NCM 116 Lecture Notes ( Gastrointestinal)

The Anatomy and Physiology of the Digestive System (GIT, Alimentary Tract)
Functions:
1. Ingestion – Mobility of ingested foods
2. Digestion – Secretion of digestive juices, enzymes & hormones
3. Absorption & assimilation of essential nutrients
4. Elimination of waste products of digestion
LAYERS OF THE GIT
1. Tunica Mucosa
This is the innermost layer & has protective, secretory & absorptive functions. There are
lymphocytes in this area which are the main sources of gamma globulins.
2. Tunica Submucosa/Tela Submucosa
It is composed of connective tissues, blood vessels, & nerve fibers. The nerve fibers &
parasympathetic ganglia form the Meissner’s plexus which contains the autonomic
nervous system.
3. Tunica Muscularis
This is the muscle layer & responsible in mixing the contents of the lumen with the
digestive juices & moves them by means of peristalsis. The Auerbach’s plexus of nerve
fibers & terminal parasympathetic ganglia are found in this layer.
4. Tunica Serosa
This is the outermost layer of the alimentary tract. It is fibrous above the diaphragm &
below the diaphragm is the largest serous membrane of the body called the peritoneum.

Parts of the Digestive System

1. Main organs of digestion
a. Mouth
b. Pharynx
c. Esophagus
d. Stomach
 e. Small intestine
f. Large intestine
2. Accessory organs of digestion
a. teeth
b. tongue
c. salivary glands
d. appendix
e. gall bladder
f. liver
g. pancreas.

MOUTH (ORAL CAVITY, BUCCAL CAVITY)

The following structures/parts are found in the mouth:
• Teeth, tongue, salivary glands, lips
& cheeks
1. Teeth

a. Dentin
b. Enamel-hardest part
c. Cementum
d. Pulp
e. Root
The teeth are derivatives of the oral mucous membrane which has two sets. These are
the deciduous or the milk teeth (20) and the permanent or succedaneous teeth
(32).These are the incisors, canine, premolars or bicuspids and molars. The teeth are
responsible in chewing and grinding the food that we eat.

1. Tongue
The tongue consists of interlacing bundles of striated
muscles with chief function for the sense of taste. The
mucous membrane on the undersurface of the tongue
forms a fold known as the frenulum linguae which
extends from the tip of the tongue to the floor of the
 oral cavity. The mucous membrane of the dorsum of the tongue is thick and is studded with
papillae namely filiform, fungiform, circumvallate and foliate. The taste buds are found in the
fungiform and circumvallate papillae and has an opening called taste pores. The tongue is
important in chewing, swallowing and speaking. Cranial nerve XII (hypoglossal nerve) is the
motor nerve to the tongue and the Cranial nerve V (trigeminal nerve) supplies the receptors of
touch, temperature, and pain in the tongue. Cranial nerve VII and IX carry impulses concerned
with taste.

2. Salivary Glands
Numerous salivary glands are found in the oral
cavity. They secrete saliva continuously which is
viscous colorless, opalescent liquid containing
water, mucoprotein, immunoglobulin,
carbohydrates, calcium, phosphorus, sodium,
potassium, magnesium, chloride, traces of iron,
and iodine and enzymes specially ptyalin or
salivary amylase which splits starch into smaller,
water soluble substance. There are three pairs
of salivary glands namely parotid glands which
pour its secretion through the Stensen’s duct,
submandibular glands which pour its secretions
through the Wharton’s duct and the sublingual
glands which pour its secretion through several ducts in the floor of the mouth.
3. Lips
The lips are composed of striated muscles or orbicularis oris and connective tissue. They contain
large amount of eleidin which is responsible for its translucent appearance and has numerous
capillaries giving rise to the red color of the lips.
4. Cheeks
The cheeks are lined with mucous membrane. The main substances of the cheeks are the
striated muscles known as the buccinators which are the muscles of mastication.
PHARYNX
This is also known as the throat which serves both the passageway of food & air. It
conveys food from the mouth to the esophagus. It is composed of skeletal muscle fibers
concerned with swallowing known as the constrictors that move the bolus of food to the
esophagus
.
ESOPHAGUS
This is a long muscular collapsible tube about 25
centimeters long. It conveys food from the pharynx to
the stomach which lies posterior to the trachea and
anterior to the vertebral column. It passes through the
diaphragm in front of the aorta to enter the stomach.

STOMACH
The stomach is the distensible or expanded
portion of the GIT which lies in the epigastric
region of the abdomen on the left side below
the diaphragm. The right concave is the
lesser curvature while the left convex margin
is the greater curvature. The membrane of
the stomach is grayish pink and the surface
of the filled stomach is smooth and stretched
when empty it is thrown into folds known as
rugae.
Parts: Fundus, Body or Corpus, & Pylorus
Functions:
1. Reservoir of food
2. Partial digestion of food
3. Temporary storage of food
4. Secretes HCL, pepsin (pepsinogen) gastric lipase, intrinsic factor, gastrin,
serotonin and mucus.
SMALL INTESTINE
The small intestine is about 2.5 cm. in diameter and 609 cm. long which extends from the pyloric end to
the ileocecal orifice.
Functions:
1. Secretes intestinal juices and enzymes
2. Completes the digestion of foods
3. Facilitates absorption of essential nutrients by the intestinal absorptive cells known as
villi.
Parts/Divisions:
• Duodenum
• Jejunum
• Ileum
 The duodenum is the smallest part of the small intestine and it is a rough C shaped concavity
where the head of the pancreas lies. This is also the area where the common bile duct enters and the
large duct of Wirsung of the pancreas through the Ampulla of Vater guarded by the Sphincter of Oddi.
The jejunum extends from the duodenum to the ileum which is the largest part of the small
intestine. It is where digestion and absorption of nutrients is taking place and lies most in the umbilical
region. The ileum is the distal portion of the small intestine where end product of digestion is propelled
and forms the boundary between the ileum and the cecum.
In the mucosal lining of the small intestine which has structural specifications to increase the
surface area one is the plicae circularis or valves of Kerckring, then the enormous intestinal villi for
absorption. Between the enormous villi are openings known as crypts of Lieberkuhn where new cells are
formed to continually replace those that are exfoliated at the tips of the villi. The crypts also produce
intestinal juices. Occurring in the depths of the crypts are Paneth cells which are believed to contain
lysozyme, an enzyme capable of lysing or destroying bacteria.
There are three types of cells in the intestinal lining: absorptive cells which protect and participate
in the digestive process, goblet cells which secrete mucus to lubricate and protect the surface of the
epithelium and basal granular or argentaffin or enterochromaffin cells which contain serotonin causing
vigorous contraction of the smooth muscles.
In the lamina propia of the small intestine contain large number of plasma cells, eosinophils,
macrophages, and lymphocytes which form this aggregation of lymph follicles mass the Peyer’s patches
which forms the ileus defense mechanism against bacteria.

LARGE INTESTINE
The large intestine is about
6.3 cm. in diameter and 135 cm. long
which extends from the ileocecal
valve to the anus.
Parts/Divisions:
Cecum, Colon, Sigmoid,
Rectum and Anus
The large intestine differs from the
small intestine in several ways:
1.It forms no
circular folds
 except in the rectum.
2. No villi are present.
3. Goblet cells are abundant.
4. There are no Paneth cells.
5. The longitudinal muscular layer is localized in three thick bands known as
teniae coli.
6. The mucosa of the anal region is thrown into longitudinal folds known as the
rectal columns of Morgagni.
7. It forms bag like sacs called haustra when the longitudinal muscles contract.
There are segmental contractions by Haustra (sac or bag or pouch like structures) causing 3X a
day to move /propel waste products but not in Hirchsprung disease (congenital absence of
enteric nerves is obstructed by tonic contraction). It takes 1-3 days to complete the movement of
waste in the large intestine.
Functions:
➢ Reabsorbs H2O and salts as 1500 ml/day from the small intestine and only 50 – 100
ml/day excreted with foods and fast movement of chyme in the large intestine
decrease- diarrhea and abnormally slow movement – constipation
GIT BLOOD SUPPLY
• Hepatic portal artery and vein ESOPHAGUS
• Mesenteric arteries -
• Esophageal arteries
• Inferior thyroid arteries
• Left gastric artery – stomach
• Internal jugular vein - esophagus
• Spleenic artery
• Rectal arteries – large intestine
NEURAL REGULATION
Enteric nervous system – parasympathetic and sympathetic nerves

Auerbach’s plexus (motor functions) generates gastric mobility, increasing intensity

rate of contraction and release of gastrin
Meissner’s plexus (sensory function)
Sympathetic
Inhibit activity in the enteric plexuses; constrict GI system, blood vessels, and decrease
glandular secretions
Parasympathetic
Vagus nerve innervating all structures for the salivary glands to the transverse colon and
stimulate motor activity, secretory activity, endocrine secretion.
ACCESSORY ORGANS OF DIGESTION
The accessory organs of digestion play a vital role in the process of digestion where they
secrete substances necessary to prepare food for absorption in the small intestine.
1. SALIVARY GLANDS
a. Parotid glands
b. Submandibular glands
c. Sublingual glands
The parotid glands pour out their secretions through the Stenson’s duct, the
submandibular glands through the Wharton’s duct and the sublingual several
ducts in the floor of the mouth. They secrete saliva which aids in the process of
digestion in the mouth both mechanical and chemical processes.
2. LIVER
The liver is the largest organ of the body located in the hypochondriac and
epigastric regions. It consists of four lobes: the two main lobes are the right and
left separated by a falciform ligament where the right is subdivided into right lobe
proper, quadrate and caudate. Each lobe is divided into lobules which are the
functional unit of the liver.
 Functions:
1. Production of bile
2. It takes up and excretes the pigment bilirubin.
3. It performs metabolic functions
4. It stores vitamins and minerals (Vitamin K, D, A, B12 and iron)
5. It helps in blood coagulation.
6. It performs phagocytic functions.
3. GALL BLADDER
Te gall bladder is pear shaped, hollow viscous organ attached to the liver.
Functions:
1. . Stores bile
2. Concentrates bile
4. PANCREAS
The pancreas is a pinkish white organ consisting of a head body and tail. It is considered
as the romance of the abdomen and both an exocrine and endocrine glands. It is
composed of compound acinous glands, secrete pancreatic juices, enzymes and
hormones namely the insulin, a hypoglycemic agent by the beta cells of the islets of
Langerhans and glucagon by the alpha cells of the islets of Langerhans, which is a
hyperglycemic agent. It pours out its secretion through the Duct of Wirsung to the
duodenum through the Ampulla of Vater guarded by the Sphincter of Oddi.

PHYSIOLOGY OF DIGESTION
Two Processes Involve:
1. Mechanical Digestion
2. Chemical Digestion
A. Digestion In The Mouth
1. Mechanical Process
a. Chewing or Mastication – Teeth are designed for chewing.
Incisors – strong cutting action
Molars – grinding action
Jaw muscles work with the teeth. The chewing process is caused by the chewing
reflex brought about by the bolus or mass of food in the mouth with the aid of the teeth,
jaw muscles, cheek, and the tongue. Initial digestion of simple sugars is taking place in
the mouth. Act of chewing (mastication) & deglutition (swallowing) are the physical
processes to move food from the mouth to the esophagus. The tongue is responsible for
sense of taste & moves the food inside the mouth. The saliva keeps the mouth &
pharynx moist
2. Chemical Process
The source of the first secretion in the mouth is the saliva. The human saliva is
slightly acidic with a pH of 6.3 – 6.8.Saliva is composed of salts, sodium chloride,
sodium bicarbonate and organic substances and 1.5 L (1,500 cc/ml) of saliva is secreted
daily.
The following are functions of saliva:
1. It prepares the food for swallowing by moistening and lubricating it.
2. It dissolves food before they can be tasted.
3. It cleanses the mouth as it continually removes food particles that may act as
a culture media for bacteria.
4. Salivary amylase or ptyalin breaks starches to maltose, a simple form of
sugar.
5. It excretes organic substances (e.g., urea, sugar) and inorganic substances
(e.g., mercury, lead)
6. It keeps soft parts of the mouth pliable for speech.
Nervous Regulation of Salivary
Secretion – controlled by superior portions of the salivary nuclei and inferior
portions
Location: Pons Varolii and medulla oblongata
The salivary glands nuclei is exited by taste and tactile stimulate from the mouth.
Salivary secretion is reflex and involuntary.
B. Swallowing or Deglutition
This process carries food from the mouth to the stomach and a complex act
initiated voluntarily and completed involuntarily.
Three Stages of Swallowing or Deglutition
1. Voluntarily or Buccal Stage
Food is ready for swallowing by the pressure of the tongue
upward and backward against the palate and throat.
2. Pharyngeal Stage
It is brought about by pharyngeal muscle contraction.
3. Esophageal stage
It is brought about by peristaltic waves by the muscles of the
esophagus to squeeze toward the cardiac sphincter muscles of the
stomach.
Nervous Regulation of Swallowing or Deglutition
• Swallowing Center
• Location: Medulla Oblongata
Chemical Process in Deglutition
Mucus is produced by the pharyngeal and esophageal glands which facilitates
swallowing of the bolus of food. Liquids are first to empty, fat floats, gastric contents
(chyme) empty into the duodenum then to the pylorus.
C. Digestion in the Stomach
1. Mechanical Process
Three folds of the motor functions of the stomach
a. Storage of food
b. Mixing of food with secretions
c. Emptying of the stomach
This is brought about by peristaltic waves and the hormone gastrin which
increases pyloric forces and gastric motility and enterogastrone which inhibits gastric
motility thru the enteric reflex.Gastroduodenal junction with the pyloric sphincter
sequesters acid in the stomach and bile in the duodenum.Contraction after feeding
occurs at a rate of 3/minute. Rate of contraction increases by gastrin and decrease by
secretion.Sensory afferents play a role in the satiety center and increase intragastric
pressure, gastric distention, gastric acidity and pain. All lessen the desire to eat.Gastric
contents empty into the duodenum at a controlled rate. Antrum and pylorus contract
simultaneously allowing only a small amount of antral content into the duodenum.
The remaining gastric contents moves backward (retropulsion) causing further
mixing of foods (chyme)The rate of gastric emptying must meet the duodenal buffing
ability or else acid may damage duodenal mucosa and cause duodenal ulcer. The
pylorus prevents regurgitation of duodenal contents or else bile may damage stomach
mucosa causing gastric ulcer.
The rate of chyme entry into the duodenum is regulated in order to aid digestion.
Duodenal acidity (ph 3.5) decreases the rate of gastric emptying and causes secretion
release which increase HCO3 buffer secretion for pancreas and liver. Chyme becomes
more hypertonic as digestion progresses and decrease rate of gastric emptying by a
neural reflex. Fat content decreases rate of gastric emptying also CCK (cholecystokinin)
is released. Duodenum & jejunum contracts, the pyloric sphincter play a role. Fatty acids
(unsaturated fats) decrease gastric emptying and monoglycerides increase contractility
of the pyloric sphincter.Amino acids (tryptophan) and peptides enter duodenum, slow
gastric emptying by proteins & gastrin release which constrict the pylorus.
2. Chemical Process
Gastric secretions come from 3 main gastric cells and their secretions.
a. Parietal cells or oxyntic cells – HCL and intrinsic factor (IF)- which
facilitates absorption of Vit. B12 in the small intestine and failure in the
absorption of Vit. B12 leads to Pernicious Anemia.
b. Chief cells or zymogenic cells– pepsin
c. Mucous neck cells – mucus
d. Argentaffin cells-produce gastrin that causes increase gastric motility,
synthesize and store serotonin that causes vigorous contraction of the smooth
muscles of the stomach.The pyloric gland of the stomach make the mucus
alkaline.
 After a meal there are 3 phases of gastric acid secretion.
1. Cephalic – due to normal reflex initiated by sight, smell & taste of food.
2. Gastric – due to gastric distention caused by food in the stomach.
3. Intestinal – initiated by chyme entry into duodenum.
Phase of Gastric Acid Secretion
During the cephalic Phase secretion occurs even before food enters the
stomach. In result from sight, smell, thought, or taste of food. Neurogenic
signals causing the cephalic phase of secretion may originate in the cerebral
cortex or in the appetite centers of the hypothalamus. They are transmitted
through the dorsal motor nuclei of the vagus to the stomach. This phase
accounts for one-tenth of gastric secretion.In the gastric phase, as a food
enters the stomach, it excites the gastrin mechanism. This causes secretion
of gastric juice
Gastrin is liberated by the mucous membrane of the pylorus and is
carried by blood to the gastric glands causing them to secrete gastric juice
rich in acid and enzymes. This phase accounts for more than two-thirds of the
total gastric secretion.And in the intestinal phase, presence of food in the
upper portion of the duodenum also causes the stomach to secrete small
amounts of gastric juice. This is due to the release of enteric gastrin in
response to the distention or to chemical stimulation.
Inhibition of Gastric Secretion
Several conditions which inhibit gastric secretions:
1. Unappetizing food depresses the cephalic phase.
2. Accumulation of acid in the stomach inhibits gastrin release which inhibits
gastric secretion.
3. Presence of fat in the duodenum causes the release of the hormone
enterogastrone which inhibits gastric secretion
4. Stimulation of sympathetic nervous system in rage or pain inhibits secretions
and motility of the stomach
D. Digestion in the Small Intestine
1. Mechanical Process
During digestion, a milky, white fluid or a fine emulsion of neutral fats
called chyle is drained from the intestine and carried away by the
lacteals.Peristalsis moves chyme aborally an average of 10 cm per contraction &
chyme takes 2-4 hours to move through the 6m small intestine. Eating slows
aboral movement of chyme.
Movements of food in the small intestine is divided into the following:
1. Mixing contractions(Rhythmical segmenting contraction)
2. Propulsive movements (Peristalsis)
3. Movement of the mucosa and villi
2. Chemical Process
1. Pancreatic secretion
It facilitates digestion of proteins, fats and carbohydrates.( proteolytic
enzymes, lypolytic enzymes, amylolytic enzyme).
 Nervous regulation of pancreatic secretion and hormonal regulation
aid in the digestion of food in the small intestine.
2. Gall bladder secretion
The hormone cholecystokinin stimulates the gall bladder to release
bile when there is fatty content of the food that we eat into the
duodenum.
3. Intestinal Secretion
The Brunner’s glands and goblet cells secrete mucus in response
to direct tactile stimuli or irritation. The crypts of Lieberkuhn
secretes alkaline intestinal juice known as succus entericus which
is composed of water, electrolytes and the following enzymes:
a. Protease or erepsin-completes protein digestion to amino
acids.
b. Enterokinase-activates pancreatic trypsinogen
c. Amylase- splits starches to maltose
d. Sucrose- splits sucrose to glucose and fructose
e. Maltase – splits maltose to glucose
f. Lactase- splits lactose to glucose and galactose
g. Lipase- splits fats to lower glycerides, fatty acids, and glycerol
Regulation of intestinal secretion is by local reflexes and
hormonal factor like the enterocrinin as secreted by the
duodenal mucosa and carried by the blood to stimulate the
intestinal mucosa to secrete intestinal juices.
PROCESSES IN THE LARGE INTESTINE
1. Mechanical Processes
a. Mixing or myogenic movements of haustration- contaction within the
colon
b. Propulsive or neurogenic movements- mass movements propel the feces
into the anus
2. Chemical process
Goblet cells secrete mucus to lubricate the lining of the large intestine to
facilitate passing out of feces and protects the mucosa from chemical and
mechanical irritation. It also contains bacteria which act on the undigested
residue, putrify protein, ferment CHO, split products eliminated with the feces.
3. Defecation -
It is the expelling of the large intestine contents & wastes acted by
voluntary relaxation of the external sphincter muscles of the anus and
increase abdominal pressure.
Normal composition of feces
1. Residue of undigestible material in food
2. Bile pigment and salts
3. Intestinal secretions(mucus)
4. Leukocytes migrating from the blood stream
5. Sed epithelial cells
 6. Large number of bacteria(30 % of solid matter)
7. Inorganic matter(10-20 % of solid matter)
8. The characteristic odor of the stool is due to indole,
mercaptane, and hydrogen sulfideas products of bacterial
actionsbut vary as to food ingeste and intestinal bacterial
flora.
Secretions
Salivary glands – saliva (1.5L/day)
Lubricants, acids in digestion. Cleanses the mouth
Stomach – 2L/day
Pancreas – 1.5 L/day
Small intestine – 1.5 L/day
Large intestine – 400 L/day
Hepatic – 0.25–1.5 L/day

ASSESSMENT & DIAGNOSTIC EXAMINATION

Nutritional assessment
Nutritional health-results when the body’s nutrient requirements are constantly met.
Factors to consider to meet the nutritional requirement of an individual
1. Appropriate & adequate nutrition-must be delivered to transport by & absorbed by
the GIT.
2. Absorbed nutrients-must be metabolized & used at the cellular level.
3. Age, size, rate of metabolism & activity level
4. Determine exact nutrient amount required
History taking
a. The dietary information intake as to amount, types of foods & beverages for 24
hours should be taken.
b. As to typical daily food intake if not recalled, list down the food & beverages
intake for 3 days. This is a prospective method for collecting diet information
c. Food diaries noting the amount of food and drink consumed, the preparation of
food if steamed or fried, broiled & the time of day it was consumed.
d. Compare to the standard references
1. Dietary Reference Intake(DRI)
2. Food Guide Pyramid(FGP)-is a graphic representation of the categories &
servings of food for an average healthy people
With this, those who are at risk should omit one or more food types/groups.
For adequacy of essential & specific nutrients (vitamins & minerals) consult a
registered dietician especially those with avitaminosis & lack of mineral intake
& note the Recommended Dietary Allowance (RDA)
3. Calculate amount of calories required (CHO, CHON, fats).

Nutrition Screening- a method of categorizing clients who are at risk for malnutrition &
identifying risk factors of inadequate nutrition through physical assessment & diagnostic
tests.
This is being done by:
A. Getting the biographical data & demographical data of an individual.
1. Gender
2. Age
3. Religion
4. Marital status
5. Socioeconomic status
6. Preparation & purchase of food
B. Get the Body Mass Index (BMI) of an individual
BMI= weight in lbs./ height in inches/ height in inches x 703
Interpret the result either be the client is with in normal limit, underweight, over weight
or obese
Current Health History
➢ About clinical manifestation, medications, dietary supplements and allergies
• Clinical Manifestation
1. Pain – acute of steady increasing – emergency
Predisposing / Precipitating factors
Quality – intensity
Severity
Timing
2. Nausea / Vomiting – undigested food or bile color consistency, alleviation
and aggravating factors regurgitation, with pain.
Vomiting – expels gastric and duodenal contents by mouth (medullar vomiting).
Vomiting follows a set pattern:
1. Reverse peristalsis initiated in the middle of the small intestine.
2. Pyloric sphincter and stomach relax to receive duodenal content.
3. Forced inspiration against a closed glottis intrathoracic.
4. Forceful contraction of abdominal muscles increases intra-abdominal pressure.
5. Lower esophageal sphincter relaxes the pylorus with the anterior contract.
6. Gastric contents enter into the esophagus.
7. Retching occurs when upper esophageal sphincter closed.
8. Vomiting occurs when the upper esophageal sphincter opens.
9. Trachea closes as in normal swallowing to prevent aspiration, dizziness or tickling
the back of the throat induced gag reflex and vomiting.
3. Indigestion – with pain, burning radiating related to food intake.
4. Diarrhea – duration, sudden set or gradual, time, cramping associated
with bloating, flatulence or possible food poisoning.
5. Weight and appetite changes – sudden or gradual, diet modification. use
of appetite suppressant on laxatives, depression, anorexia nervosa, or
bulimia, difficulty with chewing, swallowing of food, false teeth.
Gradual development of weight loss may indicate malignancy
Review of System
1. Past medical history – recent hospitalization on gastro intestinal tract illness
2. Past surgical history – recent surgery of GIT
3. Allergies – food allergy on nuts, shellfish, lactose, sulfates.
4. Medications (OTC) medications, nutraceuticals– chronic NSAID use, high dose of
MVT,
natural supplements, use of laxative, diet suppressants. Drug nutrients
irritants.
5. Dietary habits – cultural issues related to food hydration stats, specific dietary
supplement
like ensure, alcohol, coffee intake and bowel irritants intake, low sodium diet.
6. Social history – exposure to environmental toxins. recent travel, alcohol and illicit
drugintake, occupation.
7. Family history – ulceration colitis, Crohn’s disease GI malignancies, alcoholism,
ulcer,anemia,obesity.

Physical Examination/Assessment
Anthropometric measurements like BMI, height & weight, MAMC,(divide the waist
measurement by the hip measurement & with waist to hip proportions greater than .8 for
women & .9 for men indicate fat distributions associated with negative health outcomes
like cardiovascular diseases & obesity), frame size by measuring the right wrist
circumference(r= ht. in cm divided by wrist circumference in cm., where the r for
women of small body frame for reference value r>10.9 & for men r> 10.4, medium frame
for men r> 9.6-10.4 for women r> 9.9-10.9, large body frame r<9.6 for men & r<9.9 for
women)
I. Mouth- use oral assessment guide wherein there is scoring scale that is more than 8
points indicate risk. Perform inspection & palpation in the oral cavity.
• Red lesions in the mouth – erythroplakia
• White lesions – leukoplakia
• Note any symmetry, color, lesions in the buccal cavity, dysphagia, dental
carries.
II. Abdomen
1. Inspection-note for the color of the skin, contour of the abdomen, scars, rashes,
petechiae,striae, dilated veins & & note if there are discharges of the umbilicus.
Cullen’s sign or bluish periumbilical color suggests intra-abdominal bleeding &
maybe seen in clients with pancreatitis.
2. Auscultation- Begin auscultating the client’s abdomen by pressing the diaphragm
lightly to the abdominal wall, beginning in the right lower quadrant at the area of the
ileocecal valve. Continue in clockwise fashion, auscultating each quadrant or region.
Air & fluid move through the GIT, soft clicks & gurgles can be heard in 5-15 second.
Bruits -is a venous hum & indicates turbulent blood flow, aneurysm or partial
obstruction of a vessel
Venous hum – if continuous in perumbilical area indicates engorged liver circulation
Friction Rubs – like 2 piece of leather rubbing together. Suggest a hepatic tumor –(right
or spleen inflammation) loudest over the lower ribcage in the anterior
axiliary line.
Bowel Sounds:
 a. Normal – 5-35/min sound heard
b. Hypoactive – 1 or fewer /min sound heard. & to determine the absence of
bowel sounds listen for a total of 5 min per abdominal quadrant, absence of
bowel sounds need further assessment.
c. Hyperactive – 5-6 sounds heard in less than 30 seconds.
Borborygmi – loud high pitch bowel sounds represents hyperactivity heard
when hungry with gastroenteritis or in early intestinal obstruction.
d. Absent – no sounds in 3-5 minutes
3. Percussion – presence of tympani or dullness
Percussion of the abdomen – to detect fluid, mass or air.
• High pitch musical, loud- tympanic
• Dull( thud like sounds) heard over fluid or solid organs
If with aneurysm do not percuss the abdomen or if with organ transplant
4. Palpation – light palpation for identifying areas of tenderness or swelling
• Deep for identifying masses in any of the four quadrants if discomfort is
present,assess for rebound tenderness
• Pain upon release of hand
• palpate the abdomen in a systematic quadrant to quadrant or region to region
manner & start light palpation depressing the abdomen 1-2 cm.Note any areas of
rigidity, pain & guarding behavior like the McBurney’s point in diagnosing
appendicitis
III. Anal Area
a. Inspection – anal and perineal area for hemorrhoids, areas of excoriation or rash,
fissures, or fistula or opening. Digital Rectal Examination done to note
tenderness & mass.

DIAGNOSTIC TESTS
Provides information about the nature and severity of the upper GI tract with
nutritional problems and this is ordered by the physician.
Nursing intervention on diagnostic tests
1. Providing health information about healthy diet, nutritional factors causing GIT
disease.
2. Providing needed information about the test and activities required.
3. Providing instructions about the pre and post procedure, care and activity
instructions.
4. Alleviate anxiety
5. Helping care with discomfort
6. Offering emotional support by family members.
7. Assessing for adequate hydration before, during and immediately after the procedure
8. Provide health education for hydration maintenance.

Non invasive test

1. Flat Plate on the abdomen ( X-ray/radiographic)
 • To identify abdominal abnormalities like tumors, obstruction, abnormal gas or
fluid collection or structures.
• Plain x-ray of the abdomen
2. Upper GIT Series – known also as Barium Swallow
• Radiological visualization of the esophagus, stomach, duodenum and
jejunum to detect strictures, ulcer, tumors, polyps, hiatal hernia or motility
problems.
• The patient drinks a radiopaque contrast medium (barium SO4) while
standing in front of a fluoroscopy tube.
• This test usually done last when barium enema is recommended.
>to prevent the swallowed barium from interfering with the tests like barium
enema and gallbladder radiography and to prevent impactions, a laxative is
given after barium test.
Noted in here are the following.
1. Stomach mobility
2. Thickness of the gastric wall
3. Mucosal pattern
4. Patency of pyloric valve
5. Anatomy of the duodenum as to mobility, obstruction, ileitis and diverticula.
Types as to variations of upper GIT study
1. Double Contrast Method – thick Barium suspension to outline stomach and
esophageal wall is administered
• to detect finer detail for signs of early neoplasm
1. Enteroclysis – thin barium sulfate suspension about 500-1000 ml is administered. Thin
continues infusion into the duodenum and then methylcellulose is infused into the small
intestine.
• to diagnose partial bowel obstruction or diverticula
2. Modified barium swallow or Videofluoroscopy or oropharyngeal motility study.
• To assess swallowing and risk of aspiration in sitting position. The client is asked
to swallow small amount of barium mixed with liquids and foods of various
textures and a speech therapist or radiologist observes for dysphagia.

Nursing Interventions:
1. Low residue diet for several days before the procedure
2. NPO post-midnight including medications
3. Laxative a night prior to procedure
4. No smoking on the morning before the procedure
5. Follow up care to ensure barium is totally eliminated
6. Increase fluid intake to facilitate evacuation of stool and barium
7. Monitor color of stool
8. Laxative post procedure is given or enema.

3. Lower GIT Study – Barium enema

 • To detect polyps, tumors and other lesions of the large intestine and
abnormal anatomy on malfunction of the bowel.
• The radiopaque dye or substance is instilled rectally noting mobility of the
large intestine
• This is about 15-30 min where images are taken.

Other types
1. Double contrast studies – thicker barium and air with some cramping during the
procedure to detect smaller lesion.
2. Water soluble contrast studies – gastrographic studies
• If active inflammatory disease, fistulas and perforation of the colon is
suspected thin is recommended (iodinated contrast) assess allergy first to
iodine or contrast agent.
• Diarrhea will follow after the procedure so no laxative is given.
Nursing Intervention:
1. Low residue diet for 1-2 days
2. Cleansing the lower bowel
3. Clear liquid and laxative at night before the procedure.
4. NPO post-midnight
5. Enema is contraindicated for bleeding signs of perforation or obstruction – water soluble
contrast is to be given
6. Increase fluid intake
7. Monitor for complete elimination of barium.

4. Computed Tomography (Scanning)

• To detect localized inflammatory conditions/lesions on the colon like
appendicitis, diverticulitis, regional enteritis – done by inserting a thin stray
like tube into the colon and inflating the bowel with air to generate a computer
image of the intestine and there is little discomfort and sedation is not needed
Nursing Intervention:
1. NPO x 6-8 hours before the test
2. Check for dye/contrast allergy

5. MRI (Magnetic Resonance Imaging)

It is used to supply ultrasonography and CT scanning. Non invasive using magnetic
field and radio waves to produce image of the area being studied.
• Used to detect abscesses, fistulas, neoplasm and other sources of bleeding.
Nursing Interventions:
1. Remove devices or metal devices – including jewelries
2. NPO 6-8 hours prior to procedure
3. 30-90mins – time span for procedure

6. Ultrasonography
 • Use to identify pathophysiologic procedures in the pancreas, liver,
gallbladder, spleen, and retroperitoneal tissues, fluids masses, tumors,
abscesses, hematomas.

7. Scintigraphy or radionuclide testing

• Use of radio isotopes (technetium, iodine, indium) to reveal displaced
anatomic structures changes in organ size, presence of neoplasm in other
focal lesions like cysts and abscesses
• Also used to measure the uptake of tagged RBC and WBC – to define areas
of inflammation abscess, blood loss on neoplasm.
• A sample of the blood from the patient is mixed with radioactive substance
and reinjected to the patient noting abnormal concentrations of blood cells
are detected at 24-48 hours interval.

Invasive tests
Endoscopy
• Direct visualization of the GI system by means of lightened, flexible tube and
can be attached to video and obtained clear pictures of organs examined.
Types
1. Esophagoscopy
2. Gastroscopy
3. Esophagogastroduodenoscopy
4. Fiberoscopy
5. Anoscopy
6. Proctoscopy
7. Sigmoidoscopy
8. Colonoscopy
9. Small bowel enteroscopy
10. Endoscopy thru ostomy
Indications / Uses
1. Examine clients with acute or chronic GI bleeding
2. Pernicious anemia
3. Esophageal injury
4. Masses
5. Structures
6. Dysphagia
7. Substernal pain
8. Epigastric discomfort
9. Inflammatory bowel disease
• Done thru conscious sedation with a sedative or opioid or tranquilizer, with
anticholinergic to prevent reflex bradycardia and decrease orophageal
secretions.
8. Upper Gastrointestinal Fiberoscopy / Esophagogastroduodenoscopy(EGD)
• Fiberscopes – are flexible scopes equipped with fiberoptic lenses.
 • Allows direct visualization of the esophageal gastric and duodenal mucosa
through a lighted endoscope (gastroscope)
• EGD – to identify abnormalities of esophagus, gastric or duodenum including
inflammatory neoplastic or infectious process. To evaluate esophageal and
gastric motility and to collect secretions and tissue specimen for further
analysis
• ERCP – Endoscopic Retrograde Cholangiopancreatography
Side viewing flexible scopes – to visualize common bile duct, pancreatic and
hepatic ducts thru the ampulla of Vater in the duodenum.
Uses
1. To evaluate jaundice, pancreatitis, pancreatic tumors, common bile
duct stones and biliary tract disease.
9. Therapeutic endoscopy
Uses
1. To remove common bile stones
2. To dilate strictures
3. To treat gastric bleeding by injecting scurosing solutions
4. To treat esophageal varices
5. To provide laser therapy for UGI neoplasm
6. To obtain tissue specimen 30mins time procedure
After effects:
1. Nausea
2. Gagging
3. Choking
Nursing Intervention
1. NPO x 6-12 hours before examination and 1-2 hours after procedure until gag
reflex returns.
2. Local spray anesthesia with tranquilizer (relieve anxiety and sedation)
3. AtSO4 – reduce secretion relax smooth muscles
4. Side lying to facilitate saliva drainage and easy access for the endoscope.
5. Patient with mouth gag to prevent biting of the scope.
Other GI Test
• To determine presence of malignant cells amount of HCl or hormones,
abnormalities of motor functions or etiology of chest pain
1. Exfoliative cytologic analysis
2. Gastric analysis
3. Acid perfusion test
4. Esophageal manometry
5. Bernstien test
Exfoliative Cytologic Analysis
1. To distinguish benign from malignant tissue cell becomes malignanIt it cells
exfoliating more readily than normal
Lavage is done in the anus of GIT of intent collected and sent to the
laboratory for analysis
 2. To examine stomach contents for presence of Helicobacter pylori – a bacteria
causing gastritis and PUD.

Gastric Analysis
To measure secretions of HCl and pepsin in the stomach
To aid the diagnosis of duodenal ulcer, Zollinger Ellison Syndrome, gastric
carcinoma and pernicious anemia
It consists of:
a. Basal cell secretion test
b. Gastric acid stimulation test- measures the amount of gastric acid produced
after receiving drugs that stimulate secretion ( pentagastrin,betazole)
Markedly increased level of gastric acid secretion –Zollinger Ellison
Syndrome
Moderately increased level of gastric acid secretion- duodenal ulcer
Decreased level of gastric acid secretion-gastric ulcer or gastric carcinoma
• Acid Perfusion Test – Bernstein Test
• To test whether chest pain is related to acid perfusion across the esophageal
mucosa.
• NGT is inserted and gastric contents are aspirated. NSS (.9%) and .1 of HCl
are alternately instilled into the lower esophagus – if no pain the test is
normal and if pain occurs NSS is administered until pain stops. To ensure the
pain is caused by acid perfusion 0.1 of HCl is readministered then NGT is
removed after.

Esophageal Manometry
Uses:
1. To assess esophageal motor functions.
2. To diagnose dysphagia esophageal reflux, spasm, motility disorders and
hiatal hernia.
3. To measure pressure of the esophagus and lower esophageal sphincter by
infusion of H2O into the catheters and client is asked to swallow small
amounts of H2O and esophageal pressures are recorded during muscular
relaxation and contraction.
4. To determine esophageal pressure

Ambulatory Esophageal pH monitoring

• Is used to distinguish chest pain caused by gastric acid reflux from angina
pectoris and MI.
• A nasoenteric tube is inserted with pH sensor 5cm above the lower
esophageal sphincter and it is battery operated recorder.
• Client is instructed to push button at the start of eating, sleeping, smoking
and note when indigestion starts and ends.
• Do not give drugs that affect GIT before the procedure.
• Discuss importance of recording and handle with care the device.
 LABORATORY TEST
Blood tests
1. CBC
2. CEA – carciembryonic antigen
3. Liver function test
4. Serum cholesterol and triglycerides
All of this blood test may reveal alterations in basal metabolic function and indicate
severity of the disease.
CBC
Hgb Determination, HCT
• To detect Nutritional Anemia, Fe Deficiency Anemia– Most common type of
anemia.

Serum Proteins Test (e.g. Albumin)

Serum Proteins – are carrier molecules and important for maintaining intravascular
oncotic pressure.
Global indicators of Nutritional Status
Albumin : 3.5 – 5 gms/dl - ↑ in DHN, decreased in
overhydration,
CHON loss & liver disease
Pre-Albumin : 20 – 40 mg/dl - ↑with nutritional intake and
renal failure
↓in poor dietary intake and
changes in nutritional status
Retinol Binding CHON : 3-6 mg/dl - ↓overhydration liver disease
Zinc and Vitamin A deficit
Transferritin : 200 mg/dl - ↑pregnancy Fe deficiencies
↓with chronic infection and
cirrhosis
Total Lymphocyte Count
– indicator of immune function; gross measure of nutritional status
Total WBC count x 30% = TLC
TLC ↓ 1800mm – malnutrition
↓TLC- if with chemotherapy
↑TLC – malnourished with sepsis

D – Xylose Absorption Test

D – Xylose : a monosaccharide absorbed in the small intestine used to assess
malabsorption in the small intestine
: Oral administration of D – xylose, blood and urine levels of D – xylose are measured
↓D – xylose : malabsorption in the bowel

Nitrogen Balance
• A measure of the client’s anabolic or catabolic status
 • Done by recording the amount and type of food consumed in 24° period and
obtain 24° urine collection to measure Urine Urea Nitrogen.
• CHON is 16 % nitrogen.
• Multiply the amount of protein consumed in grams by .16
• UUN (Urine Urea Nitrogen) – Major source of nitrogen excretion
• Positive Nitrogen Balance – 4-6gm – Anabolic status
• Negative Nitrogen Balance – Catabolic status

Defecography
• measures anorectal function
• Very thick barium paste is instilled into rectum and fluoroscopy is performed to
assess function of the rectum and anal sphincter while the patient attempts to
expel the barium
• Gastro-duodenal, small Intestine and colonic manometer are used to evaluate
delayed gastric emptying and gastric and intestinal motility disorders such as
irritable bowel syndrome or atonic colon.

Anorectal manometry
• It measures the resting tone of the internal anal sphincter and the contractility of
the external and use to evaluate chronic constipation or fecal incontinence and
effects for its treatment.

Rectal sensory function test

• It is used to evaluate rectal sensory function and neuropathy and can be done in
conjunction with anorectal manometry. It is used to evaluate chronic constipation
diarrhea or incontinence.
• A catheter and balloon are passed into the rectum and balloon is inflated until the
patient feels distention.

Electromyography
• It is an electrophysiological study to assess gastric motility disturbances and
electrodes are placed over the abdomen and gastric electrical activity is recorded
for 24 hours.
• To deflect motor or nerve dysfunction in the stomach. This could supplement
anorectal ,manometry.

Stool Tests
Basic examination of the stool includes inspecting the specimen for consistency, color,
and also presence of parasites, pathogens, food residues, fecal urobilinogen, fat and
residues.
Fecal occult blood test
• It is one of the most commonly performed. Stool tests and is useful in initial
screening for several disorder to note presence of blood and is most frequently
used to cancer screening programs and for early cancer detection.Hema test is
the most widely used occult blood test.

Breathing Test
1. Hydrogen Breath Test
• Used to evaluate carbohydrate absorption.
• Used to diagnose bacterial overgrowth in the intestine and short bowel
syndrome. This test determines the amount of hydrogen expelled in the colon
and absorbed in the blood.
2. Urea Breath Test
• Use to detect the presence of Helicobacter pylori, the bacteria that can live in the
mucosal lining of the stomach and cause peptic ulcer disease.
• The patient takes a capsule of carbon labeled urea and then provides a breath
sample 10-20 minutes later.
• Helicobacter pylori metabolize urea rapidly and the labeled carbon is absorbed
quickly and measured as carbon dioxide in the expired breath to determine
whether helicobacter pylori are present.
• Helicobacter Pylori also can be detected by assessing serum antibody levels.
Nursing Responsibilities
1. Patient is instructed to avoid antibiotics or loperamide (Pepto – Bismol) for 1 month
before the test.
2. To avoid Sucralfate (Carafate) and Omeprazole (Prilosec) for 1 week before the test
3. To avoid Cimetide (Zactac) and nizatidine (Axid) 24 hours before urea breath testing.

Laparoscopy (Peritoneoscopy)
• Used for diagnosis of GI disease.
• A small abdominal incision and a special fiberoptic laparoscope is inserted into
the abdomen permitting visualization and identification of abnormal growths, and
inflammatory process.
• Biopsy samples can be taken.
• Used to evaluate peritoneal disease chronic abdominal pain, abdominal masses
gall bladder and liver disease.
SPECIAL DIET FOR SPECIFIC DISEASES
Clear Liquid Diet
• To relieve thirst & maintain fluid balance
• Indicated to clients with severe vomiting, gastroenteritis, & postoperative clients.
Full Liquid Diet
• To provide nutrition to clients who cannot tolerate solid foods
• Indicated to clients with stomach upset, postoperative clients from clear liquid
Soft Diet
• Indicated to clients with ill-fitting dentures
 • Diet transition from full liquid to general diet
• Indicated to clients with GIT disturbances like gastric ulcer& cholelithiasis
• Use to provide nutrition to clients having problems in chewing.

Ash-Acid Diet
• Inhibits the formation of alkalinic renal stones.
• Indicated to clients with renal calculi ( alkali stones ).
• Examples: cheese, cranberries, eggs, meat, plums, prunes, whole grains

Alkaline- Ash Diet

• Retards the formation of acid renal stones.
• Indicated to clients with acidic stones.
• Examples: fruits ( except cranberries, plums, prunes & citrus fruits ) milk & vegetables

BRAT Diet
• Banana- Rice,-Apple- Toast
• Indicated to clients with diarrhea

Diabetic Diet
• Well balanced diet
• To maintain normal blood sugar level ( 80-120 mgs./dl )
• Indicated to clients with Diabetes Mellitus ( computed diabetic diet )

Low CHO Diet

• Indicated to clients with Dumping syndrome
• Indicated to clients with COPD

Gluten Free Diet

• Avoid gluten rich foods
• No to B R O W (Barley-Rye-Oat-Wheat)
• Indicated to clients with Celiac Disease

Butterball Diet
• Low CHON, low CHO diet
• Indicated to clients with liver disorder

Giordano diet
• Low (spare) protein diet
• Indicated to clients with chronic renal failure

High Fiber Diet

• To hasten passage of foods in the GIT
• To promote peristalsis
• Indicated to clients with constipation, diverculitis, & hyperlipidemia
• Examples: fruits & vegetables
High CHON Diet
• Indicated to clients with nephrotic syndrome
• To hasten wound healing
• To promote healing to clients with burn
Example: lean meat, eggs, cheese

Bland Diet
• Low fiber , mechanical irritants, chemical irritants
• Indicated to clients with gastritis, diarrhea, biliary indigestion, & hiatal hernia

Low Fat/Cholesterol Diet

• Indicated to clients with hyperlipidemia ( reducing high cholesterol/lipid level in 6the
blood)
• Indicated to clients with fat intolerance
• Indicated to clients with cardiovascular diseases & hypertension
• Indicated to clients who had resection of the small intestine, cholecystitis &
cholelithiasis

Low Residue diet

• Indicated to clients with ulcerative colitis, diverticulitis & those who had GIT surgery
• Use to reduce the bulk of the stool

Purine Restricted Diet

• Indicated to clients with problems in purine metabolism, gouty arthritis, & renal calculi
(gouty stone)
• Use to reduce uric acid (hyperuricemia)

Sodium Restricted Diet

• Indicated to client with heart failure, hypertension, renal diseases, PIH, & clients with
steroid therapy

Tyramine Free Diet

• Indicated to clients taking MAOI antidepressant to prevent hypertensive crisis
• Avoid ABC: Avocado-Banana-Canned processed & fermented foods

Kosher Diet
• Milk & meat cannot be served simultaneously
• Indicated diet to Orthodox Jews

Halal Diet
• No to pork
Indicated diet for Moslems

Vegan Diet
• A vegetarian diet
• Diet of the Seventh Day Adventist
Yin Diet
• Cold deserts given after surgery which is a Chinese belief

MALNUTRITION
It iis an altered state of nutrition resulting from deficiency, or excess, of one or
more nutrients.
Results when the body’s nutritional requirement is inadequately met or excess
nutrient intake.
Broad classifications:
1. Undernutrition-is a result of acute or chronic diseases & treatments that affect
the ability to ingest, digest, or absorb foods that lead to delayed wound healing,
impaired immune system& a decreased functional status. It results when
nutritional intake is insufficient. Hospitalized patients having inability to eat are
classified as undernutrition
2. Overnutrition- is obesity, excess food intake but the nutrient content of the food
is poor.
This is a condition when a patient’s intake is in excess of their need for one or
more nutrients.

Causes/ Etiology
A. Multifactorial
1. Inadequate food intake
2. Frequent infectious diseases
3. Financial constraints/Socioeconomic Status/poverty
4. Inadequate intake of calories, CHON, vitamins & minerals
5. Presence of pain due to acute or chronic diseases
6. Inadequate intake resulting from medication side effects
7. Psychological factors
8. Social isolation
9. Depression
10. Hospitalization as to differences in food preferences
11. Changes in taste & appetite true among elderly
12. Medical problems like denture problem & other diseases

Protein Energy Malnutrition (PEM)

It is a type of undernutrition when the body’s need for protein or energy is not supplied in
adequate quantity.
Types:
1. Primary- when the deficit result from poor food intake
Cause: natural disasters like drought, flood, earthquake oe famine, war,
political upheaval & economic crisis
2. Secondary- results from decreased nutrient intake or absorption.
Causes: decreased food intake, decreased nutrient absorption, increased
nutrient losses, increased nutrient requirement
Kwashiorkor-chronic deficiency in protein/CHON depletion
Clinical Manifestation
1. Appears weak
2. Lethargic
3. Edematous
4. Irritability

Marasmus- CHON & calorie deficiency

Clinical Manifestations
1. Severe tissue wasting
2. Decrease in lean body mass & subcutaneous fat stores
3. Dehydration
4. Weigt loss
5. Cacahectic appearance
6. Generalized body weakness
7. Decrease in functioning

Diagnostic Tests
1. Serum transferrinWhich ofd the - to assess visceral CHON stores & levels less than
100 mg/dl, 100-150 mg/dl,150-200 mg/dl signifies severely, moderately & mildly
depleted visceral CHON but can be decreased by medical conditions &
medications.More sensitive tan albumin as an indicator of the nutritional status of an
individual.
2. Prealbumin(transthyretin)-more sensitive indicator of the nutritional status of the
individual than serum transferritin.It is used to monitor the progress & effectiveness
of nutrition intervention.If the level increases to 1 mg/dl daily means positive
response to nutritional support & if it decreases to less tan 2 mg/dl per week means
iadequate nutritional support
3. Retinol Binding CHON-to monitor short term changes in nutritional status & elevated
by renal disease.
4. Hgb & HCT Determination
Nursing Intervention
1. Health education about nutritional diet intake as to RDA, PFG etc.
2. Measuring the intake & output of the patient
3. Identifying causative factors about problems of ingestion, digestion &
absorption
4. Monitoring the food intake of the client as to nutritional content, food selection
& food preparation
OBESITY
• It results from excessive intake or consumption of nutrients more than the
recommended dietary intake of an individual for the process of normal growth
and development. The computed BMI is greater than 30 or more than 100
pounds greater than the ideal body weight.
Causes
1. Increased caloric consumption
2. Inadequate exercise
3. Sedentary lifestyle
4. Metabolic diseases
5. Increased intake of nutrients
6. Increased consumption of fatty foods
7. Genetic predisposition

Risk Factors for the following diseases:

1. Cardiovascular diseases like HPN, ASHD, CAD
2. Arthritis
3. Asthma
4. Bronchitis
5. Diabetes mellitus
6. Hyperlipedemia
7. Gallbladder disorders

Medical Manangement
1. Consevative management
a. Weight reduction
• Diet and behavioral modification
2. Exercise regularly
3. Acupuncture
4. Hypnosis
5. Pharmacological management
a. Sibutramine HCL(Meridia)-inhibits reuptake of serotonin and norepinephrine
therby devreasing appetite
Side effects:increased BP, dry mouth, insomnia, headache, increased HR
Contraindicated to the following diseases: history of CAD, angina pectoris,
dysrhytmias, kidney diseases, those taking MAOI, pregnant and lactating
mothers
b. Orlistat(Xenical)-decreases caloric intake by binding to gastric and pancreatic
lipase to prevent digestion of fats
Side effects: increased BM, gas with oily discharges, decreased food absorption,
decreased bile flow, deceased absorption of some vitamins
Contraindications: pregnant and nursing mothers
Both of these drugs require doctor’s prescription. A multivitamin is usually
prescribed fos orlistat.

Surgical Management
1. Bariatric Surgery
a. Jejunoileal bypass
b. Gastric bypass
 c. Vertical banded gastroplasty
d. Liposuction and lipoplasty
e. Panniculectomy

DISORDERS OF THE ORAL CAVITY

1. Dental Plague and Dental Caries
Tooth Decay
• It is an erosive process that begin with the action of bacteria on fermentable
carbohydrates in the mouth which produces acids that dissolve tooth enamel
which is the hardest substance of the teeth and damage to the teeth depends on
the following:
• Presence of dental plaque – is a gluey gelatin – like substance that adheres
to the teeth.
• Strength of the acids and the ability of the saliva to neutralize them.
• Length of time the acids are in contact with the teeth.
• The susceptibility of the teeth to decay increased soft drink intake
predisposes to tooth decay.
• It begins with a small hole in the enamel and soreness and pulsating pain
develops leading to tooth abscess formation and infection.
.
Preventive Measures:
1. Proper oral hygiene
2. Reducing intake of starches and sugar (CHO)
3. Applying fluoride to the teeth
4. Drinking fluoridated water
5. Refraining from smoking
6. Controlling diabetes
7. Using pit and fissure sealants
2. Dentoalveolar Abscess/Periapical Abscess
• Known as abscess tooth – collection of pus in the apical dental periosteum
which may be acute or chronic.
• Acute periapical abscess is secondary to suppurative pulpitis (inflammation of
the pulp of the tooth)
• Chronic dentoalveolar abscess is a slow progressive infectious process and
leads to a blind dental abscess which is a periapical granuloma.
Management
• Extraction or root canal therapy with apindectomy with antibiotics. I and D of the
gums.
Signs and Symptoms
1. Dull gnawing, continuous pain often with a surrounding cellulitis and edema of the
adjacent facial structures and mobility of the involved tooth.
2. Fever malaise.
3. Swollen cheek side.
4. Cellulitis of facial structures.
5. Difficult to open the mouth.
Nursing Management:
1. Assessing bleeding.
2. Instruct patient to use warm saline or water mouth rinse to keep the area clean.
3. Take antibiotics and analgesic as prescribed.
4. Liquid diet to soft diet.
3. Malocclusion
It is misalignment of the teeth of the upper and lower dental ores when the jaws
are closed.
Causes/Etiology
1. Inherited
2. Acquired
3. Thumb Sucking, Trauma
• This condition makes the teeth difficult to clean leading to tooth decay, gum
disease, and excess wear or supporting bone and gum tissues.
Signs and Symptoms
1. Obviously misaligned bite
2. Crooked or widely spaced teeth
3. Protruding teeth
Management:
1. Braces, retainer to strait as early as the last primary teeth had shed.
2. Preventive orthodontics may start in children as early as 5 years age.
3. Proper Oral hygiene
4. Continue full correction using braces and restrains.
Disorders of the jaw
• affection involving the jaw.
• It includes the following as causes congenital malformation, fracture, chronic
dislocation, cancer and syndromes characterized by pain and limited motion
other causes, head injury, jaw in jaw trauma, stress malocclusion.
1. Tempo mandibular Disorders
a. Myofascial pain – a discomfort in the muscles controlling jaw function and in
neck and shoulder muscles
b. Internal derangement of the joint – a/an injured condyle.
c. Degenerative joint disease – rheumatoid arthritis or osteoarthritis in the jaw
joint.
Signs and Symptoms
• Dull pain to throbbing pain and debilitating pain that can radiate to the ears,
teeth, neck muscles and facial sinuses
• Restricted jaw motion.
• Locking of the jaw.
• Sudden change in the way of upper and lower teeth fit together
• Dysphagia and difficulty chewing
• Hearing grating and licking noise of the joints.
• Headache, earache, dizziness, difficulty in speech.
 • Hearing problems.
Diagnosis
• MRI, x-ray studies and arthrogram,
Management:
1. Patient education in stress management.
2. Range of motion exercise.
3. Pain management.
- NSAID
- Muscle relaxant
- Mild antidepressant
4. Intra Oral Orthotics – a plastic guard worn on the upper and the lower teeth.
Jaw disorders requiring surgery
1. Mandibular fractures
• Bone grafting may be performed to replace structural defects.
• Screw and plates may be inserted to connect the disorders.
• Tower External Fixator
Nursing Management:
• Not to chew food for 1-4 weeks after surgery.
• Liquid diet is recommended.
• Dietary counseling to ensure optional caloric and protein intake.
• Proper mouth care.
Disorders of the Salivary Glands
1. Paroritis/Mumps – inflammation of the parotid glands and communicable disease
caused by staphylococcus aureus & mumps virus.
2. Sialadenitis
- inflammation of the salivary glands causes:
- Dehydration
- Radiation therapy
- Stress
- Malnutrition
- Sialolithiasis
Agents: Staphylococcus aureus and streptococcus vividons or pheumococci
Signs and Symptoms:
• Pain, swelling and purulent discharges, fever
Management:
• Antibiotic and corticosteroids
• Massage
• Hydration
• Warm compress
• Surgical drainage of the gland or excision for chronic sialadenitis with uncontrolled pain
3. Sialolithiasis
It is described as salivary calculi or presence of stones in on salivary glands
especially the submandibular glands.
 Causes/Etiology
Salivary calculi are formed from calcium phosphate
Signs and Symptoms
Colicky pain
Swollen glands, tenderness and palpable stones
Management
4. Lithotripsy – a procedure that uses shock waves to disintegrate stones.
5. Surgical extraction of calculi
Diagnosis – X-ray
Cancer of the oral cavity
Malignant tumors in the mouth (squamous cell cancer) if detected early it is curable
before it spreads to the lymph nodes.
Cause/Etiology
Alcoholism
Smoking
Ingestion of smoked meats and fish
Dietary deficiency
Chronic irritation by a warm pipe – lip cancer
Signs and Symptoms
Painless sore or mass that does not heal and usually hardened with raised edges.
Malignant growths are found in the lateral aspects of the tongue, lips and floor of the
mouth .
Tenderness, difficulty in chewing, swallowing, speaking.
Coughing of blood tinged sputum.
Enlarged cervical lymph nodes.
Diagnosis: Biopsies
Management
Radiation Therapy
Chemotherapy
Neck dissection – surgical intervention
Nursing Management
Mouth care
Care for post effect of radiation and chemotherapy. Xerostomia – dryness of the mouth
and most common sequelae of oral cancer.
Disorders of the Esophagus
Achalasia
- absence or ineffective peristalsis of the distal esophagus accompanied by
failure of the esophageal sphincter to relax in response to swelling.Incidence
often occurs in people 40 years or older.
Signs and Symptoms
Difficulty in swallowing both liquids and solids.
Sensation of food sticking in the lower portion of the esophagus.
Chest pain
Pyrosis (heart burn) not associated with eating.
 Regurgitation
Assessment and Diagnosis
X-ray
Barium swallow
CT scan
Endoscopy
Esophageal manometry
Management
Calcium Channel Blockers
e.g. Amlodipine (Norvasc) – to relax the blood vessels, decrease BP to test
vasospasm.
• Nitrates – to decrease esophageal pressure and improve swallowing
• Injection of Botulinum Eoxin (Botox) to quadrants of the esophagus via endoscopy to
inhibit contraction of smooth muscles.
• By pneumatic dilation – to stretch the narrowed area of the esophagus and to guard
against perforation of the esophagus. For this procedure it is painful that moderate
sedation or tranquilizer be both administered (analgesic) or doctors order.
Intervention – Esophagomyotomy
Diffuse Spasm
It is a motor disorder of the esophagus.
Cause/Etiology
• Unknown but stress could be a factor common in women and usually manifest in middle
age
Sign and Symptoms
• Dysphagia, odynophagia (pain or swollen), chest pain
Assessment and Diagnosis
Esophageal Manometry – reveals simultaneous contractions of the esophagus occur
irregularly.
Barium swallow and X-ray
Management
I. Conservative Therapy
1. Administration of sedation
2. Administration of calcium channel blockers – to manage stiffest spasm by relaxing
blood vessels and treat vasospasm.
3. Small frequent feedings
4. Soft diet
To decrease esophageal pressure and irritation leading to spasm
If the pain is intolerable, the following are being done:
1. Dilation performed by bougienage – use of progressively sized flexible dilation.
2. Pneumatic dilation.
3. Esophagonyotomy.
II. Surgery
1. Transhiatal esophagectomy – open surgical approach.
2. Esophageal Helter Myotomy – minimally invasive approach
 Hiatal hernia
It is characterized through which In an opening in the diaphragm where the esophagus
passes becomes enlarged and part of the upper stomach tends to move up into the
lower portion of the thorax.More on women than in men.
Causes: aging, weakness in the opening of the diaphragm Risk factor is obesity

Types:
1. Sliding or type 1 – when the upper stomach and the gastroesophageal junction are
displaced upward and slide in and out of the thorax and more common to occur.
Manifestations: heartburn(pyrosis),regurgitation, dysphagia & reflux
2. Rolling or paraesophageal hernia-when all or part of the stomach pushes through the
diaphragm beside the esophagus.
Manifestations: sense of fullness after eating, chest pain.
Complications: hemorrhage, obstruction, strangulation
Diagnosis: Xray, Barium swallow & fluoroscopy
Management:
• Frequent small feedings
• Not to receive for 1 hour after eating to prevent reflux or movement or the hernia
• Elevate the head of the bed 4-8 minutes to prevent the hernia from moving up
• Surgery
• Reduce weight
Diverticulum
It is an outpouching of mucosa and submucosa that protrudes through a weak portion of
the areas of the esophagus: pharyngo esophageal or upper area of the esophagus, mid
esophageal area or epiphrenic or lower area of the esophagus and also intramural.
Zenker’s Diverticulum or pharyngopharyngeal outpouch – most commo type and more in
men and older than 60 years of age.
Signs and Symptoms
• Dysphagia, fullness in the neck, belching, regurgitating of the undigested food, gurgling
noises when eating.
• Halitosis.
• Sour taste in the mouth
• Chest pain
Dysphagia – most common symptoms of intramural diverticulum.
Assessment and Diagnosis
• Barium swallow, esophageal manometry.
• Esophagoscopy is contraindicated that will result to perforation and mediastinitis
Management:
• Surgery – avoid trauma to the common carotid artery and jugular vein
• diverticulectomy
• A myotomy of the cricopharyngeal muscle to relieve spasticity of the musculaturee
Perforation
CAUSES: stab wound, bullet wounds of the neck or chest, trauma from motor vehicle crash,
caustic injury from chemical burn, inadvertent puncture by surgical instrument during
endoscopy.
Signs and Symptoms
Pain, dysphagia, infection, fever, leukocytosis, severe hypotension, signs of
pneumothorax.
Assessment and Diagnosis
• X-ray, fluoroscopy, barium swallow, esophagram
Management:
• Antibiotic therapy
• NPO
• Parenteral or enteral nutrition for 1 month
• Surgery
Foreign Bodies
- Swallowed objects may injure the esophagus.
- Dentures, fish bones, pins, small batteries, items containing mercury or lead.
Signs and Symptoms
• Pain, dysphagia, Dyspnea
Assessment and Diagnosis
• X-rays
Management:
• Glucagon – injected IM to relax the esophageal muscle
• Endoscopy – to remove foreign body.
• Complication – perforation
Chemical Burns
• Intentional or unintentional swallowing or drinking strong acid base or by undissolved
medication.
• More among elderly.
Signs and Symptoms
• Severe burn of the lips, mouth, pharynx
• Pain or swallowing
• Dyspnea/respiratory distress
• Edema of the throat
• Collection of mucus in the pharynx
• Febrile, signs and symptoms of shock.
Assessment and Diagnosis
• Barium swallow, esophagoscopy
Nursing Management
• NPO
• IV fluids, enteral and parental feeding
• NGT tubing
• Gastric lavage and vomiting are avoided
• Corticosteroids administration per doctor’s order.
• Antibiotic for signs and symptoms of infection noted as prescribed
• Dilation by bouginage (Cylindrical) tube called bougies.
• Surgery
GERD (Gastroesophageal Reflux Disease)
It is the backflow of gastric or duodenal content into the esophagus
Cause: Excessive reflex may occur due to incompetent esophageal sphincter pyloric
stenosis or motility disorders and aging process

Signs and Symptoms

• Pyrosis (heartburn)burning sensation in the esophagus
• Dyspepsia (indigestion)
• Regurgitation
• Dysphagia
• Odynophagia
• Hypersalivation
• Esophagitis
Assessment and Diagnosis
• Barium swallow, endoscopy
- To evaluate the drainage of the esophageal mucosa
• Ambulatory (12-36 hours) esophageal pH monitoring
- To evaluate the degree of acid reflux
• Barium monitoring (Bilitec)
- To measure bile reflux patterns which causes mucosal damage.
Nursing Management
1. Low fat diet
2. Avoid caffeine, tobacco, beer, milk, foods containing peppermint or spearmint,
carbonated drinks.
3. Avoid eating or drinking 2 hours before bedtime.
4. Maintain normal body weight.
5. Avoid tight fitting clothes
6. Elevate head part of the bed 6-8 inches.
7. Elevate upper body or pillows if reflux persists
• Give antacids and H2 receptor antagonist as prescribed (e.g. Famotidine)
• Give PPI as prescribed
• Prokinetic agents – to accentuate gastric emptying (e.g. Motilium) betanechol
(Urecholine)
Surgery – NISSEN FUNDOPLICATION (wrapping of a portion of the gastric fundus and
wind the esophageal sphincter) by open method or laparoscopy.
Barrett’s Esophagus
chronic irritation due to reflux of gastric and duodenal contents. Alteration of the linings
of the esophagus and associated with GERD especially Long Standing Uncontrolled GERD
and chronic irritation of the esophagus.
Cause/Etiology
• associated with GERD especially Lone Standing Uncontrolled GERD and chronic
irritation of the esophagus.
Signs and Symptoms
• Precancerous cells are present in the esophageal lining leading to cancer.
• Heartburn
• Signs of peptic ulcer
• Signs of esophageal stricture

Assessment and Diagnosis

• EGD – reveals red esophageal lining rather than pinkish.
• Biopsy – high grade dysplasia is revealed
Management:
• Repeat EGD 6-12 months to note minor cell changes.
• PDT (Photo Dynamic Therapy) is a laser thermal ablation of the esophageal mucosa to
destroy metaplastic cells once the patient received photofrin – a photo sensitizing agent.
Trans hiatal – for better result if not progressing to cancer.
Benign Tumors of the Esophagus
• Leiomyoma – tumor smooth muscles – most common benign tumors of the esophagus.
Causes
• Chronic irritation of the esophagus
Assessment and Diagnosis
• Biopsy
Management
• Esophagectomy
Esophageal Cancer – malignant lesions of the esophagus.
• 3 times more common in men than women
• More in African Americans that Caucasians occurs in 5th and 6th of life.
• Increase incidence in China and Northern Iran.
Cause/Etiology
• Chroming irritation of the esophagus through smoking, alcoholism, associated with
GERD, adenocarcinoma of the esophagus found primarily in the distal esophagus and
gastro esophageal junction.
Manifestation
• Two types – adenocarcinoma and squamous cell carcinoma.
• Obstruction of the esophagus
• Perforation
• Erosion of the great vessels with in the esophagus
• Ulceration of the esophagus
• Dysphagia with solid and liquid foods increasing intensity
• Hiccups and becomes persistent
• Halitosis
• Mass of the throat
• Substernal pain
• Feeling of fullness
• Regurgitation
• Hemmorrhage
• Progressive loss of weight and strength
• Foul health
Assessment and Diagnosis
• EGD with biopsy and brushing
• CT Scan
• PET – Position Emission Tomography –to detect metastasis
Medical Management
• Chemotherapy or both.
• Radiation therapy 4-6 weeks
Surgery – esophagectomy (total resection)
Nursing Management
• Nutrition
• Prevention of complication
• Oral suctioning