GIT part 2GIT part 2Accessory OrgansAccessory Organs

Ruby Ruth T. Roces, R.N., M.D.Ruby Ruth T. Roces, R.N., M.D.

Anatomy and Anatomy and PhysiologyPhysiologyAccessory OrgansAccessory Organs PancreasPancreas LiverLiver Gall bladderGall bladder

Pancreatic secretionsPancreatic secretions

1. Bicarbonate1. Bicarbonate2. Pancreatic amylase2. Pancreatic amylase3. Pancreatic lipase3. Pancreatic lipase4. Trypsin and 4. Trypsin and chymotrypsinchymotrypsin

Liver physiology and PathophysiologyLiver physiology and PathophysiologyNormal Function Normal Function Abnormality in functionAbnormality in function

1. Stores glycogen1. Stores glycogen = Hypoglycemia= Hypoglycemia2. Synthesizes proteins2. Synthesizes proteins = Hypo-proteinemia= Hypo-proteinemia

3. Synthesizes globulins3. Synthesizes globulins =Decreased Antibody =Decreased Antibody formationformation risk for risk for INFECTIONINFECTION

4. Synthesizes Clotting 4. Synthesizes Clotting factorsfactors

= Bleeding tendencies= Bleeding tendencies

5. Secreting bile5. Secreting bile = Jaundice and pruritus= Jaundice and pruritus6. Converts ammonia to 6. Converts ammonia to ureaurea

=Hyper-ammonemia=Hyper-ammonemia

7. Stores Vitamims and 7. Stores Vitamims and mineralsminerals

=Deficiencies of Vit and min=Deficiencies of Vit and min

8. Metabolizes estrogen8. Metabolizes estrogen = Gynecomastia, testes atrophy= Gynecomastia, testes atrophy

DisordersDisorders

CONDITION OF THE CONDITION OF THE LIVERLIVERLiver CirrhosisLiver Cirrhosis A chronic, progressive A chronic, progressive

disease characterized by a disease characterized by a diffuse damage to the diffuse damage to the hepatic cellshepatic cells

CONDITION OF THE CONDITION OF THE LIVERLIVERLiver CirrhosisLiver CirrhosisETIOLOGY: ETIOLOGY:

Post-infection, Alcohol Post-infection, Alcohol (Laennac’s cirrhosis), (Laennac’s cirrhosis), Cardiac diseases, Cardiac diseases, Schisostoma, Biliary Schisostoma, Biliary obstructionobstruction

Pathogenesis: Pathogenesis:

repeated destruction of hepatic cellrepeated destruction of hepatic cell

scar tissue formation (fibrotic) scar tissue formation (fibrotic) regeneration of liver cell follows regeneration of liver cell follows

another destruction will occur another destruction will occur cycle cycle (scarring and regeneration) will be (scarring and regeneration) will be

repeated until hepatocytes becomes repeated until hepatocytes becomes fibrotic and liver function is fibrotic and liver function is

compromised compromised

CONDITION OF THE CONDITION OF THE LIVERLIVERASSESSMENT FINDINGSASSESSMENT FINDINGS1. Anorexia and weight 1. Anorexia and weight lossloss

2. Jaundice2. Jaundice3. Fatigue3. Fatigue

CONDITION OF THE CONDITION OF THE LIVERLIVERASSESSMENT FINDINGSASSESSMENT FINDINGS

4. Early morning nausea and 4. Early morning nausea and vomitingvomiting

5. RUQ abdominal pain5. RUQ abdominal pain6. Ascites6. Ascites7. Signs of Portal hypertension7. Signs of Portal hypertension

Liver function test:Liver function test: Elevated AST aspartate aminotransferase Elevated AST aspartate aminotransferase

formerly SGOTformerly SGOT 4.8 - 19 U/L4.8 - 19 U/L Elevated ALT alanine aminotransferase Elevated ALT alanine aminotransferase

formerly SGPTformerly SGPT 2.4 - 7 U/L2.4 - 7 U/Lhighly specifichighly specific

Elevated Alkaline Phosphatase-30-115 IUElevated Alkaline Phosphatase-30-115 IU Elevated Bilirubin -0.1-1.0 mg/dLElevated Bilirubin -0.1-1.0 mg/dL

COMMON COMMON LABORATORY LABORATORY PROCEDURESPROCEDURESLiver biopsyLiver biopsy IntratestIntratest

– Position: Semi fowler’s LEFT Position: Semi fowler’s LEFT lateral to expose right side of lateral to expose right side of abdomen abdomen

Post-testPost-test: position on : position on RIGHT RIGHT lateral with pillow underneath,lateral with pillow underneath, monitor VS and complications monitor VS and complications like bleeding, perforation. like bleeding, perforation. Instruct to avoid lifting objects Instruct to avoid lifting objects for 1 weekfor 1 week

CONDITION OF THE CONDITION OF THE LIVERLIVERNURSING INTERVENTIONSNURSING INTERVENTIONS 1. Monitor VS, I and O, 1. Monitor VS, I and O,

Abdominal girth, weight, Abdominal girth, weight, LOC and BleedingLOC and Bleeding

2. Promote rest. 2. Promote rest. Elevated the head of the Elevated the head of the bed to minimize dyspneabed to minimize dyspnea

CONDITION OF THE CONDITION OF THE LIVERLIVERNURSING INTERVENTIONSNURSING INTERVENTIONS 3. Provide Moderate to LOW-protein (1 3. Provide Moderate to LOW-protein (1

g/kg/day) and LOW-sodium dietg/kg/day) and LOW-sodium diet 4. Provide supplemental vitamins 4. Provide supplemental vitamins

(especially K) and minerals(especially K) and minerals Administer prescribedAdminister prescribedDiuretics= to reduce ascites and edemaDiuretics= to reduce ascites and edemaLactulose= to reduce NH4 in the bowelLactulose= to reduce NH4 in the bowelAntacids and Neomycin= to kill bacterial Antacids and Neomycin= to kill bacterial

flora that cause NH productionflora that cause NH production

CONDITION OF THE CONDITION OF THE LIVERLIVER

NURSING INTERVENTIONSNURSING INTERVENTIONS6. Avoid hepatotoxic drugs6. Avoid hepatotoxic drugs

–ParacetamolParacetamol–Anti-tubercular drugsAnti-tubercular drugs

7. Reduce the risk of injury 7. Reduce the risk of injury – Side rails reorientationSide rails reorientation– Assistance in ambulationAssistance in ambulation– Use of electric razor and soft-Use of electric razor and soft-

bristled toothbrushbristled toothbrush

CONDITION OF THE CONDITION OF THE LIVERLIVERNURSING NURSING INTERVENTIONSINTERVENTIONS

8. Keep equipments ready 8. Keep equipments ready including Sengstaken-including Sengstaken-Blakemore tube, IV fluids, Blakemore tube, IV fluids, Medications to treat Medications to treat hemorrhagehemorrhage

Wilson’s diseaseWilson’s disease

Rare autosomal-recessive Rare autosomal-recessive disorderdisorder

Excessive deposition of Excessive deposition of copper in the liver & braincopper in the liver & brain

< 30 y.o.< 30 y.o. Defect in chromosome 13- Defect in chromosome 13-

copper transporting proteincopper transporting protein

AssessmentAssessment

Liver abnormalitiesLiver abnormalities JaundiceJaundiceNeurologic Neurologic Loss of coordinationLoss of coordination TremorTremor DysphagiaDysphagia

Psychiatric abnormalitiesPsychiatric abnormalities PsychosisPsychosis Mania Mania depressiondepression AnxietyAnxiety

Kayser-Fleischer rings in the Kayser-Fleischer rings in the corneacornea

DiagnosticsDiagnostics

Decreased serum Decreased serum ceruloplasminceruloplasmin

Elevated urinary copper Elevated urinary copper excretionexcretion

Elevated hepatic copperElevated hepatic copper

ManagementManagement Dietary copper restriction Dietary copper restriction

(shellfish,liver,legumes)(shellfish,liver,legumes) Penicillamine (copper chelator), Penicillamine (copper chelator),

administered w/ pyridoxineadministered w/ pyridoxine Oral zinc ( inc fecal excretion)Oral zinc ( inc fecal excretion)

Gall bladderGall bladder

CholelithiasisCholelithiasis

Formation of Formation of GALLSTONES in the GALLSTONES in the biliary apparatusbiliary apparatus

Predisposing FACTORSPredisposing FACTORS

“ “ 5 F’s”5 F’s”FemaleFemaleFatFatFortyFortyFertileFertileFairFair

Assessment findingsAssessment findings

Asymptomatic in 80%Asymptomatic in 80%PE:PE: RUQ tendernessRUQ tenderness Palpable gallbladderPalpable gallbladder

DiagnosticsDiagnostics Ultrasound may show the Ultrasound may show the

gallstones (95%)gallstones (95%)

ManagementManagement Cholecystectomy- definitive & Cholecystectomy- definitive &

curativecurative Dietary modificationDietary modification Pharmacologic dissolution( w/ bile Pharmacologic dissolution( w/ bile

salts)salts)w/ or w/o lithotripsyw/ or w/o lithotripsy

CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDERCholecystitisCholecystitis Inflammation of the Inflammation of the

gallbladdergallbladder Can be acute or chronicCan be acute or chronic Can be calculous or Can be calculous or

acalculousacalculous

PathophysiologyPathophysiology

Supersaturated bile, Biliary stasisSupersaturated bile, Biliary stasis

Stone formationStone formation

Blockage of GallbladderBlockage of Gallbladder

Inflammation, Mucosal Damage and Inflammation, Mucosal Damage and WBC infiltration WBC infiltration

CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDERASSESSMENT findings ASSESSMENT findings for cholecystitisfor cholecystitis

1. Charcot’s triad1. Charcot’s triad2. Indigestion, belching 2. Indigestion, belching and flatulenceand flatulence

3. Fatty food intolerance3. Fatty food intolerance

CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDERASSESSMENT findings ASSESSMENT findings for cholecystitisfor cholecystitis

4. Mass at the RUQ4. Mass at the RUQ5. Murphy’s sign5. Murphy’s sign

CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDER DIAGNOSTIC PROCEDURESDIAGNOSTIC PROCEDURES1. Ultrasonography- 1. Ultrasonography- can detect the stones can detect the stones

2. Abdominal X-ray2. Abdominal X-ray3. Cholecystography3. Cholecystography

CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDER DIAGNOSTIC PROCEDURESDIAGNOSTIC PROCEDURES 4. WBC count increased4. WBC count increased 5. HIDA scan- cannot 5. HIDA scan- cannot

visualize the gallbladder- +visualize the gallbladder- + 6. ERCP: revels inflamed 6. ERCP: revels inflamed

gallbladder with gallstonegallbladder with gallstone

ERCPERCP

CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDER

NURSING INTERVENTIONSNURSING INTERVENTIONS 1. NPO in the active phase1. NPO in the active phase 2. Maintain NGT 2. Maintain NGT

decompressiondecompression 3. 3. give pain med- Demerol give pain med- Demerol

(MEPERIDINE)(MEPERIDINE)

CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDER

4. 4. AVOID HIGH- fat diet and GAS-AVOID HIGH- fat diet and GAS-forming foodsforming foods

5. Assist in surgical and non-5. Assist in surgical and non-surgical measuressurgical measures

6. Surgical procedures- 6. Surgical procedures- Cholecystectomy, Cholecystectomy, Choledochotomy, laparoscopyCholedochotomy, laparoscopy

CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDER

PHARMACOLOGIC THERAPYPHARMACOLOGIC THERAPY1.1. Analgesic- MeperidineAnalgesic- Meperidine2.2. Chenodeoxycholic acid= to Chenodeoxycholic acid= to

dissolve the gallstonesdissolve the gallstones3.3. AntacidsAntacids4.4. Anti-emeticsAnti-emetics

CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDER

Post-operative nursing interventionsPost-operative nursing interventions 1. MONITOR1. MONITOR 2. Post-operative position- 2. Post-operative position- LOW LOW

FOWLER’sFOWLER’s 3. Encourage early ambulation 3. Encourage early ambulation 4. 4. Administer medication before Administer medication before

coughing and deep breathing coughing and deep breathing exercises.exercises.Advise client to splint Advise client to splint during exercise. during exercise.

CONDITION OF THE CONDITION OF THE GALLBLADDERGALLBLADDER5. Administer analgesics, 5. Administer analgesics, antiemetics, antacidsantiemetics, antacids

6. Care of the biliary drainage 6. Care of the biliary drainage or T-tube drainage ( 200-300ml)or T-tube drainage ( 200-300ml)

7. Fat restriction is only limited 7. Fat restriction is only limited to 4-6 weeks. Normal diet is to 4-6 weeks. Normal diet is resumedresumed

CholangitisCholangitis Infection/inflammation Infection/inflammation

of biliary tree 2 to of biliary tree 2 to obstruction (stone or obstruction (stone or malignancymalignancy))

AssessmentAssessment Charcot’s triadCharcot’s triad Reynold’s pentad Reynold’s pentad

( charcot’s plus shock ( charcot’s plus shock & altered mental & altered mental status)status)

DiagnosticsDiagnostics

WBCWBC Bilirubin, alk phosphate- incBilirubin, alk phosphate- inc Blood cultures- ( gm – Blood cultures- ( gm –

enterics)enterics) ERCP- diagnostic gold ERCP- diagnostic gold

standardstandard

ManagementManagement Life threatening- ICULife threatening- ICU Iv antibioticsIv antibiotics Bile duct decompression- Bile duct decompression-

endoscopic sphicterotomy, endoscopic sphicterotomy, pecutaneous hepatic drainage pecutaneous hepatic drainage or operative decompressionor operative decompression

ERCP- stone removal, stent ERCP- stone removal, stent placement or sphincterotomyplacement or sphincterotomy

PancreasPancreas

CONDITION OF THE CONDITION OF THE PANCREASPANCREASPancreatitisPancreatitisInflammation of Inflammation of the pancreasthe pancreas

Can be acute or Can be acute or chronicchronic

Etiology & Risk FactorsEtiology & Risk Factors

– AlcoholismAlcoholism– gallstonesgallstones– HypercalcemiaHypercalcemia– TraumaTrauma– Viral infectionsViral infections– Post ERCPPost ERCP–HyperlipidemiaHyperlipidemia–Drugs(thiazideDrugs(thiazide))

CONDITION OF THE CONDITION OF THE PANCREASPANCREASPATHOPHYSIOLOGY of PATHOPHYSIOLOGY of acute pancreatitisacute pancreatitis

Spasm, edema or block in the Spasm, edema or block in the Ampulla of VaterAmpulla of Vater reflux of reflux of proteolytic enzymesproteolytic enzymes auto auto digestion of the pancreasdigestion of the pancreas inflammationinflammation

Autodigestion of pancreatic tissueAutodigestion of pancreatic tissue

Hemorrhage, Necrosis and InflammationHemorrhage, Necrosis and Inflammation

KININ ACTIVATION will result to KININ ACTIVATION will result to increased permeabilityincreased permeability

Loss of Protein-rich fluid into the Loss of Protein-rich fluid into the peritoneumperitoneum

HYPOVOLEMIAHYPOVOLEMIA

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

CONDITION OF THE CONDITION OF THE PANCREASPANCREASASSESSMENT findingsASSESSMENT findings1. Abdominal pain- 1. Abdominal pain- acute onset, occurring acute onset, occurring after a heavy meal or after a heavy meal or alcohol intakealcohol intake

2. Abdominal guarding2. Abdominal guarding

CONDITION OF THE CONDITION OF THE PANCREASPANCREASASSESSMENT findingsASSESSMENT findings 3. Bruising on the flanks 3. Bruising on the flanks and umbilicus and umbilicus Grey turner’s sign-Grey turner’s sign-purplish discoloration of the flank purplish discoloration of the flank (ecchymoses)(ecchymoses)

Cullen’s sign-periumbilical discolorationCullen’s sign-periumbilical discoloration 4. N/V, jaundice4. N/V, jaundice

5. Hypotension and 5. Hypotension and hypovolemiahypovolemia

6. Signs of shock6. Signs of shock 7. Client assumes fetal 7. Client assumes fetal

position to relieve pressure position to relieve pressure (celiac plexus nerve)(celiac plexus nerve)

CONDITION OF THE CONDITION OF THE PANCREASPANCREASDIAGNOSTIC TESTSDIAGNOSTIC TESTS 1. Serum amylase and serum 1. Serum amylase and serum

lipase- inc 3xlipase- inc 3x 2. Ultrasound2. Ultrasound 3. WBC- inc3. WBC- inc 4. Serum calcium-dec.- binds w/ 4. Serum calcium-dec.- binds w/

area of necrosisarea of necrosis 5. CT scan5. CT scan

CONDITION OF THE CONDITION OF THE PANCREASPANCREASNURSING INTERVENTIONSNURSING INTERVENTIONS Demerol is givenDemerol is given. Morphine is . Morphine is

AVOIDEDAVOIDED correction of Fluid and Blood losscorrection of Fluid and Blood loss Place patient on NPOPlace patient on NPO to inhibit to inhibit

pancreatic stimulationpancreatic stimulation NGT insertion to decompress NGT insertion to decompress

distention and remove gastric distention and remove gastric secretionssecretions

CONDITION OF THE CONDITION OF THE PANCREASPANCREASNURSING INTERVENTIONSNURSING INTERVENTIONS Position patient in Position patient in SEMI-SEMI-

FOWLER’s to decrease FOWLER’s to decrease pressure on the diaphragm pressure on the diaphragm

Deep breathing and coughing Deep breathing and coughing exercisesexercises

Provide parenteral nutritionProvide parenteral nutrition

CONDITION OF THE CONDITION OF THE PANCREASPANCREASNURSING INTERVENTIONSNURSING INTERVENTIONS Introduce oral feedings Introduce oral feedings

gradually- HIGH carbo, LOW gradually- HIGH carbo, LOW FATFAT

Maintain skin integrityMaintain skin integrity Manage shock and other Manage shock and other

complicationscomplications

Pancreatic CancerPancreatic Cancer Usually an adenocarcinomaUsually an adenocarcinoma Usually involves the HeadUsually involves the HeadRisk factors:Risk factors: SmokingSmoking High fat dietHigh fat diet MenMen > 60 y.o.> 60 y.o.

AssessmentAssessment Abdominal pain radiating to Abdominal pain radiating to

the backthe back AnorexiaAnorexia N/VN/V Weight lossWeight loss Weakness, fatigueWeakness, fatigue IndigestionIndigestion

Jaundice (obstructs the bile Jaundice (obstructs the bile duct)duct)

Trousseau’s sign- migratory Trousseau’s sign- migratory thrombophlebitis d/t ectopic thrombophlebitis d/t ectopic production of production of procoagulatantsprocoagulatants

Courvoisier’s sign- palpable Courvoisier’s sign- palpable nontender gallbladdernontender gallbladder

DiagnosticsDiagnostics

CT scanCT scan ERCPERCP Transcutaneous Transcutaneous

pancreatic biopsy- risk pancreatic biopsy- risk of spreading tumorof spreading tumor

ManagementManagement

Surgery- whipples Surgery- whipples procedure procedure (pancreaticoduodenecto(pancreaticoduodenectomy)my)

Radio/chemoRadio/chemo