Gastrointestinal Disorders and Therapeutic Management (Urden ch. 29)

Acute Gastrointestinal Hemorrhage *(Related to 3 main causes)*

- GI hemorrhage: Potentially life-threatening injury. 10% Mortality rate in the US. - GI hemorrhage occurs from bleeding in the upper OR lower GI tract. - The 3 main causes are *Peptic Ulcer Disease, Stress-Related Mucosal Disease, and Esophagogastric Varices.*

Management of Acute Pancreatitis *(Fluids given?- think fluid shift! ; Preferred nutrition?)* *(Complications- most serious ones?- think lungs and kidney)* *(How does hypovolemic shock result?)*

- *Because pancreatitis is often associated with MASSIVE FLUID SHIFTS, intravenous crystalloids and COLLOIDS are administered immediately to prevent* *hypovolemic shock and maintain hemodynamic stability.* Electrolytes are monitored closely, and abnormalities such as hypocalcemia, hypokalemia, and hypomagnesemia are corrected. *If hyperglycemia develops, exogenous insulin may be required.* - *Enteral feeding enhances immune modulation and maintenance of the intestinal barrier, and it avoids complications associated with parenteral nutrition.* - Acute pancreatitis can affect every organ system, and recognition and treatment of systemic complications are crucial to management of the patient. *The most serious complications are hypovolemic shock, acute respiratory distress syndrome (ARDS), acute kidney injury (AKI), and GI hemorrhage.*

Esophagogastric Varices *(What it is? Caused by?)*

- *Esophagogastric varices are engorged and distended blood vessels of the esophagus and proximal stomach* that develop as a *result of PORTAL HYPERTENSION caused by hepatic cirrhosis, or damaged liver.* - Portal pressure increases, resulting in Portal hypertension, and blood is shunted to the esophagus, where the vessels are weak and at high risk for rupture. Once rupture, patients lose a tremendous amount of blood.

Stress-related Mucosal Disease *(Increased ___ production and decreased ___)* *(Patients at risk?)*

- *Increased acid production and decreased mucosal blood flow, resulting in ischemia and degeneration of the mucosal lining.* - Patients at risk include patients in situations of high physiologic stress, as occurs with mechanical ventilation, extensive burns, severe trauma, major surgery, shock, sepsis, coagulopathy, or acute neurologic disease

Management: Acute Liver Failure *(Gold standard drug to give? Why?)* *(Bleeding risk and Prevention? ; ICP?)* *(Benzodiazepines- NO! why?)* *(How often to do neuro checks?)*

- *LACTULOSE is considered the gold-standard drug to give for ALF.* It binds to *ammonia* which then leaves the body as stool. Lactulose also has laxative properties to promote 2-3 stools a day to decrease ammonia levels. - If an invasive procedure (eg, central line placement, ICP monitor) will be performed OR the patient develops *active bleeding,* *vitamin K, fresh frozen plasma (to ↑ PT), and platelet transfusions are necessary.* - *ICP:* Give *MANNITOL.* (Be careful in a patient w/ renal failure to avoid hyperosmolarity). Also, *elevate HoB 30°*

Management of Acute GI Hemorrhage *(Neutralization of ___ ;)* *(Aspiration risk? Fluids?)* *(Meds to stop bleeding? ; When to give blood products- HGB <__)*

- *The initial treatment priority is the restoration of adequate circulating blood volume to treat or prevent shock.* - This is accomplished with the *administration of intravenous infusions of crystalloids, blood, and blood products.* - *Supplemental oxygen therapy is initiated to increase oxygen delivery and improve tissue perfusion.* - A large nasogastric tube may be inserted to confirm the diagnosis of active bleeding; facilitate gastric lavage; decrease the risk for aspiration; and prepare the esophagus, stomach, and proximal duodenum for endoscopic evaluation - *Interventions to control bleeding are the second priority for a patient with GI hemorrhage after hemodynamic stability is achieved.*

Acute Liver Failure *(Characterized by 3 things?)* *(Causes include ___ ; S/S?)* *(Bilirubin, Clotting, Glucose, Albumin, ARDS, AKI, Hepatic Encephalopathy)*

- Characterized by *Liver cell dysfunction, Coagulopathy (excessive bleeding risk), and Hepatic Encephalopathy.* - The causes may include infection (Hepatitis B&C), Medications (Acetaminophen), Toxins, Hypoperfusion, and ETOH. - ALF results in numerous derangements, including *impaired bilirubin conjugation (↑ Bilirubin in the blood),* *Decreased production of clotting factors (↑ risk for bleeding)*, *Depressed glucose synthesis (Hypo/Hyperglycemia),* and decreased lactate clearance. - Hypoalbuminemia (3rd spacing), fluid and electrolyte imbalances, and acute portal hypertension contribute to the development of *ascites.* - *Hepatic Encephalopathy* can result from ↑ Ammonia levels in the blood. *Remember that ammonia is toxic, and the liver normally converts it to UREA. With ALF, the liver can no longer do this properly. Monitor your patients LoC!* - Hypoxemia (from relative loss of fluid), Acidosis (from ↑ toxins), ARDS (from mediators and 3rd spacing) AKI (from relative hypovolemia) - *Diagnostic findings include prolonged prothrombin times; elevated levels of serum bilirubin, aspartate aminotransferase, alkaline phosphatase, and serum ammonia; and decreased levels of serum albumin* - *Prothrombin time (Normal 11-14 seconds) may be the most useful of these in the evaluation of acute ALF because levels may be 40 to 80 seconds above control values.*

Esophagectomy *(Indications? Involves removal of?)* *(After surgery, patient has an ___ in place)*

- Esophagectomy is usually done if there is *cancer* of the distal esophagus near the stomach. - Involves removal of all of or part of the esophagus, part of the stomach, and nearby lymph-nodes. *The stomach is then pulled up into the chest and connected to the remaining part of esophagus.* - *After surgery, the patient has a nasogastric tube (NG) in place, and it should not be manipulated because of the potential to damage the anastomosis.* Patients who undergo transthoracic esophagectomy have chest tubes.

Acute GI Hemorrhage: Pathology *(Characterized by?)* *(Results in ___, and ___ is untreated)*

- GI hemorrhage is a life-threatening disorder that is *characterized by acute, massive bleeding.* - Regardless of the cause, acute GI hemorrhage *results in hypovolemic shock, initiation of the shock response, and development of multiple organ dysfunction syndrome (MODS) if left untreated.*

Gastrointestinal Surgery *(Can involve what organs?)* *(Indications for surgery?)*

- GI surgery refers to a variety of surgeries that involve the *Esophagus, Stomach, Intestine, Liver, Pancreas, or Biliary Tract.* - Indications for GI surgery are numerous and include: *Bleeding or perforation from Peptic Ulcer Disease ; Obstruction ; Trauma ; IBD ; and Malignancy.*

Acute Pancreatitis: *Ranson Criteria* *(0-2 factors present= __% predicted mortality rate)* *(3-4 factors present= __% predicted mortality rate)* *(5-6 factors present= __% predicted mortality rate)* *(7-8factors present= __% predicted mortality rate)* *(Two most common causes of pancreatitis?)*

- In acute pancreatitis, the normally inactive digestive enzymes become prematurely activated within the pancreas itself, leading to *autodigestion of* *pancreatic tissue.* - Inflammation of the pancreas that can cause exocrine and endocrine dysfunction. Can range from mild, self-limiting disease to a *systemic process* characterized by organ failure, *sepsis,* and death. - Prognostic Scoring System- *RANSON CRITERIA:* If the patient has 0 to 2 factors present, the predicted mortality rate is 2%; with 3 to 4 factors, the rate is 15%; with 5 to 6 factors, the rate is 40%; and with 7 to 8 factors, the rate is 100% -* The two most common causes of acute pancreatitis are gallstone migration and alcoholism.* Together, they account for approximately 80% of cases. - Contrast-enhanced computed tomography (CT) is considered the gold standard for diagnosing pancreatitis and for ascertaining the overall degree of pancreatic inflammation and necrosis.

Peptic Ulcer Disease *(results from breakdown of ___?)* *(Caused by ___ and/or ___)* *(Duodenal ulcer vs Gastric ulcer pain relief by food?)*

- Peptic ulcer disease (ie, gastric and duodenal ulcers), which *results from the breakdown of the gastromucosal lining,* is the leading cause of upper GI hemorrhage, accounting for approximately 40% of cases. - After the mucosal lining is penetrated, *gastric secretions autodigest the layers of the stomach or duodenum,* leading to injury of the mucosal and submucosal layers. This results in *damaged blood vessels and subsequent hemorrhage.* - The two main causes of disruption of gastroduodenal mucosal resistance are the bacterial action of *Helicobacter pylori and nonsteroidal antiinflammatory drugs (NSAIDs)*

Acute GI Hemorrhage: Assessment *(Initial clinical presentation?)* *(Hallmarks of Acute GI Hemorrhage- 3 things)* *(HCT and Hgb if bleeding is acute?)*

- The initial clinical presentation of a patient with acute GI hemorrhage is that of a patient in *hypovolemic shock.* - *Hematemesis (bright red or brown, "coffee grounds" emesis),* *Hematochezia (bright red stools),* and *Melena (black, tarry, or dark red stools) are the hallmarks of GI hemorrhage.* - The presence of blood in the GI tract results in increased peristalsis and diarrhea. *Hematochezia occurs from massive lower GI hemorrhage and, if rapid enough, upper GI hemorrhage.* - *Melena occurs from digestion of blood from an upper GI hemorrhage and may take several days to clear after the bleeding has stopped.* - *The patient's hemoglobin level and hematocrit are poor indicators of the severity of blood loss if the bleeding is acute* ex) if the patient's hematocrit is 45% before a bleeding episode, it will be 45% several hours later. - *It may take 24 to 72 hours for the redistribution of plasma from the extravascular space to the intravascular space to occur and cause the patient's hemoglobin level and hematocrit value to decrease.*

Complications of GI Surgery *(Pulmonary complications ; Anastomotic leak?)* *(DVT and PE ; Bleeding?)*

- The risk of pulmonary complications is high after GI surgery. *Patients should participate in respiratory exercise ASAP post-op, such as ambulation, Incentive Spirometer, and pain control to decrease the risk of developing atelectasis.* Patients should be closely monitored for the development of oxygenation problems. - *Anastomotic leak:* Severe complication. * It occurs when there is a breakdown of the suture line in a surgical anastomosis and results in leakage of gastric or intestinal contents into the abdomen or mediastinum (transthoracic esophagectomy).* - *Deep vein thrombosis prophylaxis should be initiated before surgery and continued until the patient is fully ambulatory to reduce the risk of clot development.*

Pancreaticoduodenectomy *(Also called the _____ procedure ; Indicated for ___ cancer)* *(What all is removed?)*

- The standard operation for *pancreatic cancer* is a pancreaticoduodenectomy, also called the *Whipple procedure.* - The head of the pancreas, all of the duodenum, part of the jejunum, the common bile duct, the gall bladder, and part of the stomach are removed. *The continuty of the GI tract is restored by ANASTOMOSIS of the remaining pancreas, bile duct, stomach, and jejunum.

Clinical Manifestations - Acute Pancreatitis

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Postoperative Care: GI Surgery

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A patient is admitted with hepatic encephalopathy secondary to cirrhosis. Which meal option selection below should be AVOIDED with this patient? A. Beef tips and broccoli rabe B. Pasta noodles and bread C. Cucumber sandwich with a side of grapes D. Fresh salad with chopped water chestnuts

A. Beef tips and broccoli rabe - Patients who are experiencing hepatic encephalopathy are having issues with toxin build up in the body, specifically ammonia. *Remember that ammonia is the byproduct of protein breakdown, and normally the liver can take the ammonia from the protein breakdown and turn it into urea (but if the cirrhosis is severe enough this can't happen).* - Therefore, the patient should consume foods LOW in protein until the encephalopathy subsides. Option A is very high in protein while the others are low in protein. - Remember meats, legumes, eggs, broccoli rabe, certain grains etc. are high in protein.

While assisting a patient with chronic pancreatitis to the bathroom, you note the patient's stool to be oily/greasy in appearance. In your documentation you note this as: A. Steatorrhea B. Melena C. Currant D. Hematochezia

A. Steatorrhea - *Steatorrhea is an oily/greasy appearance of the stool which can occur in chronic pancreatitis.* *This occurs due to the inability of the pancreas to produce digestive enzymes which help break down fats.* Fats are not being broken down; therefore, it is being excreted into the stool. - Melena is used to describe tarry/black stool, hematochezia is used to describe red stools, and currant are jelly type stools.

Your patient with cirrhosis has severe splenomegaly. As the nurse you will make it priority to monitor the patient for signs and symptoms of? *Select all that apply:* A. Thrombocytopenia B. Vision changes C. Increased PT/INR D. Leukopenia

A. Thrombocytopenia C. Increased PT/INR D. Leukopenia - A patient with an enlarged spleen (splenomegaly) due to cirrhosis can experience *thrombocytopenia (low platelet count),* *increased PT/INR (means it takes the patient a long time to stop bleeding),* and *leukopenia (low white blood cells).* - *The spleen stores platelets and WBCs. An enlarged spleen can develop due to portal hypertension,* which causes the platelets and WBCs to become stuck inside the spleen due to the increased pressure in the hepatic vein (hence lowering the count and the body's access to these important cells for survival).

A patient with late-stage cirrhosis develops *portal hypertension.* Which of the following options below are complications that can develop from this condition? *Select all that apply:* A. Increase albumin levels B. Ascites C. Splenomegaly D. Fluid volume deficient E. Esophageal varices

B. Ascites C. Splenomegaly E. Esophageal varices -*Portal Hypertension is where the portal vein becomes NARROW due to scar tissue in the liver, which is restricting the flow of blood to the liver.* *Therefore, pressure becomes increased in the portal vein and affects the organs connected via the vein to the liver.* - The patient may experience ascites, enlarged spleen "splenomegaly", and esophageal varices etc.

You are receiving shift report on a patient with cirrhosis. The nurse tells you the patient's bilirubin levels are very high. Based on this, what assessment findings may you expect to find during your head-to-toe assessment? *Select all that apply:* A. Frothy light-colored urine B. Dark brown urine C. Yellowing of the sclera D. Dark brown stool E. Jaundice of the skin F. Bluish mucous membranes

B. Dark brown urine C. Yellowing of the sclera E. Jaundice of the skin - High bilirubin levels are because the hepatocytes are no longer able to properly conjugate the bilirubin because they are damaged. *This causes bilirubin to leak into the blood and urine (rather than entering the bile and being excreted in the stool).* - Therefore, the bilirubin stays in the blood and will enter the urine. This will cause the patient to experience yellowing of the skin, sclera of the eyes, and mucous membranes ("jaundice") and have dark brown urine. *The stools would be CLAY-COLORED not dark brown (remember bilirubin normally gives stool it brown color but it will be absent).*

The physician orders Lactulose 30 mL by mouth per day for a patient with cirrhosis. What findings below demonstrates the medication is working effectively? *Select all that apply:* A. Decrease albumin levels B. Decrease in Fetor Hepaticus C. Patient is stuporous. D. Decreased ammonia blood level E. Presence of asterixis

B. Decrease in Fetor Hepaticus D. Decreased ammonia blood level - A patient with cirrhosis may experience a complication called hepatic encephalopathy. This will cause the patient to become confused (they may enter into a coma), have pungent, musty smelling breath (fetor hepaticus), asterixis (involuntary flapping of the hands) etc. This is due to the buildup of ammonia in the blood, which affects the brain. Lactulose can be prescribed to help decrease the ammonia levels. Therefore, if the medication is working properly to decrease the level of ammonia the patient would have improving mental status (NOT stuporous), decreased ammonia blood level, decreasing or absence of asterixis, and decreased ammonia blood level. - The purpose of administering lactulose is to promote the excretion of ammonia in the stool. The nurse should instruct the client to take the medication every day and inform the client that two to three bowel movements every day is the treatment goal.

The liver receives it blood supply from two sources. One of these sources is called the _________________, which is a vessel network that delivers blood _____________ in nutrients but ________ in oxygen. A. hepatic artery, low, high B. hepatic portal vein, high, low C. hepatic lobule, high, low D. hepatic vein, low, high

B. hepatic portal vein, high, low - *Majority of the blood flow to the liver comes from the hepatic portal vein. This vessel network delivers blood HIGH in nutrients (lipids, proteins, carbs etc.) from organs that aid in the digestion of food, but the blood is POOR in oxygen.* - The organs connected to the hepatic portal vein are: small/large intestine, pancreas, spleen, stomach. - *Rich oxygenated blood comes from the HEPATIC ARTERY to the liver.*

A nurse is assessing a client who has cirrhosis. Which of the following is a priority for the nurse to report to the provider? Peripheral edema Spider angiomas Jaundice Bloody stools

Bloody Stools - *The greatest risk to the client who has cirrhosis of the liver is hemorrhagic shock due to bleeding in the esophageal varices.* Therefore, bloody stools is the priority finding to report to the provider.

. During your morning assessment of a patient with cirrhosis, you note the patient is disoriented to person and place. In addition while assessing the upper extremities, the patient's hands demonstrate a flapping motion. What lab result would explain these abnormal assessment findings? A. Decreased magnesium level B. Increased calcium level C. Increased ammonia level D. Increased creatinine level *What is the hand-flapping called?*

C. Increased ammonia level - Based on the assessment findings and the fact the patient has cirrhosis, the patient is experiencing *hepatic encephalopathy.* This is due to the buildup of toxins in the blood, specifically ammonia. - *The flapping motion of the hands is called "asterixis".* Therefore, an increased ammonia level would confirm these abnormal assessment findings.

During a home health visit, you are assessing how a patient takes the prescribed pancreatic enzyme. The patient is unable to swallow the capsule whole, so they open the capsule and mix the beads inside the capsule with food/drink. Which food or drink is safe for the patient to mix the beads with? A. Pudding B. Ice cream C. Milk D. Applesauce

D. Applesauce - *The patient should mix the medications with ACIDIC foods like applesauce.* - It is very important the patient does NOT use alkaline foods for mixing (like dairy products, pudding etc.) because they can damaged the enzyme.

A patient is admitted to the ER with the following signs and symptoms: very painful mid-epigastric pain felt in the back, elevated glucose, fever, and vomiting. During the head-to-toe assessment, you notice bluish discoloration around the belly button. As the nurse, you know this is called? A. Grey-Turner's Sign B. McBurney's Sign C. Homan's Sign D. Cullen's Sign

D. This is known as Cullen's Sign. - *It represents retroperitoneal bleeding from the leakage of digestive enzymes from the inflamed pancreas into the surrounding tissues which is causing bleeding and it is leaking down to umbilicus tissue.* Remember the C in Cullen for "circle" and the belly button forms a circle. - The patient can also have *Grey-Turner's Sign which is a bluish discoloration at the flanks (side of the abdomen).* Remember this by TURNER ("turn her" over on her side) which is where the bluish discoloration will be.

Normal INR levels? Normal Bilirubin levels? Normal Albumin levels? Normal Ammonia levels?

INR: *0.8 to 1.1. (2-3 on warfarin or heparin)* Bilirubin level: *0.3 to 1.0 mg/dL.* Albumin level: *3.5 to 5 g/dL.* Ammonia: *10 to 80 mcg/dL.*

Inside the pancreas are special cells that secrete digestive enzymes and hormones. The cells that secrete digestive enzymes are known as ______________ cells. A. Islet of Langerhans B. Protease C. Acinar D. Amylase

The answer is C. Acinar cells secrete digestive enzymes such as amylase, protease, and lipase.

Select-ALL-that-apply: In the pancreas, the acinar cells release: A. Amylase B. Somatostatin C. Lipase D. Protease

The answers are A, C, and D. - Acinar cells secrete digestive enzymes into the pancreatic ducts. These enzymes are: Amylase: breaks down carbs to glucose, Protease: breaks down proteins to amino acids, Lipase: breaks down fats

Pathophysiology of Acute Pancreatitis *(What is acute NECROTIZING pancreatitis?)*

Trypsin becomes activated too early while its still inside the pancreas, causing autodigestion and pancreatitis!