The gastro intestinal system

Disorders of the
Gastro-intestinal system:
General GIT & Hepatic system
By C Settley2018/03/15 Compiled by C Settley

Student outcomes
At the end of this unit, the student will be able to:
• Apply knowledge regarding: patho-physiology, disease process, clinical
manifestations, specific diagnostic and therapeutic interventions (diagnostic tests
and examinations)
• Distinguish between the different health problems: medical and surgical
conditions of various body systems (Peptic ulcer, Hiatus hernia, Peritonitis, Bowel
obstruction, Inflammatory bowel disease & Cirrhosis of liver).
• Assess, relate and apply the scientific process of nursing, provision and facilitation
of nursing care.
• Evaluate, analyse and solve problems in familiar and unfamiliar context in the
Comprehensive Health Care system.
• Understand the relationship between social, cultural and economic factors that
may impact significantly on the health status of clients / patients and groups
(Health education).
• Apply knowledge of emergency and trauma management principles.
2018/03/15 Compiled by C Settley

The general GIT system
• The human digestive system is a complex series of organs and glands that serve
to process food.
• During this process, the food is broken into smaller pieces and further into
smaller molecules, nutrients and waste products.
• The role of the human digestive system is to turn the food into nutrients or
energy needed by the cells, or into waste products that can be excreted from the
body.
• The human digestive system is made up of the digestive tract and composed by
the organic structures stretching from the mouth to the anus.
• Digestive system includes both the gastrointestinal tract, with stomach and
intestine, and other structures such as accessory organs of digestion: salivary
glands, liver, pancreas.
• Digestive system disorders are all those health conditions or complaints that
directly affect the digestive system.

Salivary glands

The general GIT system: Anatomy

• Mouth
• The mouth is the beginning of the digestive tract
• Digestion starts here.
• Chewing breaks the food into pieces that are more easily digested, while
saliva mixes with food to begin the process of breaking it down into a form
the body can absorb and use.
• Oesophagus
• Located in the throat near the trachea (windpipe), the oesophagus receives
food from the mouth when swallowing.
• By means of a series of muscular contractions called peristalsis, the
oesophagus delivers food to the stomach.

• Stomach
• The stomach is a hollow organ, or "container," that holds food while it is being
mixed with enzymes that continue the process of breaking down food into a
usable form.
• Cells in the lining of the stomach secrete a strong acid and powerful enzymes
that are responsible for the breakdown process.
• When the contents of the stomach are sufficiently processed, they are
released into the small intestine.

Sphincters in stomach
• Two sphincters keep the contents of the stomach contained;
• the lower oesophageal sphincter (found in the cardiac region), at the junction
of the oesophagus and stomach,
• and the pyloric sphincter at the junction of the stomach with the duodenum

Sphincters
• The pyloric sphincter is a band of smooth muscle at the junction
between the pylorus of the stomach and the duodenum of the small
intestine. It plays an important role in digestion, where it acts as a
valve to controls the flow of partially digested food from the
stomach to the small intestine.
• The lower esophageal sphincter (LES) is a bundle of muscles at the
low end of the esophagus, where it meets the stomach. It prevents
acid and stomach contents from traveling backwards from the
stomach.

• Small intestine
• Made up of three segments - the duodenum, jejunum, and ileum - the small
intestine is a 22-foot long muscular tube that breaks down food using enzymes
released by the pancreas and bile from the liver.
• Peristalsis also is at work in this organ, moving food through and mixing it with
digestive secretions from the pancreas and liver.
• The duodenum is largely responsible for the continuous breaking-down process,
with the jejunum and ileum mainly responsible for absorption of nutrients into
the bloodstream.
• Contents of the small intestine start out semi-solid, and end in a liquid form after
passing through the organ. Water, bile, enzymes, and mucous contribute to the
change in consistency. Once the nutrients have been absorbed and the leftover-
food residue liquid has passed through the small intestine, it then moves on to
the large intestine, or colon.

• Small intestine

• Pancreas
• Secretes digestive enzymes into the duodenum. These enzymes break down
protein, fats, and carbohydrates. The pancreas also makes insulin, secreting it
directly into the bloodstream. Insulin is the chief hormone for metabolizing
sugar.
• Liver
• The liver has multiple functions, but its main function within the digestive
system is to process the nutrients absorbed from the small intestine. Bile from
the liver secreted into the small intestine also plays an important role in
digesting fat.
• It takes the raw materials absorbed by the intestine and makes all the various
chemicals the body needs to function. The liver also detoxifies potentially
harmful chemicals. It breaks down and secretes many drugs.

• Gallbladder
• The gallbladder stores and concentrates bile, and then releases it into the duodenum
to help absorb and digest fats.
• Colon (large intestine)
• Connects the small intestine to the rectum. The large intestine is made up of the
cecum, the ascending (right) colon, the transverse (across) colon, the descending
(left) colon, and the sigmoid colon, which connects to the rectum. The appendix is a
small tube attached to the cecum.
• The large intestine is responsible for processing waste so that emptying the bowels is
easy and convenient.
• Stool, or waste left over from the digestive process, is passed through the colon by
means of peristalsis. As stool passes through the colon, water is removed. Stool is
stored in the sigmoid (S-shaped) colon until a "mass movement" empties it into the
rectum once or twice a day. The stool itself is mostly food debris and bacteria.

• Rectum
• It is the rectum's job to receive stool from the colon, to let the person know that
there is stool to be evacuated, and to hold the stool until evacuation happens. When
anything (gas or stool) comes into the rectum, sensors send a message to the brain.
The brain then decides if the rectal contents can be released or not. If they can, the
sphincters relax and the rectum contracts, disposing its contents. If the contents
cannot be disposed, the sphincter contracts and the rectum accommodates so that
the sensation temporarily goes away.
• Anus
• The anus is the last part of the digestive tract. The lining of the upper anus is
specialized to detect rectal contents.

Functions of the gastrointestinal system
structures (summary)

• Risk factors for the disorders of the accessory organs of digestion
• Exposure to harmful substances
• Exposure to blood and blood products contaminated with
viruses
• Invasive procedures such as blood transfusions and dental
procedures that may transit viruses
• Lifestyle
• Excessive usage of medications
• Trauma and illness

The general GIT system:
Diagnostic studies
• X ray
• Ba swallow
• To determine the cause of painful swallowing, difficulty with swallowing,
abdominal pain, bloodstained vomit, or unexplained weight loss.
• To visualize the structures of the oesophagus.
• The patient swallows liquid barium while X-ray images are obtained.
• The barium fills and then coats the lining of the oesophagus so that it can
diagnose anatomical abnormalities such as tumours.

Diagnostic studies
• Ba enema
• Detect changes or abnormalities in the large intestine (colon).
• The radiologist will insert a small tube into the patient’s rectum and introduce
the barium and water mixture.
• The radiologist may gently push air into the colon after the barium has been
delivered in order to allow for even more detailed X-ray images.

Diagnostic studies
• Endoscopies
• A procedure in which an instrument is introduced into the body to give a view
of its internal parts.

Diagnostic studies
• Fibre optic colonoscopy

Diagnostic studies
• Abdominal ultrasound
• CT scan
• MRI
• Stool tests

Peptic ulcer- pg. 747
• A lesion in the lining (mucosa) of the digestive tract, typically in the
stomach or duodenum, caused by the digestive action of pepsin and
stomach acid.
• Gastric ulcers: ulcers that develop inside the stomach.
• Oesophageal ulcers: ulcers that develop inside the oesophagus.
• Duodenal ulcers: ulcers that develop in the upper section of the small
intestines.
• Marginal ulcers: these ulcers develop most often after gastric bypass
procedures where the gastric remnant or distal stomach is stapled but not
divided.
• Stress ulcers: a single or multiple mucosal defect which can become
complicated by upper gastrointestinal bleeding during the physiologic
stress of serious illness.

Peptic ulcer
• Can be acute or chronic
• A chronic ulcer is four times as
common as an acute ulcer.

Peptic ulcer
• Causes
• An ulcer develops when the defence mechanisms protecting
the gastric mucosa from stomach acid break down, changes
• The causes of such breakdowns are not known
• The increase in gastric juice secretion may be the result of:
• Decreased inhibition of gastric secretions
• Increased capacity or number of parietal cells to secrete acid, or
increased response of the parietal cells to stimulation
• Increased stimulation of the vagus nerve

Peptic ulcer
• The gastric mucosa is the mucous membrane layer of the stomach which
contains the glands and the gastric pits. In humans it is about 1 mm thick and
its surface is smooth, soft, and velvety. It consists of simple columnar
epithelium, lamina propria, and the muscularis mucosae.

Peptic ulcer
• Risk factors
• Smoking. It causes a reduction of pancreatic bicarbonate secretion thus
creating a decreased pH in the duodenum. Nicotine is thought to
enhance a reflux of duodenal contents into the antrum of the stomach.
• The presence of biliary and liver disease increases the risk of ulcer
formation.
• Coffee, tea and fizzy drinks. It stimulates acid secretion.
• Certain medications such as corticosteroids, aspirin, NSAID’s like
ibrufen.
• Stress.
• Family history.
• Age.

Peptic ulcer
• Pathophysiology
• A physiologic balance exists between gastric acid secretion and gastric and
duodenal mucosal defense systems.
• Mucosal injury occurs when the balance between aggressive and protective
factors is disrupted.
• Thus, peptic ulcers are defined as defects in the
gastric or duodenal mucosa and submucosa,
which extend through the muscularis mucosa.

Peptic ulcer
• Pathophysiology
• Cells produce mucus and bicarbonate, which form a gel layer impermeable to
aggressive factors such as acid and pepsin.
• This layer is extremely important, as it prevents the stomach from digesting
itself.
• In the event of injury, additional mechanisms help to prevent acid and pepsin
from entering the epithelial cells.
• For example, increased blood flow removes acid that diffuses through the
damaged mucosa and provides adequate bicarbonate level in the gel layer
superficially to epithelial cells.
• Additionally, epithelial cells regulate intracellular pH by removing excess of
hydrogen ions through the ion pumps in the basolateral cell membrane.

The general GIT system: Comparison of DU & GU
Table 39,3, pg. 748
• Lesions
• Location of ulcers
• Incidence
• Acid secretion
• Associated gastritis(inflamed stomach lining)
• Bleeding pattern
• Pain
• Nutritional status
• Potential for malignancy
• Recurrence state
• Risk factors

The general GIT system: assessment and
common findings- pg. 750
• Pain
• Chronic and or periodic
• Accompanied by back pain
• Sometimes relieved by drinking milk but returns
• Results in slow passage of food

• Nausea and vomiting
• Common with gastric ulcers
• Vomiting mostly accompanied by nausea
• Bloating pain
• Relieved by ejection of stomach contents
• Oesophageal tears

• Heartburn
• Sudden accumulation of gas in the stomach

• Constipation or diarrhoea
• May result from the diet or medication
• Bleeding
• Occurs in 25% of cases of gastric ulcers as a result of erosion of a blood vessel.
• It ay occur as massive haemorrhage.
• Often a complication.
• Diagnostic tests

The general GIT system: complications- pg. 750
• Haemorrhage
• Sometimes an ulcer may involve just the surface lining of the digestive
tract.
• The person may then have a slow but constant loss of blood into the
digestive tract. Over time, anemia may develop because of this slow
blood loss.
• If ulcers become larger and extend deeper into the digestive tract lining,
they may damage large blood vessels, resulting in sudden, serious
bleeding into the intestinal tract. Without prompt medical treatment to
stop the bleeding, a person could bleed to death. Blood transfusions
often are needed when serious bleeding occurs.
• Vomiting blood and/or material that looks like coffee grounds as well as
stools that are black, look like tar, or are maroon and bloody, indicates
bleeding.

• Haemorrhage
• Endoscopy performed to locate the bleeding
• Surgical interventions may be neccesary

• Obstruction
• Swelling and inflamed tissue narrows the duodenum.
• Pain.
• Induces vomiting which is projectile and of an offensive smell.

• Perforation
• Perforation occurs when an ulcer eats through the wall of the
stomach or intestine into the abdominal cavity.
• Although perforation is a much less frequent complication than
bleeding, it is still a significant problem in people who have
unsuspected or untreated peptic ulcers.
• As people use more NSAIDs, the incidence of perforation is
increasing.
• When perforation occurs, partially digested food, bacteria, and
enzymes from the digestive tract may spill into the belly cavity,
causing inflammation and infection (peritonitis).
• Peritonitis usually causes sudden and severe pain. Treatment
usually requires urgent hospitalization and surgery.

• Penetration
• When the ulcer goes through the wall of the stomach and
continues into adjacent structures such as the pancreas, the
biliary tract, or the gastrohepatic omentum.

The general GIT system: Management of
peptic ulcers- pg. 751
• Prevent complications
• Reduce discomfort
• Allow ulcer to heal completely
• Make lifestyle changes
• Encourage compliance

• Pharmacological treatment
• Pro-kinetic drugs:
• Used to treat and prevent nausea & vomiting.
• Metoclopramide increases the rate of gastric emptying and peristalsis.
• Drugs that increase gastric pH:
• Proton pump inhibitors
• Effect: prevents secretion of HCl (gastric acid)
• Increasing pH in stomach
• E.g. Omeprazole

• Drugs that reduce gastric pH
• H2 receptor antagonists:
• Blocks gastric H2 receptors
• Reduces gastric acid secretion
• Not as effective as proton pump inhibitors
• E.g. cimetidine

• Cytoprotective drugs
• Protect cells of stomach lining against corrosive effects of
gastric acid
• By forming a protective layer
• Very good success rate in healing of ulcers
• E.g. sucralfate
• Take one hour before meals

• Anti motility agents
• First find cause of diarrhoea, not all diarrhoea must be stopped
• E.g. loperamide
• Non-analgesic opioid
• Stimulate opioid receptors in enteric nervous system
• To inhibit release of acetylcholine
• Decreases peristalsis
• A COMBINATION OF THESE DRUGS ARE PRESCRIBED IN THE
TREATMENT OF PEPTIC ULCERS!!!

• Surgical treatment
• Mainly used to deal with recurring ulcers
• Truncal vagotomy
• Selective vagotomy
• Proximal vagotomy

The general GIT system: surgical management
of peptic ulcers- pg. 752

The general GIT system: Peritonitis/acute
abdomen- pg. 757
• Inflammation of the membrane lining the abdominal wall and covering the
abdominal organs.
• Peritonitis is usually infectious and often life-threatening. It's caused by
leakage or a hole in the intestines, such as from a burst appendix. Even if the
fluid is sterile, inflammation can occur. Causative organisms.

abdomen- pg. 757
• Assessment and common findings
• Abdominal pain and tenderness
• Abdominal distention
• Fever, nausea and vomiting, tachycardia, tachypnoea, oliguria,
restlessness, weakness and pallor
• Diagnostic tests
• X-rays
• Fluid aspiration for sensitivity test and relieve of distention
• Blood tests for serum electrolytes
• Peritoneoscopy can be done for patients without ascites

abdomen- pg. 757
• Management
• Identify and eliminate the cause
• Relieve abdominal pain
• Combat infection
• Maintain nutritional status
• Prevent complications
• Bed rest
• Ventilation
• Semi fowlers
• Monitor pain and response strict intake and output
• Monitor drains
• Nasogastric tube to relieve distention
• Medication as prescribed

abdomen- pg. 757
• Essential health information
• Reinforce teaching the nature of the problem and its
management
• Ongoing support and encouragement
• Encourage verbalisation of concerns
• Encourage ambulation
• Teach coping mechanisms
• Wound management training
• Referrals

The general GIT system: Bowel obstruction-
pg. 761
• A gastrointestinal condition in which digested
material is prevented from passing normally through
the bowel.
• Blockage of the intestines
• Impairment of forward flow

The general GIT system: Causes of Bowel
obstruction- pg. 761
• 1. Mechanical causes of intestinal obstruction
• Intralumen- obstruction of lumen
• Mural causes: intussusception (a condition in which part of
the intestine telescopes into itself), hernia, volvulus,
stenosis, etc.
• Extra lumen- when pressure is
applied to the lumen. This refers to
tumours.

The general GIT system: Causes of Bowel
obstruction- pg. 762
• 2. Non mechanical causes
• If something interrupts these coordinated contractions, it can
cause a functional intestinal obstruction.
• Interruption of blood flow to areas in abdominal cavity.
• 3. Neurogenic causes
• Absence of peristalsis activity.
• 4. Other
• Collagen or muscle disorders
• Endocrine disorders
• Chronic disorders

pg. 762
• Pathophysiology
• Each day the small intestines secretes 6-8 litres of fluid rich in electrolytes.
• Most of this fluid is reabsorbed.
• Some of the fluid is lost in the stool.
• When an obstruction occurs, an imbalance between secretion and absorption
develops.
• Intestinal fluid, contents and gas accumulate above the obstruction.
• This causes abdominal distention (and pain).
• The distention is made worse by an accumulation of gas in the bowel from
swallowing air and the action of bacteria on bowel contents.
• As production of intestines increases, the pressure in the lumen also increases.
• The bowel wall becomes oedematous.

pg. 762
• Pathophysiology
• The increase in pressure results in an increase in capillary
permeability .
• The bowel wall also becomes permeable to bacteria, and
bowel organisms enter this cavity.
• Increasing pressure in the wall slows arterial blood flow,
causing necrosis and eventually rupture of the intestinal
wall.

pg. 763
• Nursing care plan
• Pain
• Nausea and vomiting
• Decreased urine output
• Anxiety
• Fever

The general GIT system: Inflammatory bowel
disease- pg. 768
• IBD—ulcerative colitis and Crohn's disease.
• Different, but striking similarities
• Both produce inflammation of the bowel, have no
causative agent, have a pattern of familial occurrences and
accompanied by systemic manifestations
• Crohn's disease
• A chronic inflammatory bowel disease that affects the lining of the digestive
tract.
• Ulcerative colitis
• A chronic, inflammatory bowel disease that causes inflammation in the
digestive tract.

Types of IBD
IBD
Ulcerative
Colitis (UC)
Crohn’s
disease (CD)
Source:
p.1886

Ulcerative Colitis (UC)
• Mucosal disease
• Involves the rectum and
extends proximally to
involve all parts of the colon
• Produces mucosal friability
and areas of ulceration

Ulcerative colitis
Assessment and common findings- pg. 769
• Ulcerative colitis is usually only
in the innermost lining of the
large intestine (colon) and
rectum.
• Forms range from mild, chronic,
chronic-intermittent, and acute
fulminating.
• Having ulcerative colitis puts a
patient at increased risk of
developing colon cancer.

Ulcerative colitis
Risk factors- pg. 768
• Laxatives
• Abusing laxatives, result in: Electrolyte and mineral imbalances, Severe
dehydration, Laxative dependence, Internal organ damage & Increased colon
cancer risk.
• Narcotics
• Can cause gastro intestinal bleeding.
• Anticholinergics (An anticholinergic agent is a substance that blocks the neurotransmitter acetylcholine in the
central and the peripheral nervous system)
• Hyperkalaemia (Hyperkalemia is the medical term that describes a potassium level in your blood that's higher than
normal; normally 3.6 to 5.2 millimoles per liter (mmol/L).

Ulcerative colitis
Risk factors- pg. 768
• Ulcerative colitis is a chronic, relapsing inflammatory disease of
the colon, and affected patients may exhibit inflammation from
cecum to rectum
• Symptoms may include abdominal pain, malnutrition, and
diarrhoea, often bloody
• Inflammation is continuous
• Ulceration extends over a large area
• Bowel eventually narrows and shortens as the wall becomes
thick and inflexible

The general GIT system: Crohn's disease- pg.
768
• Causes:
• Crohn’s is a disorder of uncertain aetiology.
• It has often been thought of as an autoimmune disease
• Crohn's disease can cause other parts of the body to
become inflammed (due to chronic inflammatory activity)
including the joints, eyes, mouth, and skin. In addition,
gallstones and kidney stones may also develop as a result
of Crohn's disease.
• ‘IMMUNE SYSTEM ATTACKING ITSELF’

Factors contributing to the development of
Crohn’s disease

768
• Smoking
• Causes death of mucosal cells
• Oral contraceptives
• OCPs may increase the risk of developing IBD through the effects of oestrogen.
Oestrogen acts as an immune enhancer, particularly in regard to humoral
immunity and the proliferation of macrophages, whereas progesterone acts as
an immune-suppressor.
• Appendectomy
• Appendectomy is negatively associated with the development of UC, particularly
among children experiencing appendicitis before 10 years of age.
• Appendectomy is associated with an increased risk of Crohn's disease that is
dependent on the patient's sex, age, and the diagnosis at operation. The pattern
of associations suggests a biologic cause.

768
• Signs and symptoms:
• Chronic diarrhoea, often bloody and containing mucus or
pus
• Weight loss
• Fever
• Abdominal pain and tenderness
• Feeling of a mass or fullness in the abdomen
• Rectal bleeding

768

Crohn's disease- pg. 768

Crohn's disease- pg. 768
• Fistulisation
• Arteriovenous fistula: An abnormal connection between an artery and a vein.
• Anal fistula: An infected tunnel between the skin and the anus.
• Obstetric fistula: An abnormal connection between the rectum and the vagina.
• Micro perforation
• Ruptured bowel
• Adhesion
• Adhesions are fibrous bands that form between tissues and organs,
often as a result of injury during surgery. They may be thought of as
internal scar tissue that connects tissue.

Crohn's disease: Pathophysiology- pg. 768
• Begins with inflammatory oedema and thickening of the
mucosa.
• This develops into an ulcer.
• These lesions are interspersed between normal segments
of the bowel.
• This disease affects the full thickness of the intestinal wall
with the submucosal layer being affected most.
• Results in obstruction.
• Affects bowel motility.
• Inflammation and abscess formation.

Crohn's disease-
• History taking
• Physical examination
• Colicky pain in right lower quadrant which worsens after having meals (a pain that starts
and stops abruptly)
• Abdominal tenderness and spasms
• Possible anorexia
• Intermittent or chronic diarrhoea
• Low grade fever
• Arthritis, skin lesions, conjunctivitis and mouth ulcers
• Diagnostic studies:
• FBC (increased leukocytes, low Hb
• Examine stool for ova and parasites
• Radiological studies- Ba Swallow + Ba Enema

Crohn's disease-
• Management
• Arresting the inflammatory process
• Anti- inflammatory agents such as corticosteroids (Corticosteroids mimic the
effects of hormones your body produces naturally in your adrenal glands, which sit on top of your kidneys. When
prescribed in doses that exceed your body's usual levels, corticosteroids suppress inflammation),
sulphasalazine (this medication does not cure this condition, but it helps decrease symptoms such as fever,
stomach pain, diarrheal, and rectal bleeding), and antibiotics such as flagyl.
• Immunosuppressive drugs (e.g. azathioprine OR
Mercaptopurine)
• Usually next in line of treatment: REMICADE® (infliximab)
• Methotrexate can be added to a conventional
glucocorticosteroid in people who cannot tolerate azathioprine
or mercaptopurin

Crohn's disease-
• Management
• Surgical interventions
• Resection of the diseased bowel, drainage of
abscess, and repair of fistula.
• The illustrations show the surgical approach to
treat a stricture

Crohn's disease-
• Management
• Promoting comfort and healing
• Providing total nutrition while food cannot be tolerated or absorbed from the intestine
• Bulk free oral diet
• Maintaining adequate nutrition
• Highly nutritious diet with additional vitamins and calories for energy.
• The patient’s appetite should be stimulated by serving small frequent meals.
• Analgesic should be given before meals
• Early identification and treatment of complications
• Identification of obstruction such as increased abdominal pain, tenderness.
• Systemic manifestations should be assessed.

Case scenario 1
• Presentation
Ben has recurrent abdominal pain, weight loss and diarrhoea. He has been finding it difficult to
manage at school because he finds his diarrhoea embarrassing. This has led to him missing school.
• Medical history
Ben is an 8-year-old boy who presented in primary care. There are concerns about his growth, his
appetite is reduced and he is losing weight. He has been referred to secondary care for
investigation.
• On examination
Ben is small for his age (height on the 9th centile) and quite thin (weight below the 2nd centile). He
appears tired, is pale and is tender in the right iliac fossa.
• Next steps for management
Blood tests show that he is anaemic with a high platelet count, low albumin level and raised
inflammatory markers (ESR and C-reactive protein). Ben is referred for endoscopy, which shows
patchy inflammation in the terminal ileum (the most distal part of the small intestine) – a typical
appearance of Crohn’s disease.

Case scenario 1
• 1.1 Question
What are Ben’s treatment options?
• 1.2 Question
What do Ben and his parents need to know?
Next steps for management
Enteral nutrition has not induced remission after 4 weeks. Ben has worsening
abdominal pain, continuing diarrhoea and weight loss.
• 1.3 Question
What treatment should Ben be offered next?

Case scenario 1
Ben is started on glucocorticosteroids. There is an initial improvement
in his symptoms (abdominal pain and diarrhoea) but they recur when
the dosage is reduced.
• 1.4 Question
What other treatments could be offered to Ben and his family?

Case scenario 1
Since the azathioprine has been added to Ben’s treatment there has
been little benefit and after 4 months Ben’s symptoms are as bad as
ever whenever the glucocorticosteroid dosage is reduced.
• 1.5 Question
What other treatments could be offered to Ben and his family?

Case scenario 1
After discussing the potential benefits and risks with Ben and his parents,
Ben starts infliximab treatment. At his 6-month review, Ben has
unfortunately not made as much progress on infliximab as hoped for, he has
continued to have abdominal pain and diarrhoea and there are still concerns
about his growth. Therefore, medical treatment has failed to control Ben’s
condition. A repeat upper and lower endoscopy and MRI scan shows that his
disease is limited to the distal ileum.
• 1.6 Question
What are Ben’s treatment options?

Case scenario 2
• Presentation
Rosie has abdominal pain and diarrhoea.
• Medical history
Rosie is a 15-year-old girl with a 6-month history of abdominal pain and diarrhoea.
She was initially thought to have irritable bowel syndrome but has now developed
rectal bleeding, weight loss and amenorrhoea.
• On examination
Rosie appears well grown but is pale and thin with diffuse abdominal tenderness.
Blood tests reveal mild anaemia and raised inflammatory markers (ESR and
Creactive protein). Endoscopy reveals distal ileitis and extensive severe colitis.
Histology shows typical features of Crohn’s disease. Rosie is sitting her GCSEs in 6
months’ time. She needs to get her Crohn’s disease under control quickly.

Case scenario 2
• 2.1 Question
What are Rosie’s treatment options?
For the first 6 months the treatment appears to have worked, but then over
the course of the next 2 months Rosie calls her IBD nurse and paediatric
gastroenterology department three times because her symptoms (diarrhoea,
rectal bleeding and weight loss) are recurring.
• 2.2 Question
What treatment can Rosie be offered to alleviate her symptoms?

Case scenario 2
Rosie is unable to tolerate azathioprine because of severe
neutropenia (the presence of abnormally few neutrophils in the blood, leading to increased susceptibility to
infection).
• 2.3 Question
What are Rosie’s other treatment options?

Biliary system: Cholecystitis- pg. 813
• Inflammation of the gallbladder, a small
digestive organ beneath the liver.
• May be acute or chronic.
• Gallstones are the most common cause of
gallbladder inflammation but it can also
occur due to blockage from a tumour or
scarring of the bile duct.
• Inflammation causes the majority of
gallbladder diseases due to irritation of
the gallbladder walls, which is known as
cholecystitis.
• This inflammation is often due to
gallstones blocking the ducts leading to
the small intestine and causing bile to
build up

Endoscopic retrograde cholangiopancreatography
(ERCP)
• Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that
combines the use of endoscopy and fluoroscopy to diagnose and treat certain
problems of the biliary or pancreatic ductal systems.

Endoscopic retrograde cholangiopancreatography
(ERCP)
• The endoscope does not interfere with breathing.
• Taking slow and deep breaths during the procedure may help the patient relax.
• The length of the examination varies between 30 and 90 minutes.
• After ERCP, monitor the patient while the sedative medications wear off.
• Abscess formation following spilled gall-stones during laparoscopic cholecystectomy
occurs infrequently.
• Pre op med most commonly used for procedure: Morphine and Phenergan
• Infection almost always causes inflammation, inflammation is very often present in
the absence of infection. Infection involves colonization of body tissues by
microorganisms such as bacteria, viruses, fungi. Inflammation is a common response
by the body to a disturbance in which part of the body becomes reddened, swollen,
hot, and often painful, especially as a reaction to injury or infection.

Biliary system: Management of Cholecystitis-
pg. 813
• Conservative management
• Anticholinergics
• Analgesics
• Antacids
• Surgery when above does not relieve symptoms- removal
of gallbladder. This operation is called a cholecystectomy.
When the gallbladder is removed, bile made by the liver
can no longer be stored between meals. Instead, the bile
flows directly into the intestine anytime the liver produces
it.

Biliary system: Cholelithiasis- pg. 813
• Presence of gallstones often
associated with inflammation of
the gallbladder

Causes
• Obesity, multiple pregnancies & oral contraceptives
• Cause stasis of bile flow and excretion of increased amounts of cholesterol by the liver
into the bile.
• Oestrogen reduces the synthesis of bile acid in women.
• Bile: a bitter greenish-brown alkaline fluid which aids digestion and is secreted by the
liver and stored in the gall bladder.
• Malabsorption disorders
• Interferes with absorption
• Drugs that lower serum cholesterol
• Also increases excretion into the bile.

Causes
• Starvation and rapid weight loss
• Causes bile to become thick
• DM
• Interferes with the metabolism of fat in the body
• Vagotomy (a surgical operation in which one or more branches of the vagus nerve are cut, typically to reduce
the rate of gastric secretion (e.g. in treating peptic ulcers).
• Decreases motility of the gallbladder
• Inflammation of the gallbladder
• Alters the absorptive characteristics of the mucosal layers resulting in excessive
absorption of water

Causes
• Chronic haemolytic disorders
• Sickle cell disease which results in higher amounts of bile
that gets released
• Cirrhosis of the liver
• Alters the formation of bile
• Obstruction of the biliary tract
• Causes stasis of bile

Biliary system: Cholelithiasis - pg. 813
Pathophysiology
• Gallstones are hard, pebble-like structures that obstruct the cystic duct.
• The formation of gallstones is often preceded by the presence of biliary
sludge, a viscous mixture of glycoproteins, calcium deposits, and cholesterol
crystals in the gallbladder or biliary ducts.
• This results from the cholesterol concentration being greater than its
solubility percentage.
• Is caused primarily by hypersecretion of cholesterol due to altered hepatic
cholesterol metabolism.
• A distorted balance occurs.

Pathophysiology
• Loss of gallbladder muscular-wall motility occurs.
• Excessive sphincter contractions also are involved in gallstone formation.
• Accumulation of bile
• ASSOCIATED WITH THE IMBALANCE OF CHOLESTEROL, BILE SALTS AND
CALCUIM
• NOT NECCESARILY DUE TO INFECTION OR INFLAMMATION!!!

WHEN GALLSTONES DROP INTO THE BILE DUCT, THEY CAN
POTENTIALLY CAUSE OBSTRUCTION TO THE FLOW OF BILE FROM
THE LIVER, RESULTING IN JAUNDICE

BLACK BILIARY GALLSTONES

Assessment and common findings
• Most patients are without symptoms until the stones are less than 8mm in diameter
• Detected incidentally
• Symptoms: abdominal distention, epigastric fullness and vague to severe pain in the
right upper quadrant, which is aggravated by fatty meals
• Possible fever due to inflammation
• Jaundice
• Anorexia, nausea and vomiting
• Palpable abdominal mass
• Urine- dark due to presence of bilirubin
• Stools are fatty
• X-ray will show the stones

• Ultrasonography
• Cholescintigraphy
• Cholecystography
• Percutaneous trans hepatic cholangiography:
to distinguish between jaundice caused by the liver
and that caused by biliary tract.

Nursing diagnosis
• Pain and discomfort
• Fever
• Easy bruising tendencies
• Altered nutrition
• Altered breathing

Management
• Medical management
• Goal is to reduce the incidence of acute episodes of biliary colic and cholecystitis by
removing the cause through pharmacological therapy
• Nursing care- table 41.2
• Conservative treatment
• Nutritional and supportive therapy.
• Diets high in protein and carbs.
• Ursodeoxycholic acid & chenodeoxycholic acid. They inhibit the synthesis and secretion
of cholesterol

Procedures
• Endoscopic procedures
• May result in perforation, bleeding and infection
• Extracorporeal shockwave lithotripsy
• Non invasive shockwave where fragments of the stones are moved spontaneously to the
duodenum and removed via endoscopy
• Intracorporeal lithotripsy
• Ultrasound which is applied through an endoscope directly to gallstones to crush them.
Small fragments are then irrigated and aspirated out

Surgical management
• Laparoscopic cholecystectomy
• Laparoscopic cholecystectomy is a procedure in which the gallstones are removed by
laparoscopic techniques. Laparoscopic surgery also referred to as minimally invasive
surgery describes the performance of surgical procedures with the assistance of a video
camera and several thin instruments.

Surgical management
• Surgical cholecystectomy
• When the patient’s condition contraindicates more extensive surgery.
• Incision and drainage.
• Cholecystectomy
• Surgical removal of the gall bladder.
• It is put in place after bile duct surgery to drain bile while the duct is healing. The tube
drains into a bag that is attached to the patient’s body.

Biliary system: Cholecystectomy - pg. 816
Complications
• Destruction of bile ducts
• Haemorrhage
• Bile leakage
• Jaundice
• Pancreatitis
• Abscess
• pg. 816-817
care of the T tube

The hepatic system: Liver cirrhosis- pg. 790
• Chronic liver damage from a variety of causes leading to scarring and liver failure.

The hepatic system: Liver cirrhosis- pg. 790
• Causes
• Alcohol and viral hepatitis B and C are common causes of cirrhosis, although there are many
other causes.

The hepatic system: Liver cirrhosis:
Pathophysiology- pg. 791
• Cirrhosis is the final stage of many types of liver injury
• The most prominent feature is the nodular consistency

Pathophysiology- pg. 791
• The fibrotic changes distorts the hepatic structures
• Results in obstruction of veins and portal blood flow
• Causes problems such as: fluid retention, oedema, ascites
• Portal pressure increases and results in splenomegaly and altered function of
the spleen
• The spleen plays multiple supporting roles in the body.
It acts as a filter for blood as part of the immune system.
Old red blood cells are recycled in the spleen, and platelets and
white blood cells are stored there.
The spleen also helps fight certain kinds of bacteria
that cause pneumonia and meningitis

Clinical manifestations- pg. 792
• Pain areas: in the abdomen
• Gastrointestinal: bleeding, dark stool from digested blood, fluid in the abdomen, nausea,
passing excessive amounts of gas, vomiting blood, or water retention
• Whole body: fatigue, loss of appetite, or reduced hormone production
• Skin: web of swollen blood vessels in the skin or yellow skin and eyes
• Weight: weight gain or weight loss
• Also common: bleeding, breast enlargement, bruising, dark urine, enlarged veins around belly
button, itching, mental confusion, muscle weakness, shortness of breath, swelling, swelling in
extremities, or swollen veins in the lower oesophagus, foul breath, jaundice
• Bilirubin is the yellow pigment formed by the breakdown of these old cells. Jaundice occurs
when your liver doesn't metabolize bilirubin the way it's supposed to

Clinical manifestations- pg. 792
• Peripheral neuropathy
• Failure of liver to metabolise thiamine, folic acid and Vit. B12
• Splenomegaly
• Congestion / backing up of blood from the portal vein into the spleen
• Jaundice
• Compression of bile ducts preventing flow of bile
• Dysfunctional liver cells unable to conjugate and excrete bilirubin
• Anaemia
• Due to inadequate production of red blood cells
• Poor diet/ lack of appetite
• Poor absorption of e.g. folic acid
• Bleeding from varices
• RBC have shorter lifespan

Diagnostic evaluation- pg. 794
• Ultrasound
• Liver biopsy
• Liver scan/ MRI
• Stool test
• FBC to detect anaemia, leukopenia or thrombocytopenia
• Blood tests… enzyme levels are increased
• AST
• ALT
• Alkaline phosphatase
• SGPT
• SGOT

management- pg. 794
• The 2 main goals are to
• Maximise liver function by improving the diet, discouraging alcohol intake, controlling
infection and encouraging rest;
• Controlling disabling symptoms.
• Nursing management:
• Monitor vital signs and overall status
• Monitor speech and report deviations
• Protect from injury
• Fluid balance monitoring
• Family education

management- pg. 794
• Pharmacological:
• Narcotics and sedatives should not be administered
• As these are detoxified by the liver
• If sedatives are necessary, only drugs that can be excreted
by the kidney should be used
• See general nursing care plan of a patient with cirrhosis of
the liver

Reference list
• http://humananatomychart.us/category/inner-body/page/59/
• https://my.clevelandclinic.org/health/articles/7041-the-structure-and-function-of-the-digestive-system
• https://www.ehealthstar.com/anatomy/liver
• http://wellbeingsecrets.info/colon-cleansing/should-you-get-a-colonoscopy-or-not/
• Mogotlane, S. Chauke, M. Matlakala, M, Mokoena , J. & Young, A. (eds). 2013. Juta’s complete Textbook of Medical Surgical Nursing. Cape Town: Juta.
• https://www.healthy-inside.com/health/digestion-and-nutrition/bowel-obstruction/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886488/
• https://www.discountdrugnetwork.com/struggling-to-afford-ibd-medication/
• https://www.aviva.co.uk/health-insurance/home-of-health/medical-centre/medical-encyclopedia/entry/test-ercp/
• http://columbiasurgery.org/conditions-and-treatments/crohns-disease
• http://thesurgeonsclub.com/gallstones/
• http://clinicfordigestivesurgery.com/resources/gallstones
• Fausto Dávila, Daniel Tsin, Gloria González, M. Ruth Dávila, José Lemus, Ulises Dávila
• Utilidad de las agujas percutáneas en la factibilidad de la colecistectomía laparoscópica con un puerto
• Cirugía Española, Volume 92, Issue 4, April 2014, Pages 261-268

The gastro intestinal system

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