Gastrointestinal Abnormalities o The pyloric sphincter controls food

passage into the small intestine.

Abnormalities of the GI tract include major
pathologies such as: 2. Small Intestine
• Bleeding o Longest segment of the GI tract.
• Perforation o Three sections:
• Obstruction  Duodenum (proximal section)
• Inflammation  Jejunum (middle section)
• Cancer  Ileum (distal section, ending at
the ileocecal valve)
Other factors affecting the GI system:
o Ileocecal valve prevents reflux of
• Congenital, inflammatory, infectious, traumatic, bacteria into the small intestine.
and neoplastic lesions.
o Common bile duct allows bile and
• Circulatory disturbances, nervous system pancreatic secretions into the duodenum.
dysfunction, and aging.
3. Large Intestine
• External influences like stress, anxiety, fatigue,
and diet changes affecting GI function. o Composed of:
Role of Healthcare Professionals  Ascending colon (right side of
the abdomen)
• Nurses should assess and educate patients on
mental and physical factors impacting GI health.  Transverse colon (upper
abdomen)
Anatomic and Physiologic Overview
 Descending colon (left side of
General Structure the abdomen)
• The GI tract is 7 to 7.9 meters (23 to 26 feet) long.  Sigmoid colon, rectum, and anus
• Extends from the mouth → esophagus → o Regulated by internal and external anal
stomach → small intestine → large intestine → sphincters.
rectum → anus.
4. Blood Supply
• The esophagus is located between the spine,
trachea, and heart, passing through the diaphragm o Blood from the digestive organs is
at the diaphragmatic hiatus. collected in the portal venous system:
Key Organs and Functions  Superior mesenteric vein
1. Stomach  Inferior mesenteric vein
o Located in the left upper abdomen  Gastric vein
beneath the liver and diaphragm.
 Splenic vein
o Functions:
 Cystic vein
 Stores food during eating.
o Blood enters the liver via the vena portae
 Secretes digestive fluids. and exits through the hepatic veins into
the inferior vena cava.
 Propels chyme into the small
intestine. o GI blood flow is 20% of cardiac output
and increases significantly after eating.
o Four regions: Cardia (entrance), Fundus,
Body, Pylorus (outlet). 5. Nervous System Control

1
 o Sympathetic stimulation: Decreases
gastric secretion and motility, constricts
sphincters. Types of Contractions in the Small Intestine

o Parasympathetic stimulation: Increases • Segmentation Contractions:

peristalsis and secretions, relaxes o Move intestinal contents back and forth
sphincters (except upper esophagus and in a churning motion.
external anal sphincter, which are
voluntarily controlled). o Aid in mixing food with digestive
enzymes.
Function of the Digestive System
• Intestinal Peristalsis:
Major Functions:
o Propels contents toward the colon.
1. Breakdown of food particles into molecular form
for digestion. o Stimulated by the presence of chyme.
2. Absorption of nutrients into the bloodstream. Breakdown of Food

3. Elimination of undigested and waste materials. • Carbohydrates:

o Broken into disaccharides (sucrose,
maltose, galactose) and monosaccharides
Digestive Process (glucose, fructose).
1. Chewing & Swallowing o Glucose is the primary energy source for
o Food is broken down into smaller tissue cells.
particles. • Proteins:
o Salivary glands produce 1.5 L of saliva o Broken into amino acids and peptides.
daily, containing:
o Serve as an energy source.
 Ptyalin (salivary amylase):
Begins starch digestion. • Fats:
 Water & mucus: Lubricate food o Converted into monoglycerides and fatty
for swallowing. acids through emulsification.

o Swallowing is controlled by the medulla o Makes absorption easier.

oblongata.
o The epiglottis covers the trachea to
Absorption in the Small Intestine
prevent aspiration.
• Time in the Small Intestine: 3 to 6 hours.
o Esophageal peristalsis propels food to the
stomach. • Villi Function:
o The lower esophageal sphincter prevents o Produce digestive enzymes.
stomach content reflux.
o Absorb nutrients.
2. Gastric Function
• Absorption Locations:
o The stomach stores, mixes, and digests
food. o Jejunum: Nutrients, sodium, chloride.

o Gastric enzymes & hydrochloric acid o Ileum: Vitamin B12, bile salts.
break down food. o Throughout the Small Intestine:
o Chyme is propelled into the small Magnesium, phosphate, potassium.
intestine for further digestion and
absorption
2
4. Colonic Function o Rectal distention triggers reflex
contractions.
• Movement to the Colon:
o Internal anal sphincter relaxes
o Residual waste moves into the right (involuntary control).
colon within 4 hours after eating.
o External anal sphincter is voluntarily
o Small intestine peristalsis pushes controlled.
contents into the colon through the
ileocecal valve. o Straining aids in emptying the colon.
• Role of Gut Microbes: o Normal defecation frequency varies but
averages once per day.
o Help break down waste.
o Process undigested proteins and bile
salts. Gut Microbiome
• Colonic Secretions: • Functions:
o Electrolyte solution (bicarbonate): o Assists in waste breakdown.
Neutralizes bacterial byproducts.
o Plays a role in vitamin synthesis and
o Mucus: Protects mucosa and supports immune defense.
fecal mass movement.
o Protects against pathogens.
• Peristalsis in the Colon:
• Factors Affecting Gut Microbiota:
o Slow, weak waves allow water and
electrolyte reabsorption. o Genetics, diet, hygiene, infections,
vaccinations.
o Strong peristaltic waves occur after
meals. o Chronic diseases and medications,
including antibiotics, can alter
o Waste reaches and distends the rectum composition.
within 12 hours.
• Role in Immune Protection:
o Produces anti-inflammatory metabolites.
Waste Products of Digestion
o Prevents pathogen colonization.
• Composition of Feces:
o Epithelium contains immune cells
o 75% fluid, 25% solid. (macrophages, dendritic cells, mast
cells).
o Mostly non-dietary materials from GI
secretions. o Peyer’s patches help in immune
response.
• Fecal Characteristics:
Diagnostic Finding
o Brown color: Result of bile breakdown.
Overview
o Odor: Due to intestinal bacterial activity.
• GI diagnostic studies confirm, rule out, stage, or
• Gas Formation: diagnose disease states, including cancer.
o Includes methane, hydrogen sulfide, • After diagnosis, discussions and resource
ammonia. materials should be provided to the patient.
o Can be absorbed and detoxified by the • Most diagnostic tests are outpatient-based (e.g.,
liver or expelled as flatus. endoscopy suite, GI laboratory).
• Elimination Process:

3
 • Preparation includes dietary restrictions, fasting, • Fecal Immunochemical Test (FIT):
bowel preparations, laxatives, enemas, and
contrast agents. o Reacts to human hemoglobin.

• Special considerations for older adults and those o No dietary or medication restrictions.
with comorbidities due to fluid/electrolyte o Recommended annually.
imbalance.
• FIT-fecal DNA test:
• Hospital admission may be needed for further
assessment/treatment. o Detects abnormal DNA from
cancer/polyp cells.
General Nursing Interventions
o Recommended every 3 years.
1. Assess the need for more information.
2. Educate patients and families on tests and
pre/post-procedure care. Breath Tests
3. Help patients cope with discomfort and anxiety. • Hydrogen breath test: Assesses carbohydrate
absorption and bacterial overgrowth.
4. Inform the provider of conditions or abnormal lab
values affecting procedures. • Urea breath test:

5. Monitor hydration status before, during, and after o Detects Helicobacter pylori (H. pylori),
procedures. linked to peptic ulcer disease.
o Requires avoiding antibiotics (1 month),
PPIs (2 weeks), H2 blockers (24 hours)
Serum Laboratory Studies before testing.
• Initial tests: CBC, metabolic panel, PT/PTT,
triglycerides, liver function, amylase, lipase.
Abdominal Ultrasonography
• Cancer-specific markers:
• Uses high-frequency sound waves to detect
o CEA: Not present in healthy individuals; gallstones, pancreatitis, ovarian enlargement,
indicates cancer presence but not type. appendicitis.
o CA 19-9: Tumor marker shed by cancer • Advantages:
cells, useful in tracking colorectal cancer.
o No radiation, minimal side effects, cost-
• Tumor markers help assess treatment effective, immediate results.
effectiveness or cancer recurrence.
• Limitations:
o Affected by body type, bowel gas, bone
Stool Tests interference.
• Inspect consistency, color, and occult blood. o Cannot visualize structures behind bones
• Additional tests: fecal urobilinogen, fecal fat, or gas-filled organs.
nitrogen, C. difficile, fecal leukocytes, parasites, • Endoscopic Ultrasonography (EUS):
pathogens.
o Provides high-resolution imaging for GI
• Guaiac-based fecal occult blood test (gFOBT): disorders.
o Used for early cancer detection. o Useful for Barrett’s esophagus,
o Performed bedside, in a lab, or at home. pancreatic issues, ulcerative colitis.

o Avoid red meat, aspirin, NSAIDs, and • Nursing Interventions:

vitamin C before testing. o Fast 8-12 hours before testing.

4
 o Eat a fat-free meal before gallbladder Variations:
studies.
1. Double-contrast study: Uses barium and carbon
o Schedule barium tests after ultrasound to dioxide tablets for finer detail, detecting early
prevent interference. neoplasms.
o Monitor sedation effects and provide 2. Enteroclysis: Detailed double-contrast study of
post-procedure care. the small intestine using continuous barium
infusion.
Genetic Testing
Nursing Interventions:
• Identifies risk for GI disorders (e.g., gastric
cancer, lactose deficiency, IBD, colon cancer). • Pre-procedure: Low-residue/clear liquid diet;
NPO after midnight; avoid smoking/gum
• Lynch Syndrome: chewing.
o Inherited disorder linked to colon and • Post-procedure: Encourage fluid intake to
extracolonic cancers. facilitate barium elimination.
o Accounts for 3% of new colon cancer
cases.
Lower Gastrointestinal Tract Study
• Genetic counseling helps patients understand
risks, prevention, and treatment options. Procedure:
• Involves rectal instillation of barium to detect
polyps, tumors, or abnormalities.
Imaging Studies
• Variations:
Definition: Numerous minimally invasive and
noninvasive imaging studies are available today, o Double-contrast barium enema (thick
including: barium + air for enhanced visibility).
• X-ray and contrast studies o Water-soluble contrast study (for
suspected inflammatory disease, fistulas,
• Computed Tomography (CT) scan or perforation).
• Magnetic Resonance Imaging (MRI) scan Nursing Interventions:
• Positron Emission Tomography (PET) scan • Pre-procedure:
• Scintigraphy (Radionuclide Imaging) o Low-residue diet 1-2 days before.
• Virtual Colonoscopy o Clear liquid diet + laxative the evening
before.

Upper Gastrointestinal Tract Study o NPO after midnight.

Procedure: • Post-procedure: Increase fluid intake, monitor

bowel movements to ensure barium is expelled.
• Uses fluoroscopy with a contrast agent (e.g.,
barium sulfate) to visualize the upper GI tract.
• Helps detect ulcers, varices, tumors, regional Computed Tomography (CT) Scan
enteritis, and malabsorption syndromes. Procedure:
• Can extend to include the small bowel follow- • Provides cross-sectional images of abdominal
through. organs.
• Multiple X-rays taken; additional images may be • Useful for detecting appendicitis, diverticulitis,
captured over 24 hours to evaluate gastric ulcerative colitis, liver/kidney diseases.
emptying.
5
 • Can be done with or without contrast. o Esophageal, gastric, or duodenal
disorders
Nursing Interventions:
o Inflammatory, neoplastic, or infectious
• Assess for allergies (contrast agents, iodine, processes
shellfish).
• Can evaluate esophageal and gastric motility
• Check serum creatinine levels for kidney
function. • Can collect secretions and tissue specimens
• Hydration is key to prevent contrast-induced Procedure Details
nephropathy (CIN).
• Uses a gastroscope (lighted endoscope)
Magnetic Resonance Imaging (MRI)
• Electronic video endoscopes convert signals into
Procedure: pictures for documentation
• Uses magnetic fields and radio waves to produce • PillCam ESO (Capsule Endoscopy):
detailed images.
o Patient swallows a capsule containing a
• Enhances diagnosis of GI diseases, blood vessels, video camera
abscesses, fistulas, neoplasms.
o Used for esophageal diseases when EGD
Nursing Interventions: is not tolerated
• Screen for contraindications (e.g., metal implants, o Capsule colonoscopy approved for
pacemakers, claustrophobia). incomplete colonoscopies or non-
candidates
• Remove ferromagnetic objects (e.g., metal
jewelry, watches). • Endoscopic Retrograde
Cholangiopancreatography (ERCP):
o Uses x-rays with an endoscope
Endoscopic Procedures
o Views bile ducts, pancreatic ducts,
Overview gallbladder
• Used for GI tract assessment o Helps evaluate jaundice, pancreatitis,
• Includes: pancreatic tumors, bile duct stones, and
biliary tract disease
o Fibroscopy/Esophagogastroduodenosco
py (EGD) Therapeutic Uses of Upper GI Fibroscopy

o Colonoscopy • Removal of bile duct stones

o Anoscopy • Dilation of strictures

o Proctoscopy • Treatment of gastric bleeding and esophageal

varices
o Sigmoidoscopy
• Laser therapy for upper GI neoplasms
o Small-bowel enteroscopy
• Sclerosing solution injection for bleeding control
o Endoscopy through an ostomy
Procedure Process
Upper Gastrointestinal
Fibroscopy/Esophagogastroduodenoscopy (EGD) • Patient is sedated

• Direct visualization of the esophageal, gastric, • Endoscope lubricated and passed down the
and duodenal mucosa esophagus

• Valuable for detecting: • Viewing of gastric wall and sphincters

• Examination of the duodenum
6
 • Tools used: Biopsy forceps, cytology brushes o Surveillance for past colon cancer or
polyps
• Duration: Approximately 30 minutes
o Diagnosis of diarrhea, occult bleeding,
• Possible Side Effects: Nausea, gagging, choking anemia, inflammatory bowel disease
Nursing Interventions o Removal of polyps (polypectomy)
• Pre-procedure: o Treatment of bleeding or strictures
o NPO for 8 hours before o Bowel decompression
o Local anesthetic gargle or spray o Laser therapy for colonic neoplasms
o Sedation with midazolam Procedure Process
o Atropine to reduce secretions, glucagon • Patient lies on the left side with legs drawn up
to relax muscles
• Scope advanced through rectum and colon
o Position: Left lateral for secretion
clearance • Tools used: Biopsy forceps, cytology brushes
• Post-procedure: • Complications:
o Monitor consciousness, vitals, oxygen o Cardiac arrhythmias, respiratory
levels depression
o Watch for perforation signs (pain, o Vasovagal reactions, circulatory
bleeding, swallowing issues, high overload or hypotension
temperature)
• Capsule Colonoscopy Alternative:
o Gag reflex returns before oral intake
allowed o Swallowed capsule with a two-sided
camera
o Offer lozenges, saline gargle, or
analgesics for throat discomfort o Requires more bowel prep than regular
colonoscopy
o For Outpatients:
o Positive results require follow-up
 Must have someone to colonoscopy
accompany them home
Nursing Interventions
 Follow-up call the next day to
check on patient • Pre-procedure:
o Colon cleansing is crucial

Fiberoptic Colonoscopy o Laxatives and enemas may be used

• Direct visualization of the bowel (anus, rectum, o PEG electrolyte lavage solutions
sigmoid, transverse, ascending colon) (GoLYTELY, CoLyte, NuLYTELY)

• Virtual Colonoscopy (CT Colonography): o Nonsplit vs. split dose regimen for bowel
prep
o Less risk of perforation
• During and Post-procedure:
o Requires bowel preparation
o Monitor cardiac, respiratory function,
• Uses flexible fiberoptic colonoscope oxygen saturation
• Diagnostic and Screening Uses: o Administer supplemental oxygen as
needed
o Cancer screening

7
 o Post-procedure discomfort due to air o Enema given 1 hour before the test.
instillation
o Patient positioned in prone or lateral
o Follow-up for any complications or position.
concerns
Rectal Sensory Function Studies:
• Evaluates rectal sensory function and neuropathy.
Manometry and Electrophysiologic Studies
• Procedure:
Overview:
o Catheter and balloon inserted into the
• Used to evaluate GI motility disorders. rectum.
• Manometry measures intraluminal pressures and o Increasing balloon inflation until
muscle coordination. distention is felt.
• Electrophysiologic studies assess nerve and o Measures tone and pressure of rectum
muscle function in the GI tract. and anal sphincter.
Esophageal Manometry: • Useful for patients with chronic constipation,
diarrhea, or incontinence.
• Detects motility disorders in the esophagus and
esophageal sphincters. Electrogastrography:
• Helpful in diagnosing achalasia, diffuse • Assesses gastric motility disturbances.
esophageal spasm, scleroderma, and GERD.
• Detects motor or nerve dysfunction in the
• Procedure: stomach.
o NPO for 8-12 hours before the test. • Procedure:
o Medications affecting motility withheld o Electrodes placed on the abdomen.
for 24-48 hours.
o Gastric electrical activity recorded for up
o Pressure-sensitive catheter inserted to 24 hours.
through the nose.
o Identifies rapid, slow, or irregular
o Patient swallows small amounts of water waveform activity.
while pressure changes are recorded.
Defecography:
Gastroduodenal, Small Intestine, and Colonic
Manometry: • Measures anorectal function using barium paste.

• Evaluates delayed gastric emptying and motility • Fluoroscopy assesses rectum and anal sphincter
disorders (e.g., IBS, atonic colon). function during expulsion.

• Outpatient procedure lasting 24-72 hours. • No preparation required.

Anorectal Manometry: Gastric Analysis, Gastric Acid Stimulation Test, and

pH Monitoring
• Measures:
Overview:
o Resting tone of the internal anal
sphincter. • Analyzes gastric juice to assess secretory activity
and gastric retention.
o Contractibility of the external anal
sphincter. • Diagnoses Zollinger-Ellison syndrome, atrophic
gastritis, and ulcers.
• Used for chronic constipation, fecal incontinence,
and biofeedback therapy. Gastric Analysis Procedure:

• Procedure: • NPO for 8-12 hours before the test.

8
 • Medications affecting gastric secretions withheld • More accurate than traditional catheter-based
for 24-48 hours. methods.
• Smoking prohibited before the test. Laparoscopy (Peritoneoscopy)
• Small nasogastric tube inserted into the stomach. Overview:
• Stomach contents aspirated and samples collected • Minimally invasive diagnostic tool for GI
every 15 minutes for 1 hour. disease.
Diagnostic Findings: • Cost-effective and efficient.
• Pernicious anemia: No acid secretion under basal Procedure:
conditions.
• Pneumoperitoneum created by injecting carbon
• Chronic atrophic gastritis/gastric cancer: Little to dioxide.
no acid secretion.
• Small incision made near umbilicus for fiberoptic
• Gastric ulcer: Some acid secretion. laparoscope insertion.
• Duodenal ulcer: Excess acid secretion. • Direct visualization of abdominal organs.
Gastric Acid Stimulation Test: • Biopsy samples can be taken.
• Performed with gastric analysis. • Used for evaluating peritoneal disease, chronic
pain, abdominal masses, gallbladder, and liver
• Histamine or pentagastrin injected to stimulate disease.
gastric secretions.
Benefits:
• Possible side effects: Flushed feeling.
• Allows simultaneous diagnosis and treatment
• Monitored for hypotension (blood pressure and (e.g., gallbladder removal).
pulse checks).
• Less invasive than traditional surgery.
• Gastric specimens collected every 15 minutes for
1 hour. Limitations:
pH Monitoring for Esophageal Reflux: • Not commonly used for acute abdominal pain due
to availability of CT and MRI scans.
• Diagnoses and evaluates GERD.
• General anesthesia often required.
• Procedure:
o NPO for 6 hours before the test.
o pH sensor inserted via endoscopy and
connected to a recording device.
o Patient wears device for 24 hours.
o Data analyzed for reflux events.
Bravo pH Monitoring System:
• Capsule attached to esophageal wall via
endoscopy.
• pH data transmitted to an external receiver.
• Data collected for up to 96 hours.
• Capsule detaches and passes through the
digestive system in 7-10 days.

9
 next to the esophagus.Type IV: Most severe, may
involve other organs (colon, small intestine).
Symptoms (Clinical Manifestations)
• Sliding Hernia:
o Heartburn (pyrosis), regurgitation,
difficulty swallowing (dysphagia).
o Some patients have no symptoms.
o May cause vague stomach pain or
fullness after meals.
• Large Hiatal Hernias:
o Nausea, vomiting, food intolerance.
• Complications (More common in
paraesophageal hernias):
o Bleeding, obstruction, twisting of
intestines (volvulus), strangulation of the
stomach.
Diagnosis (Assessment & Diagnostic Tests)
• X-ray
• Barium swallow (contrast dye swallowed to see
the esophagus and stomach)
• EGD (Esophagogastroduodenoscopy) –
fiberoptic scope to view inside the stomach
• Esophageal manometry – measures pressure in
the esophagus
• Chest CT scan

ORAL (4)
Treatment & Management
Hiatal Hernia
1. Lifestyle Changes
Definition
o Eat small, frequent meals to reduce
• A hiatal hernia occurs when the opening in the pressure on the stomach.Avoid lying
diaphragm (where the esophagus passes) down for 1 hour after eating.Elevate the
becomes enlarged.This allows part of the upper head of the bed (4–8 inches).
stomach to move into the lower thorax. More
common in women than men. 2. Surgical Treatment (For severe cases)

Types of Hiatal Hernia o Laparoscopic surgery (Toupet or

Nissen fundoplication) is preferred.Open
1. Sliding Hiatal Hernia (Type I)The upper surgery is done only in complicated
stomach and gastroesophageal junction move up cases (bleeding, adhesions, spleen
and down into the thorax.90–95% of cases.Often injury).Surgery is mainly done to relieve
linked to GERD (acid reflux). GERD symptoms.
2. Paraesophageal Hiatal Hernia (Types II, III, 3. Postoperative Care
IV)The stomach pushes through the diaphragm
10
 o Gradual diet transition (liquids → soft • Esophagoscopy – Usually avoided due to the risk
foods → solids). of perforation.
Treatment and Management
o Monitor for belching, vomiting, gagging, • Zenker Diverticulum:
bloating, and chest pain (signs of o Endoscopic Treatment (rigid or flexible).
complications). o POEM (Peroral Endoscopic Myotomy) –
o Complications needing surgery: Preferred due to lower recurrence risk.
o Surgery (Diverticulectomy & Myotomy)
 Gastric strangulation (can cause – Removes the diverticulum and relieves
stomach ischemia, necrosis, muscle spasticity.
perforation). • Epiphrenic & Midesophageal Diverticula:
o Surgery only if symptoms worsen.
Diverticulum
o Diverticulectomy & Long Myotomy –
Definition Treatment option if needed.
• An esophageal diverticulum is an out-pouching • Intramural Diverticula:
of mucosa and submucosa that protrudes through o Usually improves with esophageal
a weak area in the esophageal musculature. stricture dilation.
• It can occur in three areas:
o Pharyngoesophageal (upper) – Most
common, known as Zenker diverticulum
Gastroesophageal Reflux Disease (GERD)
(ZD).
o Midesophageal (middle) – Rare and Definition
usually does not require surgery.
o Epiphrenic (lower) – Located just above GERD is a common disorder caused by the
the diaphragm, linked to sphincter backflow of stomach or duodenal contents into the
dysfunction or motor disorders. esophagus, leading to symptoms and possible esophageal
Causes damage. It often results from a weak lower esophageal
• Dysfunctional sphincter failing to open, leading sphincter, pyloric stenosis, hiatal hernia, or motility
to increased pressure. disorders. GERD is linked to aging, irritable bowel
• Weakness in esophageal musculature. syndrome, respiratory conditions (asthma, COPD), peptic
• Motor disorders affecting esophageal function. ulcers, and lifestyle factors such as smoking, alcohol,
Types caffeine, and H. pylori infection.
1. Zenker Diverticulum (ZD) – Upper esophageal Clinical Manifestations
diverticulum due to sphincter dysfunction.
2. Midesophageal Diverticulum – Less acute • Hallmark symptoms: Heartburn (pyrosis) and
symptoms, rarely requires surgery. regurgitation
3. Epiphrenic Diverticulum – Lower esophagus,
larger, associated with sphincter or motor • Other symptoms: Indigestion (dyspepsia),
dysfunction. difficulty swallowing (dysphagia), pain with
4. Intramural Diverticulosis – Small diverticula in swallowing (odynophagia), hypersalivation, and
the upper esophagus with stricture. esophagitis
Signs and Symptoms • Complications: Dental erosion, esophageal
• Dysphagia (difficulty swallowing). ulcers, laryngeal damage, strictures,
• Fullness in the neck. adenocarcinoma, and pulmonary issues
• Belching and regurgitation of undigested food.
• Gurgling noises after eating. Assessment & Diagnosis
• Halitosis (bad breath) and sour taste in the mouth.
• History review is key for diagnosis
• Coughing when lying down (due to aspiration).
Diagnostic Tests • Tests:
• Barium Swallow – Determines the location and
nature of the diverticulum. o Ambulatory pH monitoring (gold
• ESOPHAGEAL MANOMETRY standard)
/Manometric Studies – Used for epiphrenic o PPI trial
diverticula to rule out motor disorders.
11
 o Endoscopy or barium swallow to assess Management
mucosal damage, strictures, or hernias
• Lifestyle modifications: Eat slowly and drink
Management fluids with meals
• Lifestyle modifications: • Medical treatment:
o Quit smoking and alcohol o Botulinum toxin injections:
Temporarily relaxes esophageal muscles
o Lose weight but has limited long-term effectiveness
o Elevate the bed head o Pneumatic dilation: Expands the
o Avoid eating before bedtime narrowed esophagus (high success rate,
but multiple sessions may be needed)
o Dietary adjustments
• Surgical options:
• Medical treatment: Proton pump inhibitors (PPIs)
and other medications o Heller myotomy: Laparoscopic
esophageal muscle cutting, often
• Surgical option: Nissen fundoplication (wrapping combined with fundoplication to prevent
part of the stomach around the esophagus to GERD
reinforce the sphincter) if medical treatment fails
o Per-oral endoscopic myotomy
(POEM): Minimally invasive alternative
for high-risk patients
Achalasia
Achalasia is a rare esophageal motility disorder
characterized by ineffective or absent peristalsis in the Gastric and Duodenal (3)
lower esophagus and failure of the lower esophageal
sphincter to relax during swallowing. This results in Gastritis
esophageal narrowing above the stomach and gradual Definition
dilation in the upper chest. It commonly affects
individuals between 20–40 and 60–70 years old. Gastritis is the inflammation of the stomach
lining and is a common gastrointestinal condition. It can
Clinical Manifestations be acute, lasting a few hours to days, or chronic, resulting
• Hallmark symptom: Dysphagia, especially with from repeated irritation.
solid food Causes
• Other symptoms: • Acute Gastritis: Caused by NSAIDs (e.g.,
o Sensation of food sticking in the lower ibuprofen, aspirin), alcohol, corticosteroids, and
esophagus infections (H. pylori). Severe cases may result
from ingesting strong acids or trauma-related
o Regurgitation (spontaneous or stress.
intentional)
• Chronic Gastritis: Often due to H. pylori
o Noncardiac chest or epigastric pain infection, long-term NSAID use, bile reflux, or
autoimmune disorders like Hashimoto’s and
o Heartburn (pyrosis)
Addison’s disease.
Assessment & Diagnosis
Symptoms
• X-ray: Shows esophageal dilation above the
• Acute Gastritis: Sudden epigastric pain, nausea,
narrowed area (bird’s beak deformity)
vomiting, hiccups, indigestion, and possible
• Other tests: Barium swallow, CT scan, bleeding (hematemesis or melena).
endoscopy
• Chronic Gastritis: Symptoms include persistent
• Gold standard: High-resolution manometry stomach discomfort, bloating, heartburn, nausea,
(measures esophageal pressure and peristalsis) and vitamin B12 deficiency (leading to anemia).
12
Diagnosis • Genetics & conditions (blood type O, COPD,
liver disease, chronic kidney disease)
• Endoscopy with biopsy to examine the stomach
lining. • Zollinger-Ellison Syndrome (ZES) – tumors
producing excess gastrin leading to severe ulcers
• Blood tests to check for anemia.
Pathophysiology
• H. pylori tests (breath, stool, or blood tests).
Peptic ulcers form when digestive acids (HCl & pepsin)
Treatment & Management erode the mucosal lining.
• For Acute Gastritis: • Duodenal ulcers: Linked to increased acid
o Avoid alcohol and irritants. production

o Use antacids, H2 blockers (famotidine), • Gastric ulcers: May occur with normal or
or proton pump inhibitors (omeprazole). decreased acid levels

o Severe cases may require IV fluids, • Stress ulcers: Caused by burns, sepsis, or major
endoscopy, or surgery if bleeding occurs. trauma (e.g., Curling’s ulcers in burns and
Cushing’s ulcers in brain injuries)
• For Chronic Gastritis:
Symptoms
o Modify diet, avoid alcohol and NSAIDs,
and manage stress. • Burning, gnawing pain in the epigastric area or
back
o Treat H. pylori with a combination of
antibiotics and proton pump inhibitors. • Gastric ulcers: Pain occurs immediately after
eating
Nursing Considerations
• Duodenal ulcers: Pain occurs 2-3 hours after
• Reduce anxiety by explaining procedures and meals or at night, relieved by food or antacids
treatments.
• Some cases are silent, especially in older adults
• Support nutrition by advising a non-irritating diet and NSAID users
and monitoring for vitamin deficiencies.
Intestinal and Rectal (3)
• Monitor for complications like ulcers, gastric Constipation
cancer, or perforation. Definition
Constipation is defined as fewer than three bowel
movements per week or bowel movements that are hard,
Peptic Ulcer Disease dry, small, or difficult to pass (Simren, Palsson, &
Whitehead, 2017). Approximately 63 million Americans
Definition suffer from chronic constipation, making it a prevalent
PUD affects around 4.6 million Americans gastrointestinal (GI) disorder.
annually, with peak onset between ages 30-60. It involves Risk Factors
ulcers forming in the stomach (gastric ulcer), duodenum Individuals more likely to experience constipation
(duodenal ulcer), or esophagus (esophageal ulcer). Most include:
• Women, particularly pregnant women
cases are due to H. pylori infection or NSAID use.
• Patients who have recently undergone surgery
Causes & Risk Factors • Older adults
• Non-Caucasians
• H. pylori infection (via food, water, or person-to- • People with a history of irritable bowel syndrome
person transmission) (NIDDK, 2018)
• NSAIDs (ibuprofen, aspirin) impairing the Causes
protective gastric lining Constipation may result from:
• Medications: Anticholinergic agents,
• Smoking & alcohol consumption (possible risks antidepressants, anticonvulsants, antispasmodics,
but inconclusive evidence) calcium channel blockers, diuretics, opioids,

13
 aluminum- and calcium-based antacids, and iron • Sensation of anorectal blockage in 25% of bowel
supplements. movements
• Physical conditions: Weakness, immobility, • Manual maneuvers required in 25% of bowel
debility, fatigue, celiac disease, and conditions movements
affecting intra-abdominal pressure (e.g., • Fewer than three spontaneous bowel movements
emphysema, spinal cord injury). per week
• Lifestyle factors: Ignoring the urge to defecate, Complications
low dietary fiber intake, inadequate hydration, • Increased Arterial Pressure: Straining (Valsalva
lack of exercise, and high stress levels. maneuver) may decrease cardiac output, causing
Pathophysiology dizziness or syncope.
The pathophysiology of constipation involves • Fecal Impaction: Hard stool accumulation
dysfunction in one of three major areas of the colon: leading to ulcer formation, pain, and
1. Mucosal transport: Mucosal secretions aid stool incontinence.
movement. • Hemorrhoids & Anal Fissures: Due to straining
2. Myoelectric activity: Propulsion and mixing of and hard stool passage.
rectal contents. • Rectal Prolapse: The rectum protrudes through
3. Defecation processes: Dysfunction in pelvic floor the anal canal.
coordination. • Megacolon: Atonic and dilated colon caused by
Types of Constipation stool obstruction, leading to distention and
1. Functional Constipation: Normal transit but incontinence.
difficulty in bowel movements, often managed
with fiber and fluids. Fecal Incontinence
2. Slow-Transit Constipation: Delayed movement Definition Fecal incontinence, also known as inadvertent
of stool due to motor dysfunction. bowel leakage, refers to the recurrent involuntary passage
3. Defecatory Disorders: Dysfunction in pelvic floor of stool from the rectum for at least three months. Several
and anal sphincter coordination. factors contribute to this disorder, including the rectum’s
4. Opioid-Induced Constipation: Occurs due to ability to sense and accommodate stool, stool consistency,
opioid therapy and meets criteria for functional the integrity of the anal sphincters and musculature, and
constipation. rectal motility. It is a prevalent condition, affecting at least
Clinical Manifestations 7 out of 100 nonhospitalized adults and nearly half of
Symptoms include: adults in long-term care facilities, such as nursing homes.
• Fewer than three bowel movements per week The impact on quality of life can be substantial.
• Abdominal bloating and pain Pathophysiology Fecal incontinence can stem from
• Straining and incomplete evacuation multiple causes and risk factors and may indicate an
• Hard, dry, or lumpy stools underlying medical condition. It generally results from
• Tenesmus (painful straining) disruptions to the anorectal unit’s structure or function.
Diagnosis Common causes include:
Diagnosis is based on: • Anal sphincter weakness – Due to trauma (e.g.,
• Patient history and physical examination surgery) or non-traumatic conditions (e.g.,
• Stool testing for occult blood scleroderma).
• Imaging: Barium enema, sigmoidoscopy, X-ray, • Neuropathies – Peripheral (e.g., pudendal nerve
or colonoscopy damage) or generalized (e.g., diabetes-related
• Functional tests: Anorectal manometry, nerve damage).
defecography, colonic transit studies • Pelvic floor disorders – Such as rectal prolapse.
Rome IV Diagnostic Criteria for Functional Constipation • Inflammation – Conditions like radiation
Symptoms must be present for at least three months, with proctitis or inflammatory bowel disease (IBD).
onset six months prior to diagnosis, and include at least • Central nervous system disorders – Including
two of the following: dementia, stroke, spinal cord injury, and multiple
• Straining in 25% of bowel movements sclerosis.
• Hard or lumpy stools in 25% of bowel • Diarrhea and fecal impaction – Both can lead
movements to incontinence.
• Sensation of incomplete evacuation in 25% of • Behavioral disorders – Affecting bowel control.
bowel movements • Aging – Leading to weakness or loss of anal or
rectal muscle tone.

14
Clinical Manifestations Symptoms of fecal incontinence • Bowel training programs – Establishing regular
vary in severity: bowel habits and scheduling toileting times.
• Minor soiling. • Biofeedback and pelvic floor exercises –
• Occasional urgency and loss of control. Strengthen sphincter control.
• Complete incontinence. • Dietary modifications – Encouraging foods that
• Poor control of flatus, diarrhea, or constipation. thicken stool (e.g., applesauce) and avoiding
• Passive incontinence – Occurs without warning. stool-loosening foods (e.g., prunes, rhubarb).
• Urge incontinence – The sensation to defecate is • Medication management – Antidiarrheal agents
present, but the individual cannot reach the toilet like loperamide and diphenoxylate with atropine
in time. can be prescribed, with loperamide preferred due
Assessment and Diagnostic Findings A thorough to fewer central nervous system effects.
medical history helps identify the cause of fecal • Skin integrity maintenance – Preventing
incontinence. Diagnostic studies include: perineal excoriation through meticulous hygiene,
• Rectal and endoscopic examinations (e.g., skin cleansers, and protective products.
flexible sigmoidoscopy) to rule out tumors, • Use of continence aids –
inflammation, fissures, or impaction. o Incontinence briefs are used sparingly to
• Anorectal manometry, defecography, minimize skin exposure to fecal material.
electromyography, anal endosonography, pelvic o Foam anal plugs may be an option,
MRI, and transit studies to assess muscle tone and though not always well tolerated.
structural abnormalities. o Fecal incontinence devices like external
Medical Management Treatment focuses on addressing collectors or internal drainage systems
the underlying cause: (e.g., Flexi-Seal Fecal Management
• Diarrhea-related incontinence – Managed by System) help manage chronic cases.
treating diarrhea.
• Fecal impaction – Resolving the impaction may Irritable Bowel Syndrome
stop incontinence. Irritable Bowel Syndrome (IBS) is a chronic functional
• Drug-induced incontinence – Adjusting disorder causing recurrent abdominal pain and bowel
medication regimens (e.g., reducing laxatives, movement irregularities, such as diarrhea, constipation, or
magnesium-containing antacids) can help. both, without an identifiable cause. The global prevalence
• Dietary adjustments – Adding psyllium fiber is 11%, with 12% of American adults affected. It
supplements can improve stool consistency. primarily affects individuals under 45 and is more
• Medications – Loperamide, taken 30 minutes common in women. IBS onset is linked to genetic,
before meals, can help control symptoms. environmental, and psychosocial factors, with triggers
• Biofeedback therapy – Used for sensory including stress, sleep deprivation, neurohormonal
awareness and sphincter control. deregulation, bacterial overgrowth, infections,
• Bowel training programs – Techniques like inflammation, and food intolerance.
abdominal massage, Valsalva maneuver, and
digital rectal stimulation assist in stool Pathophysiology:
evacuation. IBS results from intestinal motility dysfunction due to
• Sacral nerve stimulation – Involves implanting neuroendocrine dysregulation, serotonin signaling
a stimulator that delivers low-amplitude electrical changes, infections, irritation, or metabolic disturbances.
stimulation to the sacral nerve. The peristaltic waves are altered, impacting bowel
• Surgical interventions – May include sphincter movement propulsion, though no inflammation or
repair, artificial sphincter implantation, anal structural tissue damage is observed.
sphincter bulking, fecal diversion, or sacral nerve Clinical Manifestations:
stimulation. Symptoms range from mild to severe and include altered
Nursing Management bowel patterns:
• Comprehensive health history collection – • IBS-C: Constipation-dominant
Includes surgical history, chronic conditions, • IBS-D: Diarrhea-dominant
dietary patterns, bowel habits, and medication • IBS-M: Mixed type
use. • IBS-U: Unclassified type
• Bowel diary and stool charting – Helps track Other symptoms include pain, bloating, and distention,
elimination patterns. often relieved by defecation. IBS can co-occur with

15
GERD, chronic fatigue syndrome, fibromyalgia, (iron, calcium), and nutrients (carbohydrates,
interstitial cystitis, migraines, anxiety, and depression. fats, proteins).
Assessment & Diagnosis: • The disruption can occur anywhere in the
The Rome IV criteria diagnose IBS based on recurrent digestive tract, leading to decreased nutrient
abdominal pain at least once daily for three months, with absorption.
at least two of the following: Causes
• Pain related to defecation • Mucosal (transport) disorders – e.g., celiac
• Pain with a change in stool frequency disease, Crohn’s disease, radiation enteritis.
• Pain with a change in stool appearance • Luminal disorders – e.g., bile acid deficiency,
A stool diary (e.g., Bristol Stool Form Scale) helps Zollinger-Ellison syndrome, pancreatic
categorize IBS type. Diagnostic tests (CBC, C-reactive insufficiency, small bowel bacterial overgrowth,
protein, fecal calprotectin, serologic tests for celiac chronic pancreatitis.
disease, stool studies, colonoscopy) rule out other • Lymphatic obstruction – e.g., neoplasms, surgical
conditions like IBD and colorectal cancer. trauma, interfering with fat transport.
Medical Management: Types of Malabsorptive Disorders
Treatment aims to relieve pain and control bowel • Celiac disease – Autoimmune response to gluten,
irregularities through lifestyle modifications, dietary leading to villous atrophy in the small intestine.
changes, and medications: • Lactose intolerance – Deficiency of lactase
enzyme, leading to intolerance to milk products.
• Pancreatic insufficiency – Reduced enzyme
activity, leading to poor digestion of fats and
• Dietary Management: proteins.
o Soluble fiber (e.g., psyllium) • Zollinger-Ellison syndrome – Excess gastric acid
o Low-FODMAP diet (avoiding inactivates pancreatic enzymes.
fermentable foods like wheat, dairy, • Whipple disease – Bacterial invasion of intestinal
high-fructose fruits, and artificial mucosa.
sweeteners) • Parasitic infections – Damage or invasion of
• Medications: intestinal mucosa (e.g., giardiasis).
o IBS-D: Loperamide, alosetron, Signs and Symptoms
rifaximin, eluxadoline • Gastrointestinal symptoms: Diarrhea, steatorrhea
o IBS-C: Lubiprostone (fatty stools), bloating, flatulence, abdominal
o Antispasmodics (e.g., dicyclomine) for pain, weight loss.
pain • Non-GI symptoms: Fatigue, anemia,
o Antidepressants to modulate serotonin osteoporosis, neurological symptoms
levels and intestinal transit (paresthesia, seizures), dermatitis herpetiformis
o Peppermint oil for symptom relief (rash associated with celiac disease).
o Probiotics (Lactobacillus, Diagnostic Tests
Bifidobacterium) for bloating and gas • Serologic tests:
reduction o Immunoglobulin A (IgA) anti-tissue
Nursing Management: transglutaminase (tTG) for celiac
Nurses play a vital role in patient education, focusing on: disease.
• Encouraging the use of a bowel diary (e.g., • Endoscopic biopsy:
Bristol Stool Form Scale) o Biopsy of small intestine to assess villous
• Promoting good sleep and dietary habits atrophy (for celiac disease).
• Advising meal regularity and fluid intake • Lactose intolerance test:
management (avoiding fluids with meals to o Measures the body's response to lactose
prevent bloating) ingestion.
• Helping identify and eliminate food triggers via a • D-xylose test:
1-2 week food diary o Measures carbohydrate absorption
efficiency.
Malabsorption Syndrome Medical Management
Definition • Celiac disease: Lifelong gluten-free diet, dietitian
• Malabsorption occurs when the digestive system consultation.
is unable to absorb vitamins (A, B12), minerals

16
 • Lactose intolerance: Lactase enzyme Diagnosis
supplements, avoiding dairy, calcium and vitamin • Lab Tests:
D supplementation. o WBC count >10,500/mm³ (in 80-85% of
• Pancreatic insufficiency: Pancreatic enzyme cases).
replacement therapy (PERT). o Neutrophils >75%.
• Zollinger-Ellison syndrome: Acid suppression o Elevated C-reactive protein (CRP)
therapy. within the first 12 hours.
• Parasitic infections: Antiparasitic medications. • Imaging: CT scan or ultrasound confirms
Nursing Management diagnosis.
• Educate patients about dietary modifications • Pregnancy test for women to rule out ectopic
(e.g., gluten-free, lactose-free). pregnancy.
• Monitor for nutrient deficiencies and recommend • Urinalysis to rule out UTI or kidney stones.
supplementation (e.g., vitamin B12, iron, Complications
calcium). • Perforation → leads to peritonitis, abscess
• Assess for complications like osteoporosis, formation, or portal pylephlebitis (septic
anemia, or neurological deficits. thrombosis of the portal vein).
• Encourage compliance with medical treatments • Perforation risk: Occurs within 6-24 hours after
and lifestyle changes. pain onset.
• Provide resources for support groups or Special Considerations (Older Adults)
specialized dietitians. • Uncommon but dangerous. Symptoms may be
• vague or absent, leading to delayed diagnosis
Appendicits and increased risk of complications.
Definition: Medical Management
• The appendix is a small, worm-like structure • Immediate surgery (appendectomy) to prevent
attached to the cecum. perforation.
• It can become obstructed, leading to infection • Pre-op care:
(appendicitis). o IV fluids for hydration and electrolyte
• Most common cause of acute abdominal pain balance.
requiring emergency surgery. o Antibiotics to prevent infection.
• Typically affects ages 10-30, more common in o Pain management with analgesics.
males, with a familial tendency. o NO laxatives or enemas (risk of
Pathophysiology rupture).
• Blockage can occur due to fecalith, lymphoid • Surgical options:
hyperplasia, foreign bodies, or tumors. o Laparoscopic appendectomy (preferred
• Leads to inflammation, increased pressure, for faster recovery).
bacterial growth, and possible gangrene or o Open appendectomy (if complications
perforation. occur).
Clinical Manifestations • Antibiotics:
• Early symptoms: Vague periumbilical pain o <24 hours for non-perforated cases.
with anorexia. o Up to 5 days for perforated cases.
• Later symptoms: Sharp, localized right lower • If abscess is present → drainage first, then
quadrant pain, nausea, and possible low-grade delayed appendectomy.
fever. Postoperative Care
• Key signs: • High Fowler’s position to reduce pain and
o McBurney’s point tenderness (midway improve breathing.
between umbilicus and iliac spine). • Incentive spirometer use to prevent lung
o Rebound tenderness (increased pain complications.
when pressure is released). • IV fluids for hydration.
o Rovsing’s sign (pain in the right lower • Pain management: Switch from IV to oral
quadrant when the left side is pressed). analgesics when tolerated.
• If perforation occurs → symptoms of peritonitis, • Monitor for bowel function return (auscultate
abdominal distention, worsening condition. bowel sounds, check for flatus).
• Constipation may occur, but laxatives should be • Early ambulation to prevent blood clots and
avoided (risk of perforation). lung issues.

17
• Diet: Clear liquids → regular diet as tolerated.
• Discharge criteria:
o Normal temperature.
o Tolerable pain.
o No complications.
• Recovery:
o Resume normal activities in 2-4 weeks
(avoid heavy lifting).

Inflammatory Bowel Disease

Definition: Inflammatory Bowel Disease (IBD) is a

group of chronic disorders, including Crohn’s disease and
ulcerative colitis, that cause inflammation and ulceration
in the bowel.

18
Prevalence and Risk Factors
• High prevalence in: U.S., Canada, Europe
(Germany, Norway), and increasing in South Symptoms
America, Africa, and Asia. • Crohn’s Disease:
• Risk Factors: o Right lower quadrant pain (not relieved
o Family history (especially first-degree by defecation)
relatives) o Crampy pain after meals, leading to
o Caucasian and Ashkenazi Jewish descent reduced food intake, weight loss,
o Living in northern climates and urban malnutrition
areas o Chronic diarrhea with steatorrhea (fatty
o Age: Diagnosed commonly between 15– stools)
40 years, with another peak at 55–65 o Possible perforation, fistulas, abscesses
years o Extraintestinal symptoms: Joint pain
o Smoking: (arthritis), skin issues, eye inflammation
 Increases risk for Crohn’s (uveitis), mouth ulcers
disease • Ulcerative Colitis:
 Ex-smokers/nonsmokers at o Severe, bloody diarrhea
higher risk for ulcerative colitis o Left-sided abdominal pain (descending
Causes (Theories) colon involvement)
• Genetic predisposition o Fever, fatigue, weight loss
• Altered immune response o Extraintestinal symptoms similar to
• Environmental triggers: Air pollutants, food, Crohn’s
tobacco, viral illnesses Diagnosis
• Inflammatory cytokines play a key role in disease • CT Scan: Detects bowel wall thickening,
progression abscesses, obstructions
• MRI: Useful for pelvic and perianal
complications
• Blood tests:
o CBC: Check for anemia (low
hematocrit/hemoglobin), elevated WBC
(infection/inflammation)
o ESR: Elevated (indicates inflammation)
o Albumin and protein: Decreased levels
suggest malnutrition

19
 • Endoscopy & Biopsy: Used for definitive • Progression: Ulcers expand longitudinally and
diagnosis transversely, creating a cobblestone
Complications appearance.
• Crohn’s Disease: • Complications: Inflammation leads to fistulas,
o Intestinal obstruction fissures, abscesses, and granulomas.
o Malnutrition due to malabsorption • Skip lesions: Diseased sections are sharply
o Fistulas and abscesses demarcated from normal bowel tissue.
o Colon cancer • Advanced stage: The bowel wall thickens and
• Ulcerative Colitis: narrows, potentially causing obstruction.
o Toxic megacolon (life-threatening bowel
dilation) Clinical Manifestations
o Perforation (hole in intestine) • Gastrointestinal Symptoms:
o Severe bleeding (hemorrhage) o Chronic diarrhea
o Increased risk of colon cancer o Right lower quadrant (RLQ)
Treatment Options abdominal pain (crampy, worsens after
• Medications: meals)
o Corticosteroids (reduce inflammation) o Weight loss and malnutrition (due to
o Aminosalicylates (e.g., sulfasalazine) pain-induced food avoidance)
o Immunomodulators (e.g., azathioprine) o Anemia (due to nutrient malabsorption)
o Monoclonal antibodies (e.g., infliximab, o Steatorrhea (fatty stools)
adalimumab) • Systemic Symptoms:
o Antibiotics (especially for Crohn’s) o Fever, fatigue, and night sweats
• Nutritional Support: o Joint pain (arthritis)
o Parenteral nutrition (IV feeding for o Skin issues (erythema nodosum)
severe cases) o Eye inflammation (uveitis)
o High-calorie, low-fiber diets o Mouth ulcers
• Surgical Options:
o Crohn’s Disease: Partial bowel removal; Diagnosis
recurrence common • Imaging Tests:
o Ulcerative Colitis: Total colectomy o CT scan: Detects bowel thickening,
(removal of colon), which may cure the abscesses, and obstructions.
disease o MRI: Best for identifying perianal
abscesses and fistulas.
Crohn’s disease, • Lab Tests:
Definition: also called regional enteritis, is a chronic o CBC (Complete Blood Count): Checks
inflammatory condition of the gastrointestinal (GI) tract for anemia (low hemoglobin) and
that affects all layers of the bowel wall (transmural infection (high WBC count).
inflammation). It can occur anywhere in the GI tract but o ESR (Erythrocyte Sedimentation
most commonly affects the distal ileum and ascending Rate): Elevated levels indicate
colon. inflammation.
o Albumin & Protein Levels: Low levels
Prevalence suggest malnutrition.
• 35% of patients have ileitis (affecting only the
ileum). Complications
• 45% have ileocolitis (affecting both the ileum • Intestinal obstruction or strictures
and colon). • Fistula and abscess formation (most commonly
• 20% have granulomatous colitis (affecting only enterocutaneous fistula)
the colon). • Severe malnutrition due to malabsorption
• Increased risk of colon cancer in colonic
Pathophysiology Crohn’s disease
• Initial stage: Inflammation starts in the intestinal •
crypts, forming small ulcers and abscesses. Ulcerative colitis
Definition: is a chronic inflammatory disease that affects
the mucosal and submucosal layers of the colon and

20
rectum. It is characterized by unpredictable periods of o Elevated C-reactive protein
remission and exacerbation, with symptoms such as (inflammation marker).
abdominal cramps and bloody or purulent diarrhea. o Increased antineutrophil cytoplasmic
antibodies.
Pathophysiolog • Rule Out Other Causes:
• Affects the superficial mucosa of the colon. o Stool tests to exclude infections (e.g., C.
• Causes multiple ulcerations, inflammation, and difficile, Salmonella, Shigella, etc.).
shedding of the colonic epithelium.
• Leads to bleeding due to ulcerations. Complications
• The mucosa becomes swollen and inflamed. 1. Toxic Megacolon
• Lesions occur one after another (contiguous). o Severe inflammation extends into the
• Over time, the bowel narrows, shortens, and muscle layer.
thickens. o Symptoms: fever, abdominal pain and
• Unlike Crohn’s disease, ulcerative colitis does distension, vomiting, and fatigue.
not usually cause abscesses, fistulas, o Treatment: NG suction, IV fluids,
obstructions, or fissures. corticosteroids, and antibiotics.
o If no improvement in 72 hours, surgery is
Clinical Manifestations required.
• Remission and exacerbations occur. 2. Perforation
• Symptoms include: o Can occur if inflammation is severe.
o Diarrhea with mucus, pus, or blood. o Requires immediate surgical
o Abdominal pain (especially in the left intervention.
lower quadrant). 3. Increased Risk of Colon Cancer
o Intermittent tenesmus (urge to defecate). o After 20 years, 7–10% of patients with
o Pallor, anemia, and fatigue due to extensive ulcerative colitis develop colon
bleeding. cancer.
o Anorexia, weight loss, fever, vomiting, 4. Osteoporotic Fractures
and dehydration. o Due to decreased bone mineral density,
o Six or more liquid stools per day. often worsened by corticosteroid use.
• Classified as mild, severe, or fulminant based on
symptom severity. Medical Management
• Possible complications: Pharmacologic Therapy
o Hypoalbuminemia, electrolyte 1. Aminosalicylates (First-line treatment)
imbalances, and anemia. o Examples: Sulfasalazine, mesalamine,
o Extraintestinal symptoms: skin lesions, olsalazine, balsalazide.
eye inflammation, arthritis, and liver o Purpose: Induce and maintain remission.
disease. o Side Effects: Headaches, nausea,
diarrhea.
Assessment and Diagnostic Findings 2. Antibiotics (For perianal fistulas and abscesses
• Imaging Tests: in Crohn’s disease, not primary treatment for
o Abdominal X-ray to rule out obstruction ulcerative colitis)
or perforation. o Examples: Metronidazole, ciprofloxacin.
o Colonoscopy (definitive test) to observe o Side Effects: Nausea, diarrhea, risk of C.
inflamed mucosa and ulcerations. difficile infection, peripheral neuropathy.
o CT scan, MRI, or ultrasound to check for 3. Corticosteroids (For severe flare-ups, short-
abscesses. term use)
• Laboratory Tests: o Examples: Prednisone (oral),
o Stool test: positive for blood. hydrocortisone (IV), budesonide (rectal).
o Low hematocrit and hemoglobin o Purpose: Reduce inflammation.
(anemia). o Side Effects: Delayed wound healing,
o Elevated WBC count immunosuppression.
(infection/inflammation). 4. Immunomodulators (For long-term
o Low albumin (indicating malabsorption). maintenance therapy)
o Electrolyte imbalances.

21
 o Examples: Azathioprine, o Not restricted for most patients in
mercaptopurine, methotrexate, remission.
cyclosporine. • Dietitian consultation: May be recommended
o Purpose: Reduce inflammation, decrease for personalized meal plans.
need for steroids. 4. Malnutrition Risks & Management
o Risks: Bone marrow suppression, liver • Risk Factors:
toxicity, increased infection risk. o Losing more than 10% of lean body
o Monitoring: Regular CBC, liver function mass.
tests, cancer screenings. o Increased risk of infection and poor
5. Anti-Tumor Necrosis Factor (TNF) wound healing.
Medications • Nutritional Therapy:
o Monoclonal antibodies that inhibit o Oral or enteral nutrition: Preferred over
inflammation. IV nutrition.
o Parenteral (IV) nutrition: Used for
Nutritional Therapy for IBD (Inflammatory Bowel patients with bowel obstruction, short
Disease) bowel syndrome, or severe Crohn’s
disease.
1. Diet During Induction Therapy
• Purpose: Reduce inflammation, control pain, Surgical Management of IBD
and manage diarrhea.
• Recommended Diet: 1. When Surgery is Needed
o Low-residue: Reduces bowel movement • Ulcerative Colitis:
frequency. o Colon cancer, severe bleeding,
o High-protein, high-calorie: Supports megacolon, or perforation.
energy and muscle maintenance. • Crohn’s Disease:
o Vitamin and iron supplements: Prevent o Small bowel obstruction (most common).
deficiencies. o Abscess, perforation, hemorrhage, or
o Calcium & Vitamin D: Needed if patient fistula formation.
is on corticosteroids to prevent 2. Common Surgical Procedures
osteopenia. • Strictureplasty: Widening of blocked or narrowed
• Fluid Management: sections of the intestine.
o IV fluids: Given in hospitals for • Small Bowel Resection: Removing diseased
dehydration from diarrhea. portions and reconnecting the intestines.
o Oral fluids: Encouraged for at-home • Intestinal Transplant: Used in severe Crohn’s
care. disease; high risk and cost.
2. Avoiding Triggers 3. Proctocolectomy & Ileostomy
• Cold foods & smoking: Increase bowel • Proctocolectomy (removal of colon and rectum)
movement frequency. with ileostomy (stoma for waste elimination).
• Problematic foods: Avoid foods that cause • Curative for ulcerative colitis, but not for Crohn’s
bloating or diarrhea. disease.
• Special Diets: 4. Restorative Proctocolectomy with Ileal Pouch Anal
o FODMAP diet: May help some patients Anastomosis (IPAA)
with IBS symptoms. • Procedure: Removes colon & rectum while
o Lactose restriction: Beneficial for those preserving anal function.
with lactose intolerance. • Benefits:
3. Nutrition During Remission o Avoids permanent ileostomy.
• Avoid known food triggers. o Reduces stool frequency over time.
• Probiotics: • Complications:
o Helpful for ulcerative colitis (e.g., o Perianal irritation, fistulas, small bowel
Escherichia coli Nissle, Lactobacillus obstruction, and pouchitis.
rhamnosus). o May affect female fertility.
o Not effective for Crohn’s disease. 5. Continent Ileostomy (Kock Pouch)
• Fiber: • Alternative to traditional ileostomy.
• No external fecal collection bag needed.

22
 • Complications: • Personal hygiene and avoiding straining.
o Valve malfunction requiring additional • High-residue diet (fruits, bran, increased fluids).
surgery. • Hydrophilic bulk-forming agents (e.g., psyllium).
o Fistulas, strictures, and stoma issues. • Warm compresses, sitz baths, analgesic
• Less commonly used due to high complication ointments, and astringents (e.g., witch hazel).
rates.
Nonsurgical Treatments:
Nursing Process for IBD Management • Infrared photocoagulation, bipolar diathermy,
and laser therapy.
1. Patient Assessment • Injection of sclerosing agents (e.g., 5% phenol in
• Symptoms to monitor: saline) to cause blood vessel thrombosis.
o Abdominal pain, diarrhea, nausea,
weight loss. Surgical Treatments:
o Diet and bowel habits. 1. Rubber Band Ligation:
• Lifestyle factors: o Hemorrhoid is tied off with a small
o Smoking, diet patterns, family history. rubber band.
2. Patient Education & Care o Tissue becomes necrotic and sloughs off.
• Nutritional guidance to prevent malnutrition. o Can cause pain, secondary hemorrhage,
• Post-surgical care for ostomies and pouch or infection.
maintenance. 2. Stapled Hemorrhoidopexy:
• Avoiding dietary triggers to maintain remission. o Uses surgical staples to treat prolapsing
hemorrhoids.
Hemorrhoids o Less postoperative pain and fewer
Definition: complications.
• Dilated portions of veins in the anal canal. 3. Hemorrhoidectomy:
• Affects approximately 10 million people in the o Complete surgical excision of
U.S., with one-third seeking treatment annually. hemorrhoidal tissue.
o Rectal sphincter may be dilated digitally.
Causes & Risk Factors: o Clamp, cautery, or ligation used for
• Shearing of mucosa during defecation. removal.
• Increased pressure due to pregnancy.
• Aggravated by excessive straining.

Types of Hemorrhoids: Pilonidal Sinus or Cyst

1. Internal Hemorrhoids: Located above the internal Definition:
sphincter. • Found in the intergluteal cleft on the lower
2. External Hemorrhoids: Appear outside the sacrum.
external sphincter. • Caused by local trauma or congenital infolding of
epithelial tissue.
Classification of Internal Hemorrhoids:
• First degree: Do not prolapse. Symptoms & Risk Factors:
• Second degree: Prolapse during defecation but • Often asymptomatic until adolescence or
reduce spontaneously. adulthood.
• Third degree: Require manual reduction. • Infection leads to drainage or abscess formation.
• Fourth degree: Cannot be reduced, risk of • Aggravated by perspiration and friction.
strangulation and thrombosis.
Treatment:
Symptoms: • Incision and drainage under local anesthesia.
• Itching and pain. • Further surgery may be required to excise the cyst
• Bright red bleeding during defecation. and sinus tracts.
• Severe pain with external hemorrhoids due to • Healing occurs by granulation; absorptive
thrombosis and inflammation. dressings used to keep wound edges separated.

Management & Treatment: Nursing Management of Anorectal Disorders

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 o Systemic nutritional deficiencies due to
Home & Community-Based Care: micronutrient and macronutrient loss
• Patients are usually treated as outpatients.
• If hospitalized, stays are typically short (24 hours
or less). Clinical Manifestations
Patient Education for Self-Care: Gastrointestinal (GI) Symptoms (more common in
• Keep perianal area clean using warm water and children):
absorbent wipes. • Diarrhea
• Avoid rubbing with toilet tissue. • Steatorrhea (fatty stools)
• Sitz baths (3-4 times/day) to relieve soreness and • Abdominal pain
spasms. • Abdominal distention
• Use of ice packs and analgesic ointments for pain • Flatulence
relief. • Weight loss
• Wet dressings with witch hazel to reduce edema. Non-GI Symptoms (common in adults, variable
• Assume prone position periodically to minimize presentation):
tissue swelling. • Fatigue, general malaise
Continuing & Transitional Care: • Depression
• Sitz baths should be taken after each bowel • Hypothyroidism
movement for 1-2 weeks. • Migraine headaches
• Hydration: Drink at least 2L of water daily. • Osteopenia, anemia
• High-fiber diet to ease bowel movements. • Seizures, paresthesias (hands and feet)
• Bulk laxatives (e.g., psyllium) and stool softeners • Red, shiny tongue
(e.g., docusate) may be recommended. • Dental enamel ridges, discoloration
• Encourage moderate exercise to promote healthy • Dermatitis herpetiformis (rash with erythematous
bowel function. macules, papules, and vesicles)

Celiac Disease Assessment & Diagnostic Findings

Definition: is a disorder of malabsorption caused by an Key steps in diagnosis:
autoimmune response to gluten, a protein found in wheat, 1. Comprehensive assessment:
barley, rye, malt, dextrin, and brewer’s yeast. o Signs and symptoms
• Prevalence: 1% of the U.S. population o Family history
• More common in women (2:1 ratio) o Risk factor evaluation
• Higher incidence among Caucasians but 2. Serologic Testing:
increasing in non-Caucasians o Immunoglobulin A (IgA) anti-tissue
• Genetic component: First-degree relatives at transglutaminase (tTG) test
higher risk o Sensitivity: 90%, Specificity: 95%
• Higher risk in individuals with: o Patient must continue gluten
o Type 1 diabetes consumption for accurate results
o Down syndrome 3. Confirmatory Testing:
o Turner syndrome o Upper endoscopy with biopsy of the
proximal small intestine
Pathophysiology
• 30% of the U.S. population may have a genetic Medical Management
predisposition. • Lifelong gluten-free diet (no drug-induced
• Key genetic markers: HLA-DQ2 or HLA-DQ8 remission available)
alleles. • Symptoms may take a year to fully resolve as
• Autoimmune response triggered by gluten intestinal villi recover
ingestion, leading to: • Additional treatments based on complications:
o Inflammation of small intestine o Anemia: Supplement with folate,
epithelium (proximal portion most cobalamin, or iron
affected) o Osteopenia: Osteoporosis treatment
o Damage to mucosal villi, leading to
malabsorption Nursing Management
• Patient Education:

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 oAdherence to a gluten-free diet o Rovsing’s sign: RLQ pain when
oIdentifying hidden gluten in processed palpating LLQ.
foods • Complications if Ruptured:
o Avoiding cross-contamination (e.g., o Peritonitis symptoms (abdominal
shared toasters, restaurant preparation distention, worsening condition)
areas) o Paralytic ileus
• Non-Food Gluten Sources: o Constipation (laxatives may cause
o Medications with gluten gels perforation)
o Toothpaste Assessment & Diagnostic Findings
o Communion wafers • Laboratory Tests:
o Cosmetics (e.g., lipsticks) o WBC count >10,500/mm³ in 80-85% of
o Art supplies (e.g., modeling clay) cases
• Regulatory Guidelines: o Neutrophilia (>75% neutrophils in WBC
o U.S. Food and Drug Administration count)
(FDA) oversees gluten-free labeling o Elevated C-reactive protein (especially
Appendicitis within first 12 hours)
• Imaging:
Definition & Overview o CT scan or ultrasound (preferred
• The appendix is a small, vermiform appendage diagnostic tools)
(8-10 cm long) attached to the cecum. o Pregnancy test (to rule out ectopic
• It fills with digestive byproducts and empties into pregnancy before radiologic studies)
the cecum. o Urinalysis (to rule out UTI or renal
• Due to its small lumen, it is prone to obstruction calculi)
and infection (appendicitis). Complications
• Appendicitis is the most common cause of acute • Major complications:
abdomen and emergency abdominal surgery. o Gangrene
• Typically occurs between ages 10-30, slightly o Perforation (leading to peritonitis,
more common in males, and may have a familial abscess formation, or septic thrombosis
predisposition. of the portal vein)
Pathophysiology • Perforation typically occurs within 6-24 hours
• Inflammation occurs due to obstruction by: after symptom onset.
o Fecalith Gerontologic Considerations
o Lymphoid hyperplasia (from infection or • Uncommon in older adults, but when it occurs:
inflammation) o Symptoms are often altered or minimal.
o Foreign bodies (e.g., fruit seeds) or o Pain may be absent or vague.
tumors (rare) o Fever and leukocytosis may not be
• Leads to increased pressure, edema, and bacterial present.
overgrowth. o Delayed diagnosis increases risk of
• Can result in ischemia, gangrene, or perforation. complications.
Clinical Manifestations o Often diagnosed only after gangrene or
• Initial Symptoms: perforation occurs.
o Vague periumbilical pain (dull, poorly Medical Management
localized) • Immediate surgery (appendectomy) to prevent
o Anorexia perforation.
• Progression: • Pre-surgical care:
o Right lower quadrant pain (sharp, well- o IV fluids for hydration
localized) o Antibiotics to prevent infection
o Nausea o Pain management
o Low-grade fever • Types of Surgery:
• Signs: o Laparotomy: Open surgical removal.
o McBurney’s point tenderness: Pain on o Laparoscopy (preferred): Minimally
pressure at RLQ. invasive, faster recovery.
o Rebound tenderness: Pain upon release • Post-surgical Antibiotics:
of pressure. o Nonperforated cases: <24 hours

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 o Perforated cases: <5 days
• Abscess Management:
o Drained percutaneously or surgically
before delayed appendectomy.
Nursing Management
Goals:
• Relieve pain
• Prevent fluid volume deficit
• Reduce anxiety
• Prevent/treat infection
• Prevent atelectasis
• Maintain skin integrity
• Ensure optimal nutrition
Preoperative Care:
• IV infusion for hydration
• Antibiotics
• Pain management
• Avoid enemas (risk of perforation)
Postoperative Care:
• Positioning: High Fowler’s position (reduces
tension on incision, promotes lung expansion)
• Pain Management:
o Parenteral opioids (e.g., morphine)
o Transition to oral pain relievers once
tolerated
• Monitoring:
o Bowel sounds return before starting oral
intake
o Urine output to assess hydration
• Activity:
o Early ambulation to prevent VTE and
atelectasis
• Diet:
o Oral fluids once tolerated
o Solid food as tolerated
Discharge & Home Care
• Discharge criteria:
o Normal temperature
o No excessive discomfort
o Laparoscopic procedure completed
successfully
• Follow-up:
o Suture removal & wound inspection in 1-
2 weeks
• Activity restrictions:
o Avoid heavy lifting postoperatively
o Resume normal activities in 2-4 weeks
• Additional care for complicated cases:
o Hospital stay extended for gangrenous or
perforated appendicitis
o Home health nurse may assist with
wound care and monitoring

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