Adult III- GI

• Parietal cells
• Chief cells

• Hydrochloric acid
• Intrinsic factor

• Secreted by gastric mucosa and is vital for the absorption of vitamin B12
• Without vitamin B12 combining with intrinsic factor pernicious anemia develops

Pepsinogen which is a precursor to pepsin which is a major factor in the digestion of protein

Smooth, sore, beefy red tongue, diarrhea, listlessness, fatigue, confusion, paresthesia and neuro issues

Vitamin B12 shots on a routine and permanent monthly basis

• Pancreas exocrine
• Pancreas endocrine

• Acinar cells, secretion of pancreatic enzymes which are very alkaline into the GI tract through pancreatic duct
• Amylase-Carbs
• Lipase-Fats
• Trypsin-Proteins

• Islets of Langerhans, the endocrine part of the pancreas are collections of cells embedded in the pancreas. They are composed of alpha, beta, and delta cells
• Secretion of Insulin, glucagon, and somatostatin directly into the bloodstream

• Produces insulin
• Insulin permits entry of glucose into the cells of the liver, muscle and other tissues where it is either stored as glycogen or used as energy

• Secretes glucagon
• Works with your liver to turn a type of stored sugar called glycogen into glucose, increases blood sugar

• Somatostatin
• A hormone that regulates a variety of bodily functions by hindering the release of other hormones, has an effect on the activity of your GI tract, interferes with the release of growth hormone from pituitary gland, regulates the release of glucagon and the reproduction of cells

• Storage
• Protective
• Ammonia conversion
• Protein metabolism
• Glucose metabolism

• Stores vitamins and minerals
• Vitamins B12 and small amounts of C
• Iron, magnesium, copper
• Fat soluble vitamin A (80%), D, E, K

Kupffer cells phagocytic

Gluconeogenesis uses amino acids from protein and creates ammonia as a waste product. The liver then converts ammonia into urea which is excreted by the kidneys

• Break down proteins, synthesis of almost all of the plasma proteins Synthesis of albumin, alpha-globulins, and beta-globulins, blood clotting factors, specific transport proteins and most of the plasma lipoproteins.
• No vitamin K= no prothrombin

The liver converts glucose in the blood to glycogen, which is stored, until needed

Diagnose anemia, infection, GI bleed most common cause of anemia in adults, cancer, inflammatory bowel

• Liver is the site of all protein synthesis involved in coagulation
• Measures the rate at which prothrombin is converted to thrombin
• Process depends on vitamin K associated clotting factor
• Severe or acute liver disease leads to elevated prothrombin time

Cholesterol 20 years of age and older should have a fasting lipid profile every 5 years (more if abnormal)

<200

• <100
• >160 is high risk
• <70 with high risk such as family history

• >40 for males
• >50 for females

<150

• 8.5-10.5
• Less than 8 can develop tetany
• May detect malabsorption
• Gastroparesis

135-145

• 3.5-5.0
• Absorbed in GI tract
• Vomiting and diarrhea may cause depletion

• Enzymes found in liver involved in protein metabolism elevated in liver disease
• Normal AST: 10-40
• Normal ALT: 8-40

• Normally used to rebuild amino acids or is converted to urea for excretion
• Elevated during liver failure
• Lactulose is used to decrease levels

• Elevations indicate acute pancreatitis
• Not elevated in presence of extensive pancreatic necrosis d/t destruction of pancreatic cells that manufacture the enzymes
• Normal 0-54/10-180

Shed by tumor cells it is elevated in most patients with advanced pancreatic cancer, but can be elevated in other cancers and condition as well (colorectal, stomach cancer, bile duct cancers, and some non-cancerous conditions)

• Used to indicate cancer is present
• Can be used in staging after diagnosis
• Monitor success of cancer therapy
• Assess for recurrencetest is done every 6 mo for life
• Can be elevated in benign GI conditions
• Used frequently to diagnose and stage colorectal cancer
• Monitor concerning trends to help assist in staging

• Detects certain DNA related to colon cancer
• Can detect neoplasia anywhere in the colon

• Measures microscopic amounts of blood in feces also known as a guaiac smear test or hemoccult
• Can be done bedside
• Two methods
• If blood is detected then a follow up with colonoscopy should be done

• Test for blood in stool at home
• Hemoccult II
• Requires 2 samples from different areas of stools test often repeated for Dx

• FIT
• Only detects human hemoglobin
• Don’t use while on menses or if you have an active hemorrhoid
• Requires 1 sample

• Allows visualization of common bile duct and pancreatic ducts
• Allows removal of gallstones, placement of stents, allows for biopsies, can snip sphincter if it is constricted

• Ensure that the patients gag reflex has returned before giving foods fluids
• Monitor for complications at home such as fever, intense abdominal pain, increase in original symptoms being hospitalized for, low bp, chills

• Interact with acids at the chemical level to neutralize them
• Precautions may neutralize some other medicines don’t take at the same place as other meds wait at least 30 mins

• -prazol
• Inhibits the secretory surface of the gastric parietal cells, decreasing gastric acid production
• Causes a higher risk for c diff
• Can interfere with mineral absorption such as b12, magnesium can lead to higher risk of fracture
• Prevents ulcers

• -tidine
• Histamine-2 receptor sites located on parietal cells, works by blocking the histamine receptors in parietal cells to decrease the amount of acid produced
• Increases risk of c diff
• Potential for QT elongation (if pt has heart or renal issues)

• Sucralfate (Carafate)
• Coat injured area in the stomach
• Give on an empty stomach-1 hour prior to meals
• Protects eroded ulcer sites in the GI tract from further damage by acid and digestive enzymes

• Misoprostol(Cytotec)
• Inhibit the secretion of gastrin and increase the secretion of the mucous lining of the stomach providing a buffer
• Used to protect the lining of the stomach in situations that might lead to serious GI complications such as ulcerations, chronic NSAID use
• Digestive Enzymes- Saliva substitutes
• help in conditions that result in dry mouth
• not absorbed
• mouthkote, salivart

• Replace pancreatic enzymes to aid in digestion
• GIVE WITH FOOD
• Creon, Pancreas

• Decrease inflammation
• Enter target cells and binds to cytoplasmic receptors, initiating many complex reaction that are responsible for anti-inflammatory and immunosuppressive effects\
• Can cause stomach and esophageal irritation take with food or milk
• PO= prednisone (Deltasone)
• IV, IM, PO= methylprednisolone (Medrol)

• The autodigestion of the pancreas by its own enzymes (trypsin, lipases, amylase). The pancreatic duct becomes obstructed temporary due to gallstones moving from gallbladder to the bile duct leading to inflammation
• These enzymes enter the bile duct, activate, combine with bile and reflux back into the pancreas. The pancreas becomes inflamed as it is being auto digested by these enzymes!
• Severely painful, pain is generally noted in the abdomen and back
• Typically a result of alcoholism or gallstones

Pancreatitis with absence of organ failure and local or systemic complications with a prognosis that resolves within 6 months

• Edema
• Inflammation
• Minimal organ dysfunction
• Stabbing pain from abdomen to the back
• Can be a medical emergency

• Alcohol abuse (underlying chronic pancreatitis)
• Biliary tract disease (underlying chronic)
• Gallstones
• Instrumentation on the duct (ERCP)
• Surgery on or near the duct and abdomen
• Alcohol and biliary tract disease account for 80%

During illness has a potential for hypovolemic shock, sepsis, electrolyte imbalances

• Severe abdominal pain (knifelike)- guarding
• Severe back pain
• Often 24-48 hours post large meal or drinking episodes
• Pain is most severe after meals
• Abdominal distention
• N/V emesis may be bile colored and doesn’t help
• Fever
• Jaundice

• Elevated lab values: Amylase >54, lipases >180, indicates a patient is very sick
• WBC>10,000
• Decreased calcium <8
• Xrays of abdomen and chest to rule out other causes
• H&H or CBC to monitor for bleeding

• Scoring system that uses 11 parameters to assess the severity of acute pancreatitis
• Gives an estimated mortality rate based on the # of criteria present between admission and 48hr of hospitalization

• Age > 55
• WBC > 16,000
• Serum glucose > 200
• Serum lactic acid dehydrogenase (LDH) > 350
• AST > 250 aspartate transaminase - released when liver or muscles are damaged.

• Fall in HCT >10%
• BUN increase > 5
• Serum Ca++ < 8
• Base deficit > 4 (increased acidity)
• Fluid shift > 6L
• PO2 < 60

• Hypocalcemia - tetany with less 8, leads to seizure as lowers
• Hyperglycemia - from impared insulin secretion damages pancreas
• Hypoxemia- due to pain or elevated diaphragm due to swelling of pancreas
• Fluid shift
• Ileus
• DIC
• Infection
• Pseudocysts
• Necrosis
• Hemorrhage- enzymes damage blood vessels (Cullens & Turners signs)
• peritonitis

• Relieve symptoms and prevent or treat complications
• Pain control- morphine is fine as long as we are not currently looking at the sphincter of oddi
• IVF
• Nutritional support
• NPOwhen reintroducing food diet is low protein, low fat, high carb
• I&O/ daily weights
• Stool monitoring-fatty/floater turds
• Goal is to rest pancreas so med orders-pancreatic enzymes, stomach acid blocker

• Reposition
• Lean forward
• Semi fowlers
• Do not put supine-stretches already painful pancreas

• Ciprofloxacin (prophylactic antibiotic) with flagyll
• Opioids- fentanyl & dilaudid
• Morphine may be contraindicated due to potentially causing spasms in the sphincter of Oddi
• Histamine 2 antagonists
• PPIs
• Antiemetics
• Insulin
• Goal is to rest pancreas so med orders-pancreatic enzymes, stomach acid blocker

High levels of inflammation and damage to the pancreas from autodigestion (primary culprit trypsin), pain that occurs after a meal and becomes more severe with each meal

• Shock, anoxia, hypotension, fluid and electrolyte imbalances, necrosis of the pancreas, peritonitis, organ failure, GI bleed, bruising, fluid shifts
• Prognosis - 10-30% mortality.

• IV Hydration
• FFP (fresh frozen plasma) - To prevent and reduce bleeding
• Pressors - because hypotension
• IV Abx - To prevent and treat pancreatic necrosis
• ERCP - within 24 hours if stones suspected in common bile duct
• Surgery
• Calcium gluconate - To rapidly replace Calcium, Calcium levels are a direct indicator of severity and low calcium levels are deadly (tetany, arrhythmias, seizures)
• With necrotic-Super ill, usually leave open to check to see if more needs done like debridement

• Eat low protein, low fat, high fiber, increase vegetables, use skim milk
• No alcohol
• No cigarettes
• No spices
• No caffeine

• An inflammatory disorder characterized by PROGRESSIVE DESTRUCTION of the pancreas this is caused by repeated episodes of pancreatitis
• Cells that should secrete no longer can and pressure inside the pancreas increases as fibrous tissue replaces healthy tissue. (Fibrosis/Scarring).
• Pancreatic duct and common bile duct obstructions occur.
• Repeated hospitalizations

• Recurring severe upper abdominal and back pain
• Vomiting
• Pain is chronic and severe often unrelieved by large doses of opioids(=risk of dependency)
• Weight loss d/t decreased intake secondary to anorexia or FEAR that eating will cause an attack
• Malabsorption of protein and fats
• Malnutrition
• Steatorrhea( frequent, frothy, foul smelling stools) due to decrease in pancreatic enzymes

• ERCP- allows for visualization, biopsy
• CT- detects cysts
• Xray
• MRI
• Ultrasound- can detect cysts
• Lab analysis of fecal fat content
• Increased serum amylase levels or normal d/t destruction of pancreatic cells

• Prevent & manage attacks
• Treat pain- antioxidants, lifestyle changes, yoga and meditation
• Treat DM resulting from pancreatic islets cell dysfunction
• Correct malabsorption w/ pancreatic enzyme replacement meals mixed with acidic foods
• Endoscopy to remove stones
• Surgical Whipple procedure

Removal of the head of the pancreas and attach common bile duct to the duodenum

• Steroids with food
• PPI on empty stomach
• H2 antagonist b4 meals
• Pancreatic enzymes with food
• Insulin fast acting with food

• 4th leading cause of cancer death in men in US and 5th in woman
• 73% die within first year
• <5 year survival rate is in single digits

• Increasing age (peak 70-80)
• Sex- males slightly higher than woman
• Cigarette smoking
• Chemical exposures
• Diets high in fat or meat
• DM, chronic pancreatitis, hereditary pancreatitis
• Obesity

• Vague, nonspecific
• Vague pain, epigastric pain may radiate to the back, increases with food
• Rarely diagnosed at this point

• Most diagnosis of pancreatic cancer happens in the late stage when no treatment options are available
• Metastasis to other organs
• Symptoms of obstruction
• Pain,Jaundice, Weight loss**classic symptoms
• Ascites from cancer cells in peritoneum
• Pain is more intense at night when supine
• Itching, pruritus, glucose intolerance or sudden onset DM

• Spiral CT is 85-90% accurate in diagnosis and staging
• CA 19-9, CEA, DU-PAN2 tumor markers used to mark disease progression

• Surgical resection- Whipple/ pancreaticoduodenectomy
• NG for TPN
• Biliary stent to prevent jaundice
• Chemo
• IORT- radiation to shrink cancer
• Palliative care- most frequent due to late diagnosis

• Jaundice
• Portal hypertension

Caused by an accumulation of bilirubin in the blood that the liver is unable to break down

Increased pressure throughout the portal venous system caused by obstruction of blood flow throughout the damaged liver

• Varices
• Ascites

• Varicose veins of the esophagus
• Dilated tortuous veins found in submucosa of lower esophagus
• Bleed easily
• Vomiting blood=EMERGENCY
• Triggers for bleeding= sneezing, coughing, vomiting, eat something crunch/hard, reflux, drinking alcohol, NSAIDS

• Hematemesis- blood in vomit
• Melena- tarry stools
• Shock
• Mental/ physical deterioration

• Pale
• Cold
• Clammy skin
• Shallow, rapid breathing
• Difficulty breathing
• Anxiety
• Rapid heartbeat
• Low urine output

• Endoscopy
• Portal system pressure
• Endoscopic video capsules

• Endoscopic procedures- balloon tamponade, banding applies pressure on the varices so they cannot bleed
• Vasopressin- 1st line in urgent/emergency situations for pts without CAD
• Octreotide- synthetic somatostain 1st line tx when available decreases bleeding by causing selective splanchnic vasoconstriction
• Beta blockers- prevent bleeding or rebleeding
• Nitrates- decrease oirtal hypertension long acting
• TIPS procedure

• Monitor VS- look for increased HR and decreased BP= hemorrhage
• Assess LOC
• Soft diet
• Monitor I&Os
• Educate on meds and disease process
• Assess and assist with support with anxiety

Obstruction increased capillary pressure fluid shift into intraperitoneal space

• Increased abdominal girth (measured assessment)
• Raid weight gain
• Striae across abdomen
• Umbilical hernial

• Accumulation of fluid in the peritoneal cavity from the vascular system
• Obstruction of venous blood flow
• Increased capillary pressure
• Fluid shift into intraperitoneal spaxe
• Sodium and water retention

• Low sodium diet (500mg/day) avoid salt substitutes, decrease protein (ammonia)- diet alone only works on 10% of pts
• Diuretics
• Bed rest
• Paracentesis- removal of fluid in abdomen in sterile procedure
• TIPS

• Shunt blood from the portal venous system to the arterial system
• Could cause decreased renal output and decreased blood flow, decreased cardiac output

• Monitor I&O
• Abdominal girth measurement
• Daily weights
• Labs- ammonia, total protein, albumins, electrolytes
• Frequent rest periods
• Small frequent meals

• Chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver
• Scarring the liver
• Seen 2x more in men

• Liver cells necrose and are replaced by scar tissue
• Eventually there is more scar tissue than functioning liver tissue
• Hobnail appearance due to island of normal tissue and regenerating liver tissues

• Alcoholic (Laennecs)
• Post necrotic
• Biliary
• Crytogenic

most common type, scar tissue surrounds the portal area of the liver, due to alcoholism

broad bands of scar tissue due to acute viral hepatitis or IV drug abuse

scarring around bile duct due to biliary obstruction, infection, or cholangitis

unknown cause, possible fatty liver disease related, non-alcoholic

• Labs- PT and INR greater than 3
• Elevated liver functions
• >AST, >ALT, >GGT
• Liver biopsy

• GI disturbances like anorexia, dyspepsia, flatulence, NV, diarrhea or constipation
• Abdominal pain, dull heavy feeling in RUQ
• Fever, lethargy, weightloss
• Enlargement of liver and spleen (painful)
• Stool/urine changes to pale stool and dark orange urine due to bilirubin

• Hematologic problems- jaundice, anemia, bleeding
• Portal obstruction
• Skin lesions
• Endocrine problems
• Peripheral neuropathy
• Encephalopathy- fatigue, decreased LOC

• Symptomatic and designed to slow disease progress
• Eliminate alcohol
• Avoid Tylenol
• High calorie diet
• Supplement A, Cm K and B complexes
• Sodium restriction

• PPI, H2 blockers, antacids- treat/prevent PUD and bleeding
• Anti-inflammatories
• Colchicine- gout medication can improve hepatic function
• Spironolactone- decrease ascites potassium sparing diuretics

• Promote rest
• Improve nutrition
• Skin care
• Decreased risk of injury
• Monitor potential complications- hemorrhage, hepatic encephalopathy, fluid volume excess

• Accumulation of ammonia and toxic metabolites in the blood and brain
• Liver cells are unable to convert ammonia to urea
• Increased ammonia causes brain dysfunction and damage which leads to poor hygiene, lethargy, sleep more

• Confusion
• Unkempt- having an untidy or disheveled appearance
• Mood changes
• Impaired sleep pattern
• Somnolence- sleeping more and more
• Asterixis- flapping tremor of hands

• Labs for ammonia level
• EEG- shows slowing
• Fetor hepaticus- sweet slightly musty/fecal odor to breath

• No alcohol
• Lactulose- promotes excretion of ammonia from the colon must be titrated so the pt is only having 2-3 bm/day
• Neomycin- antibiotic given to suppresses GI bacteria that produces ammonia
• AVOID acetaminophen, sedatives, tranquilizers

• 2nd most common and 3rd leading cause of cancer death for men and women
• 1 in 20 people will develop it in their lifetime
• Asymptomatic for long time seeking help when bowel habits change
• 90% 5 year survival rate if detected and treated early only 39% are caught early

• History of Gastrectomy
• History of IBD
• History of Genital Cancers (including breast cancer)
• History of Type 2 Diabetes
• Male
• Racial/ethnic background: African American or Ashkenazi Jewish
• Increasing age 60-70
• Family history of colon cancer or polyps (Lynch Syndrome)
• Previous colon cancer or adenomatous polyps

• High fat, high protein, low fiber diet
• High alcohol intake
• Cigarette smoking
• Obesity

Diet encourage low red meat, low fat, low protein, high fiber, smoking cessation and don’t drink to excess

• 95% adenocarcinoma
• Rising from the epithelial lining of colon
• Usually starts as benign polyp
• Transforms to malignancy
• Invades and destroys normal tissues
• Highly vascular area and near lymph nodes so it can move

0-4

• Changes in bowel habits most common**
• Blood in stool
• Melena (black tarry stools)
• Unexplained anemia
• Anorexia
• Weight loss
• Fatigue

• Ascending, 1st half of transverse
• Present as occult rectal bleeding and anemia
• Dull pain
• Black tarry stool

• Descending sigmoid rectum second half of transverse
• Associated with obstruction
• Changes in bowel habits
• Obstructive symptoms like colicky abdominal pain, stool streaked with blood, thin pencil like stools, alterations between diarrhea and constipation, abdominal distention, rectal lesions

• Bowel obstruction- partial or complete
• Hemorrhage- tumor invades surrounding blood vessels
• Sepsis, peritonitis, shock and death

• Stools for occult blood (FIT)
• Colonoscopy** gold standard

• CEA- increased represents cancer cells
• Will need to forever check for recurrence or progression

• Surgery 1st choice treatment
• Semental resection with anastomosis to remove diseased tissue and put everything back together and let everything rest then resume soft diet
• Bowel resection with colostomy
• Temporary or permanent ileostomy- allows body time to heal
• Colonic J pouch- rectal sphincter is preserved remove lining of rectum and large intestines and make a small pouch out of small intestine that connected to anus

• Bowel prep prior to surgery
• Antibiotics - pre-op to decrease bacteria prior to surgery

• Monitor for anastomosis leakage- pain, fever, muscle rigidity, gastric content can cause big issues (peritonitis)
• Prolapse stoma (goes out)
• Perforation
• Stoma retraction
• Fecal impaction
• Skin irritation- fistulas

• TPN or IVF until bowel function returns
• Slow advancement of diet
• Healthy diet
• Trial and error to find foods that help control
• constipation or diarrhea
• Food diary

• Monitor stoma- beefy red stoma that bleeds slightly when disturbed is normal
• Swelling
• Color - pink, red NOT purple, black or blue= lack of blood flow
• Discharge - small amount normal
• Bleeding - normal to bleed a little, monitor drains, dressing

• Stool consistency depends on colostomy site
• Ascending - liquid
• Transverse - soft mushy
• Descending/sigmoid - formed stool
• Enterostomal nurse therapist referral
• Irrigating colostomy- Helps schedule bowel movements, similar to an soap sud enema
• Support positive body image
• Provide emotional support
• Monitor and manage complications