GI

Premedicate

Often an antibiotic prophylaxis is ordered in anticipation of prventing an infection when the sphincterotomy is done, or if there isbiliary or pancreatic stasis Confirm whether the patient is receiving a broad spectrum antibiotic and discuss with MD if antibiotic is ordered Gentamicin and/or Ampicillin are most commonly given

what is a polyp

a lesion that protrudes from the mucosal layer of the gi lumen

dysphagia or odynophagia or dyspepsia

difficulty swallowing(dysphagia), painful swallowing, (odynophagia) or dyspepsia can cause malnutrition over time and usually requires supplementing nutrition through a feeding tube

arteriovenous maformations AVMs

dilated blood vessels in the submucosa also called angiodysplagias

endoscopy procedure

esophagogastroduodenoscopy and colonoscopy

ligation or banding

rubber bands or o rings ligate the varrix

perforation

incidence is rare it is a cut through the esophagus, sstomach, or duodenum. usual signs and symotoms include neck, back, chest,shoulder, or abdominal pain as well as tachycardia, diaphoresis, and hypotension

ulcerative colitis

inflammation of the colon

the importance of teaching

teaching will not only inform your patient about the procedure and what to expectit may also reduce anxiety, and it will explain conscious sedation

patient IV

should always have a patent IV must be confirmed prior to any procedure. make sure the iv is patent by flushing it with saline if it is a saline lock. patients may be given sedation and analgesia, as well as fluid resuscitation, blood products, and possible rescue medication as well as the treatment of cardiac or respiratory arrest during the procedure

less common indications for egd

suspected esophageal stenosis suspected hiatal hernia , persistent esophageal reflux, obstructive lesions, caustic ingestion, chronic abdominal paine, persistent unexplained vomiting

which of the followin statements best describe the goalof ERCP when the patient has a diagnosis of Choled

...

how do gallstones form

When the bile is supersaturated, it forms crystal nucleates that cluster together in the form of "stones" in the gallbladder

Lithotripsy

Crushing of gallstones by using a mechanical lithotripter. Lithotripsy can also be done by focused shock waves but during ERCP it is most commonly done mechanically

early signs and symptoms of bowel perforation

Early signs: Fever, abdominal or rectal pain, abdominal distention, abdominal rigidity, increased HR, increased RR Late sign: Hypotension-impending shock Perforation is confirmed by XRAY showing free air under the diaphragm

Teaching to reduce anxiety

Educating and informing the patient (and family) of the procedure and what to expect may be the most effective way to reduce fear and anxiety. The patient will be in a prone position with their head to one side during the procedure, conscious sedation is used, they are monitored for O2, HR, RR, BP and LOC throughout the procedure. Procedure is done under XRAY (fluoroscopy)

treatments by ERCP

Endoscopic Retrograde Cholangiopancreatotography with Sphincterotomy or Papillotomy Lithotripsy Cytology Balloon Dilation Stent placement

ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that uses x-ray to view the patient's bile and pancreatic ducts

GI bleedingvisualized by endoscopy

If the GI bleed is active and profuse it is difficult to find the site of the bleeding through all that bleeding

Elevated PTT?

If the patient has an elevated PTT, they are at increased risk of bleeding. ERCP usually requires that a sphincterotomy is performed

cholangitis

Infection of the bile ducts (cholangitis) is rare in general, but it can occur, particularly in patients with certain preexisting conditions. Treatment of infections requires antibiotics and drainage of excess fluid

nursing responsibilities pre-procedure of ERCP

Know the patient's PTT, make sureMD is aware of the most recent PTT, especially if elevated NPO(IDDM) Pain control Patent IV teaching/reduce anxiety Pre-medicate

patent IV?

When sending a patient to a procedure , ALWAYS confirm they have a patent IV. If IV is infusing-check the site and confirm good placement and infusion without swelling or goodness. If saline lock, flushwith saline and confirm patency prior to sending patient for procedure. Procedure is delayed if IV is not patent

ERCP preparation

You will be asked not to eat or drink anything for six to eight hours before the test. It is important for the stomach to be empty to allow the endoscopist to visualize the entire area, and to decrease the chance of vomiting during the procedure. You may be instructed to adjust the dose of your medications or stop taking specific medications prior to the examination

balloon dilation

a balloon is used to expand a narrowed area within the bile duct that could be contributing to obstruction. The cause for the narrowing is further evaluated using a cytology brush

mallory-weiss tear

a tear in esophagus or gastroesophageal junction caused by severe retcing, vomiting, or coughing and is usually associated with alcoholism

pancreatitis

following an ercp, 7% of cases result in pancreatitis signs and symptoms include 1. pain in mid epigastrium, left chest, shoulder and back 2. n/v 3. low-grade fever 4. abdominal swelling and tenderness 5. shock,hypovolemia, hypotension, hypoxia 6. serum amylase, lipase greater than 3x normal

THe gi endoscope

gastroscope: 103 cm long 11mm diameter colonoscope:180 cm long 13 mm diameter flexible, channel for biopsy, air, water, suction not a sterile procedure

good oral care

good general practice-especially prior to procedure

what is electrocoagulation

heat is applied throughdirect heat (heater probe) or non touch heat (argon plasma coagulation)to the tissues. The heat coagulates the proteins in the tissue, thereby causing a burn (or seal) over the tissue. This effectively 'seals' a bleeding vessel

electrocoagulation/electrocautery

heater probe: probe that applies heat to the tissue. argon plasma coagulation the probe come out through the tip of the scope

electrocoagulation

heater probe:probe applies heat to the tissue argon plasma coagulation (APC) the proble comes out through the tip Argon plasma plus heat is sprayed onto the tissue causing coagulation

therapeutic treatments for bleeding cancers, AVMS,polyps

hemostasis is achieved by electrocoagulation, injection therapy, polypectomy, clipping and foreign body removal

a patient who is scheduled for an egd and has an episode of hematemesis she is complaining of starving the nurse knows the reason the patient needs to be kept NPO

in order for bleeding site to be visualized the stomach must be empty, if there is food or water in the client's stomach there is an increased risk of aspiration

erosive gastritis/esophagitis

inflammation and erosion of the stomach (gastritis) or esophagus(esophagitis)

hemorrhoids

internal veins around anus that can bleed

clipping

involves actual titaium clips which are used to pinch the vessel and surrounding tissue closed

clipping

involves actual titanium clips which are used to pinch the vessel and surrounding tissue closeed

Complications of ERCP

most common: pancreatits, sepsis, biliary sepsis Also observe for: Cholangitis (infection in stagnant duct), aspiration, bleeding, perforation, respiratory depression or arrest, cardiac arrythmia or arrest

consent tidbits

must spell out EGD out completely you must include the possible adjunct procedures involved (ie treatment to bleeding site, procedural sedation, etc) on the consent formm, MD must explain procedure before you can obtain consent

injection therapy

nonvariceal bleed, hypertonic saline and epinephrine(vasoconstricor) or just saline is injected into the vessel that is bleeding

indications for colonoscopy

outpatient: colon cancer screening inpatient: gi bleeding/anemia cancer/tumors AVMs bleeding polyps, ulcerative colitis, hemorrhoids, diverticulosis colonic ischemia, post polypectomy

Risk factors for ERCP

pancreatitis, cholangitis, aspiration, perforation of the intestine, bleeding from the ampulla by cut by surgeon

oxygen

patients receiving conscious sedation should always have appropriate o2 monitoring in addition make sure there is oxygen and equipment nearby and available conscious sedation may affect respiration, ventilation and oxygenation

pain control?

patients with suspected biliary disease or obstruction or pancreatitis generally have abdominal pain. Consider medicating patient for pain so they can tolerate the prone position required for the procedure. Communicating this to the endoscopy team performing the procedure is important. Additional analgesia and sedation will be given during the procedure

types of feeding tubes

peg tube -percutaneous endoscopic gastrostomy tube or a pej tube -percutaneous endoscopic jejunostomy tube

the endoscopy found a large gastric ulcerwhich required electrocoagulation therapy when assessing the client upon return from the procedure he reports severe back and abdominal pain and appears diaphoretic the abdomen is distended and he is tachycardic the nurse knows that these assessment findings are most consistent with which potential complication of the GI procedure

perforation this is one of the major complications of an EGD , although the incidence is rare. It is a perforation of the submucosal layer of the lumen in the GI tract.usual signs and symptoms include neck, back, chest, shoulder, or abdominal pain, as well as tachycardia, diaphoresis,, and hypotension

laser therapy

photocoagulation-laser coagulates tissue, photovaporization-laser vaporizestissue laser can reach 1-4 mm tissue depth

complications of egd

respiratory depression or arrest, perforation of esophagus, stomach, or duodenum, hemmorrage related to trauma or perforation, pulmonary aspiration of blood, secretions or gastric contents, infection, sepsis, cardia arrhthmia or arrest, vasovagal response, allergic reaction to topical anesthetic o IV meds

why isnt this a sterile procedure

the GI tract isnt sterile the mouth itself isnt sterile so no reason for it to be sterile

polypectomy

the removal of a polyp

NPO

the stomach must be completely empty in order to: 1)visualize the interior appropriately 2)prevent aspiration of gastric contents visualization is key to a successful endoscopic procedure

diagnostic treatment in gi endoscopy

therapy intended to confirm or rule out a diagnosis gi endoscopy does this by: gross visualization during the procedure and/or biopsy: taking a specimen(piece of tissue) to study the cells (cytology) or tissue for disease (hystopathology

how is a polyp removed

transection by a snare and a high frequency current

sclerotherapy

variceal bleed chemical injected into bleeding site or varix( singular form of varices)

what can endoscopy do?

visualizes upper and lower GI tract, diagnostic and therapeutic treatment

2 types of gallstones

cholesterol stone:made up of bile that is supersaturated with cholesterol or with a reduced bile-salt secretion. Cholesterol stones make up 75% of all stones Pigment stones- made up of bilirubin polymers, calcium salts and fatty acids

nursing responsibilities pre procedure of colonoscopy

consent, administer bowel prep, NPO prior to procedure, IDDM -consult with MD, patent IV, added IV fluids, oxygen if indicated (make sure the tank is full), pre-med antibiotics if ordered

nursing pre-procedure of egd

consent, teaching/reduce anxiety, patient IV(large >20), oxygen, premedicate if indicated, good oral care prior to procedure, NPO, remove dentures

Bowel preparation

critical element in a successful colonoscopy most common: golytely(4 liters) less common: phosphosoda(3oz) A primary factor of successful colonoscopy depends on how well the bowel is visualized. It is imperative for the bowel to be cleansed as thoroughly as possible prior to the procedure

tumors

benign or malignant 95% of all stomach cancers are adenocarinoma

Therapeutic treatment in gi endoscopy

1.treat bleeding by hemostasis -stop bleeding 2. treat problems of nutrition or dysphagia by placement of a gastrostomy or jejunostomy tube 3.foreign body removal-removing something foreign to the body from the GI tract 4.gastric or colon polypectomy-removal of a polyp 5.stricture dilation-tearing open a structure in the esophagus 6. obtain tissue sample for diagnosis

colonoscopy

A colonoscopy is an exam of the lower part of the gastrointestinal tract, which is called the colon or large intestine (bowel

Cytology

A cytology brush is passed through the endoscope and into the bile duct in order to obtain cells for microscopic examination

stent placement

A flexible or metal mesh stent is placed within the CBD to allow for bile flow through the endoscope. A flexible stent is removed 6-8 weeks later through endoscopy. If an additional stent needs to be replaced, it must be done under fluoroscopy in ERCP. A mesh stent adheres to the inner lumen of the common bile duct and cannot removed once in place. This is most often used for palliative measures, once a diagnosis of pancreatic CA is confirmed

What is GI endoscopy

A therapeutic and diagnostic gastroenterological procedure that allows for direct visualization of the lumen of the GI tract

The docto has ordered a bowel preparation prior to a colonoscopy. The client is supposed to drink the 4 liter bowel prep and remain on clear liquids until midnight; at which time the client is then supposed to be NPO. the nurse explains that a thorough preparation of the bowel is important to:

A.Visualize the inner lumen B. Reduce methane gas in the colon C find the source of bleeding D.all of the above All of the above A. A thorough prep allows for visualization of the inner lumen. Stool may be difficult to flush away during the procedure and may prevent the endoscopist from accurately visualizing the colon B. stool produces methane gas C The source of bleeding may be a small area that has bled slowly over a long period of time, or a larger vessel. If the bowl preparation is thorough. there is a greater chance that the bleeding site is found during the colonoscopy D-all the above

The most common reasons for colonoscopy are to evaluate the following

As a screening exam for colon cancer Rectal bleeding A change in bowel habits, like persistent diarrhea Iron deficiency anemia (a decrease in blood count due to loss of iron) A family history of colon cancer As a follow-up test in people with colon polyps or colon cancer Chronic, unexplained abdominal or rectal pain An abnormal x-ray exam, like a barium enema or CT scan

nursing responsibilities post procedure of ERCP

Assess your patient: vital signs, LOC, O2 sat Maintain NPO status until gag reflex returns or further orders are written Observe for abdominal distention and signs of pancreatitis, including : chills, low-grade fever, pain, vomiting, tachycardia Observe patient for any adverse drug reaction

A client returning from an ERCP procedure is drowsy, but easily arousable. The client appears warm, feverish with chills and is mildly hypotensive. The nurse knows that these findings are consistent with what complication following an ERCP: Pneumonia Sepsis Hemorrhage Duodenal perforation

B. The patient is exhibiting early signs of sepsis following the ERCP. This is one of the common complications following an ERCP and early recognition is crucial

preparation for a colonoscopy

Before colonoscopy, your colon must be completely cleaned out so that the doctor can see any abnormal areas. To clean the colon, you will take a strong laxative and empty your bowels the night before your testYou will need to avoid solid food for at least one day before the test. You should also drink plenty of fluids on the day before the test. You can drink clear liquids up to several hours before your procedure, including: Water Clear broth (beef, chicken, or vegetable) Coffee or tea (without milk) Ices Gelatin (avoid red gelatin) The day or night before the colonoscopy, you will take a laxative in two parts: A pill that you take by mouth A powder that is mixed with water The most common laxative treatment is called Go-Lytely® or Half-Lytely®. Some medicines increase the risk of heavy bleeding if you have a biopsy during the colonoscopy. Ask your doctor how and when to stop these medicines, including warfarin/Coumadin® and clopidogrel/Plavix®.

colonoscopy complications

Bleeding can occur from biopsies or the removal of polyps, but it is usually minimal and can be controlled. The colonoscope can cause a tear or hole in the colon. This is a serious problem, but it does not happen commonly. It is possible to have side effects from the sedative medicines. Although colonoscopy is the best test to examine the colon, it is possible for even the most skilled doctors to miss or overlook an abnormal area in the colon.

Which of the following statements best describes the goal of ERCP when the patient has diagnosis of Choledocholithiaasis A. sphincterotomy B. Dilation of the bile duct C.Removal of gallstones in the bile duct D. Biopsy for cytology of the pancreatic duct

C. Choledocolithiasis is the appropriate medical terminology that refers to a stone in the common bile duct. Therefore , treatment goal would be removal of the stone, and therefore the obstruction

how is a colonoscopy performed

Colonoscopy is performed by inserting a device called a colonoscope into the anus and advanced through the entire colon (figure 1). The procedure generally takes between 20 minutes and one hour.

Diagnostic treatment:Biopsy therapeutic treatments

For hemmorrhage/bleeding: Gastrosomy or jejunostomy tube placement, foreign body removal, gastric polypectomy, mucosal resection, stricture dilation

Endoscopic Retrograde Cholangiopancreatography (ERCP) Most common indications

Gallstone pancreatitis Pancreatic malignancy obstruction of the CBD or in biliary system Choledocholiathiasis Chole=bille +docho=duct +iasis=condition

What causes GI bleeding

Gastric, esophageal or duodenal ULCERS (80% of all peptic ulcers are duodenal)

pancreatitis

Pancreatitis (inflammation of the pancreas) is the most frequent complication, occurring in about 3 to 5 percent of people undergoing ERCP. When it occurs, it is usually mild, causing abdominal pain and nausea, which resolve after a few days in the hospital. Rarely pancreatitis may be more severe.

call doctor if you experience this

Severe abdominal pain (not just gas cramps) A firm, bloated abdomen Vomiting Fever Rectal bleeding (greater than a few tablespoons)

followin symptoms that should be reported immediately when ERCP has been done

Severe abdominal pain (not just gas cramps) A firm, distended abdomen Vomiting Fever or chills Difficulty in swallowing or a severe sore throat A crunching feeling under the skin

colonoscopy proceedure

The colonoscope is a flexible tube, approximately the size of the index finger. The scope pumps air into the colon to inflate it and allow the doctor to see the entire lining. You might feel bloating or gas cramps as the air opens the colon. Try not to be embarrassed about passing this gas, and let your doctor know if you are uncomfortable. During the procedure, the doctor might take a biopsy (small pieces of tissue) or remove polyps. Polyps are growths of tissue that can range in size from the tip of a pen to several inches. Most polyps are benign (not cancerous). However, some polyps can become cancerous if allowed to grow for a long time. Having a polyp removed does not hurt

function of common bile duct and pancreatic duct

The function of the common bile duct and the pancreatic duct is to drain the gallbladder, liver, and pancreas

Most common reason for someone to get a ERCP

The most common reason why someone would need an ERCP is because of a blockage of one of these ducts (often due to gallstones).

why NPO?

The patient must be NPO prior to the procedure because conscious sedation will be given Pt will be in a prone position, they may be unable to protect their airway. the pt will be at risk for aspiration

Goals of an ERCP

To investigate the obstruction of bile in the common bile duct-diagnostic To evaluate the condition of the obstruction and obtain cytology brushing for further diagnosis(diagnostic) for possible pancreatic cancer To evaluate for pancreatitis To clear the CBD of it obstruction by removing the stones-(therapeutic) To evluate jaundice or abnormal CT caused by biliary disease

most common indications for egd

acute or chronic GI bleed, removal of ingested foreign object, dysphagia or odynophagia or dyspepsia

Sphincterotomy (papillotomy)

bile drains into the duodenum by way of the sphincter of Oddi. This outlet is too small to allow for a stone to pass through. A small cut is made into the opening (ampulla) of the sphincter, in order to allow the stone to pass through. When possible, a sphincterotomy is performed during an ERCP. But this is only the first step in the procedure

complications of colonoscopy

bleeding (up to 21 days post polypectomy) Adverse reactions to sedation Transmural burns(Abd pain, leukoctosis, fever without free air) Bowel perforation :Emergency! Xray to OR Risk of explosion (due to hydrogen and methane in bowel ) ensure a good bowel prep

remove dentures

dentures should be removed because they may become loose during the procedure dentures should be marked clearly and in a safe place at all times to ensure that they do not get lost during a hospital admission

esophageal varices

dilated esophageal veins from portal hypertension and cirrhosis. Once dilated pressure builds up and bleeding occus varices (bulging vein)

Sepsis

early signs: chills, fever, warm flushed skin, mild hypotension ( increased CO) LAte signs:severe hypotension, tachycardoa (appears similar to hypovolemic shock), antibiotic prophylaxis in high risk patients may prevent complication of sepsis (bacteremia)

how does endoscopy achieve hemostasis

electrocoagulation/electrocautery, injection therapy, laser therapy, ligation/banding, clipping, all of these therapies are wired through an endoscope and come out at the tip to perform their function

colonoscopy

endoscopic visualization of colon as far as the terminal ileum

other causes of gi bleeding

esophageal varices, mallory-weiss syndrome which causes a mallory-weiss tear, erosive gastritis,, esophagitis, duodenitis(think erosive inflammation, AVMs( arteriovenous malformations), tumor