Chapter 29: Disorders of Gastrointestinal Function Porth

Define perforation

An ulcer erodes through all the layers of the stomach

_____ of the colon is one of the feared complications of ulcerative colitis.

Cancer

____ is a complication of diverticulosis in which there is inflammation and gross or microscopic perforation of the diverticulum.

Diverticulitis

Define tracheoesophageal fistulae

Esophagus is connected to the trachea

Define Zollinger-Ellison Syndrome

Gastrin-secreting tumor

_____ refers to inflammation of the gastric mucosa.

Gastritis

Define Celiac disease

Immune-mediated disorder triggered by ingestion of gluten-containing grains

Diverticulitis is a herniation of tissue of the large intestine through the muscularis layer of the colon. It is often asymptomatic and is found in approximately 80% of people over the age of 85. Diverticulitis is often asymptomatic, but when symptoms do occur what is the most common complaint of the client?

Lower left quadrant pain with nausea and vomiting. One of the most common complains of diverticulitis is pain in the lower left quadrant, accompanied by nausea and vomiting, tenderness in the lower left quadrant, a slight fever, and an elevated white blood cell count.

What are the typical characteristics of irritable bowel syndrome?

The condition is believed to result from deregulation of intestinal motor and sensory functions modulated by the central nervous system. Irritable bowel disease is characterized by persistent or recurrent symptoms of abdominal pain, altered bowel function, and varying complains of flatulence, bloatedness, nausea, and anorexia, constipation or diarrhea, and anxiety or depression. A hallmark of irritable bowel syndrome is abdominal pain that is relieved by defecation and association with a change in consistency or frequency of stools. Abdominal pain is intermittent, cramping, and in the lower abdomen.

Describe the progression and remission of peptic ulcers.

A peptic ulcer can affect one or all layers of the stomach or duodenum. The ulcer may penetrate smooth muscle layers. Occasionally, an ulcer penetrates the outer wall of the stomach or duodenum. Spontaneous remissions and exacerbations are common. Healing of the muscularis layer involves replacement with scar tissue; although the mucosal layers that cover the scarred muscle layer regenerate, the regeneration often is less than perfect, which contributes to repeated episodes of ulceration.

Irritable bowel syndrome is thought to be present in 10% to 15% of the population in the United States. What is its hallmark symptom?

Abdominal pain relieved by defection with a change in consistency or frequency of stools. A hallmark of irritable bowel syndrome is abdominal pain that is relieved by defecation and associated with a change in consistency or frequency of stools. Nausea, altered bowel function, and diarrhea are also symptoms of irritable bowel syndrome but not combined with abdominal pain that is unrelieved by defecation. A bowel impaction is not a symptom of irritable bowel syndrome.

What is hypothesized to be a cause of inflammatory bowel disease (ulcerative colitis and Crohn disease)?

According to the currently accepted hypothesis, this normal state of homeostasis is disrupted in inflammatory bowel disease leading to unregulated and exaggerated immune responses against bacteria in the normal intestinal flora of genetically susceptible individuals. Thus, as in many other autoimmune disorders, the pathogenesis of Crohn disease and ulcerative colitis involves a failure of immune regulation, genetic predisposition, and an environmental trigger, especially microbial flora.

____ is the most commonly associated with local irritants such as aspirin or other nonsteroidal anti-inflammatory agents, alcohol, or bacterial toxins.

Acute gastritis

The stomach secretes acid to begin the digestive process on the food that we eat. The gastric mucosal barrier works to prevent acids secreted by the stomach from actually damaging the wall of the stomach. What are the factors that make up the gastric mucosal barrier?

An impermeable epithelial cell surface covering, characteristics of gastric mucus, mechanisms for selective transport of hydrogen and bicarbonate ions. The stomach lining usually is impermeable to the acid it secretes, a property that allows the stomach to contain acid and pepsin without having its wall digested. Several factors contribute to the protection of the gastric mucosa, including an impermeable epithelial cell surface covering, mechanisms for the selective transport of hydrogen and bicarbonate ions, and the characteristics of gastric mucus. These mechanisms are collectively referred to as the gastric mucosal barrier.

One of the accepted methods of screening for colorectal cancer is testing for occult blood in the stool. Because it is possible to get a false-positive result on these test, you would instruct the client to do what?

Avoid nonsteroidal anti-inflammatory drugs for 1 week prior to testing. To reduce the likelihood of false-positive tests, persons are instructed to avoid nonsteroidal anti-inflammatory drugs such as ibuprofen and aspirin for 7 days prior to testing, to avoid vitamin C in excess of 250 mg from either supplements or citrus fruits for 3 days before testing, and to avoid red meats for 3 days before testing.

Define Gastroesophageal reflux

Backward movement of gastric contents into the esophagus

Define adenomatous polyps

Benign neoplasms that arise from the mucosal epithelium of the intestine

Define Rotavirus

Causes diarrhea in children

____ diarrhea is often associated with conditions such as inflammatory bowel disease, irritable bowel syndrome, malabsorption syndrome, endocrine disorders, or radiation colitis.

Chronic

_____ is denoted by the absence of grossly visible erosions and the presence of chronic inflammatory changes leading eventually to atrophy of the glandular epithelium of the stomach.

Chronic gastritis

What is the relationship between Helicobacter pylori infection and the development of stomach cancer?

Chronic infection with Helicobacter pylori appears to serve as a cofactor in some types of gastric carcinomas. The bacterial infection causes gastritis, followed by atrophy, intestinal metaplasia, and carcinoma. This sequence of cellular events depends on both the presence of the bacterial proteins and the host immune response; the latter being influenced by the host genetic background. However, most people with Helicobacter pylori infection will not develop gastric cancer, and not all H. pylori infections increase the risk of gastric cancer, suggesting that other factors must be involved.

_____ provides a means for direct visualization of the rectum and colon.

Colonoscopy

____ anomalies of the esophagus require early detection and correction because they are incompatible with life.

Congenital

____ can be defined as the infrequent and/or difficult passage of stools.

Constipation

_____ disease is a recurrent, granulomatous type of inflammatory response that can affect any area of the gastrointestinal tract.

Crohn

The term inflammatory bowel disease is used to designated two related inflammatory intestinal disorders: _____ disease and _____.

Crohn, ulcerative colitis

Define dysphagia

Difficulty in swallowing

Define achalasia

Difficulty passing food into the stomach

____ is a condition in which the mucosal layer of the colon herniated through the muscularis layer.

Diverticulosis

____ can result from disorders that produce narrowing of the esophagus, lack of salivary secretion, weakness of the muscular structures that propel the food bolus, or neural networks coordinating the swallowing mechanism.

Dysphagia

____ is the retention of hardened or puttylike stool in the rectum and colon, which interferes with normal passage of feces.

Fecal impaction

The most frequent symptom of _____ is heartburn.

GERD

What is GERD? What is the mechanism of damage?

GERD is Gastroesophageal reflux disease. It is thought to be associated with a weak or incompetent lower esophageal sphincter that allows reflux to occur, the irritant effects of the refluxate, and decreased clearance of the refluxed acid from the esophagus after it has occurred. In most cases, reflux occurs during transient relaxation of the esophagus. Gastric distention and meals high in fat increase the frequency of relaxation. Delayed gastric emptying also may contribute to reflux by increasing gastric volume and pressure with greater chance for reflux. Esophageal mucosal injury is related to the destructive nature of the refluxate and the amount of time it is in contact with mucosa. Acidic gastric fluids (pH < 4.0) are particularly damaging.

Helicobacter pylori gastritis has a prevelance of over 50% of American adults over the age of 50, which is thought to be caused by a previous infection when the client was younger. What can chronic gastritis caused by H.pylori cause?

Gastric atrophy. Helicobacter pylori gastritis can be a chronic infection that can lead to gastric atrophy, peptic ulcer, and is associated with increased risk of gastric adenocarcinoma and a low-grade B-cell gastric lymphoma (mucosa-associated lymphoid tissue).

Define cobblestone appearance

Hallmark symptom of Crohn disease

____ is characterized by a protrusion of the stomach through the esophageal hiatus of the diaphragm.

Hiatal hernia

_____ is the major physiologic mediator for hydrochloric acid secretion.

Histamine

What is the mechanism of diverticulosis formation?

In a manner similar to the small intestine, bands of circular muscle constrict the large intestine. As the circular muscle contracts at each of these points (approximately every 2.5 cm), the lumen of the bowel becomes constricted, so that it is almost occluded. The combined contraction of the circular muscle and the lack of a continuous longitudinal muscle layers cause the intestine to bulge outward into pouches called haustra. Diverticula develop between the longitudinal muscle bands of the haustra, in the area where the blood vessels pierce the circular muscle layer to bring blood to the mucosal layer. An increase in intraluminal pressure in the haustra provides the force for creating these herniations. The increase in pressure is thought to be related to the volume of the colonic contents. The scantier the contents, the more vigorous are the contractions and the greater is the pressure in the haustra.

_____ commonly is associated with acute or chronic inflammation or intrinsic disease of the colon, such as ulcerative colitis or Crohn disease.

Inflammatory diarrhea

Crohn disease is a recurrent inflammatory disease that can affect any area of the bowel. Characteristic of Crohn disease is granulomatous lesions that are sharply demarcated from the surrounding tissue. As the nurse caring for a client with newly diagnosed Crohn disease, you would know to include what in your teaching?

Information on sulfasalazine including dosage, route, frequency, and side effects of the drug. A characteristic feature of Crohn disease is the sharply, demarcated, granulomatous lesions that are surrounded by normal-appearing mucosal tissue. When the lesions are multiple, they often are referred to as skip lesions because they are interspersed between what appear to be normal segments of the bowel.

____ is a functional gastrointestinal disorder characterized by a variable combination of chronic and recurrent intestinal symptoms not explained by structural or biochemical abnormalities.

Irritable bowel syndrome

Characteristic of ulcerative colitis are the lesions that form in the crypts of ____ in the base of the mucosal layer.

Lieberkuhn

Define Helicobacter pylori

Most common cause of chronic gastritis in the United States

Diarrhea is described as a change in frequency of stool passage to a point where it is excessively frequent. Diarrhea can be acute or chronic, inflammatory, or noninflammatory. What are the symptoms of noninflammatory diarrhea?

Nonbloody stools, periumbilical cramps, and nausea and/or vomiting. Noninflammatory diarrhea is associated with large-volume watery and nonbloody stools, periumbilical cramps, bloating, and nausea and/or vomiting.

_____ deficiencies are common in Crohn disease because of diarrhea, steatorrhea, and other malabsorption problems.

Nutritional

_____ obstruction results from neurogenic and muscular impairment of peristalsis.

Paralytic

_____ is a term used to describe a group of ulcerative disorders that occur in areas of the upper gastrointestinal tract that are exposed to acid-pepsin secretions.

Peptic ulcer

Define hypergastrinemia

Presence of an excess of gastrin in the blood

_____ involves mucosal injury to the esophagus, hyperemia, and inflammation.

Reflux esophagitis

Celiac disease commonly presents in infancy as failure to thrive. It is an inappropriate T-cell-mediated immune response and there is no cure for it. What is the treatment of choice for celiac disease?

Removal of gluten from the diet. The primary treatment of celiac disease consists of removal of gluten and related proteins from the diet.

Hiatal hernias can cause severe pain if the hernia is large. Gastroesophageal reflux is a common comorbidity of a hiatal hernia, and when this occurs, what might the hernia do?

Retard esophageal acid clearance. Esophageal acid clearance can be retarded in cases of severe erosive esophagitis where Gastroesophageal reflux and a large hiatal hernia coexist.

A client in a nursing home complains to her nurse that she is not feeling well. When asked to describe how she feels, the client states that she really is not hungry anymore and seems to have indigestion a lot. The nurse checks the client's chart and finds that her vital signs are normal, but that she has lost weight over the past 2 months. She also notes that there is a history of gastric cancer in the client's family. The nurse notifies the physician and expects to receive what orders?

Schedule a barium radiograph and an endoscopy and order cytologic studies to be done during the endoscopy. Diagnosis of gastric cancer is accomplished by means of a variety of techniques, including barium radiographic studies, endoscopic studies with biopsy, and cytologic studies (e.g. Papanicolaou smear) of gastric secretions. Cytologic studies can prove particularly useful as routine screening tests for persons with atrophic gastritis or gastric polyps. Computed tomography and endoscopic ultrasonography often are used to delineate the spread of a diagnosed stomach cancer. Papanicolaou smears are done on gastric secretions but not by the nurse. A lower gastrointestinal study would be of no value in diagnosing this client.

A 39-year-old white woman presents at the clinic with complaints of epigastric pain that is cramplike, rhythmic, and just below the xiphoid. She states that it wakes her up around 1 am, and she is not sleeping well because of it. She further states that this is the third episode of having the pain in the past year. The nurse suspects the client has a peptic ulcer and expects to receive what orders from the physician?

Schedule client for a complete metabolic panel and a complete blood count. Diagnostic procedures for peptic ulcer include history taking, laboratory tests, radiologic imaging, and endoscopic examination.

Describe how the gastric mucosal barrier functions to protect the stomach from its own secretions.

Several factors contribute to the protection of the gastric mucosa, including an impermeable epithelial cell surface covering, mechanisms for the selective transport of hydrogen and bicarbonate ions, and the characteristics of gastric mucus. The gastric epithelial cells are connected by tight junctions that prevent acid penetration, and they are covered with an impermeable hydrophobic lipid layer that prevents diffusion of ionized water-soluble molecules. The secretion of hydrochloric acid by the parietal cells of the stomach is accompanied by the secretion of bicarbonate ions. For every hydrogen ion that is secreted, a bicarbonate ion is produced, and as long as bicarbonate ion production is equal to hydrogen ion secretion, mucosal injury does not occur. Water-soluble mucus forms a thin, stable gel that adheres to the gastric mucosal surface and provides protection from the proteolytic (protein-digesting) actions of pepsin. It also forms an unstirred layer that traps bicarbonate, forming an alkaline interface between the luminal contents of the stomach and its mucosal surface. The water-soluble mucus is washed from the mucosal surface and mixes with the luminal contents; its viscid nature makes it a lubricant that prevents mechanical damage to the mucosal surface.

Define Barrett esophagus

Squamous mucosa that lines the esophagus gradually is reduced by columnar epithelium

Define steatorrheic

Stools contain excess fat

Define odynophagia

Swallowing is painful

Define Mallory-Weiss syndrome

Tears in the esophagus at the esophagogastric junction

How does diet expose a patient to colon cancer?

The cause of colon cancer is unknown, but attention has focused on dietary fat intake, refined sugar intake, fiber intake, and the adequacy of such protective micronutrients such as vitamin A, C, and E in the diet. It has been hypothesized that a high level of fat in the diet increases the synthesis of bile acids in the liver, which may be converted to potential carcinogens by the bacterial flora in the colon. Bacterial organisms in particular are suspected of converting bile acids to carcinogens; their proliferation is enhanced by a high dietary level of refined sugars. Dietary fiber is thought to increase stool bulk and thereby dilute and remove potential carcinogens. Refined diets often contain reduced amounts of vitamins A, C, and E, which may act as oxygen free radical scavengers.

What is the pathophysiologic of constipation?

The pathophysiology of constipation can be classified into three broad categories: normal-transit constipation, slow-transit constipation, and disorders of defecator or rectal evacuation. Normal-transit constipation (or functional constipation) is characterized by perceived difficulty in defecation and usually responds to increased fluid and fiber intake. Slow-transit constipation, which is characterized by infrequent bowel movements, is often caused by alterations in intestinal innervation. Hirschsprung disease is an extreme form of slow-transit constipation in which the ganglion cells in the distal bowel are absent because of a defect that occurred during embryonic development; the bowel narrows at the area that lack ganglionic cells. Although most persons with this disorder present in infancy or early childhood, some with a relatively short segment of involved colon do not have symptoms until later in life. Defecatory disorders are most commonly due to dysfunction of the pelvic floor or anal sphincter.

Peritonitis is an inflammatory condition of the lining of the abdominal cavity. What is one of the most important signs of peritonitis?

The translocation of extracellular fluid into the peritoneal cavity. One of the most important manifestations of peritonitis is the translocation of extracellular fluid into the peritoneal cavity (through weeping or serous fluid from the inflamed peritoneum) and into the bowel as a result of bowel obstruction.

Define esophageal atresia

The upper esophagus ends in a blind pouch

Infants and children commonly have Gastroesophageal reflux. Many times it is asymptomatic and resolves on its down. What are the signs and symptoms of Gastroesophageal reflux in infants with severe disease?

Tilting of the head to one side and arching of the back may be noted in children with severe reflux. Early satiety is another indication of Gastroesophageal reflux, but not coupled with consolable crying.

Define Fistulas

Tubelike pasages that form connections between different sites in the gastrointestinal tract.

Define penetration

Ulcer crater erodes into adjacent organs

Rotavirus is a common infection in children younger than 5 years of age. Like other diseases, rotavirus is most severe in children under 24 months of age. What is a symptom of a rotavirus infection?

Vomiting that disappears around the second day. Rotavirus infection typically beings after an incubation period of less than 24 hours, with mild to moderate fever, and vomiting, followed by onset of frequent, watery, stools. The fever and vomiting usually disappear on about the second day, but the diarrhea continues for 5 to 7 days. Dehydration may develop rapidly, particularly in infants.

Define osmotic diarrhea

Water is pulled into the bowel by hyperosmotic nature of its contents

Most squamous cell esophageal carcinomas are attributable to ____ and _____ use.

alcohol, tobacco

The pain associated with _____ is caused by stretching of the appendix during the early inflammatory process.

appendicitis

There is considerable evidence linking gastroesophageal reflux with _____.

asthma

Autoimmune gastritis results from the presence of ____ to components of gastric gland parietal cells and intrinsic factor.

autoantibodies

The complications of ____ result from massive fluid loss or destruction of intestinal mucosa.

bacterial enterocolitis

Laboratory findings of hypochromic anemia and occult blood in the stools indicate _____.

bleeding ulcers

Gastric ____ is the second most common tumor in the world.

carcinoma

Intestinal obstruction designates an impairment of movement of intestinal contents in a _____ direction.

cephalocaudal

Ulcerative colitis is confined to _____ and _____.

colon, rectum

The usual definition of _____ is excessively frequent passage of stools.

diarrhea

The ____ functions primarily as a conduit for passage of food and liquid from the pharynx to the stomach.

esophagus

Celiac disease is an immune-mediated disorder triggered by ingestion of _____ containing grains.

gluten

The most common complications of peptic ulcer are ____, perforation and penetration, and gastric outlet ____.

hemorrhage, obstruction

The stomach lining usually is ____ to the acid it secretes, a property that allows the stomach to contain acid and pepsin without having its wall digested.

impermeable

Symptoms of the reflux esophagitis in an ____ include evidence of pain when swallowing, hematemesis, and anemia due to esophageal bleeding, heartburn, irritability, and sudden or inconsolable crying.

infant

Toxin-producing bacteria or other agents that disrupt the normal absorption or secretory process in the small bowel commonly cause _____.

noninflammatory diarrhea

The ____ are thought to exert their effects through improved mucosal blood flow, decreased acid secretion, increased bicarbonate ion secretion, and enhanced mucus production.

prostaglandins

Peritonitis is an inflammatory response of the _____ that lines the abdominal cavity and covers the visceral organs.

serous membrane

Persons at high risk for development of _____ include those with large-surface area burns, trauma, sepsis, acute respiratory distress syndrome, severe liver failure, and major surgical procedures.

stress ulcers