105 Module G Gastrointestinal Diagnostics Serum Lab Studies:

Initial diagnostics begin with lab studies, such as: CBC Complete Metabolic Panel PTT Triglycerides Liver Function Tests Studies such as Carcinoembryonic Antigen (CEA) and Cancer Antigen (CA) that have sensitivity for colorectal cancer and alpha-fetoprotein that has sensitivity for liver cancer

Stool Tests:
Fecal Occult Blood Testing: Most common Can be useful in initial screening for several disorders but is more commonly used in early cancer detection. Can be performed at bedside, in the lab, or at home Hemoccult II most widely used in office and in home If done at home, patient mails the test to lab Inexpensive, noninvasive, and minimal risk to the patient Red meats, aspirin, NSAIDS, turnips, and horseradish should be avoided 72 hours prior to the study, may cause false positive.

Esophagogastroduodenoscopy (EGD)
NPO for 8 hours prior Before procedure, patient is given a local anesthetic gargle or spray Versed Provides moderate sedation and decreased anxiety. May be administered prior to procedure Atropine May be administered to decrease gastric secretions Glucogon Relaxes smooth muscle

Afterwards, assess:
LOC, Vital Signs, O2 Saturation, Pain Levels, Monitor for S/S of perforation, Monitor gag reflex

After gag reflex has returned lozenges, saline gargle, and oral analgesic agents may be offered to relieve minor throat discomfort. Patients who were sedated must remain in bed until fully alert. After moderate sedation, patient must be transported home with a family member or friend and someone must stay with the patient until morning after the procedure. Follow up and discharge are given to the person accompanying the patient home.

Upper GI Tract Study:

Enables detection of anatomical or functional disorders of the upper GI organs or sphincters Aids in diagnosis of: Ulcers Varices Regional Enteris Malabsorption Syndromes An upper GI Fluoroscopy delineates the entire GI tract after the introduction of contrast. A radiopaque liquid is commonly used (barium sulfate) however Hypaque and at times water are used due to the lower associated risk. As barium descends into the stomach, the position, patency, and caliper of the esophagus are visualized enabling the examiner to detect any problems. The exam extends to the stomach allowing observation of stomach motility, thickness of gastric wall, mucosal pattern, patency of the pyloric valve, and anatomy of the duodenum. Multiple X-Rays are obtained during the procedure and additional images may be taken for a period up to 24 hours afterward to evaluate rate of gastric emptying.

Nursing management:
Education regarding dietary changes prior to the study should include: Clear liquid diet NPO after midnight prior to the study Withhold morning medications the morning of the study No smoking, chewing gum, or mints can stimulate gastric motility

Insulin dependent diabetic Patient:

When NPO, Insulin requirements need to be adjusted accordingly

Follow up:
Ensure elimination of barium and increase fluids to facilitate evacuation of stool and barium

Lower GI Tract Study:

Can be used to detect presence of: Polyps, tumors, and other lesions of the large intestine and demonstrate any anatomical abnormalities or malfunctioning of the bowel After proper prep and evacuation of the entire colon each portion can be readily observed. Process takes about 15-30 minutes, during which x-ray images are obtained Double or air contrast enema involves instillation of a thicker barium followed by installation of air. Patient may feel cramping. Provides contrast between air filled lumen and the barium coated mucosa allowing detection of smaller lesions. If active inflammatory disease, perforated intestine, obstruction, or fistulas of the colon is suspected a water soluble iodinated contrast agent can be used. Procedure is the same as barium enema but you must assess for allergy to iodine or contrast. The contrast is eliminated soon after, so there is no need for post-procedure laxatives. Some diarrhea may occur.

Nursing Management:
Prep includes emptying and cleansing of the lower bowel Low residue diet for 1-2 days before the test Clear liquid diet Laxative the evening before the procedure NPO after midnight Cleansing enemas until residue returns clear the following morning Post-procedure Education: Educate with information about: Increasing fluid intake Evaluating bowel movements for evacuation of barium. Noting increase number of BM because barium due to its high osmolarity may draw fluid into the bowel, increasing the intraluminal contents and resulting in greater output

Colonoscopy:
Direct visual inspection of the large intestine is possible by means of flexible fiberoptic colonoscope. Used for: Cancer screening Surveillance in patients with history of colon cancer or polyps Tissue biopsies Polyp Removal Evaluation of patients with diarrhea of unknown cause, occult bleeding, or anemia Can be used for removal of polyps with a special snare and cautery tool. Many colon CA begin with adenomatous polyps, so one goal of colonoscopic polypectomy is early detection and prevention of colorectal cancer. Can be used to treat bleeding laser compatible scopes provide laser therapy for bleeding lesions or colonic neoplasms Bowel decompression (removal of intestinal contents to prevent gas and fluid from distending the coils of the intestine) can also be completed.

Procedure:
Lasts about 1 hour . Discomfort results from instillation of air and insertion and movement of the scope Patient is positioned on the left side with legs drawn up towards chest. Position may be changed during the procedure to facilitate advancement of the scope. Monitored for: Respiratory function and O2 Sat. are monitored continually with supplemental O2 used if needed; V/S; Skin color and temp; LOC; Abdomen distention; vagal response; Pain level

Complications:
Dysrhythmias Respiratory depression Vasovagal reactions Circulatory over/underload

Nursing Management:
Teaching:

Laxative for 2 days prior to exam and Fleets or saline enema until return is clear on the morning of the exam. (Go-Lytely, Colyte, and Nu-Lytely are more commonly used as cleansing agents) Clear liquid diet starting at noon the day before the procedure, then ingests the laxative solution at intervals over 3-4 hours.

Lavage laxative solution can be given through a feeding tube or to a patient with a colostomy. CANNOT be given to a patient with intestinal obstruction or Irritable bowel. Patient can drink the preparation cold to make it easier to ingest. S/E of laxative solution: Nausea Bloating Cramps Fullness F/E Imbalance Hypothermia After Procedure: Bedrest until fully alert Some patients have cramps caused by increase peristalsis stimulated by air inserted into bowel during procedure Monitored for S/S of bowel perforation, rectal bleeding, fever Provide written instructions due to inability to recall info. given due to Versed. Outpatient- Someone must transport patient home Contraindications: Colon perforation Acute, severe diverticulitis Fulminant Colitis Patient with prosthetic heart valves History of endocarditis requires prophylactic antibiotics prior to procedure

Elderly: problematic. Increased side effects and have difficulty taking in the required amount of solution. Monitoring very important! Because their ability to compensate for fluid loss is diminished

Diabetic: Advise to consult with doctor about medication regimen to prevent hypo/hyperglycemia resulting from the require dietary modifications All patients: Increase fluid intake, maintain adequate F/E and caloric intake while undergoing bowel cleansing Implantable defibrillators/pacemakers are at increased risk of malfunction if electrosurgical procedures are performed in conjunction with colonoscopy Consult cardiologist Turn off defibrillator And carefully monitor cardiac function

Flexible Sigmoidoscopy
Exam of the anus, rectum, and sigmoid colon. Permits the colon to be examined up to 40-50 cm from the anus. Patient is positioned on left side with right leg bent and placed anteriorly. Keep patient informed throughout the procedure and explain sensations associated. Used to evaluate: Chronic diarrhea Fecal incontinence Ischemic colitis Lower GI hemorrhage Used to observe for: Ulceration Fissures Abscesses Tumors Polyps Can be used for removal of polyps, they must be removed, placed immediately in moist gauze or appropriate receptacle and transported to the lab for examination.

Nursing Management:
Limited bowel prep

Warm tap water or Fleets enema until returns are clear Dietary restrictions are not necessary Sedation usually not required

During procedure: Monitor V/S Skin color and temp. Pain tolerance Vagal response After procedure: Monitor for rectal bleeding S/S of intestinal perforation On completion of procedure, patient can resume regular activities and diet

GI Disorders Cancer of the Oral Cavity and Pharynx:

Risk Factors: Smoking/Smokeless tobacco use Excessive use of alcohol More common in men Ages 50 +

Pathophysiology:
Malignancies squamous cell cancer Any area of oropharynx can be a site of growth but the lips, lateral aspects tongue, and the floor of the mouth are the most commonly affected areas

Clinical Manifestations:
Many oral cancers produce little or no symptoms in the early stages. Later the S/S include: Painless sore or mass that does not heal. Sore may bleed easily, and may present as a red or white patch o Painless, hardened ulcer with raised edges Tenderness as cancer progresses Difficulty chewing, swallowing, speaking Cough Blood tinged sputum Enlarged cervical lymph nodes

Assessment and Diagnostic findings:

Oral exam and an assessment of cervical lymph nodes to detect possible metasteses Biopsies are performed on suspicious lesions (those who have not healed in two weeks

Medical Management
Varies with nature of the lesion Surgical resection, radiation therapy, and chemo for advanced disease One common reconstructive technique involves use of a radial forearm free flap (thin layer of skin from forearm and radial artery)

Nursing Management:
Nutritional status preoperatively - dietary consultation may be necessary Patient may require enteral or parenteral feedings before and after surgery to maintain adequate nutrition If radial graph is performed Allen test must be performed on donor arm to assure patency of ulnar artery and ability to provide blood flow Verbal communication may be impaired by radical surgery for oral cancer. It is vital to assess patients ability to write pen and paper may be only means of communication afterwards. Postop: Airway patency Suctioning as needed - if grafting was a part of the surgery, suctioning should be carefully to prevent damage to the graft

Stomatitis:
Inflammation and breakdown of oral mucosa Often a S/E of chemo or radiation therapy prophylactic mouth care begins at beginning of therapy but may become so severe that treatment has to be withheld for a period of time. If patient has poor dentition, extraction of teeth before radiation therapy may be necessary Fluoride use if recommended Promoting mouth care: If patient cannot tolerate brushing teeth and flossing use 1 tsp. baking soda to 8 oz. warm water.

Hiatal hernia:
Opening in the diaphragm through which the esophagus passes, becomes enlarged, and the upper part of the stomach moves up into the thorax Occurs more in women Two types: Sliding and paraesophageal

Sliding occurs when the upper stomach and gastroesphageal junction are displaced upward and slide in and out of the thorax. Accounts for 90% of all cases. Classified as Type I Paraesophageal occurs when all or part of the stomach pushes through the diaphragm beside the esophagus. Classified as Types II, III, or IV; IV being greatest amount of herniation.

S/S:
Sliding Hernia Heartburn Regurgitation Dysphagia But at least 50% of all patients are asymptomatic Paraesophageal Hernia Sense of fullness Chest pain after eating Or Asymptomatic Hemorrhage, obstruction, and strangulation can also occur with any type of hernia

Management:
Frequent small feedings that can easily pass through the esophagus Advise not to recline for 1 hr. after eating Elevate HOB on 4-8 inch blocks Avoid anticholinergics

Medical Surgical Management Similar to GERD but may require emergency surgery to correct torsion (twisting) of the stomach, which decreases blood flow.

GERD Gastroesphageal Reflux Disease

Backflow of gastric content into esophagus; Occurs due to incompetent esophageal sphincter, pyloric stenosis or motility disorder. Incidence Increases with age

S/S:
Pyrosis (burning sensation in esophagus) Dyspepsia (indigestion) Regurgitation Dysphagia Odynophagia (painful swallowing) Hypersalivation Esophagitis Symptoms may mimic those of a heart attack

Assessment and diagnostics:

Endoscopy and barium swallow to evaluate damage to esophageal mucosa Ambulatory 12-36 hour esophageal pH monitoring used to evaluate degree of acid reflux Bilirubin used to measure bile reflux patterns

Management
Avoid irritating factors Low fat, high fiber diet Avoid caffeine, tobacco, alcohol, cigarettes, milk, spearmint and peppermint, carbonated drinks, as well as decaffeinated coffee Avoid eating or drinking 2 hours before bed Avoid tight fitting clothing Elevate HOB 6-8 inches and upper body with pillows Do not give anticholinergics, NSAIDS, aspirin will delay gastric emptying

Medications: H2 Receptor antagonists: If reflux persists, antacids such as Pepcid, Axid, and Zantac may be prescribed Proton Pump Inhibitors: Decrease release of gastric acid (Prevacid, Protonix, Prilosec) Prokinetic: Increase gastric emptying (Urecholine, Motilium, Reglan) Surgery may be required if medical management fails. Involves Nissen fundoplication: wrapping a portion of the gastric fundus around the sphincter area of the esophagus. May be performed by open method or laparoscopic

Esophageal Cancer
Two cell types: adenocarcinoma and squamous cell Found primarily in the distal esophagus and gastroesphageal junction

Risk Factors:
Excessive alcohol use Tobacco use GERD (adenocarcinoma) Barrets disease(caused by chronic irritation of the mucous membranes due to reflux of gastric and duodenal content) Chronic ingestion of hot liquids or foods Nutritional deficiencies Poor oral hygiene Exposure to Nitrosamines in food or environment Some esophageal medical issues such as caustic injury

S/S:
Dysphagia A sensation of a mass in throat Substernal pain and fullness (Late symptom) Regurgitation with foul breath and hiccups (Late symptom) Intermittent and Increasing difficulty swallowing (Late symptom)

As the tumor grows and obstruction becomes complete, even liquid cant pass into the stomach. Regurgitation of food and saliva occur, hemorrhage may take place, and progressive weight loss and decreased strength from decreased nutritional intake

Assessment and diagnostics:

EGD with biopsy and brushings CT of abdomen and chest to determine metastasic disease Ultrasound to detect metastases of lymph nodes

Medical Management:
Esophageal cancer is usually caught at the late stage and at the late stage typically cannot be cured only relief of signs and symptoms. If caught early enough, it can be cured. Treatment: (Surgery, Radiation, Chemo) Surgical resection of the esophagus has a high mortality rate due to infection, pulmonary complications or leakage through the anastomosis Postop: NG tube that should not be manipulated NPO until X-Ray studies confirm that the anastomosis is free from esophageal leak, there is no obstruction, and no evidence of pulmonary aspiration

Nursing Management:
High calorie, high protein diet in liquid or soft form Parenteral or enteral nutrition if indicated Low fowlers position after anesthesia, then fowlers Carefully observe for regurgitation and dyspnea

Common complication is aspiration pneumonia. Include in the careplan: Incentive spirometer, sitting up in chair, nebulizer treatment if indicated. Avoid chest physiotherapy due to risk of aspiration. Increase temp. may indicate aspiration or seepage of fluid through the operative site into the mediastinum, which would indicate an esophageal leak. Drainage from wound is also usually indicative of a leak. During surgery, NG tube is inserted and on low intermittent suction. Do not manipulate! If displacement occurs, it is not replaced because it may cause damage to the anastomosis. NG tube is removed 5-7 days after surgery. Barium swallow must be done to asses for leaks before patient can begin eating. Start with small sips of water Eventually advanced to soft mechanical diet Remain upright 2 hr. after eating

Antacids (metoclopramide) may help Supplements such as Boost and Ensure should be avoided because they can cause dumping syndrome: o S/S: Borborygmi, epigastric fullness, tachycardia, weakness, dizziness, sweating, cramping

Gastritis:
Inflammation of stomach/gastric mucosa. Scarring may occur resulting in pyloric stenosis or obstruction. Chronic Gastritis may be cause by ulcers of the stomach or the bacteria Helicobacter Pylori. Often occurs from eating foods that are irritating, too highly seasoned, or contaminated with disease causing microorganism. Other causes: Overuse of Aspirin, NSAIDS Excessive alcohol intake Bile reflux Radiation therapy

Patho:
Gastric mucous membrane becomes edematous and hyperemic and undergoes superficial erosion. Secretes scant amount of gastric juice containing very little acid but much mucus. Ulceration may occur, which could lead to hemorrhage.

S/S:
Abdominal discomfort HA Nausea and vomiting Hiccups Anorexia Heartburn Belching Sour taste in mouth

Assessment and Diagnostics

Upper GI X-ray series Endoscopy and histologic exam of tissue specimen obtained by biopsy

Management:
No alcohol, NSAID, caffeine, smoking, spicy foods NPO until symptoms subside progress to a nonirritating diet Teach importance of B12 injections if deficiency is present Modify diet Promote rest Decrease stress and anxiety Be alert to indicators of hemorrhage which include hematemesis, tachycardia, and low BP and notify Dr.

Peptic ulcer disease (PUD)

A hollowed out area that forms in the mucosal wall of the stomach, pyloris, duodenum, or esophagus. Occurs most often between 40-60 years of age.

S/S:
Dull gnawing pain or burning sensation in the midepigastrium or the back which is usually relieved for a short period of time after eating because food neutralizes the acid o occurs 2 hr. after meal and frequently awakens patient at night o Antacids, eating, and vomiting help relieve the pain Heartburn associated with sour eruction and burping Nausea, Vomiting, Diarrhea, Constipation Bleeding which may present with black tarry stool or coffee ground emesis

Assessment may reveal pain, epigastric tenderness, and abdominal distention

Diagnostics:
Barium study of upper GI may show ulcer Endoscopy is preferred because it allows direct visualization of inflammatory changes, ulcers, and lesions Stools may be tested periodically until they are negative for occult blood

Medical Management:
Antibiotics, proton pump inhibitors, and bismuth salts that suppress H. pylori. H2 Receptors/Proton pump inhibitors are used to treat NSAID induced ulcers Rest, sedatives, and tranquilizers may be added for comfort

Surgery Recommended for patients with intractable ulcers that fail to heal in 12-16 weeks of therapy or if hemorrhage, perforation, or obstruction occur.

Nursing Management:
Avoid Aspirin, NSAIDS, caffeine, smoking, chocolate Decrease stress and anxiety Monitor for S/S of hemorrhage. Report black tarry stools or coffee ground emesis. Encourage frequent follow up care

Gastric Surgery
Nursing management (Preop): Monitor bowel sounds and palpate abdomen to detect any masses or tenderness Assess nutritional status Assess knowledge of procedure Postop: Assess for complications such as hemorrhage, infection, distention, atelectasis, or impaired nutritional status Reduce anxiety, pain Resume enteral intake after return of bowel sounds After removal of NG tube, nurse may give fluids, followed by food in small portions, Clear liquids are introduced slowly in 1 oz cups per serving, then pureed foods, juices, thin soups, and milk 24-48 hours after clear fluids are tolerated. Food is added gradually until patient can eat 6 small meals a day and drink 120 ML between meals Obstacles include dysphagia and gastric retention NPO and NG suction

Teaching:
To delay stomach emptying/dumping suddenly, patient should assume low fowlers position while eating and 20-30 minutes afterward No fluid intake during meals. No fluids up to 1 hr. before and after meals. Meals should contain more dry items than liquid Can eat small amounts of fat, but keep carb. Intake low Smaller, more frequent meals Supplemental vitamins and injections of B12 injections and Iron may be prescribed