med surg

• upper GI- mouth ends @ jejunum
• lower GI- ileum eands @ anus

accessory structures include peritoneum, liver, gallbadder, & pancreas

primary function- digestion & distrubution of food

mouth: contains enzyme salivary amylase which os secreted by salivary gland (moisten food), adds ptyalin enzyme 4 digestion of starched foods

• esophagus: starts @ pharynx & ends opening of stomach, has straied muscle @ proximal ends, straided & smooth muscle @ mid, & smooth muscle @ lower esophagus
• upper esphageal & hypopharyngeal sphincter prevents fluids from re-enterin pharynx

• stomach:
• lower esophageal/cardiac sphincter- between esophagus & stomach
• pyloric sphincter- between stomach & duodenum
• both are circular bands of muscle fibers

Gastric secretions: acidic b/c contain hydrochloric acid(HCI), this mixture with food is call chyme, & move by peristalisis 2 sm. intestine

• primary function is 2 absorb nutrients from chyme, type of nutrient depends on site of sm. intestine (see pg 636, TBL-44-3)
• divided to 3 parts:
• duodenum- 10 in. long, 1st part of sm. intestine & where bile & pancreatic enzymes enter, which promote chemical breakdown of food, from chyme 2 a alkalin state
• jejunum & ileum- 23ft 2gether

• ileocecal valve- @ distal end, regulates flow of liquid content 2 lrg. intestine
• if any part diseased or removed absorption is reduced or lost

• 4-5in long, 2inches in diameter
• recieves waste & sends it to anus
• absorbs water, eletrolytes, & bile acids

• parts of lrg intestine
• cecum- pouch-like, begining of lrg. intestine, appendix- narrow blind tube @ tip of cecum, no known use
• colon (3 parts)
• ascending, transverse, descending, sigmoid & rectum
• In colon unabsorbed material becomes fecal matter (water, food residue, microorganism, digestive secretion, & mucus), water reabsorbed by diffusion, when mixture reaches descending itz already a formed mass
• internal & external anal sphincters holds feces, when accumulates urge to defecate occurs, & sphincters are relaxed

if any part diseased/removed absorption is reduced/lost, leadin 2 loss stool, potential fuid & electrolyte imbalance, passage of stool that has bile salts lead to risk of skin breakdown, & if stool stays in lrg intestine too long it leads 2 constipation

• peritoneum:
• lines inner abd., encloses viscera & serous fluid it secretes, allows abd. organs 2 move w/o friction
• walls prevent gastric & intestinal content from escaping into peritoneal cavity
• peritonitis- when the content escape thru a perforation of wall

• live:
• largest glandular organ, weighs 1-1.5kg, in R upper abd. under diaphragm which serperates from R lung
• forms & releases bile, processes vit. proteins, fats, & carbs, stores glycogen, for blood coagulation, metabolizes & biotransforms chemical, bacteria & foreign matter, from antibodies & immunizing substances (gamma globulin)

• Gallbladder:
• attached to mid-portion in under surface of liver, has thin wall & holds 60ml of bile
• water & minerals absorbed
• triggered by ingested food (especially fats), causes bile to b released 1st by cystic duct then by common bile duct into duodenum where absorption of fats, fat-soluble vit., iron & calcium
• bile activates pancreas to release digestive enzymes & alkalin fluid that nuetralizes stomach acid that reach duodenum

• Pancreas:
• exocrine gland- releases secretions into duct or channel
• endocrine gland- releases substances directly to bloodstream
• endocrine organ releases insuline & glucagon
• exodrine organ- produces fats, protein, carb-digested enzymes
• panceatic emzyme- released in inactive form & transported to duodenum where activated

• b/c of GI disorders disturbances in ingestion, digestion, absorption, & elimination
• pt HX- c/o, focus on nutrition, metabolic & elimination patterns
• why pt needs tx & current symptoms, how long & cause
• foods that produce distress & when symptoms likely 2 occur
• ? pt does to releive symptoms
• pt appetite, problems w/ chewing/swallowing, ?/how much pt eats, any discomfort around consumption, any nutritional supplements
• wt gain/loss
• hx of medical/surgical procedures
• family health/death hx, family hx of digestive disorders
• work hx 2 exposure if chemical/toxins/radioactive materials
• allergy/med hx

• v/s, breathing pattern
• appearance w/ regard to age & body size
• hygiene
• energy
• emotional attitude, mental status

• skin:
• abnormal color (jaundice) in well lit room
• if dark skinned pt. inspect hard palate, gums, conjunctiva, & surroundng tissue 4 discoloration
• if jaundice, inspect sclera
• inspect skin of abd. & face (looking 4 spider angiomas- superficial red discoloration from blood vessels
• distended abd. veins (caput medusae), & scars
• oral dryness & skin turgor

• mouth:
• inspect lips 4 sores, cracks, lesions, abnormalities
• using tongue blade check 4 inflammation, discoloration
• quality of oral care, lookin 4 missin teeth, partial plates, dentures & ask if well fittin & if pt could eat reg. food

• abd: discribed in quads
• pt supine, knees flexed (helps 2 relax abd muscles)
• whether flat, round, concave, distended, & effort when breathing, (distention could cause dyspnea from upward pressue on diaphragm
• auscultation before palpation lower liver margin if tender liver may be enlarged (R lower rib cage) suggest liver disorder, gallbladder/intestinal disease or pancreatic disorder , mesurement of abd. girth
• percuss 4 changes in dullness over solid mass like liver

• Anus:
• hemorrhoid
• skin tags
• fissures (sm. tears), breaks, lesions, rash, inflammation, drainage
• stool characteristics
• (see pg 639 TBL. 44-4)

used interchangeably

• barium swallow: flouroscopic observation
• faciliates identification of abnormalities of esophagus, swallowing dyfunctins & oral aspirations

• upper GI series: radiographic observation
• barium moving from stomach to 1st part of sm. intestine

• abnormalities in esophagus include tumors, peptic ulcers, gastric disorders
• if only barium swallow done takes 20min, but if stomach filling & emptyin then takes 1hr

• nurse teaching:
• pt needs to be on low-residue diet, NPO for 8-12hr before
• laxative given
• no smoking b/c it stimulates gastric mobility
• sometimes meds held like insuline & anticonvulsives
• barium is very constipating so after procedure pt needs fluids
• advise that stool may look white, streaky, clay color, of pt doesnt have bowel movement notify DR. b/c barium may cause blockage

• flouroscope in sm. intestine after ingestion of contrast medium
• 2 identify inflammation/obstruction in jejunum or ileum
• like GI series but pt swallow more barium so sm. intestine could be well visualized
• if fissure or obstruction suspected substitute a water-soluble contrast medium like methylglucamine(gastrografin)
• takes 5hr till reaches lower portion of sm. intestine
• if series fails enteroclysis done

• nasal/oral placement of feedig tube, tip positioned @ proximal jejunum
• uses 2 contrast- 1st 750-1000ml of thin barium, then 750-1000ml of methylcellulose, both pass thru intestinal loop, DR. observes continuosly by flouroscopy & take some x-ray in sections
• takes up to 6hr

• nurse:
• if sedation ensure pt comfortable & monitor
• risk 4 aspiration especially if pt vomits while sedation
• position pt on side & have suction available

• 2 identify polyps, tumors, inflammation, strictures, abnormalities in colon
• radiographic tech, rectally instills 1000-1500ml barium
• observes rectum, sigmoid colon, & desending colon flouroscopically during fillin
• to facilitate process instruct to have multiple postion changes
• pt needs to retain bariun during test which takes 30 min
• pt may have abd. cramping & urge to defecate, nurse ensures pt thatmost pt could retain barium throughout test
• radiographs taken again after pt expels barium
• sometimes air instilled to compress barium residue against wall to help detect mucosal defect
• stool specimens not collected till barium expelled completely

• pt teaching to reduce formation of stool & remove residual stool:
• restrictions & process 24-48hr before barium enema
• low-residue diet 1-2 days before
• clear liquid diet evening before
• laxative evening before
• NPO after mid-night
• cleansing enema morning of (if not contraindicated b/c inflammation/active bleeding

• checks 4 stone, tummors, obstruction in gallbladder or common duct
• also checks gallbladders ability 2 concentrate/store dyelike iodine-based radiopaque contrast, after dye absorbed goes 2 liver excreted into the bile & passes into gallbladder makin it radiographic visible
• radiography should be done before GI exam w/ barium b/c it obscures image of gallbladder/ducts

• Nurse teaching:
• eat fat-free meal night before
• allergy to iodine, pt swallow 6 iodine tabs 1q5min after evenin meal bight before w/ 250ml of water, then pt needs to be NPO after mid-night
• if nausea/vomiting tell DR. so more tabs ordered or test rescheduled
• once radiography done, a fatty-test meal/fatty synthetic substance given 2 stimulate gallbladder contraction & emptying, checked by more radiography

• performed in radiology or during surgery
• determines patency of ducys from liver & gallbladder
• used when gallbladder not seen w/ oral cholecystogram, vomite interferes w/ w/ retention of dye

• endoscopic retrograde cholangiopanceatography (ERCP):
• dye injected thru cath into pancreatic duct & common bile duct

• intraoperative cholangiography:
• contrast injected directly to bile dict during gallbladder surgery

• magnetic resonance cholangiopancreatography(MRCP):
• sees bile/pancreatic duct & gallbladder w/ no dye uses MRI, gives clear & detailed view

• percutaneous transhepatic cholangiogrphy:
• ultrasound used to guide needle into bile duct & directl injected

• no matter of dye given it travels into biliary system, x-ray taken to see narrowing/blackage
• nurse teaching:
• pt must sign consent
• ask about allergy to iodine/shellfish
• check orders for enema, & any food restrictions
• inform pt that warm feelng & nausea may happen when instilling dye
• pt may eat after procedure
• promote fluids for excretion of dye

• checks 4 lesions of liver or pancreas, & checks gastric emptying
• natural/synthetic, given IV or orally
• scanner used over body organ
• shows size of organ, & tumors, identifies site 4 bleeding/inflammation in GI tract
• have shorter half-lives lasting hr-days

dosed by wt, preg

• tube inserted & air introduced & images done
• detect structual abnormalities of GI tract
• detect metastic lesions
• oral barium sulfate or IV calcium phosphate 4 contrast
• pt NPO 6-8hr before
• bowel cleansed
• med may be given to lower paristalisis or improve gastric motility

• if test not good MRI done:
• check soft tissueGI disorders- abscess/bleeding

• Nurse:
• pt NPO 6-8 before
• remove metal objects
• pt w/ pacemakers need cardiologist consult 1st
• IV fluids, if req., by gravity
• inform that tunnel like maccin that makes load noises
• if claustrophobic- sedation needed

• low frequency sound waves (shear waves)
• checks firmness of liver , leads to prediction of fibrosis (scar tissue) & eventually cirrhosis (hardeni of liver)
• great promise like breast, muscle. & brain tissue

• high frequency sound waves
• liver & pancreas
• shows size & location of orgns outlines stuctures & abnormalities like cholecytitis, cholelithiasis, pyloric stenosis, & disorders of billary system
• pt could have fluids but instructed not too, also no smoking chewing gum, they may swallow air distort sound waves

• checkin 4 malignant changes infectious & inflammatory process, liver damage (cirrhosis), & signs of liver rejection if transplant
• coagulation test done b/c biopsy could lead to bleeding, if @ risk give vit. k 2 promote coagulation
• CT 4 correct site of biopsy
• sedation & anesthics give 4 comfort & cooperation, monitor pt closley

• visual exam of lumen
• flexible endoscope
• detects lesions

• nurse teaching:
• NPO
• bowel preps
• pt needs to spray & gargle anesthetic
• pt given anxiolytic 4 sedation
• monitor v/s, including pain, LOC, abd symptoms
• monitor signs of perforation like fever, abd distention, abd/chest pain vomiting blood, rectal bleeding
• pt may eat when gag reflex returns
• if sore throat gargle saline, ice chips, & cool drinks

• CBC, urinalysis, serum bilirubin, cholesterol, ammonia level, PT, protein electrophorisis, & enzyme (amylase, lipase, aspertate aminotransferase, lactic acid dehydrogenase
• common tumor markers carcinoembryonic antigen & alpha-feto-protein

gastric analysis- activitiy of gastric mucosa, retention, NPO 8-12hr, nasogastric tube into stomach, content aspirated q15min for 1hr, checkin ph, volume, cytology

• H-pylori- 4 peptic ulcers,
• blood test, urea breath test, stool,
• more invasive biopsy could be done;
• raid ureas test (enzyme), histology (actual bacteria), culture(growing bacteria in tussue sample)

hydrogen brething test- collecting breath before & after ingestion of cardohydrate solution, detect types of malabsorption of lactose (most common)

• stool analysis- check WBC(inflammation), RBC(GI blood loss), fat(malabsorption), infection
• detects bacteria, parasites, ova
• hemocult test (blood)
• false + include red meat, iodine having antiseptic prep, asprin, & NSAIDS, alcohol
• false - include ascorbic acid (vit. C), iron supplements