Chapter 42: Disorders of the Upper and Lower Gastrointestinal System
A participant in a community education program asks what causes colon cancer. Which modifiable risk factor should the nurse include when responding to this person?
"Eating a diet high in fat and low in fiber." A diet that that is heavy on red and processed meats and light on fruits and vegetables is a modifiable risk factor for the development of colon cancer. Infection is a risk factor for inflammatory bowel disease (Crohn and ulcerative colitis). Chronic constipation is a risk factor for intestinal obstruction. Jewish ancestry is a risk factor for Crohn disease.
After learning the diagnosis of irritable bowel syndrome, a patient is concerned about permanent damage. Which should be the nurse's response?
"The symptoms are troublesome, but irritable bowel syndrome doesn't cause permanent damage to the colon." Irritable bowel syndrome does not cause permanent damage to the colon. Damage to the colon is not influenced by the duration of disease, and damage does not depend on diet or steroid use.
Risk factors for GERD include the following:
- Decreased LES tone - Surgical vagotomy, decreased endogenous gastrin levels - Pregnancy - Impaired esophageal motility - Obesity. GERD has been associated with asthma, atrial fibrillation, and lower systolic blood pressure measurements.
Gastroesophageal reflux disease (GERD)
A constellation of esophageal and extraesophageal symptoms associated with chronically refluxed gastric contents
gastropathy
A gastric mucosal disorder that does not produce inflammation
Stomach cancer
A malignant growth or tumor resulting from the division of abnormal cells in the stomach
Transient LES relaxation (TLESR)
A motor pattern triggered by vagal afferents in the stomach causing raid relaxation of the LES, esophageal shortening, and inhibition of the crural diaphragm; a means for the stomach to vent excess gas
Vomiting
A neuromuscular reflex that results in forceful expulsion of gastric contents through the oral or nasal cavity; also called emesis
Acid pockets
A pocket, or reservoir, of gastric acid that floats on top of a recently ingested meal in the stomach
Esophageal chest pain
A pressure-like sensation felt in the midchest that may radiate to the back, arms, and jaws
The nurse is caring for a patient experiencing abdominal distention after surgery. Which additional clinical manifestation should the nurse expect with a possible small-bowel obstruction (SBO)?
Abdominal pain and nausea The classic signs and symptoms of SBO are abdominal pain, nausea, vomiting, and abdominal distention. Patients report the inability to satisfactorily pass gas or stool. The absence of bowel sounds accompanies an ileus. SBO bowel sounds are hyperactive and high pitched. Rectal itching is a clinical manifestation of hemorrhoids. Dysphagia accompanies esophageal issues.
A patient is diagnosed with possible diverticulitis. For which complication should the nurse monitor this patient?
Abscess and perforation Complicated diverticulitis is inflammation associated with formation of an abscess, fistula, obstruction, bleeding, or a perforation. The other health problems are not associated with diverticulitis.
Esophageal diverticula
Acquired outpouchings of the esophagus that may be located in the upper, middle, or lower esophagus
The nurse is caring for a patient with newly diagnosed diverticula. Which factor is a risk for this health problem?
Affects those with advanced age One risk factor for diverticular disease is advanced age. Diverticular disease affects men and women equally. Diverticula most often develop in the descending and not the ascending colon. Diverticula occur everywhere in the colon except the rectum.
A patient is being evaluated for a lower GI disorder. Which symptom should indicate to the nurse that the patient has colorectal cancer (CRC)?
Change in bowel habits Early CRC typically does not have symptoms. However, when symptomatic, patients present with a complaint of hematochezia and change in bowel habits. Other complaints may include fatigue, weight loss, generalized or localized abdominal pain, and symptoms of anemia.
A patient reports blood in the stool and an unexpected weight loss. Which health problem should the nurse suspect in this patient?
Colorectal cancer When symptomatic, patients with colorectal cancer (CRC) present with a complaint of hematochezia and change in bowel habits. Other complaints may include fatigue, weight loss, generalized or localized abdominal pain, and symptoms of anemia. The other disease processes do not include blood in the stool and weight loss as primary symptoms.
A patient with small bowel obstruction exhibits fever, tachycardia, and continuous pain. Laboratory findings reveal leukocytosis and metabolic acidosis. Which of the following is the priority action for the nurse?
Contact the physician immediately
The nurse on the GI unit is caring for a patient with pain on defecation from an anorectal fissure. Which of the following conditions does the patient most likely have?
Crohn disease Rationale: Patients with Crohn disease may experience pain with defecation due to anorectal fissures.
The nurse is preparing a booth for a health fair. Which modifiable risk factor should the nurse identify that decreases the risk of developing colon cancer?
Daily aspirin The use of NSAIDs, particularly aspirin, reduce the risk of developing colon cancer. Smoking, alcohol, and red meat are identified as factors that increase the risk for the disease.
A patient is diagnosed with stomach cancer. Which should the nurse expect to assess in this patient?
Early satiety Early satiety is a manifestation of stomach cancer. The other symptoms are not associated with this disease.
The nurse is teaching a class in the community about colon cancer prevention and detection. Which of the following should the nurse teach about modifiable risk factors?
Eat a diet that is rich in fiber Rationale: Modifiable factors that decrease the risk of colon cancer includes a diet that is rich in whole-grain fiber and the use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin. Other factors that increase risk of colon cancer include obesity, a sedentary lifestyle, smoking, moderate to heavy alcohol ingestion, and a diet that is heavy on red and processed meats and light on fruits and vegetables.
The nurse is caring for a patient with Barrett esophagus. For which type of cancer should the nurse assess this patient?
Esophageal Adenocarcinoma of the esophagus is defined as a carcinoma displaying glandular differentiation that arises in the esophagus. Risk factors of adenocarcinoma include Barrett esophagus (BE). BE does not cause oral, stomach, or liver cancer.
A patient reports hearing a gurgling sound when swallowing. Which health problem should the nurse suspect is occurring with this patient?
Esophageal diverticula Most esophageal diverticula are asymptomatic. However, when large enough to hold undigested food and fluids, hypopharyngeal diverticula present with symptoms that affect the upper esophagus and airway. Patients may experience a gurgling sound during swallowing. This symptom is not associated with the other disease processes.
The nurse notes that a patient is prescribed morphine for pain control. On which teaching topic should the nurse prepare material for this patient?
Gastric reflux Morphine is a medication that decreases the tone of the lower esophageal sphincter. This increases the risk for gastric reflux. The other choices are not appropriate for this patient.
A patient is diagnosed with esophageal dysfunction. Which health problem most likely contributed to the development of this disorder?
Gastroesophageal reflux disease Eosinophilic esophagitis (EoE) is an allergic esophagitis, characterized by histologic evidence of eosinophil-induced inflammation and clinical symptoms of esophageal dysfunction. Risk factors for EoE include gastroesophageal reflux disease (GERD). The other choices are not associated with the development of EoE.
A patient is diagnosed with esophageal diverticula. Which symptom should the nurse expect to assess in this patient?
Gurgling when swallowing Most esophageal diverticula are asymptomatic. However, when large enough to hold undigested food and fluids, hypopharyngeal diverticula present with symptoms that affect the upper esophagus and airway. Patients may experience a gurgling sound during swallowing. This health problem does not affect bowel sounds or causes abdominal tenderness.
A patient is being tested to confirm the diagnosis of gastritis. Which infection is most frequently the cause of chronic gastritis?
H. pylori Chronic gastritis is often caused by infectious agents, primarily bacteria, specifically H. pylori. Less commonly, acute gastritis may be caused by other bacterial infections or viral, parasitic, or fungal infections.
Which is the most common symptom of a hiatal hernia?
Heartburn Patients most frequently report symptoms of gastroesophageal reflux, such as heartburn, nocturnal epigastric distress, and a sour or acidic taste at the back of the throat. The patient's symptoms do not indicate any of the other disease processes.
What differentiates esophageal chest pain from heartburn?
Heartburn is discomfort or a burning sensation behind the sternum that originates from the epigastrium. It is an intermittent symptom and is commonly experienced after eating, during exercise, and while in the supine position. Esophageal chest pain, like heartburn, is experienced as a pressure-like sensation felt in the midchest. What differentiates esophageal chest pain from heartburn is its likeness to cardiac chest pain, in that it may radiate to the back, arms, and jaw.
A patient reports reflux and a sour taste in the mouth. Which health problem should the nurse suspect this patient is experiencing?
Hiatal hernia Patients most frequently report symptoms of gastroesophageal reflux, such as heartburn, nocturnal epigastric distress, and a sour or acidic taste at the back of the throat. The patient's symptoms do not indicate any of the other disease processes.
Which of the following diets should the nurse recommend to a patient with diverticulosis?
High-fiber diet
The parents of an infant are concerned about a new onset of projectile vomiting and weight loss. Which health problem should the nurse suspect in this patient?
Hypertrophic pyloric stenosis The classic presentation of infantile hypertrophic pyloric stenosis (IHPS) includes gradual onset of worsening nonbilious projectile vomiting beginning at 4-6 weeks of age, dehydration or weight loss, and possibly visible peristalsis in the upper abdomen. The typical clinical feature is that the baby is hungry after vomiting and eager to feed. The other health problems would not cause projectile vomiting.
Describe the anatomic characteristics of a type II hiatal hernia.
In a type II hiatal hernia, the gastroesophageal junction remains in the normal anatomic position, and a portion of the fundus herniates through the diaphragmatic hiatus.
reflux esophagitis
Inflammation of the esophagus caused by the reflux of gastric contents
Gastritis
Inflammation of the gastric mucosa
The nurse is preparing a patient with appendicitis for surgery. Which information should the nurse include in their teaching?
Laparoscopic surgery is the preferred method of treatment. Treatment is aimed at medical stabilization with intravenous fluids, electrolyte replacements, and antibiotics. While some healthcare providers may advocate for purely medical management for some cases of simple appendicitis, surgery—most often laparoscopic surgery—remains the gold standard for treatment of simple and complicated appendicitis.
The nurse is caring for a patient with diverticulosis. Which aspect of the patient's diet places the patient at risk for diverticulosis?
Low fiber intake A diet low in fiber contributes to diverticulosis. A high intake of red meat increases the risk of colon cancer. A high intake of salt increases the risk of gastric cancer. A low-cholesterol diet does not impact diverticulitis or other gastrointestinal disease risk.
Which of the following findings are most likely to be assessed in a patient with stomach cancer?
Nausea, early satiety, and occult blood in stool Rationale: Weight loss and abdominal pain are the most common symptoms of stomach cancer at initial diagnosis. Patients may present with dysphagia from tumors of the gastroesophageal junction or proximal stomach or gastric outlet obstruction from tumors of the distal stomach. Other manifestations include nausea, early satiety, and occult gastrointestinal bleeding. A mass may be palpable in the upper right quadrant of the abdomen. Together, these clinical manifestations make up a set of features known as alarm features of stomach cancer.
What are the risk factors for diverticular disease?
Nonsteroidal anti-inflammatory drugs increase the risk of developing diverticulosis, as do advanced age, obesity, and lack of exercise. Associated factors include alterations in colonic wall resistance, alterations in colonic motility, and low-fiber diets.
A patient reports epigastric pain and dyspepsia. Which condition should nurse suspect in the patient?
Peptic ulcer disease (PUD) Patients with PUD present with epigastric pain and dyspepsia, although some patients may be asymptomatic. The other choices are not symptoms of PUD.
Which factor can cause secondary constipation?
Pharmacologic Pharmacologic causes, such as from the use of opioids, calcium carbonate, and aluminum hydroxide antacids, can cause secondary constipation. Healthy diet and exercise promote normal bowel movements. A healthy diet and low calcium are not identified as causing secondary constipation.
The nurse prepares material on gastroesophageal reflux disease for a community health fair. Which risk factor should the nurse include?
Pregnancy Pregnancy is identified as a risk factor for GERD. The other choices are not considered risk factors for the disease process.
A patient with hemorrhoids has frank bright red blood in his stool. The nurse documents this finding as:
Rationale: Hematochezia is bright red blood in the stool. Occult blood is not detectable by routine inspection of the stool or gastric secretions. Occult blood is detected only through a guaiac test. Melena is black, tarry stools caused by digestion of blood in the GI tract. Blood in the patient's vomitus, known as hematemesis, may contain frank, bright red (undigested) blood or dark, grainy (digested) blood, described as having a coffee ground appearance. It may also present as blood in the patient's stool, known as melena.
A patient is diagnosed with peptic ulcer disease (PUD). Which measure should the nurse suggest to prevent an exacerbation of the symptoms?
Reduce nonsteroidal anti-inflammatory drug use Agents that contribute to PUD are nonsteroidal anti-inflammatory drugs (NSAIDs). Tobacco use increases stomach acid. Excessive alcohol intake irritates the stomach lining. No specific food (or diet) has been identified as a risk factor. A person should avoid any foods that cause upset stomach.
What is the difference between regurgitation and vomiting?
Regurgitation is the effortless return of food and fluids into the pharynx without nausea or retching. Maneuvers that increase intra-abdominal pressure can induce regurgitation, such as overdistending the stomach (as with overeating), bending, or belching. Patients complain of a burning sensation in the throat and a sour taste in the mouth. Vomiting is the forceful evacuation of gastric contents. It is frequently preceded by the sensation of nausea.
What are the risk factors for the development of stomach cancer?
Risk factors for the development of stomach cancer include H. pylori infection, cigarette smoking, high levels of alcohol ingestion, excessive dietary salt, inadequate fruit and vegetable consumption, and pernicious anemia. Ingestion of high concentrations of nitrates also appears to be associated with a higher risk.
A patient with Crohn disease asks the nurse why they must undergo stool sampling. Which reason should the nurse include in the response?
Rule out infection The diagnosis of ulcerative colitis and Crohn disease is based first on clinical symptoms. Patients with bloody or mucoid diarrhea, cramping, and abdominal pain should undergo stool sampling to rule out infectious causes of diarrhea (infectious enterocolitis) and to determine whether markers of intestinal inflammation are in the stool. Colonoscopy is used to rule out colon cancer. Diagnosis is confirmed with lower endoscopy studies to visualize and biopsy the bowel tissues. Serum assays such as C-reactive protein and erythrocyte sedimentation rate may provide evidence and degree of inflammation.
A patient with an esophageal rupture develops a fever. For which complication should the nurse plan care for this patient?
Sepsis Patients with esophageal perforations can quickly develop septic shock; therefore, treatment needs to be initiated promptly. Myocardial infarction, aortic dissection, and pneumothorax are not complications of a ruptured esophagus.
A patient is admitted with appendicitis. Which of the following manifestations is the nurse most likely to assess?
Steady central abdominal pain that migrates to the right lower quadrant of the abdomen Rationale: Patients may present with crampy and steady central abdominal pain that migrates to the right lower quadrant of the abdomen. The pain is usually vague at first, increasing in intensity as the condition progresses.
How do the causes of structural esophageal disorders and functional esophageal disorders differ?
Structural esophageal disorders are caused by alterations in the structure of the esophagus and include acquired, congenital, and traumatic defects. Functional esophageal disorders are caused by alterations in esophageal and esophageal sphincter function and include disorders of motility, altered mucosal integrity, and manifestations of systemic diseases.
A patient with appendicitis asks how it is treated. Which response from the nurse is the most accurate?
Surgery Treatment is aimed at medical stabilization with intravenous fluids, electrolyte replacements, and antibiotics. While some practitioners may advocate for purely medical management for some cases of simple appendicitis, surgery—most often laparoscopic surgery—remains the gold standard for treatment of simple and complicated appendicitis. "Watch and wait," or watchful waiting treatment, is used for indolent (slow-growing) cancers. Enemas or laxatives are used to relieve constipation. These medicines increase the likelihood that an inflamed appendix will burst.
A patient with irritable bowel syndrome reports abdominal pain or discomfort at least 3 days a month. Which additional information is needed to use the Rome III classification?
Symptoms occur in 3 consecutive months. The Rome III criteria are used to help diagnose irritable bowel syndrome (IBS) and include the presence of abdominal pain or discomfort on at least 3 days a month. The Rome criteria also include two or more of the following: (1) improvement with defecation, (2) onset (of each episode of discomfort) associated with a change in frequency of defecation, and (3) change in consistency of stool. Weight loss, early satiety, low energy, and fatigue are not part of the Rome III classification.
What are the classic clinical manifestations of small bowel obstruction?
The classic clinical manifestations of SBO are abdominal pain, nausea, vomiting, and abdominal distention. Additionally, patients report the inability to satisfactorily pass gas or stool.
What clinical manifestations suggest that a baby has infantile hypertrophic pyloric stenosis?
The classic presentation of IHPS includes gradual onset of worsening nonbilious projectile vomiting, beginning at 4-6 weeks of age, dehydration or weight loss, and possibly visible peristalsis in the upper abdomen. The typical clinical feature is that the baby is hungry after vomiting and eager to feed. Laboratory findings include hypochloremia, hypokalemia, and metabolic alkalosis. On physical examination, some infants may have a palpable olive-sized mass in the right upper quadrant.
coffee ground appearance
The dark, grainy appearance of digested blood; may be found in vomitus. gastric secretions, or stool
Describe the Rome III classification for making a diagnosis of irritable bowel syndrome.
The diagnosis of IBS relies on the recognition of positive clinical features and elimination of other organic diseases. According to the Rome III classification, the diagnosis of IBS is made when there the patient experiences recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months associated with two or more of the following: (1) improvement with defecation, (2) onset associated with a change in frequency of stool, and (3) onset associated with a change in form (appearance) of stool.
Describe the differences in clinical presentation between a gastric ulcer and a duodenal ulcer.
Typically, the person with a gastric ulcer presents with burning or gnawing discomfort that may be precipitated by food. A person with a duodenal ulcer may also present with burning or gnawing discomfort, but these symptoms occur on an empty stomach or during the night and are usually relieved by food or antacids.
For which reason should the nurse assess a patient for a small-bowel obstruction (SBO)?
Umbilical hernia A hernia is one reason for the development of a SBO. The other choices are not identified as causing a SBO. Mechanical obstructions, which make up 90% of all obstructions, are the result of compression of the intestine by adhesion, tumors, fecal impaction, and hernias, in which the bowel becomes trapped in a weakened area of the abdominal wall.
Differentiate the appearance of bleeding from the upper and lower GI tracts.
Upper GI bleeding originates in the esophagus, stomach, or duodenum and may present as blood in the patient's vomitus, known as hematemesis. Hematemesis may contain frank, bright red (undigested) blood or dark, grainy (digested) blood, described as having a coffee ground appearance. Upper GI bleeding may also present as blood in the patient's stool, known as melena. Melena is black, tarry stools caused by digestion of blood in the GI tract. Lower GI bleeding is due to bleeding from the small intestine, large intestine, colon, or rectum. Blood in the stool from lower GI bleeding presents as black, tarry stools (melena) or frank, bright red blood in the stool (hematochezia).
The nurse is caring for a patient with chronic gastritis. Which vitamin should the nurse anticipate administering to the patient?
Vitamin B12
While in transit, ingested materials may encounter esophageal defects, leading to which of the cardinal signs and symptoms of GI disorders?
While in transit, ingested materials may encounter various defects in the esophagus, commonly causing three of the four cardinal symptoms of gastrointestinal disorders: pain, altered ingestion, and bleeding.
Adenocarcinoma of the esophagus
a carcinoma displaying glandular differentiation that arises in the esophagus - Most common cancer in United States
Ulcerative colitis (UC)
a chronic inflammatory condition limited to the mucosal layers of the colon. It is characterized by relapsing and remitting episodes of inflammation; it is considered to be an inflammatory bowel disease
Crohn disease (CD)
a chronic inflammatory condition that is characterized by transmural inflammation of the bowekk and mot commonly affects the ileum and proximal colon; it is considered to be an inflammatory bowel disease
Inflammatory bowel disease (IBD)
a chronic inflammatory disorder involving the GIT.
esophageal ring
a circumferential, nondistendable narrowing of the lumen of the esophagus
Peptic ulcer disease (PUD)
a condition of chronic erosion, destruction, and ulceration in the lining of the stomach and duodenum
Infantile hypertrophic pyloric stenosis (IHPS)
a condition that frequently affects young infants and is characterized by hypertrophy of the pylorus muscles leading to eventual gastric outlet obstruction
Irritable bowel syndrome (IBS)
a disorder of motility causing abdominal discomfort and altered bowel habits
Helicobacter pylori (H. pylori)
a gram-negative bacterium that causes gastritis and ulcers
hiatal hernia
a herniation of the stomach through the esophageal hiatus of the diaphragm.
Colon cancer
a malignant growth or tumor resulting from the division of abnormal cells in the ascending, transverse, or descending colon.
Esophageal cancer
a malignant growth or tumor resulting from the division of abnormal cells in the esophagus.
Rectal cancer
a malignant growth or tumor resulting from the division of abnormal cells in the rectum a malignant growth or tumor occurring up to 15 cm from the anal opening
gastric outlet obstruction
a mechanical obstruction in the pyloric region of the stomach
Esophageal perforation
a tear or rupture that creates a hole through the layers of the esophagus
Hemorrhoids
abnormal engorgements of the hemirrhoidal cushions of the anus
Barrett esophagus (BE)
also known as Barrett metaplasia, is a metaplastic change in the lining of the esophageal mucosa in which normal esophageal, squamous epithelium begins to resemble gastric, columnar epithelium
Diarrhea
an increase in stool content, volume, and weight as well as an increase in the frequency of evacuations of stool per day
Appendicitis
an infectious process that causes inflammation of the vermiform appendix.
Reflux
an involuntary process, is the backwards movement of GI contents at any point in the GIT.
Occult blood
blood or bleeding that is not detected by visualization
hematemesis
bright red blood in vomitus
ulcer
damage and erosion of the mucosal layers in the gastrointestinal
dysphonia
difficulty in speaking as a result of a condition of the mouth, throat, or vocal cords
Dysphagia
difficulty swallowing food and liquids, is often described as the feeling of food "sticking" in the throat or chest.
Heartburn
discomfort or a burning sensation behind the sternum that originates from the epigastrium
Diverticulosis
diverticula without evidence of inflammation
Diverticulitis
inflamed diverticula.
Esophagitis
irritation and inflammation of the tissues of the esophagus; may be due to allergic reactions, infections, radiation, ingestion of corrosive substances, or improper passage of a pill
esophageal web
is a thin, membranous tissue that occupies the lumen of the esophagus, decreasing the diameter of the lumen
Melena
is black, tarry stools caused by digestion of blood in the GIT.
Constipation
is difficult or infrequent evacuation/passage of small amount of hard, dry stool
Squamous cell carcinoma (SCC)
malignant neoplasm of the esophagus with squamous differentiation, usually with signs of keratin - most common in developing countries
Odynophagia
pain caused by swallowing
Bowel obstruction
partial or complete blockage of the intestinal tract
hematochezia
right red blood in the stool
Diverticula
small outpouchings, or hernaiations, of gastrointestinal mucosa through the muscular layers of the gastrointestinal; most commonly found in the esophagus and the colon
Regurgitation
the effortless return of food and fluids into the pharynx without nausea or retching
Globus sensation
the feeling of fullness or a lump in the throat.
dyspepsia
uncomfortable feelings including mild, gnawing discomfort in the abdomen or chest, bloating, early satiety, and nausea
