GI

Auto-digestion of the Pancreas

• The pancreas has two separate functions:
• Endocrine = insulin
• Exocrine = digestive enzymes

• Two Types:
• Acute - #1 cause is alcohol, #2 is gallbladder disease
• Chronic - #1 cause is alcohol

1st sign is pain - increases with eating

Abd distention/ascites (losing protein rich fluids like enzymes and blood into the abdomen)

Abd mass = swollen pancreas

Bruising around the umbilical area = Cullins sign

Bruising around flank area = Gray Turner's sign

• Fever (inflammation)
• Hypotension = bleeding or acites

• N/V
• Jaundice

• Serum lipase (0-110 U/L) (Most specific)
• Serum amylase (30-220)

• WBC increased
• Blood sugar increased
• PT, aPTT - longer clotting times

Serum bilirubin increased

• Hemoglobin & hematocrit could be up or down:
• Up is dehydrated, Down is bleeding

• Control Pain!
• Decrease gastric secretions (NPO, NGT to suction, bed rest) - Want the stomach empty and dry
• PCA narcotics, morphine sulfate, Fentanyl patches

Steroids to decrease inflammation

Anticholinergics to dry secretions

GI protectants (Pantoprazole, antacids)

Maintain fluid/electrolyte balance

Will give insulin - Because pancreas is sick. Steriods = increased BS or on TPN = lots of sugar

Will take daily weights

Eliminate alcohol!

AST = 8 - 40

ALT = 10 - 30

• 1. Detox the body
• 2. Helps your blood clot
• 3. The liver helps to metabolize (break down) drugs
• 4. The liver synthesizes albumin

• Patho:
• Liver cells are destroyed and are replaced with connective/scar tissue = alters the circulation within the liver = the BP in the liver goes up, which is called portal hypertension

BLEEDING!!!

If liver is sick, decrease the dose of meds!

• Never give Tylenol to liver pt. 
• Antidote is Acetylcysteine

• Firm, nodular liver (lumpy, bumpy)
• Abd pain - liver capsule has stretched
• Chronic dyspepsia (GI upset)
• Change in bowel habits

• Ascites
• Splenomegaly - immune system has kicked in. *When spleen is enlarged, immune system is involved
• Decreased serum albumin = causing 3rd spacing
• Increased ALT & AST
• Anemia - due to internal bleeding

*Can progress to hepatic encephalopathy/coma = toxins (ammonia) building up in blood. Ammonia is a sedative

Ultrasound/CT/MRI

• Liver biopsy: *remember risk for bleeding
• Clotting studies before procedure and position with right arm on back of head, spine.
• After procedure, lie on right side.

• Antacids, vitamins, diuretics (ascites)
• NO more alcohol
• I&O + daily weights (ascites = fluid prob)
• Rest
• Bleeding precautions
• Measure abd girth to monitor ascites
• Paracentesis
• Avoid Narc's, liver can't metabolize when it's sick.  If you give, it's same a double dosing

• Diet:
• Decrease protein. Otherwise ammonia level will continue to go up = LOC down
• Low sodium!

Normally: When you eat protein, it breaks down into ammonia, and the liver converts is to urea. Urea can be excreted through the kidneys w/o difficulty

Patho: When the liver becomes impaired, it can't make this conversion. Ammonia then begins to build up in the blood. 

This causes a decrease in LOC

• Will have minor mental changes/motor problems
• Difficult to wake up
• Asterixis = hands shake.  "liver flap"
• Handwriting changes and reflexes slow down
• EEG slows
• Fetor = breath smells like fruit
• Anything that increases ammonia will aggravate the problem = #1 thing being protein

Liver people tend to be GI bleeders!!

Lactulose = will decrease serum ammonia

Cleansing enemas to get rid of blood

Decrease protien in diet - duh

Monitor serum ammonia

• High BP in the liver (Portal HTN) forces collateral circulation to form.
• This collateral circulation forms in 3 places: stomach, esophagus, and the rectum.

When you see an alcoholic client that is GI bleeding, it is usually esophageal varices.  Usually no problem until rupture

• Replace blood loss
• Monitor VS and CVP
• Oxygen
• Balloon tamponade
• Cleansing enema 
• Saline lavage to get blood out of stomach

• Octerotide - lowers BP in liver
• Lactulose

• Patho: Common cause of GI bleed
• Can be in esophagus, stomach, or duodenum
• Mainly in males, but increasing for females
• Erosion is present

• S/S: Burning pain usually in mid-epigastric area
• Dyspepsia - (heartburn)

Dx: Gastroscopy = endoscopy or they look at Upper GI with dye

• Endoscopy: NPO pre-procedure, will be sedated
• NPO until gag reflex returns
• Watch for perforation by watching for pain, bleeding, or if they are having trouble breathing

• Upper GI: looks at esophagus and stomach with dye
• NPO past midnight. This includes chewing gum or mints. Remove nicotine patch and no smoking as it increases stomach motility which will affect the test. Smoking also increases stomach secretions = increased risk for aspiration

• Meds:
• Antacids - liquid is best to coat the stomach. Take on empty stomach at bedtime when stomach is empty
• Proton pump inhibitors: decrease acid secretions
• H2 antagonist: ranitidine (zantac) or famotidine (Pepcid)

Antibiotics for H. Pylori

• Teaching: decrease stress
• Stop smoking
• Eat what you can tolerate. avoid temp extremes, spicy food, caffeine
• Need to be followed for one year

Gastric ulcers: malnourished, pain usually 1/2 hour to hour after meals. Food doesn't help, but vomiting does; vomit blood.

Duodenal ulcers: Well nourished, night time pain common and occurs 2-3 hrs after meals. eating helps, blood in stools

• Patho: This is when the hole in the diaphragm is too large to the stomach moves up into the thoracic cavity. 
• Main cause is large abd. Other causes include congenital abnormalities, trauma, and straining. 

• S/S: Heartburn
• Fullness after eating
• Regurgitation
• Dysphagia (difficulty swallowing)

• Tx: Keep stomach in down position by: eating small frequent meals, sit up 1 hr after eating, elevate HOB
• May need surgery 

Teach life style changes and healthy diet

Common with gastric bypass

Path: Stomach empties too quickly after eating and client experiences many uncomfortable to severe side effects... usually secondary to gastic bypass, gasterectomy, or gall bladder disease

S/S: Fullness, weakness, palpitations, cramping, Diarrhea

• Tx: Semi-recumbent with meals
• Lie down after meals
• NO fluids w meals. Drink in btwn meals
• Meals should be small and frequent rather than large
• Avoid foods high in carbs and electrolytes as they empty fast

Ulcerative Colitis is ulcerative inflammatory bowel disease = just the LARGE INTESTINE

Crohn's disease (also called Regional Enteritis) is inflammation and erosion of the ilium but it can be found anywhere in the small or large intestines

• S/S: diarrhea
• rectal bleeding
• weight loss
• vomiting
• cramping
• dehydration
• rebound tenderness (means there is peritoneal inflammation)

CT

• Colonoscopy: clear liquid for 12-24 hr prior
• NP 6-8 hrs prior, avoid NSAID
• Polyethylene glycol (Go Lytely) - serve cold
• Post op: watch for post-op perf

Barium enema - done if colonoscopy is incomplete. (involves an xray of intestines)

• Diet:
• low fiber - trying to limit GI motility
• Avoid cold or hot foods, and NO smoke - they all increase motility

• Meds:
• Antidiarrheals - only given with midly symptomatic ulcerative colitis as it doesn't work well in severe cases
• Antibiotics
• Sterioids - decrease inflammation

• Surgery:
• Ulcerative colitis - Total colectomy (ileostomy formed)
• Crohn's - may only remove affected area. Pt may end up with ileostomy or colostomy, just depends on area affected

• Ileostomy care:
• It's going to drain liquid stool all the time. Don't have to irrigate
• Avoid foods hard to digest as it increases motility
• Gatorade or similar electrolyte replacement in summer
• At risk for kidney stones, always a little dehydrated

As waste moves through colon, water and nutrients are being absorbed and stool is forming. 

• Colostomy ⇾ ascending and transverse ⇾
• semi liquid stools

Colostomy ⇾ descending or sigmoid ⇾ semi-formed or formed.

• Only irrigate descending or sigmoid for regularity in elimination. Same time everyday, after a meal.
• When irrigating, pt should lay on same side as if they were getting enema = LEFT side

Patho: related to a low fiber diet.

Place pt on RIGHT side. Worried about rupture. 

Test for rebound tenderness at McBurney's point!

• Dx: WBC will be up
• Ultrasound or CT

Tx: Surgery!!

Keep refrigerated and warm for administration

Must be given through central line. It's packed with particales and sugar which will eat up veins.  Must be dedicated line. 

Have to discontinue gradually to avoid hypoglycemia.

• Will monitor:
• daily weights
• may have to start taking insulin
• Monitor blood glucose every 6 hrs
• Check urine for ketones and glucose!

**Protein can't leak through glomerulus unless there's kidney damage!! 

IV bag may be covered with dark bag to prevent chemical breakdown from light