GASTROINTESTINAL SYSTEM DISORDERS MEDICAL-SURGICAL NURSING

BOLUSO, BRUSAS, CASTANARES, ELIZARDE, FRANCO, REYES, RUIZ, SALVO, SANCHEZ, UMLAS

GASTROINTESTINAL ASSESSMENT ▪ Kapag walang contrast ang makikita mo ay

simply back the gas-filled na shape ng colon.
FECALYSIS To see the actual shape of colon, if there is
• Examination of the stool consistency, color and the obstruction, if merong twisting of the small
presence of occult blood. intestine. Hindi makikita to sa x-ray or CT
• Special tests for fat, nitrogen, parasites (tape worm, scan, kapag may contrast medium mas
ascaris), ova, pathogen, and others. makikita.
o Nitrogen in the stool – common with patient na o It is still a toxic chemical, so it may cause toxicity,
may problem sa circulation, blood contains other so it needs to be eliminated.
elements such as nitrogen. Maalter and nitrogen o Eliminated thru stool, and through the kidney. If
content sa GIT. not eliminated, it may cause constipation,
• Test for clients with manifestations of GI bleeding and obstruction and to remove may be subject to
problems or complication. surgery.
• Gross bleeding – hematochezia ▪ So important na ma-instruct and patient na
• Black starry stool – melena mag intake ng water, take laxatives, high-
• Fats in stool – called the steatorrhea, patients with fibre diet para maeliminate ang barium.
Celiac disease, have difficulty to digest fats. Bubbly • Pre-test
and fat like content of stools may indicate problems o NPO post-midnight
with fat metabolism. • Post-test
o GIT, the colon, is containing bacteria, some o Laxative is ordered - to eliminate the barium.
client’s such as yung andun sa happy land, may o Increase OFI – to flush the barium content.
kumakain ng mga pagpag (mga tira sa o Instruct that the stools will turn white.
restaurant), and then iluluto. Kaya Deworming o Monitor for obstructions.
activity in the community until the age of 18 years ▪ Kapag di na eliminate or di naabsorb properly
old, especially in populations na high-risk to ang barium it may cause obstruction kaya
parasites, and worms na pwedeng magdevelop monitor for obstructions.
sa GIT. • Barium examination is a series of x-ray, sometimes,
• Parasitic culture – to determine the right anti-parasitic with the aid of fluoroscope for easier visualization of
drug to prescribe. Can also be prescribed broad- the internal organs.
spectrum antibiotic.

OCCULT BLOOD TESTING

• Instruct the patient to adhere to a 3-day meatless diet.
o Meat less para walang false na results, meat may
lead to wrong result of bleeding sa stool.
• No intake of NSAIDS, aspirin, anti-coagulants, or
thrombocytopenic medications.
o NSAIDS – bawal to track presence of occult
blood. Kung ang patient ay nagtetake nito baka
mag cause ng GIT bleeding and leads to false
reading.
• Screening test for colonic cancer
o Colonoscopy – to visualize the wall of the colon.
▪ To visualize presence of polyps and nodule,
which may indicate start or manifestations of
colon cancer.
o Fecalysis is non-invasive type to see if there is
developing colon cancer.

UPPER AND LOWER GIT STUDY BARIUM ENEMA

• Examines the lower GIT.
BARIUM SWALLOW o Barium enema- visualization of lower GIT, insert
• Examine the upper GIT. a probe in the colon of the patient that has barium
• Barium sulfate is usually used as contrast medium. sulfate, it examines the GIT.
o Tablet or chalk-like upon swallowing o For patients at risk or with manifestations ng
o Gives visualization of the Upper GIT. colon cancer, Chron’s disease, IBS, and colon
problems.

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GASTROINTESTINAL SYSTEM DISORDERS MEDICAL-SURGICAL NURSING
BOLUSO, BRUSAS, CASTANARES, ELIZARDE, FRANCO, REYES, RUIZ, SALVO, SANCHEZ, UMLAS

• Pre-test GASTRIC ANALYSIS

o Clear liquid diet and laxatives, NPO post- • Used to patients with increased frequency of gastritis,
midnight, cleansing enema prior to test. development of hyperacidity problems leading to
▪ Nagkakaroon ng exhaustion dun sa patient in possible ulcer formation leading to gastric erosion.
need to defecate, kasi may laxative, then • Aspiration of gastric juice to measure pH,
suppository, in the morning ipeperform and appearance, volume, and contents.
cleansing enema, so need ng IV kasi may o Can insert NG tube to patient, NG tube to be
chances ng fluid and electrolyte losses. used to aspirate stomach gastric juices to
Check the tolerance of the client. determine the pH, appearance, volume, and
• Cleansing enema – used soapsuds solution (fleet contents.
enema, commercially manufactured), run through a o Especially to patients that frequently experience
rubber tubing with a straight catheter at the end, retain gastritis, GERD, peptic ulcer disease, they are at
for a few minutes, when the client has the urge to increase likelihood of H. Pylori infection
defecate stop the cleansing enema, let the client • Pre-test
defecate. Until return flow is white to clear. o NPO 8 hours, avoidance of stimulants, drugs,
• Barium sulfate through enema – injected in the and smoking
colon too, after less than an hour patient can be o NPO foods and fluids.
subject to visualizations depending on the condition o Patient is at risk of F&E imbalance, IV fluid is
being determined. Together with x-ray, some may necessary especially to very young or very
have barium swallow (Upper IGT), and enema (Lower old patients because they immediately
GIT) and endoscopy procedure. experience early symptoms of DHN,
intolerable.
o Avoid prokinetic drugs like Metoclopramide
because it facilitates digestion of GI tract
contents that we want to be analyzed; NPO
status purpose is to retain the contents.
o Drugs also triggers gastric peristaltic activity;
Smoking triggers increased acidity of the
stomach.
• Post-test
o Resume normal activities.
▪ Slowly return the patient to the normal diet
(gradual)
▪ Clear liquid > general liquid > soft diet/ diet
as tolerated/small frequent meals.
▪ No need to sedate the patient in the
procedure.
• Signs of obstruction:
o Enlargement of abdomen (indicative of retaining, H. PYLORI
build-up of fluid and gas in relation of the intake • Gram negative bacteria
recently of barium sulfate and barium enema) • Common culprit from frequent gastritis > erode the
• Nursing assessment is important. lining stomach > continuous release of gastric acid =
o Determine the abdominal measurement of the destruction of the lining of the stomach’ s mucous
client before and after the procedure, then membrane that can alter the normal release of
evaluate. mucous, bicarbonate of the GI tract that is to balance
o Note tenderness or softness of the abdomen the acidity in the stomach.
when being palpated. o H. Pylori Infection leading to possible erosion of
o Hard abdomen signifies build-up of fluid and the GI mucosa > GI bleeding.
stool. o Found from food that we intake, not observing
o Listen to peristaltic activity of the GI tract. the proper handwashing, cleaning of utensils
o Suspect complications of obstruction post and food preparation.
procedure. • Hides underneath the mucous membrane of the GI
• Note: If absent to excessively hypoactive of the bowel tract na naeerode na so hindi sya natatamaan ng
sounds, no bowel movement and if the abdomen is released gastric acid dun sya nag proliferate.
enlarged. (If there is, patient is subjected again for • Continue to cause the additional injury to the mucosa
visualization) leading to destruction of mucus, alteration of GI tract,
mabutas yung stomach or even the duodenum,

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GASTROINTESTINAL SYSTEM DISORDERS MEDICAL-SURGICAL NURSING
BOLUSO, BRUSAS, CASTANARES, ELIZARDE, FRANCO, REYES, RUIZ, SALVO, SANCHEZ, UMLAS

mapunit yung mga blood vessels (GI bleeding), LOWER GI-SCOPY

lalabas sa peritoneal cavity yung mga stomach • Use of endoscope to visualize, he anus, rectum,
contents. sigmoid and colon.
o Indicative sa mga conditions affecting the lower
EGD (ESOPHAGOGASTRODUODENOSCOPY) GI.
• Visualization of the upper GIT by endoscope o If you have family hx of colon cancer, subject
o Very common to patients with peptic ulcer yourself to colonoscopy every 5 years for early
disease, duodenal ulcer, frequent gastritis. detection of cancerous lesions.
o Also for visualization of esophagus: hiatal hernia, • Pre-test
achalasia, GERD (to the point na eroded na and o Consent, NPO 8 hours, cleansing enema until
may lesions at the esophagus because of the return flow is clear.
backflow of the acidic gastric secretions due ▪ Dahil iv-visualize, dapat malinis ang colon.
incompetent valve at the lower esophageal ▪ Dapat walang maiwan na stool para walang
sphincter. room for false reading
o For suspected stomach or duodenal cancer ▪ I-ensure na nagawa ang cleansing enema
• Pre-test sa ward.
o Ensure consent, NPO 8 hours, premedication ▪ Dapat may swero ang patient
like atropine and anxiolytics. • Intra-test
▪ Minimally invasive procedure: patient will be o Position is left lateral sims position, right leg is
sedated (usually local/inhaled/oral bent and placed anteriorly.
anesthesia in the mucosa to paralyze the ▪ Para di makainterfere sa pagpasok ng
gag reflex – usually in the adult); done in the scope yung right leg
OR; aseptic technique. ▪ Left lateral because of the pathway of colon,
▪ No need for general anesthesia BUT mas madali ipasok by gravity.
depending on the case for intolerance. • Post-test
▪ Atropine – anticholinergic to lessen the o Bed rest monitor for bleeding and perforation.
secretions to avoid altered visualization. ▪ Bago ipasok ang probe, dapat may lubricant
▪ Anxiolytic – for sedation; Benzothiazepine, para maiwasan ang trauma
Diazepam, Cocktail combination • Colonoscopy – flexible fiberoptic scope is inserted
promethazine with anticholinergic, Nubain. through the anus, and the interior of the bowel can be
But depends on the assessment of the directly viewed on a television monitor.
doctor. If no problem (30 minutes). • Some of the endoscopes have the capacity to take
▪ NPO status to avoid aspiration of contents tissue samples.
when gag reflex is stimulated. • Pag di makuha dahil larger ang size, patient is
• Intra-test subjected to open exploratory laparotomy.
o Position: left lateral to facilitate salivary drainage
and easy access.
▪ To facilitate salivary drainage and provides
easy access.
▪ Some endoscopes can suction or has a
pickup forceps for cancerous tissue
detection.
• Post-test
o NPO until gag reflex returns, place patient in
sims position until he awakens, monitor for
complications, saline gargles for mild oral
discomfort.
▪ If gag reflex is not yet intact then patient
eats already, it will cause aspiration.
▪ SIMS position in case of regurgitation when
gag reflex returned. CHOLECYSTOGRAPHY
▪ Some client post procedure complains pain • Examination of the gallbladder to detect stones, its
– sore throat, dysphagia. ability to concentrate, store and release the bile.
▪ If patient complains SEVERE discomfort, o Kelangan ma-injectionan ng dye/contrast
inspect for bleeding tendencies. medium ang patient
• Pre-test

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GASTROINTESTINAL SYSTEM DISORDERS MEDICAL-SURGICAL NURSING
BOLUSO, BRUSAS, CASTANARES, ELIZARDE, FRANCO, REYES, RUIZ, SALVO, SANCHEZ, UMLAS

o Ensure consent, ask allergies to iodine, ▪ Baseline assessment dapat liliit yung
seafood, and dyes; contrast medium is abdominal girth dahil nabawasan yung fluid
administered the night prior, NPO after contrast o Weight is taken before and after the procedure
administration. to provide an indication of the effectiveness of
▪ Para mavisualize kung merong procedure in fluid removal.
obstruction ▪ Best way to assess the effectiveness of the
▪ Nursing responsibility: allergies to procedure. 500 g increase/decrease in body
seafood/iodine, administer antihistamine weight per day. 500 g = 500 ml. use the
to lessen the chances of anaphylaxis. same weighing scale, same time of day,
▪ Nursing responsibility: check renal same clothing to make it accurate.
function (creatinine and BUN). Dyes • Intra-test
should be eliminated by the kidneys dahil o Upright on the edge of the bed, back supported
magiging toxic ito sa katawan. Dapat hindi and feet resting on a foot stool.
ma stimulate ang gallbladder prior the ▪ Edematous ang lower extremities so
procedure. kailangan may patungan yung paa (foot
▪ Sa mga claustrophobic patients, stool)
binibigyan ng sedative or anti-allergy ▪ Best position: 90-degree position ang
(diphenhydramine: may konting sedative flexion pf body sa thorax as well as sa hip
effect) area and lower leg to lessens the chances
• Post-test na mapuncture yung ibang organs in the
o Advise that dysuria is common as the dye is abdomen para mafacilitate ang draining
excreted in the urine, resume normal activities. through gravity in the peritoneal spaces.
▪ Flush the patient with fluids, encourage to ▪ Nurse responsibility: instruct the client not to
urinate frequently. move.
PARACENTESIS ▪ Needle gauge 16
• Removal of peritoneal fluid • Post-test
• Clients with ascites, liver cirrhosis, hepatobiliary tract o Apply a dressing to the site of puncture.
problems that leads to the accumulation of fluid in ▪ Pressure dressing to lessen the bleeding
peritoneal space. episodes. Check dressing if it is soaked to
• Maglalagay ng catheter sa abdomen and ithethread lessen the likelihood of infection.
doon sa peritoneum then idedrain by gravity yung o Monitor vital signs, weigh the client, and maintain
fluids para ma-decrease kasi yung accumulation the client on bed rest.
nagcacause ng compression sa diaphragm and sa ▪ Bumabalik ang fluid in less than a week or
ibang internal organs leading to DOB. more than a week doon sa peritoneum.
• Pre-test o Measure the amount of fluid removed.
o Ensure consent - invasive. ▪ Document and describe the characteristic of
o Obtain baseline VS. fluid na na-drain. Initially, blood-ish because
▪ Litro litro ang nakukuhang fluids that would of the trauma cause by the puncture, later it
cause alteration sa fluid volume status ng will turn yellow-ish serum like color. If
patient causing sudden dropdown of BP. infection is present pus like content -
Orthostatic hypotension sometimes occur, peritonitis
kasi normally ang fluid nagmomove sa o Label and send the fluid for laboratory analysis.
interstitial spaces, decrease colloid/albumin ▪ Identify the protein, WBC, RBC, organisms
that maintains colloid osmotic pressure na o Document the event, client’s response, and
naglelesssen ng fluid shifting. appearance and amount of fluid removed.
▪ Patients with liver problems cannot or ▪ 4 vials for specimen/sample usually to test
decrease capacity to manufacture albumin for protein, WBC, RBC, organisms must be
and globulin, thus decrease colloid osmotic sent within 1hr after procedure.
pressure that holds fluid into the
intravascular spaces and prevent it from LIVER BIOPSY
fluid shifting. • A needle is inserted through the abdominal wall to the
o Instruct to void and empty bladder. liver to obtain a tissue sample for biopsy and
▪ If the bladder is distended during the microscopic examination.
procedure pwedeng ma-hit yung bladder • FNAB most common
accidentally causing severe problem like • Route: intercostal or midaxillary line around 4th to 5th
opening, then suturing of the bladder ICS
o Measure abdominal girth.

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GASTROINTESTINAL SYSTEM DISORDERS MEDICAL-SURGICAL NURSING
BOLUSO, BRUSAS, CASTANARES, ELIZARDE, FRANCO, REYES, RUIZ, SALVO, SANCHEZ, UMLAS

• May use spinal needle due to increase chances of o Increased urea sa breath test = (+) H. pylori
puncture on pleural space that may cause infection
pneumothorax. • Avoid the following medications before testing:
• Excision can also be done. o Antibiotics or bismuth subsalicylate (Pepto-
• Needle gauge 16 or 19 Bismol) for 1 month before the test
• Pre-test ▪ Antibiotics can possibly eradicate the H.
o Consent Pylori infection that may lead to false
o NPO negative result.
▪ Not required kapag FNAB ▪ Pepto-Bismol - it is an antacid at may
o Check for the coagulation tests (prothrombin possibility na mawala or hindi maging highly
time, partial thromboplastin time, platelet count) active yung H. pylori during breath test.
▪ To check the liver functioning that may o Sucralfate (Carafate) and omeprazole (Prilosec)
increase risk for bleeding. for 1 week before the test; and
o Administer a sedative as prescribed. ▪ Sucralfate lines the area of GI tract and the
▪ Local anesthesia is not enough, painful sa ulcer itself with protective coating, it may
client since there nerve endings sa promote healing ng ulcer, so most likely
abdomen and sa surrounding ng liver. hindi magpo-proliferate yung H. Pylori –
o Note that the client is placed in supine or left false negative result again.
lateral position during ▪ Omeprazole decreases the Hydrochloric
• Intra-test acid may lead to false negative reading
o Position: Semi fowler’s LEFT lateral to expose again.
right side of abdomen o Cimetidine (Tagamet), Famotidine (Pepcid),
▪ Position may depend on the condition and Ranitidine (Zantac) and Nizatidine (Axid) for 24
comfort of the patient. like in ascites hours before breath testing.
inflamed ang liver compressing diaphragm ▪ H2 receptor blockers (tidine) – it decreases
pag naka left lateral. the HCl secretion or the acidity in the
▪ Last resort ang liver biopsy for diagnostic stomach.
• Post-test ▪ H. Pylori can also be detected by assessing
o Assess VS and maintain on bed rest for several serum antibody levels. Increased H. pylori
hours (or as prescribed) antibodies = (+) H. pylori infection
▪ No extraneous and excessive movement
because of high risk for bleeding SERUM TEST FOR GI TRACT PROBLEMS/ HEPATO-
o Position on Right lateral with pillow (or sandbag) BILIARY TRACT PROBLEMS
underneath or under the coastal margin to • Alkaline Phosphatase
decrease the risk of hemorrhage. o Is released with liver damage or biliary
▪ Para magiging pressure dressing or ma- obstruction.
compress yung puncture site. o Reference value: 35-85 IU/ml (SI 42-128
o Instruct the client to avoid coughing and units/L)
straining. • Prothrombin Time
▪ Increase intrathoracic pressure might o Is prolonged with liver damage.
trigger to bleeding episode dahil sa o Reference value: 10 – 14 seconds (SI 10-14
nagrupture na vessels. secs)
o Monitor VS and complications like bleeding, ▪ Prolonged PTT = ↑ bleeding.
perforation, and peritonitis. ▪ Patients undergoing heparin therapy PTT
▪ Peritonitis if hindi nag adhere sa aseptic normal value is 1 – 1.5 x the normal
technique during operation. value.
o Instruct to avoid lifting heavy objects and • Serum Ammonia
strenuous exercise for at least 1 week. o Level assesses the ability of the liver to
▪ Decrease bleeding episodes. deaminate protein by-products.
▪ If hindi magiging capable ang liver to
UREA BREATH TEST metabolize ammonia, it may be an
• Detects the presence of Helicobacter pylori, the indication na may extensive liver damage.
bacteria that cause peptic ulcer disease. o Reference value
• Preparation: the client consumes a capsule of carbon ▪ Adults 18 & above: 5-125 units/L (SI 0.4 -
labelled urea and provides a breath sample 10 to 20 2.1µkat/L)
minutes later. ▪ Adults 60 & above: 24-151 units/L (SI 0.4 -
2.1µkat/L)

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GASTROINTESTINAL SYSTEM DISORDERS MEDICAL-SURGICAL NURSING
BOLUSO, BRUSAS, CASTANARES, ELIZARDE, FRANCO, REYES, RUIZ, SALVO, SANCHEZ, UMLAS

• Liver Enzyme Levels (Transaminase Studies) PATHOPHYSIOLOGY

o Elevated with liver damage. • More than normal backflow of gastric acids into
o Reference value: esophagus –
▪ Alanine Aminotransferase (ALT) – formerly o ↑ incidence with age, >17 million Americans
known as SGPT (Serum Glutamic Pyruvic o Frequently caused by incompetent lower
Transaminase) – 8-50 international units/L esophageal sphincter (LES) or hiatal hernia &
(SI 0.14 – 0.85 µkat/L) pyloric stenosis.
▪ Asparate Aminotransferase (AST): Adult – ▪ Can also be experienced by highly stressed
7-24 units/L (SI 0.12 – 0.5 µkat/L) individuals.
o ALT is the sensitive indicator of liver disease. ▪ Hiatal hernia literally umaangat yung certain
o AST is formerly known as SGOT (Serum area ng stomach doon sa hiatal ring,
Glutamic Oxalate Transaminase) – it also opening sa diaphragm para pumasok yung
represents injury or destruction ng liver, pero area ng esophagus pababa sa stomach.
compare with ALT mas significant and specific in
terms of determining liver damage kasi sa CLINICAL MANIFESTATIONS
Myocardial Infarction ang AST pwede ring mag-
• Heartburn (Pyrosis)
elevate so hindi specific for the liver alone.
o If both liver enzymes are elevated = (+) liver • Chest pain or epigastric pain
damage • Regurgitation or vomiting
• Burping
DISTURBANCES IN INGESTION • Indigestion and/or dyspepsia
• Dysphagia
GASTROESOPHAGEAL REFLUX (GERD) • Odynophagia
• The backward flowing of gastric contents into the • Let the patient describe yung heartburn na
esophagus nararamdaman niya.
• The reflux is caused by an incompetent lower • Heartburn sa angina is substernal and more on dahil
esophageal sphincter, pyloric stenosis, or motility sa chest pain, can be relieved by deep breathing and
disorder. oxygen supplementation.
• Lining of the stomach is thicker than the esophagus • Heartburn caused by GERD will not be relieved by
kaya yung recurrent na reflex ng acid papunta sa oxygen supplementation.
esophagus may cause Barrett’s Esophagus wherein
yung dating smooth muscle lining ay napapalitan ng LABORATORY AND DIAGNOSTICS
lining similar to the GI tract which may lead to the • 24-hour pH monitoring in the lower esophagus
development of esophageal cancer. • Barium swallow
• Endoscopy and Biopsy
o 24-hour pH monitoring, confirmatory test ng
GERD
o Increased acidity = GERD

4 PHASES OF COLLABORATIVE CARE

• Lifestyle Management including diet changes and
positioning.
• Drug therapy (Antacids, PPI, Sucralfate,
Metoclopramide)
• Intensive Drug therapy (combination)
• Anti-reflux surgery (Nissen, Hill and Belsey)
o Most common surgery is the Nissen
Fundoplication – basically gumagawa ng parang
pang-cover doon sa area ng LES to strengthen
ang lessen chances of reflux.

NURSING INTERVENTIONS
• Instruct client to avoid factors that decrease lower
esophageal sphincter pressure or cause esophageal
irritation.

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GASTROINTESTINAL SYSTEM DISORDERS MEDICAL-SURGICAL NURSING
BOLUSO, BRUSAS, CASTANARES, ELIZARDE, FRANCO, REYES, RUIZ, SALVO, SANCHEZ, UMLAS

o AVOID: Peppermint, chocolate, coffee, fried fatty (Metoclopramide • Accelerates gastric

foods, carbonated beverages (Reglan)) emptying.
• Instruct the client: • To aid movement of
o Eat a low-fat, high fiber diet. food in GI
▪ High fat: increase gastric juices to digest
more food. HIATAL HERNIA
▪ High fiber: firm stools and promote • Also known as esophageal or diaphragmatic hernia
defecation. • a portion of the stomach herniates through the
• Avoid eating and drinking 2 hours before bedtime. diaphragm and into the thorax.
• Avoid wearing tight clothes.
o Can cause pressure in the intrathoracic space
(e.g., corsets).
o Restricting could create pressure to stomach
and forces sphincter to open.
• Elevate the head of the bed on 6-to-8-inch blocks.
o Facilitates drainage.
o Prevents backflow to esophagus.
o After eating remain seated and avoid overeating
lalo na pag gabi.
• Avoid the use of the following medications:

Anticholinergics Delay’s stomach CAUSES

(e.g., Atropine SO4) emptying • Herniation results from weakening of the muscles of
NSAIDs and ASA- Promotes additional the diaphragm (congenital)
containing medications acidity in the stomach • Further aggravated by factors that increase
abdominal pressure:
• Instruct the client regarding prescribed medications: o Pregnancy
o Ascites
• Neutralizes acid o Obesity
secretions in o Tumors
stomach. Combi of o Heavy lifting
aluminum and mg • Other factors can be trauma to the abdomen.
components. o Pressure buildup in abdomen kaya nagpupush
Antacids
• Al: causes diarrhea. pataas
(e.g., Mylanta, Maalox)
• Mg: causes
constipation COMPLICATIONS
• Combination • Ulceration
compliments effect of o In the stomach due to bleeding, retention doon
both. kaya nagsstay either sa hiatal or diaphragm
Histamine 2-receptors
• Decreases histamine • Regurgitation
(Cimetidine, Ranitidine, o Communication between esophageal space and
in the stomach
Famotidine) stomach kaya increase chance of regurgitation.
• To facilitate acid back o Kasi nasa taas na ng hiatus kaya accumulation
to stomach, lessens of gastric contents could aspirate to respiratory
chance. tract.
• Mas effective if given
at 30 mins to 1 hr 2 TYPES OF HIATAL HERNIA
Proton Pump Inhibitors
before meals • Sliding Hiatal Hernia
(PPI)
(BETTER) or 2hrs o MOST COMMON
(Omeprazole,
after meals. o Equal or both sides of herniation
Esomeprazole)
• If with food, it already • Paraesophageal Hiatal Hernia
stimulates gastric o One side only, unequal paglusot sa opening and
cells in digestion kaya di symmetrical
wala rin magiging o Could lead to strangulation, mas panget ang
effect ang meds. effect.
Prokinetic medications • If prescribed.

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GASTROINTESTINAL SYSTEM DISORDERS MEDICAL-SURGICAL NURSING
BOLUSO, BRUSAS, CASTANARES, ELIZARDE, FRANCO, REYES, RUIZ, SALVO, SANCHEZ, UMLAS

CLINICAL MANIFESTATIONS esophagus kasi naiipon yung food since walang

• Heartburn (pyrosis) peristaltic activity
• Reflux • Affects 1.6 in 100,000 people.
• Regurgitation or vomiting • Usually presents between 25-60 y/o equally for both
• Chest pain men and women.
• Dysphagia o No symptoms early in the disease pero later in
the disease nagiging relevant yung
• Feeling of fullness
manifestation sa client.
• Important in asking the patient to describe the type of
pain they are feeling.
• Could be misdiagnosed for MI.

MANAGEMENT
• Same as GERD
• Surgical- Nissen Fundoplication
o Wrap fundus of stomach around lower
esophagus.
▪ In wrapping around compared to GERD,
nilalagyan ng suture above area of
diaphragm to strengthen muscle at di umulit
ang paglusot or out pouch of fundus above
diaphragm.

NURSING INTERVENTIONS ETIOLOGY

• Medical and surgical management are similar to • Unknown
those for GERD.
• Theories of disease causation: loss of nerve
• Provide small frequent meals and limit the amount of endings and loss of hormones (no specific hormone)
liquids taken with meals. o T-cell destruction and fibrosis of the esophageal
o Napupuno ang stomach with liquid. Resulting to myenteric neuronal plexus
a feeling of fullness ▪ Di na nagreresponse sa innervation yung
o Liquid will pass through the stomach first than esophagus
the solid. o Loss of inhibitory neuron in the wall of the
o If food is not properly chewed, bolus will stay in esophagus
LES and will not go to the stomach. ▪ Imbalance kung loss of inhibition and
o Strangulate by the ring of diaphragm. persistent stimulation
• Advise client not to recline for 1 hr after eating to • Risk of Esophageal Cancer
prevent regurgitation. o Nagiging enlarged yung tissue and naalter yung
• Avoid anticholinergics, which delay stomach normal tissue ng esophagus.
emptying. • Scleroderma – an autoimmune disease that causes
fibrosis of many organs and causes severe
ACHALASIA abnormality of peristalsis of the lower 2/3 of the
• A degenerative esophageal disease that results in esophagus.
aperistalsis of the esophageal body and the abnormal o LES become incompetent > severe esophagitis.
relaxation of lower esophageal sphincter (LES) o Esophagus and stomach are visualized as one
o Motor disease although unknown the primary cavity.
cause pero may several factors like infection, ▪ Kapag relax na thus anytime pwede
autoimmune magbackflow yung acid from the stomach
• Motor disorder characterized by progressive up to the esophagus.
incomplete relaxation of the LES and progressive
incomplete loss of peristalsis in the esophageal body. PATHOPHYSIOLOGY
o Nawawala yung esophageal peristaltic activity
• Impaired motility of the lower 2/3 of the esophagus
thus nareretain; increase chance na di mapush
pababa yung food kaya naretain lang yung food • LES fails to relax with swallowing.
dun sa lower esophageal segment. o Because nerve impulses cannot pass through or
o Bird’s Beak - nagiging narrow yung lower the sympathetic division is absent. There is a
esophageal space, tortuous and dilated ang possible degeneration of the ganglion cells and

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GASTROINTESTINAL SYSTEM DISORDERS MEDICAL-SURGICAL NURSING
BOLUSO, BRUSAS, CASTANARES, ELIZARDE, FRANCO, REYES, RUIZ, SALVO, SANCHEZ, UMLAS

impairment of impulses in the Auerbach’s o Pinaka nakakaconfirm na achalasia talaga yung

(myenteric) plexus. nararamdaman ng patient
• Impaired propulsion of bolus food/fluid and o Pressure is around 10 to 45 mmHg.
• A constricted LES results in the accumulation of food o Kapag elevated yung pressure ng LES, it is the
and fluid within the esophagus indication of Achalasia.
o When hydrostatic pressure exceeds the o If totally absent yung peristaltic activity, that
pressure in the contents pass into the stomach. further confirms the diagnosis of Achalasia kasi
▪ Makakalusot yung food kapag nag exceed sa Achalasia lang nangyayari yun.
yung hydrostatic pressure. o Initially, yung mga patient nahihirapan lumunok
kapag solid food. Later in the disease, pati mga
CLINICAL FINDINGS liquid hirap na rin lunukin ng patient.
• Common findings
o Dysphagia TREATMENT
▪ Impaired normal functioning of swallowing • No cure for achalasia
o Regurgitation o But symptoms can usually be managed with
▪ Di nakakalusot yung food minimally invasive therapy or surgery which
o Weight loss focuses on relaxing or forcing open the lower
▪ Loss of digestion and absorption of esophageal sphincter so that food and liquid can
nutrients move more easily through your digestive tract.
• Less common findings • Goal of Treatment
o Chest pain o Symptom relief
▪ Proximity duns sa chest. o Improve esophageal emptying.
o Recurrent respiratory infections o Prevent Megaesophagus.
▪ Since the food retains in the esophagus ▪ Kapag persistently stretched yung
o Aspiration pneumonia esophagus, may possibility na magrupture.
▪ May passage of secretions in and out ▪ If it is ruptured, yung mga contents ng
pwede maaspirate sa tract undigested food, added to the fact na may
o Lung abscess possible na naregurgitate na gastric juices,
▪ Accumulation of irritant sa respiratory tract mag-aaccumulate yun sa mediastinal area
that could lead to inflammation and lung leading to mediastinitis.
abscess later on which could trigger to • Non-Surgical Management
develop other respi disease. o Lifestyle changes (both before and after
treatment)
DIAGNOSTIC TESTS ▪ To eat slowly, chew very well, drink plenty
• Barium Swallow of water with meals, and avoid eating near
o Reveals non propulsive waves and esophageal bedtime.
dilatation. • Chew 36 times or around 20 seconds
o NOTE: Barium may also be retained in the to facilitate better mechanical
esophagus digestion.
o Bird’s Beak image • Mas bagalan pa kumain
• Endoscopy • Encourage na damihan yung fluid.
o Reveals status of LES, amount of dilation and • Kapag nag lie down tayo, by gravity
presence of food. magmomove yung contents ng mga
o Useful because walang specific na signs na kinain natin so lalo magiincrease yung
magbibigay sa doctor, sa nurse or even sa chances na magpunta sa tubo ng respi
patient na itong nararamdaman ng patient is tract yung kinain natin.
highly specific sa achalasia kasi nagooverlap ng • Raise the head off the bed or sleeping
manifestations with hiatal hernia as well as with with a wedge pillow promotes
GERD. emptying of the esophagus by gravity.
o So, para maprove na Achalasia talaga sya, o Semi-Fowler’s and put wedge
endoscopy would be used to rule it out. pillow kapag nakahiga to promote
• Esophageal Manometry (measurement of pressure gastric emptying compared with
in the esophagus) lying flat on bed.
o Confirms the diagnosis with elevated resting • After surgery or pneumatic dilatation:
pressure in the LES, or slow, low amplitude or o Proton pump inhibitors are
absent peristalsis. required to prevent reflux damage

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GASTROINTESTINAL SYSTEM DISORDERS MEDICAL-SURGICAL NURSING
BOLUSO, BRUSAS, CASTANARES, ELIZARDE, FRANCO, REYES, RUIZ, SALVO, SANCHEZ, UMLAS

by inhibiting gastric acid • Kahit ang purpose ay for Achalasia

secretion. lang, maaapektuhan parin yung blood
o Avoidance of food that can vessels and magrerelax pa din sila
aggravate reflux, including • Surgical Management
ketchup, citrus, chocolate, o Laparoscopic Heller Myotomy
alcohol, and caffeine. ▪ Last resort
o Pneumatic Dilation ▪ Surgical myotomy of the muscle layer of the
▪ A balloon is inserted into the esophageal distal esophagus and LES
sphincter and inflated to enlarge the ▪ Also known as Heller myotomy
opening. ▪ A time-honored treatment for achalasia
• I-tthread down yung catheter from the ▪ LES is enlarged by incising the circular
oropharynx down to the esophagus, fibers down the mucosa.
and yung balloon iiinflate doon sa • Sinisira yung area ng LES and inoopen
constricted na area up
• Iinflate sya several times until maopen • Mas matagal yung magiging benefit
up yung LES kapag ginawa itong surgical procedure
• Yung balloon pwede nya masira yung na to compare sa pneumatic dilation.
mga tissue doon sa lower segment, in ▪ 80% of client experience improvement of
the long run pwedeng mamaintain condition
open na sya and di na maging ▪ Major side effect
competent in closing • Severe reflux esophagitis
▪ This outpatient procedure may need to be • Since inopen up na and sinira na yung
repeated if the esophageal sphincter does area na yun, yung reflux ng gastric
not stay open. mucosa hindi mapipigilan and
▪ Nearly 1/3 of people treated with balloon magkakaroon ng consistent na reflux
dilation need repeat treatment within six • This is permanent since surgical
years. procedure sya, di na sya marereverse.
▪ 2% perforation rate
o Botox (Botulinum toxin type A) DISTURBANCES IN GASTRIC DIGESTION
▪ This muscle relaxant can be injected
directly into the esophageal sphincter with GASTRITIS
an endoscope. • Inflammation of the gastric mucosa
▪ The injections may need to be repeated, • Attributed to different factors.
and repeat injections may make it more • May be acute or chronic.
difficult to perform surgery later if needed.
• May trigger antibody formation which
will eventually destroy the toxin
injected, which can result to the
ineffectivity of the injected Botox.
▪ Recommended only for people who are not
good candidates for pneumatic dilation or
surgery due to age or overall health.
• Medication
o Smooth Muscle relaxants such as Nitroglycerin
(Nitrostat) or Nifedipine (Procardia) before eating
▪ Have limited treatment effect and severe
side effects.
▪ Medications are generally considered only if
you are not a candidate for pneumatic ETIOLOGY
dilation or surgery, and Botox has not
helped. • Acute Gastritis
• Since general naman yung effect nito o Bacteria
and hindi sya localized, may tendency ▪ H. Pylori around 90% of infection
na maapektuhan din yung blood ▪ From maduming food fecal oral route
pressure. o Irritating foods
▪ Spicy foods
o Alcohol

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GASTROINTESTINAL SYSTEM DISORDERS MEDICAL-SURGICAL NURSING
BOLUSO, BRUSAS, CASTANARES, ELIZARDE, FRANCO, REYES, RUIZ, SALVO, SANCHEZ, UMLAS

▪ Irritant and increases gastric acid ▪ Parang you are gasping for air, parang
secretions. hiccups.
o Bile ▪ Attributed to development of inflammatory
▪ Pag nagbacklflow ang bile secretion na process happening in the stomach.
dapat nasa duodenum lang, magiging o Sour taste in the mouth
additional acid and will cause irritation. ▪ Secondary to gastric acid
o Radiation o Dyspepsia
▪ Pag natamaan ng radiation, for example sa o Anorexia
cancer treatment, they not only destroy o N/v
cancer cells but also normal cells, like the o Pernicious anemia
lining of the GI tract.
• Chronic Gastritis DIAGNOSIS
o Ulceration • EGD – to visualize the gastric mucosa for
▪ Nagkaroon kana ng recurrent gastritis na inflammation.
naglead na sa ulcer formation, pag may o If nakita na increase likelihood of ulcer formation
butas na, magkakaron ng inflammation; H. sa mucosa ng stomach, nagpeperform narin ng
Pylori padin ang common cause biopsy.
o Bacteria • Low levels of HCl
▪ H. Pylori padin ang common • Biopsy to establish correct diagnosis whether acute
o Autoimmune disease or chronic.
▪ Tinatarget ang parietal cells ng gastric
mucosa and nagiging reason para NURSING INTERVENTIONS
magkaron ng gastritis
▪ Unknown ang cause bakit natatarget ang • Give bland diet.
parietal cells o Acute: NPO and TPN
▪ Type A Gastritis – autoimmune disease ▪ Jejunostomy feeding if possible – to rest the
▪ Type B Gastritis – caused by H. Pylori. stomach.
▪ CD4 cells targets the parietal cells of GI ▪ If px can tolerate oral intake give non-
tract. irritating food.
o Diet o Lesser irritants that can cause additional insult to
▪ Highly nagtitrigger ng acidity sa stomach the lining of the stomach.
o Alcohol • Monitor for signs of complications like bleeding,
▪ Irritant and increases gastric acid obstruction, and pernicious anemia.
secretions. o Pwedeng mag hematemesis (magsuka ng
o Smoking blood) si patient, but most probably melena
▪ Further aggregate the condition because upper GI.
o Management: gastric lavage (parang enema);
PATHOPHYSIOLOGY flushing ng coffee ground like bleeding.
o Gastric lavage = 60 ml
• Insults > cause gastric mucosal damage > o Uses gravity so bababa mo below the stomach.
inflammation, hyperemia, and edema > superficial o Sa ibang hospitals: hinahaluan yung irrigant ng
erosions > decreased gastric secretion, ulceration, 1amp of epinephrine > minimizes the instances
and bleeding. of bleeding because of vasoconstriction.
o “perform gastric lavage until return is clear”
ASSESSMENT doctor’s order.
• Acute Gastritis o In gastric lavage I&O is very important.
o Dyspepsia ▪ Uses asepto syringe – usually 60 ml.
▪ Common in patients with gastritis Binababa lower than the GI track for aid in
o Headache gravity.
▪ Manifestation of inflammatory process ▪ Usually used for patients with GI bleeding
o Anorexia o Important: input 60 ml = output 60 ml dapat > if
▪ Walang gana kumain 40 ml lang nilabas record as input yung
o N/v difference > sometimes naddrain din yung 20ml
▪ Mas common ang vomiting sa acute o Patient can have complication such as
gastritis. obstruction > accumulation of blood clot/kumain
• Chronic Gastritis sya and then stomach is still bleeding can also
o Pyrosis cause obstruction.
o Singultus o If patient is bleeding:

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GASTROINTESTINAL SYSTEM DISORDERS MEDICAL-SURGICAL NURSING
BOLUSO, BRUSAS, CASTANARES, ELIZARDE, FRANCO, REYES, RUIZ, SALVO, SANCHEZ, UMLAS

▪ NPO > Decompress (NGT for draining) > patients, the gastritis progresses to involve the gastric
Gastric lavage (para maflush out yung body and fundus.
clots).
o Pernicious anemia = given supplementation of HELICOBACTER PYLORI VIRULENCE
vit B12 • Flagella – allows the bacteria to be motile in viscous
▪ Pwedeng hinahalo sa IV. mucus.
▪ Helicobacter releases carbon dioxide and o Allows the bacteria to be motile in the viscous
ammonia kapag binreakdown nya yung mucus.
urea = produces additional gas that • Urease – generates ammonia from endogenous urea.
accumulates in the stomach = additional o Urease enzyme – secreted by the
feeling of fullness in the stomach. bacteria.
• Instruct to avoid spicy foods, irritating foods, alcohol, o Converts urea into ammonia and carbon dioxide.
and caffeine. • Adhesins – enhance their bacterial adherence.
o If cannot totally avoid then minimize. • Toxins – such as cytotoxin-associated gene.
• Administer prescribed medications – H2 blockers, o Toxins secreted: cag and vac a.
antibiotics, mucosal protectants. o Layers from top to bottom:
o H2 blockers – decreases hydrochloric acid = ▪ Ammonia – highly alkaline; responsible for
decreases acidity of stomach. balancing the acidity of the stomach.
▪ Cimetidine ▪ Mucus
▪ Ranitidine ▪ Epithelium
▪ Famotidine • Overtime chronic antral H. pylori gastritis may
o Antibiotics – wide spectrum ang ginagamit progress to pangastritis, resulting in multifocal
▪ Most common causative agent: H. pylori but atrophic gastritis.
can also be others like E. coli.
o Mucosal protectants DIAGNOSIS
▪ Administer 30 mins – 1hr before eating. • Urea breath test – patient swallow urea labelled with
▪ Gives protective covering to the area na radioactive carbon. In subsequent 10-30 mins,
may erosion/ulceration. detection of isotope labelled CO2 in exhaled breath
▪ Ginagamit minsan for abortion. indicated urea was split that is urease enzyme is
▪ E.g., sucralfate (Carafate) present.
▪ Misoprostol – restricted ang pagamit • Antigen detection in stool
because of the side effect of abortion. • Gastric biopsy
o Proton pump inhibitor – pinaka potent na o Within the stomach, H. pylori are typically found
decrease ng GI secretions. in the antrum. Thus, an antral biopsy is preferred
▪ Sinasabi na may antibiotic effect din sya for evaluation of H. pylori gastritis.
(anti H. pylori effect) o When viewed endoscopically, H. pylori-infected
▪ H. pylori infections na recent is developing antral mucosa is usually erythematous and has
resistance to omeprazole. a coarse or even nodular appearance.
• Inform the need for vitamin B12 injection if deficiency
is present. MORPHOLOGY
o Swero na may yellowish tinge. • The organism is concentrated within the superficial
o Lessens chances of pernicious and mucus overlying epithelial cells.
megaloblastic anemia. • The distribution can be irregular, with areas of heavy
colonization adjacent to those with few organisms.
HELICOBACTER PYLORI
• H. pylori shows tropism for gastric epithelia and is
• Gram Negative bacteria generally not found in association with gastric
• Humans are the only known host. intestinal metaplasia or duodenal epithelium.
• Fecal-oral, and environmental spread the most likely • Organisms are most easily demonstrated with a
routes of infection. variety of special stains: Warthin Starry silver stain.
• Most common cause of chronic gastritis. • The inflammatory infiltrate generally included variable
• Most often presents as a predominantly antral numbers of neutrophils within the lamina propria and
gastritis. accumulate in the lumen of gastric pits to create pit
• High acid production abscesses.
• Hypogastrinemia • Large numbers of plasma cell and increased numbers
• In most gastritis is limited to the antrum with of lymphocytes and macrophages
occasional involvement of the cardia. In a subset of • Intraepithelial neutrophils and subepithelial plasma
cells are characteristic of H. pylori gastritis.

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GASTROINTESTINAL SYSTEM DISORDERS MEDICAL-SURGICAL NURSING
BOLUSO, BRUSAS, CASTANARES, ELIZARDE, FRANCO, REYES, RUIZ, SALVO, SANCHEZ, UMLAS

• Lymphoid aggregates preset and represent an • Often associated with other autoimmune diseases
induced form of mucosa-associated lymphoid tissue, like:
or MALT, that has the potential to transform into o Hashimoto thyroiditis
lymphoma. o Type I DM
• Long standing H. pylori gastritis may extend to involve o Addison disease
the body and fundus, and the mucosa can become o Primary hypoparathyroidism
atrophic. o Grave’s disease
o Myasthenia gravis.
Characteristics of Helicobacter pylori-associated and
autoimmune gastritis CHARACTERISTICS
H. pylori-associated autoimmune • Loss of parietal cells and intrinsic factor
Location Antrum Body • Defective gastric acid secretion (achlorhydria)
Inflammato neutrophils, Lymphocytes, • Reduced serum pepsinogen I concentration
ry infiltrate subepithelial plasma macrophages • Vit B12 deficiency
cells
Acid Increased to slightly Decreased PATHOGENESIS
production decreased • It was initially thought that the autoantibodies to
Gastrin Normal to decreased Increased parietal cell components, proton pump, and intrinsic
Other Hyperplastic/inflammat Neuroendocrin factor were involved in the pathogenesis of
lesions ory polyps e hyperplasia autoimmune gastritis.
Serology Antibodies to H. pylori Antibodies to • It is more likely that CD4+ T cells directed against
parietal cells parietal cell components, including the H+, K+-
(H-, K – ATPase, are the principal agents of injury.
ATPase, • Proton pump – responsible for hydrogen, potassium,
intrinsic factor) and ATPase in the gastric mucosa to decrease acid
Sequelae Peptic ulcer, Atrophy, formation.
adenocarcinoma pernicious • If autoimmune gastritis ang cause yung proton pump
anemia, inhibitors ay hindi effective.
adenocarcino
ma, carcinoid MORPHOLOGY
tumor • Autoimmune gastritis is characterized by diffuse
Associatio Low socioeconomic Autoimmune mucosal damage of mucosa within the body and
ns status, poverty, disease, fundus. Damage to the antrum and cardia is typically
residence in rural area thyroid, absent or mild.
diabetes • With diffuse atrophy, the oxyntic mucosa of the body
mellitus, and fundus appears markedly thinned, and rugal folds
grave’s are lost.
disease • Chronic gastritis starts as superficial gastritis =
erosion of superficial lining of stomach > atrophic
TREATMENT gastritis = lalalim na yung area of inflammation; pati
• Combination of antibiotics and proton pump chief cells and parietal cells nasisira na because they
inhibitors. are exposed na; glandular layers ay nasisira na; may
• Individuals with H. pylori gastritis usually improve possibility na maapektuhan na ang pepsin at HCL
after treatment, although relapses can occur after secretion > hypertrophic gastritis = inflammation
incomplete eradication or re-infection. creates nodules/matitigas na mga tissue; basically di
na normal tissue wala ng ruggae etc > nagpapakapal
AUTOIMMUNE GASTRITIS ng layer of tissue (fibrosis)
• Accounts for less than 10% of cases of chronic • Because of this nodule the gastric mucosa na numipis
gastritis. na natatakpan ng mga nodules > in the long run
• There is loss of parietal cells, which are responsible because of the thinned gastric mucosa, naeexpose
for secretion of gastric acid and intrinsic factor. yung mga blood vessels nan aka adheres sa gastric
• Absence of acid production stimulates gastrin mucosa > if the nodules/infiltrate ay natuklap > it can
release, resulting in hypergastrinemia and lead to bleeding.
hyperplasia of gastrin-producing G cells. • Nodules – can be a reason for gastric cancer
• Lack of intrinsic factor disables ileal vit. B12 formation.
absorption, leading to B12 deficiency and
megaloblastic anemia (pernicious anemia).

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GASTROINTESTINAL SYSTEM DISORDERS MEDICAL-SURGICAL NURSING
BOLUSO, BRUSAS, CASTANARES, ELIZARDE, FRANCO, REYES, RUIZ, SALVO, SANCHEZ, UMLAS

• If Vitamin B12 deficiency is severe – nuclear

enlargement (megaloblastic change) occurs within
the epithelial cells of the intestine.
• Inflammatory infiltrate is composed of lymphocytes,
and plasma cells. Lymphoid aggregates may be
present.
• The superficial lamina propria plasma cells of H. pylori
gastritis are absent, and is most often deep and
centered on the gastric glands.

CLINICAL COURSE
• Women are more affected than men.
• Antibodies to parietal cells and to intrinsic factors are
present early in the disease course.
• Progression to gastric atrophy probably occurs over 2
to 3 decades, and anemia is seen in only a few
patients.
• Slow onset and variable progression, patients are
generally diagnosed only after being affected for
many years; median age = 60 years old.

CLINICAL PRESENTATION
• Vitamin B12 Deficiency may cause any of the
following:
o Atrophic glossitis – smooth and beefy red tongue
o Peripheral neuropathy – paraesthesia and
numbness of fingers.
o Spinal lesions – loss of vibration and position
sense, Sensory ataxia, Limb weakness,
spasticity, and extensor plantar responses.
o Cerebral manifestations – mild memory losses,
personality changes, that may lead to psychosis.
▪ Neurologic changes are not reversible by
Vitamin B12 replacement therapy.
• Bottom line is around 10% ang autoimmune type ng
gastritis kesa H. pylori connected gastritis. And when
this gastritis ay hindi naagapan it will lead to
complications or factors that predisposes the patient
to gastritis or stomach cancer.

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