Gastrointestinal and

Hepatobiliary
Disorders

Diagnostic Exams
Radiographic tests
scout film of the abdomen/flat plate
Barium Studies- barium color: ______
Nursing Considerations: drink water after procedure; stools will
be ___
Barium swallow
UGIS- NPO 6-8hrs
LGIS (Barium enema)- Clear liquid diet then NPO,
laxatives/enema

Endoscopy- check gag reflex has returned

UGI endoscopy
LGI endoscopy : proctosigmoidoscopy
colonoscopy

Diagnostic Tests
Cholangiography
- Consent form; allergies to dye; cleansing enema ;
NPO
Liver Biopsy
- Position before and after the procedure
Lab Tests
- CBC, serum bilirubin, ammonia, amylase, lipase,
LDH, CEA, Alpha-fetoprotein
PY test
- H. Pylori infection; C-capsule given, blow balloon,
presence of gastric urease

GERD
Gastric contents flow upwards to
esophagus
Common in obese and pregnant women
Any activity that increase intraabdominal
pressure (overeating, bending, tight
clothing), foods that relax cardiac
sphincter (alcohol, peppermint, caffeine,
high fat diet), lying down after meals

GERD
Assessment:
dyspepsia, dysphagia, odynophagia (painful
swallowing), esophagitis

Management
Avoid alcohol, peppermint, caffeine, high fat diet
Lose weight
Avoid over-eating and tight fitting clothes
Elevate HOB during and after meals

 How can gastric regurgitation best be

reduced?
A. eat small frequent feedings and avoid
overeating
B. small evening meals with bedtime snacks
C. belch frequently
D. swallow air

GASTRITIS

Acute
Chronic
Causes:
Meds (ASA, NSAIDS, steroids)
Foods (oily, caffeine, spicy, alcohol)
Stress (ischemia of gastric mucosa)

GASTRITIS
Assessment:
- vomiting, diarrhea, anorexia,
abdominal pain, melena,
hematemesis
- CBC- anemia

PEPTIC ULCER DISEASE

Impaired GI mucosa leading to erosion
and ulceration
May be gastric or duodenal (most
common)

 Predisposing factors
Stress
Food (MILK included)
cigarette smoking and alcohol
caffeine
Drugs
H. pylori (90%)

PUD
Manifestations:
- Bloating, belching, n/v, pain (burning,
gnawing or aching) located in the upper
abdomen and occurring between mealtimes
or at night, pain associated with ingestion of
specific foods and ASA, relief of pain after
administration of antacids and food
- Hematemesis, hemorrhage or melena may
occur

NURSING MANAGEMENT
Relieve the pain
lifestyle modification
dietary modification

quit smoking
stress therapy
pharmacotherapy
antacids
aluminum or magnesium or AlMgOH

Suppress gastric acid secretions

Histamine (H2) blockers
ranitidine, famotidine, nizatidine, cimetidine

Proton Pump Inhibitors

omeprazole, esomeprazole, lansoprazole

Coats the ulcer

cytoprotective drugs
sucralfate

 Antibiotics
bismuth-sulfate (Pepto-bismol)
amoxicillin and metronidazole

Surgery
vagotomy
Billroth I and II- gastric resections
Gastrectomy (Pernicious anemia)

TOTAL/SUBTOTAL
GASTRECTOMY
Billroth I and Billroth II

POST-OPERATIVE CARE AFTER

GASTRIC RESECTION
pain management
Maintain on fowlers position for comfort and to
promote drainage
Gastric drainage system management- dont
reposition NGT
Monitor dressings for drainage (bleeding)
Assess bowel sounds; maintain on NPO
Nutritional support

DUMPING SYNDROME
rapid emptying of gastric contents into the small
intestine which has been anastomosed to the
gastric stump
Cause: Ingestion of food high in CHO and
electrolytes, which must be diluted in the
jejunum; ingestion of fluid at mealtimes
Signs
weakness, tachycardia, pallor, feeling of
fullness and discomfort, nausea and (3Ds)
dizziness, diaphoresis diarrhea
late signs maybe hypoglycemia (pancreas
secrete excessive insulin)

NURSING MANAGEMENT
Eat in a recumbent or semi -recumbent
position
small frequent feedings
moderate fat, high protein diet
limit carbohydrates, no simple sugars
give fluids after meals

Following a subtotal gastrectomy, a

client develops dumping syndrome. The
nurse understand that dumping
syndrome refers to:
A. nausea due to a full stomach
B. rapid passage of osmotic fluid into the
jejunum
C. reflux of intestinal contents into the
esophagus
D. buildup of feces and gas within the large
intestine

APPENDICITIS
Obstruction of vermiform appendix
signs
acute abdominal pain (RLQ) McBurneys point
anorexia, nausea and vomiting
rigid abdomen with guarding
rebound tenderness
fever
elevated WBC count
Sudden cessation of pain means rupture

NURSING MANAGEMENT
Bed rest
NPO
Do not give NARCOTICS initially - will
mask the pain
antibiotic therapy
surgery : appendectomy

PERITONITIS
Caused by perforation of the GI tract and
hepatobiliary structures; ectopic pregnancy;
peritoneal dialysis
Spillage of chemicals and bacteria inflames the
peritoneum fluid shifts hypovolemia shock
(septic)
signs

abdominal pain and tenderness with guarding and rigidity

paralytic ileus (absent bowel sounds)
abdominal distention (gas and fluids accumulate)
fever

PERITONITIS
Interventions:
-Maintain fluid and electrolyte balance- treat shock,
IVF and NPO with NGT to reduce pressure
- Analgesics, paracentesis, monitor weight
- TPN and Antibiotics
Prepare for surgery- treat the cause- drains will be
placed; ATB irrigation of peritoneum, wound care,
pain
Avoid lifting and straining of abdominal muscles x
6wks post-op

Crohns disease vs Ulcerative Colitis

Autoimmune
Ileum and ascending
colon
Right lower quadrant pain
Diarrhea
3-5 watery stools
mucoid stools with pus
Transmural involvement
Ileostomy
Steroids and Flagyl

Autoimmune
Rectosigmoid
Lower left quadrant pain
Diarrhea
15-20 watery stools
bloody mucoid stools with
pus
Shallow ulcerations
Colostomy
Steroids and Flagyl

ULCERATIVE COLITIS
Interventions:
Steroids, Flagyl, antidiarrheal (Imodium, Psyllium
and antispasmodic agents)
low residue, lacto-free diet, elemental type diet,
TPN, monitor weights, I&O, stool specimens
prepare for bowel resection (administer antibiotic
bowel prep- Neomycin)
After surgery: wound care, F&E, pain, bowel
function (paralytic ileus) , manage ileostomy or
colostomy, emotional support

CROHNS DISEASE
Interventions:
ATB, diet therapy, vitamin supplements,
stool specimens, F&E
-

Prepare for surgery if there is obstruction

provide wound management with skin
care; fistulas may require placement of
drains, pouches, skin barriers

SAMPLE QUESTIONS
The nurse is performing a physical
assessment of a client with ulcerative colitis.
The finding most often associated with a
serious complication of this disorder would
be:
a. decreased bowel sounds
b. loose, blood tinged stools
c. distention of the abdomen
d. intense abdominal discomfort

A client is scheduled to have a

permanent colostomy. Before the
surgery, a low residue diet is
ordered. The nurse explains that it is
necessary to:
a. lower the bacterial count in the GI tract
b. limit production of flatus in the intestine
c. prevent irritation of the intestinal mucosa
d. reduce the amount of stool in the large
bowel

The dietary teaching for a client diagnosed with

ulcerative colitis with a new colostomy is:
a. food low in fiber so that there is less stool
b. bland foods so that the intestines do not get
irritated
c. everything as long as foods that are gas
forming are avoided
d. soft foods that are easily digested and
absorbed by the large intestine

 A client is scheduled to have a bowel resection

and is to receive antibiotics preoperatively. The
nurse should teach the client that the purpose of
the antibiotics is to help:
a. prevent incisional infection
b. eliminate bacteria from the GI tract
c. avoid postoperative pneumonia
d. limit the risk of UTI

CIRRHOSIS
irreversible chronic inflammatory diseasemassive degeneration and destruction of
hepatocytes resulting in disorganized
lobular pattern of regeneration
Types:
- Laennecs cirrhosis, postnecrotic (viral
hepatitis), biliary and cardiac ( ___ CHF)

CIRRHOSIS
GI effects like anorexia, constipation or diarrhea,
abdominal pain, flatulence, n/v, weight loss (increased
portal pressure)
Excessive bile salts
RBC > unconjugated bilirubin > LIVER > conjugated
bilirubin > duodenum > stools (color)
LIVER damage: ________ bilirubin increases?
HYPERBILIRUBINEMIA
Bilirubin > kidneys > __________ urine
Stools > ___________ color
jaundice, tea-colored urine, acholic stools

Cirrhosis
Deamination of CHON > removing of N > Ammonia
> > LIVER > >UREA
Hepatic encephalopathy, asterixis (hand flapping
tremor in hepatic coma)
anemia, thrombocytopenia
Ascites (decreased albumin > decreased colloidal
osmotic pressure), peripheral edema, dry skin,
pruritus, peripheral neuropathies,
portal hypertension, esophageal varices (most
common cause of death), hemorrhoids, caput
medusae

ASCITES

INTERVENTIONS
- Assess for bleeding, impaired skin integrity

- Monitor I&O, VS and lab results

- daily weight and abdominal girth
- administer meds (Vit K, vasopressin if
bleeding)
- IV therapy using volume expanders
- Assess for breathing problems

- Paracentesis
- Lactulose and Neomycin - hepatic
encephalopathy- excreted in feces
- Tap water enemas to remove ammonia
- Potassium sparing diuretics
- High calorie diet, mod to high CHON,
moderate to low fat and low Na diet

Esophageal Varices

MANAGEMENT
Prevent bleeding if possible
Administer FFP aimed at increasing clotting time
Assist with insertion of Sengstaken-Blakemore
tube- assess for esophageal necrosis ( release
pressure periodically)
- assess for aspiration pneumonia- suction prn
- prevent airway obstruction (gastric balloon
deflation or breakage)- cut asap
Provide soft diet and adequate nutrition

SENGSTAKEN BLAKEMORE
TUBE

SAMPLE QUESTIONS
A client has been treated for cirrhosis of the liver
for 3 years. Now he is hospitalized for treatment of
recently diagnosed esophageal varices. Which of
the following should the nurse teach the client?
a. eat foods quickly so they dont get cold and
cause distress
b. avoid straining at stool to keep venous
pressure low
c. decrease fluid intake to avoid ascites
d. avoid exercise because it may cause
bleeding of the varices

 A client being treated for esophageal varices has

a Sengstaken Blakemore tube inserted to control
bleeding. The most important assessment is for
the nurse to:
a. Check that a hemostat is at the bedside
b. Monitor IV fluids for the shift
c. Regularly assess respiratory status
d. Check that the balloon is deflated on a
regular basis

BILIARY DISORDERS
1. CHOLECYSTITIS
- ACUTE OR CHRONIC
- ASSOCIATED WITH GALLSTONE OR BILIARY OBST.
- OCCURRENCE: WOMEN 40-50 Y.O.
SEDENTARY
OBESE
- MANIFESTATIONS:
ACUTE:
NAUSEA & VOMITING
-INDIGESTION, BELCHING, FLATULENCE
-EPIGASTRIC PAIN >>SCAPULA 2-4 HRS
AFTER FATTY MEAL & LAST 4-6 HRS
-TACHYCARDIA, TACHYPNEA, FEVER
-LEUKOCYTOSIS

Demerol: Drug of Choice for pain

SURGICAL:
- CHOLECYSTECTOMY
- CHOLEDOCHOTOMY
- LAPAROSCOPIC CHOLECYSTECTOMY
- ESWL
POST-OP CARE:
- MONITOR RESPIRATORY COMP.
- MAINTAIN RESPIRATORY FUNCTION
- NPO, NGT>>SUCTION
- MEDS: ANTIEMETICS, ANALGESICS
- T-TUBE CARE (Choledocotomy)

Post operative nursing Care:

1. Maintain patency of NGT
2. Assess T-tube if common bile duct is
manipulated
3. position: low to SF
4. monitor dressing
5. clamp T-tube as ordered
6. IVFs and vitamin supplementation
7. deep breathing exercise
8. early ambulation
9. Fat free diet for 6 weeks

Surgical interventions
Abdominal Cholecystectomy

Laparoscopic Cholecystectomy

Extracorporeal shock wave

(Lithotripsy)

PANCREATITIS
INFLAMMATION >>
> AUTODIGESTION BY THE
TRAPPED PANCREATIC ENZYMES
> OBSTRUCTION & EDEMA
> INTERSTITIAL HEMORRHAGE &
TISSUE NECROSIS

MANIFESTATIONS:
1. STEADY, SEVERE EPIGASTRIC
PAIN
>>BACK, AGGRAVATED BY FATTY
MEAL & RECUMBENT POSITION.
2. VOMITING
3. FEVER, TACHYCARDIA, LOW BP
4. ABDOMINAL DISTENTION
5. ELEVATED SERUM : LIPASE & AMYLASE CHARACTERISTIC INDICATORS
6. ELEVATED WBC, BLOOD SUGAR AND
BILIRUBIN

GOALS OF CARE
1. CLIENT WILL BE FREE FROM PAIN OR LESS
PAIN
- NPO PREVENTS AUTODIGESTION
- ANALGESIC: DEMEROL DRUG OF
CHOICE
* NO MORPHINE CAUSES SPASM
OF SPHINCTER OF ODDI
2. CLIENT WILL BE FREE FROM SHOCK
- IV FLUIDS

3. CLIENT WILL HAVE ADEQUATE NUTRITION

- NPO >>CLEAR LIQUIDS OR ELEMENTAL
DIET
- NGT TO DRAINAGE- DECREASE
DISTENTION &
SECRETION
- TPN & VITAMIN SUPPLEMENTS
- INSULIN AS NEEDED
4. CLIENT WILL INSTITUTE MEASURES TO
PREVENT CHRONIC PANCREATITIS
- ELIMINATE CAUSE
- ALCOHOL REHAB PROGRAM

Sample Questions

A client with a T-tube following

choledochostomy asks the nurse why
the tube is being clamped during
mealtimes. The most accurate response
by the nurse is
a.
b.
c.
d.

It will help the tube come out quickly

It causes less pain during mealtimes
It will help in the digestion of fats
It helps keep the common bile duct open

 The nurse planning the care of a

client admitted with severe acute
pancreatitis would anticipate the
diet order of:
a. NPO
c. enteral feedings
b. soft low fat diet
d. TPN