI Bleeding
* Signs and Symptoms
* Abdominal/chest pain
* Nausea/vomiting
* Stools
* Change in LOC
* Assessment
* VS
* Cardiovascular/Respiratory
* GI
* s/s hypovolemic schock
* Diagnostic Tests
* CBC, chem panel, APTT, PT
* Blood type and cross
* Interventions
* Position patient
* Administer oxygen
* Monitor cardiac rhythm
* IV solutions
* Crystalloids
* Colloids
* Prevent hypothermia
* Insert NGT
* Gastric lavage
* Administer medication
* Vitamin K
* Vasopressin
* Insert F/C
* Prepare for EGD or surgery

Management of Patients With Gastrointestinal Disorders