GITDS Edited by Shegaw

Chapter –Five
Gastro Intestinal Tract Disorders (GITDs)
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Objective
After the end of this session the student will be able to :
•Describe Anatomical & Physiological over view of GIT
•Perform physical examination for patient with GIT disorders
•Identify common GIT diseases, pathophysiology, cause & C/

feature.
•Identify Assts. & Dx. evaluation methods for each GIT disorders.
•Managing patient with GIT disorder
•Prepare Nursing care plan of each problem.
Outline
• Anatomy and physiology
• Assessment:
– Relevant history - Subjective
– Physical exam - Objective
– Diagnostic test - Objective
• GIT disorders:
– Upper GIT
– Lower GIT
– Accessory organ
Anatomy and physiology
• The GIT tract is pathway (23-to-26 feet or 7-8 meter

in length) that extends from the mouth through the
esophagus, stomach and intestines to the anus.
• It also includes accessory organs that lie out side the
digestive tract i.e. pancreas, liver and gall bladder.
Con…
Mouth and related structures
• Digestion normally begins in the mouth,

 Mouth and related structures includes
– Mucus membranes of the mouth
– Teeth
– Gums
– Lips
– Soft and hard plates
Mouth and related structures
Cont---
 Esophagus: is located in the mediastinum in the thoracic
cavity anterior to the spine and posterior to the trachea and
heart.
• Length: 23-25 cm (10 inch).
• At the upper end of the esophagus there is a sphincter i.e.

upper esophageal sphincter.
Cont---
Cont---
 Stomach
• Location: is a J- shaped saclike structure situated in the upper

portion of the abdomen to the left of the midline.
• capacity: about 1.5-2 L.
• The stomach can be divided in to four anatomic regions
• Cardia (entrance),
• Funds
• Body and
• Pylorus (outlet)
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Anatomical regions of the stomach
• The inlet of the stomach is

called the esophagogastric
junction.
• In the inlet there is lower
esophageal sphincter (or cardiac
sphincter).
• In the out let: pyloric sphincter.
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Cont---
 Small intestine: is the longest segment of the GI tract accounting
for about 2/3 of the total length
• Length: 5-6meters (16-19 feet)
• It is divided in to three anatomic parts
• The upper part, called the duodenum,
• The middle part called the jejunum and
• The lower part called the ileum.
 The large intestine: consists of
• Ascending colon
• Transverse colon
• Descending colon
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Cont.---
 Cecum: is found in junction between the small and large
intestine.
 This is located in the right lower portion of the abdomen.
• The ileocecal value is located at this junction.
• The vermiform appendix is located near this junction and it

has no clearly known function.
 The terminal portion of the large intestine consists of two parts
• The sigmoid colon and the rectum
• The rectum is continuous with the anus.
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Accessory organs
•Liver,
•Gallbladder
•Pancreases
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Function of the Digestive system
 Digestion – break down
 Absorption - in to the blood stream
 Elimination- undigested and unabsorbed food stuffs and waste

products
 Secretion of chemicals
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Assessment and Diagnosis
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Assessment
 Relevant History
 Changes in bowel habits
Diarrhea
Constipation
Alternating diarrhea and constipation
Frank blood in stools
Tarry stools
 Changes in Appetite
Anorexia
Polyphagia
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Relevant History
Emesis: Vomiting Abdominal Pain
 Timing
• Characteristics of vomitus:
 Course
 Partially digested food
 Location
 Undigested food
 Quality
 Fecal material
 Radiation
 Frank blood
 Characteristics
 “Coffee grounds”
 Steady/constant
• Timing of emesis  Often well localized
 Meals, Activities
 Not related to peristalsis
 Person lies still with knees
up
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Important Aspects of Physical Examination?
• Wash your hands, preferably while the patient is

watching.
• Washing with soap and water is an effective way to
reduce the transmission of disease.
 Gloves should be worn when:
• Examining any individual with exudative lesions or
weeping dermatitis
• When handling blood-soiled or body fluid-soiled
sheets or clothing
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General principles of exam
• Exposing only the area that

are being examined.
• Take a spare bed sheet and
drape it over their lower
body such that it just covers
the upper edge of their
underwear
• Offer a chaperone for both
sexes.
• Explain what you're going
to do
• Sequential
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• Good light
• Relaxed patient
• Full exposure of abdomen from
above the xiphoid process to the
symphysis pubis.
• Have the patient empty their
bladder before examination.
• Have the patient lie in a
comfortable, flat, supine
position.
• Have them keep their arms at
their sides or folded on the chest
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• Before the exam, ask the patient to
identify painful areas so that you can
examine those areas last.
• Pay attention to their facial expression to
assess for sign of discomfort.
• Distract the patient if necessary with
conversation or questions.
• Use warm hand, warm stethoscope, and
have short finger nails.
• Approach the patient slowly and
deliberately explaining what you will be
doing.
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• Stand right side of the bed.
• Exam with right hand
• Head just a little elevated
• Ask the patient to keep the
mouth partially open and
breathe gently
• If muscles remain tense,
patient may be asked to rest
feet on table with hips and
knees flexed
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General Principles of Physical
Examination
• If the patient is ticklish or
frightened
 Initially use the
patients hand under
yours as you palpate.
 When patient calms
then use your hands to
palpate.
• Watch the patient’s face
for discomfort.
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Landmarks of the abdominal wall
• When looking, listening,
percussing and feeling
imagine what organs
live in the area that you
are examining.
• Costal margin,
umbilicus, iliac crest,
anterior superior iliac
spine, symphysis pubis,
pubic tubercle, inguinal
ligament, rectus
abdominis muscle,
xiphoid process.
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Abdominal Regions
Right Left
hypochondria hypochondria
c region c region
Right lumbar Left lumbar

region region
Right iliac region Left iliac region
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Abdominal Quadrants
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Right Upper Quadrant (RUQ)
• Liver,
• Gallbladder,
• Duodenum,
• Head of pancreases
• Right kidney and adrenal
• Hepatic flexure of colon
• Part of ascending and
transverse colon
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Right Lower Quadrant (RLQ)
• Cecum,
• Appendix
• Right ovary & tube(in
case of female),
• Right ureter
• Part of ascending colon
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Left Lower Quadrant (LLQ)
• Sigmoid colon
• Left ovary & tube(in case
of female)
• Part of descending colon
• Left ureter
• Sigmoid colon is
frequently palpable as a
firm, narrow tube
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Left Upper Quadrant (LUQ)
• Stomach,
• Spleen,
• Left lobe of liver
• Left kidney,
• Pancreas (tail),
• Left kidney and adrenal
• Splenic flexure of colon
• Part of transverse and descending
colon
• The tip of a normal spleen is palpable
below the left costal margin in a small
percentage of adults
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Epigastric Area
• Stomach,
• Pancreas (head and body),
• Aorta
• Pulsations of the
abdominal aorta are
frequently visible and
usually palpable in the
upper abdomen
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Physical Examination of the Abdomen
 Stand at the patient’s
right side and
proceed in an orderly
fashion:
Inspection
Auscultation
Percussion
Palpation
Special Tests
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ABDOMEN: Inspection
INSPECTION
There should be adequate exposure of the abdomen for proper inspection. The
patient should be exposed from the inferior chest to the anterior iliac spines
bilaterally.
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Contents of inspection
 Abdominal contour/appearance
 Respiratory movement
 Abdominal skin
 Abdominal vein
 Symmetry
 Peristalisis
 Hernial sites
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Abdominal contour/appearance
 Standing at the right side

of the bed, inspect the
abdomen.
 As you look at the contour
of the abdomen and watch
for peristalsis, it is helpful
to sit or bend down so that
you can view the abdomen
tangentially.
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Abdominal contour/appearance
 Normal – slightly retracted from the xiphoid,
symmetrical, flat
 Abdominal localized bulge – mass
 Scaphoid – retracted backward – malnutrition
 Distension – fluid, air, pregnancy, obesity
 Global abdominal enlargement is usually caused by air,
fluid,
fluid or fat.
fat
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Abdominal Contour
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Respiratory Movement
• Abdomen moves with respiration
– Predominantly seen in children and men
• Decreased abdominal movement with respiration
– Peritonitis (acute)
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Appearance of Skin in the abdomen
Note the skin, including:

 Scars:
Scars Describe or diagram their location.
 Striae:
Striae Old silver striae or stretch marks are normal.
 Dilated veins:
veins A few small veins may be visible
normally.
 Rashes and lesions
 The umbilicus:
umbilicus Observe its contour and location, and
any signs of inflammation or hernia.
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Appearance of the abdomen(Skin)
• Abnormal venous
patterns
• Abnormal discoloration
• Umbilicus is sunken
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Striae
• Stretch marks are a light
silver hue.
• Pregnancy, chronic
ascites, rapid weight
gain and obese
individuals
• Cushing’s syndrome
(more purple or pink).
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• Tattoos
• Scars can be drawn on
schematic diagrams of
the abdomen (a picture
is worth a thousand
words).
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Cullen’s sign
• Ecchymosis
periumbilically.
(intraperitoneal
hemorrhage, ruptured
ectopic pregnancy,
hemorrhagic
pancreatitis..)
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Grey-Turner’s sign
• Ecchymosis of
flanks.
(retroperitoneal
hemorrhage such as
hemorrhagic
pancreatitis)
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Abdominal wall veins
• Normally – mostly not seen
– Drain away from the
umblicus
– Veins in the upper
quadrants drain to SVC
– Veins in the lower
quadrants drain to IVC
• During venous obstruction
– Drainage direction will
be reversed
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How to Check Venous
Drainage
The vein is
emptied between two
fingers to a distance
of a few centimeters,
then allows blood to
refill the vein from
one direction by removing
one compressing finger
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Visible Pulsations
• More conspicuous in the thin than in the fat
• Greater in the old than in the young.
• Increased in thyrotoxicosis, hypertension, or aortic

regurgitation)
• In those with an aortic aneurysm and tortuous aorta
• In those who have a mass joining the aorta to the

anterior abdominal wall
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Peristalsis
Peristalsis. Observe for several minutes if you suspect
intestinal obstruction.
 Visible bowel motion on the abdominal surface
 Normally peristalsis is not seen but it may be visible
normally in very thin people.
 Observed during obstructive conditions
 Pyloric stenosis, small bowel obstruction, …
 Increased peristaltic waves of intestinal obstruction and
diarrhea.
 Direction – LUQ to RLQ
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Hernia
• Hernia the protrusion of an organ or tissue out of
the body cavity in which it normally lies.
• Passage of intra abdominal content via weak
abdominal wall sites
• Hernial sites are:
– Epigastrium, periumblical, inguinal, femoral,
incisional,…
• Examined by asking the patient to strain/cough
while inspecting and palpating the hernial sites
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Auscultation
 It is performed before
percussion or
palpation
• Bowel sounds
• Vascular sounds
(bruits)
• Friction Rubs
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Auscultation for bowel sounds
• Auscultation can be done
with the diaphragm.
• You should listen for at
least 10-15 seconds and
note the pitch and
frequency of bowel
sounds.
• If you do not hear any
bowel sounds, you should
listen for 3-5 minutes
before you can state that
the patient does not have
any bowel sounds.
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• Normal sounds are due

to peristaltic activity.
• Peristalsis: A
pregressice wavelike
movement that occurs
involuntarily in hollow
tubes of the body.
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1. Diaphragm of
stethoscope used
2. Skin depressed to
approximately 1 cm
3. Listening in one spot
is usually sufficient
4. Listening for 15-20 or
30-60 seconds
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1. Bowel sounds cannot be
said to be absent unless
they are not heard after
listening for 3-5
minutes.
 Listen for bowel sounds
and note their frequency
and character.
character
 Normal sounds consist
of clicks or gurgles,
gurgles
occurring at an estimated
frequency of 5 to 34 per
minute.
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Three things about bowel sounds
Abnormal findings of BS
1. Are bowel sounds Absent
present? Bowel obstruction,
2. If present, are they Peritonitis,
Paralytic ileus.
frequent or sparse Low Potassium
(i.e.quantity)? Surgical manipulation
3. What is the nature of Increased Bowel sounds
the sounds Increased motility of
fluids
(i.e.quality)? Diarrhea
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Bowel sound
Bowel sound Decrease:
•Inflammatory processes
of the serosa
•After abdominal surgery
•In response to narcotic
analgesics or anesthesia.
•Inflammation of the
intestinal mucosa will
cause hyperactive bowel
sounds.
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• Processes which lead to
intestinal obstruction
initially cause frequent
bowel sounds, referred to
as "rushes.“
• “Rushes" means as the
intestines trying to force
their contents through a
tight opening.
• “Rushes" is followed by
decreased sound,
sound called
"tinkles,"
tinkles and then silence.
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• After silence the

appearance of bowel
sounds marks the
return of intestinal
sounds activity, an
important phase of the
patient's recovery.
recovery
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Bowel sound Signs
• Splashing: a sound indicative of air
or fluid in body cavity with shaking
individual;
individual normal in the stomach.
• Bruits: a vascular sound; confined
to systole do not necessarily indicate
disease.
 Aortic (midline between umbilicus
and xiphoid)
 Renal (two inches superior to and two
inches lateral to umbilicus)
 Common iliac (midway between
umbilicus and midpoint of inguinal
ligament).
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Auscultation for vascular sounds (bruits)
• Presence of a bruit on the

renal artery would lend
supporting evidence for the
existence of renal artery
stenosis.
stenosis
• When listening for bruits,
you will need to press down
quite firmly as the renal
arteries are retroperitoneal
structures.
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Friction rubs (rare)
Rubs–Rubs occur in:
•Liver
•Spleen
•Cardiac
•Pulmonary
•Right and left upper quandrants
•Grating sound with respiratory
movement
•Indicates inflammation of the
capsule of the liver or spleen
(infection or infarction).
infarction)
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Percussion Technique
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Percussion
• Percussion helps you to assess the amount and
distribution of gas in the abdomen and to
identify possible masses that are solid or fluid
filled.
• Percuss the abdomen lightly in all four
quadrants to assess the distribution of tympani
and dullness.
• A protuberant abdomen that is tympanitic
throughout suggests intestinal obstruction.
obstruction
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Percussion
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There are two basic sounds with Percussion
• Tympanitic (drum-
like) sounds
produced by
percussing over air
filled structures.
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There are two basic sounds with Percussion
• Dull sounds that

occur when a solid
structure (e.g. liver)
or fluid (e.g. ascites)
lies beneath the region
being examined.
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The two solid organs are percussable in
the normal patient
• Liver:
Liver will be entirely
covered by the ribs.
Occasionally, an edge
may protrude 1-2
centimeter below the
costal margin.
• Spleen:
Spleen The spleen is
smaller and is entirely
protected by the ribs.
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Examination of Liver (Percussion)
• Midclavicular line is
noted
• Second intercostal
space is noted
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To determine the size of the liver
• Measure the liver span by
percussing hepatic
dullness from above
(lung) and below
(bowel). A normal liver
span is 6 to 12 cm in the
midclavicular line.
4-8 cm in
Midsternal
line
6-12 cm from right

mid clavicular line Tympanitic
Normal liver
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span
To determine the size of the liver
• Percussion just below the right
breast in a line with the middle
of the clavicle and resonant note.
• Move down a few centimeters
then you will be over the liver,
dull sounding tone.
• Continue downward until the
sound changes once again.
• Upper margin is noted by first
dull percussion note
• Lower margin is noted by first
tympanitic note.
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Examination of Spleen(Percussion)
• When a spleen enlarges, it expands anteriorly, downward, and
medially, often replacing the tympany of stomach.
• It then becomes palpable below the costal margin.
• Percussion cannot confirm splenic enlargement but can raise
your suspicions of it.
• Palpation can confirm the enlargement, but often misses large
spleens that do not descend below the costal margin.
• Two techniques may help you to detect splenomegaly/enlarged
splenomegaly
spleen:
1. Percuss the left lower anterior chest wall between lung resonance
above and the costal margin (an area termed Traube’s space).
2. Dullness raises the question of splenomegaly
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Negative Splenic Percussion Sign Positive Splenic Percussion Sign
Inspiratory
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2. Check for a spleenic percussion sign
• Percuss the lowest inter space in the left anterior
axillary line,
line as shown below. This area is usually
tympanitic.
• Then ask the patient to take a deep breath, and percuss
again. When spleen size is normal, the percussion note
usually remains tympanitic.
• A change in percussion note from tympany to dullness
on inspiration suggests splenic enlargement.
 This is a positive splenic percussion sign.
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Percussion at Castell’s Spot

• Castell’s Spot identified:
 Left anterior axillary line identified
 Left lower costal margin identified
• Percussion at Castell’s Spot while patient
inhales and exhales deeply
 Dull tone indicates possible
splenomegaly.
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4. Abdominal Palpation
• Technique • Liver edge

• Light • Spleen tip
• Deep • Kidneys
• Bimanual • Aorta
• Masses
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Light Palpation
• Palpate four quadrants
superficially from LLQ
counterclockwise.
• Is used to evaluate general
condition, nature of any distention,
and gross abnormalities and
painfulness.
 During light palpation:
 Looking for areas of tenderness
 Voluntary or involuntary
guarding
 The most sensitive indicator of
tenderness is facial expression
 So - watch the face, not your
hands!!
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Light Palpation
 First warm your hands by rubbing them together.
 Abdominal wall depressed approximately 1-2 cm.

 Keeping your hand and forearm on a horizontal plane, with fingers
together and flat on the abdominal surface, palpate the abdomen
with a light, gentle, dipping maneuver.
 Tenderness is a physical exam finding a reflex occurs (muscle
splinting, wide eyes, moaning, teeth gritting).
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Light Palpation
• Involuntary rigidity
(muscular spasm)
 It indicates peritoneal
inflammation.
• Presence of superficial
(intramural) masses is
more prominent if patient
raises their head, intra-
abdominal mass is less
prominent if patient raises
their head Next palpate deeply to detect large
masses or tenderness
DEE
PALP P
ATIO
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Deep Palpation
This is usually required to detect any organ
enlargement, abdominal masses or swellings.
Entire palm
Either one- or two handed technique isacceptable
Use on42ee hand on top of another and push dow slowly.
two-handed deep palpation

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Deep Palpation
One handed technique:
• Use palmar surface of fingers of one hand (greatest
number of fingers)
fingers and a deep, firm, gentle maneuver to
examine abdomen.
• Palpate deeply with finger pads (do not “dig in” with
finger tips).
tips
• Palpate tender areas last and ry to identify masses or
areas of deep tenderness.
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Deep Palpation
• Push as deeply as patient will allow without
significant discomfort
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Normal structure that may be palpable
• Sigmoid colon
• Liver • They may shift
• Kidney down with
• Abdominal aorta inspiration and back
• Iliac artery with expiration. (not
• Distended bladder
true of masses within
the abdominal wall
• Gravid and non-gravid
uterus or retroperitoneal
• Xyphoid process structures).
structures
• Spleen
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Liver Palpation (Standard Method)
• Start in the RUQ, 10
centimeters below
the rib margin in
the mid-clavicular
line.
• Place left hand
posteriorly parallel
to and supporting
11th & 12th ribs on
right.
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Standard Method Liver palpation
• Ask the patient to take a

deep breath.
• You may feel the edge of
the liver press against
your fingers.
• Palpating hand is held
steady while patient
inhales
• Palpating hand is lifted
and moved while the
patient breathes out.
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Liver Palpation
Note any tenderness.
If palpable at all, the edge of a
normal liver is soft,
soft sharp,
sharp and
regular,
regular its surface smooth.
smooth
Firmness or hardness of the Large irregular liver
liver, bluntness or rounding of its
edge, and irregularity of its
contour suggest an abnormality.
On inspiration, the liver is
palpable about 3 cm below the
right costal margin in the mid
clavicular line Large smooth liver
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Hepatomegaly
• More than 1cm below
the costal margin
• An exception is a
congenitally large right
lobe of the liver
• Severe, chronic
emphysema
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Standard Method of Liver palpation
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Hooking Technique
 This is helpful for obese cases
 Hooking procedure:
Stand to the right of the patient’s chest
Place fingers curved under the rib cage
Have patient inhale
Feel the border of the liver descend to your fingers
Note smoothness, or nodules
 Tenderness over the liver suggests inflammation, as in
hepatitis, or congestion, as in heart failure.
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Hooking Technique
The liver edge shown below is palpable
with the finger pads of both hands.
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• Liver exam video
07/16/22 by Shegaw T 93
Spleen palpation
• Seldom palpable in normal
adults.
• Causes include COPD,
COPD and
deep inspiratory descent the
diaphragm downward.
• Patient is supine and Support
the lower left rib cage with left
hand.
Three methods:
1. Palpate upwards toward spleen
with finger tips of right hand
starting the RLQ.
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Examination of Spleen (Palpation)
• Have the patient take a
deep breath and
synchronize palpation
with the breathing cycle.
• Try to feel the tip or
edge of the spleen as it
comes down to meet
your fingertips.
• Note any tenderness,
assess the splenic
contour.
 Deep technique used
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Examination of Spleen (Palpation)
2. From left anterior axillary to costal margin:

The patient lying on the right side with legs some what
flexed at hips and knees. In this position gravity may bring
the spleen forward and to the right into a palpable location.
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3.. Hooking
methods
07/16/22 by Shegaw T 97
Spleen palpation
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Spleen palpation
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• Spleen exam video
07/16/22 by Shegaw T 100

Special Abdominal examination
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Special exam
• Murphy’s Sign • Re bound Tenderness
• McBurney’s Point • Costovertebral
• Rovsing’s Sign tenderness
• Psoas Sign • Shifting Dullness
• Obturator Sign • Fluid wave
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Murphy’s Sign
• A test for gallbladder
disease or sign of
gallbladder disease
consisting of pain on
taking a deep breath when
the examiner's fingers are
on the approximate
location of the
gallbladder.
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Murphy’s Sign
Techniques
• Hook your left thumb or the fingers of your
right hand under the costal margin.
• Ask the patient to take a deep breath
• A sharp increase in tenderness with a sudden
stop in inspiratory effort constitutes a positive
Murphy’s sign of acute cholecystitis.
Look for Murphy’s sign when right upper
quadrant pain and tenderness suggest acute
cholecystitis,.
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McBurney’s Point
 McBurney’s Point
 Rovsing’s Sign
 Psoas Sign
 Obturator Sign
 Tenderness
 Rebound Tenderness
 Referred rebound tenderness
 Are special exam/tests which are helpful in assessing possible
appendicitis
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McBurney’s Point
• A site of extreme
sensitivity in acute
appendicitis, situated in the
normal area of the
appendix in the RLQ.
• Localized tenderness just
one third between right
anterior iliac crest and
two third the umbilicus.
umbilicus
• Heel strike, riding over
bumps in road while
driving,
driving coughing will
produce pain.
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106
Rovsing’s Sign
• Sign of appendicitis
• Patient will experience
right lower quadrant
(RLQ) pain (in region of
McBurney’s Point) when
left lower quadrant(LLQ)
is palpated.
 Referred rebound
tenderness: right lower
quadrant pain on quick
withdrawal of the LLQ.
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Iliopsoas Sign
• This is pain felt when a weight is applied on the right
knee.
• Patient can lay on side and extend leg at the hip or have
patient lay on back and try to flex hip against the
resistance of examiner’s hand on thigh. If patient has an
inflamed retrocecal appendix, this will produce pain.
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108
Iliopsoas Sign
• Anatomic basis for the

psoas sign: inflamed
appendix is in a
retroperitoneal
location in contact with
the psoas muscle, which
is stretched by this
maneuver.
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Obturator Sign
• Internally rotate right leg at the hip with the knee at

90 degrees of flexion. Will produce pain if inflamed
appendix is in pelvis.
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Rebound Tenderness
(For peritoneal irritation)
• Warn the patient about what to do
• Press deeply on the abdomen with
your hand.
• After a moment, quickly release
pressure.
• If it hurts more when you release,
the patient has rebound tenderness.
 Do this when symptoms present
 Place fingers perpendicular to skin
 Push in slowly
 Let out quickly
 Pain on release of pressure is
positive for peritoneal irritation
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Assessing Possible Ascitis
• A protuberant abdomen with bulging flanks
suggests the possibility of ascitic fluid.
fluid
• Because ascitic fluid characteristically sinks with
gravity, while gas-filled loops of bowel float to the
top, percussion gives a dull note in the
dependent areas of the abdomen.
• If you note a protruding abdomen with bulging
flanks and dull percussion sounds in dependent
areas,
areas you might perform two tests for assessing
ascites.
1. Test for shifting dullness.
2. Test for fluid wave
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Shifting Dullness
(For peritoneal fluid)
• Supine the patient and assess the
areas for tympani and dullness by
percussion.
• Percuss from anterior abdomen
laterally to outline areas of dullness
noted.
• Lie him on one side
• Percuss again, note once more any
areas of tympani and dullness.
• Patient rolled slightly toward the
examined side; movement of the dull
point medially is described as “shifting
dullness” and suggests ascites.
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Shifting Dullness
If the patient has ascites, the area of

dullness will shift down to the dependent
side and the area of tympani will shift up.
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The extra hand/patient’s as a pressure helps to
stop the transmission of a wave through fat.
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115
Fluid wave
An easily palpable impulse suggests ascites.

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• P. Exam Vedio
07/16/22 by Shegaw T 117

Recording the physical examination-
Abdomen
• “Abdomen is protuberant with active bowel sounds. It
is soft and nontender no masses or
hepatosplenomegaly. Liver span is 7 cm in the right
midclavicular line; edge is smooth and palpable 1 cm
below the right costal margin. Spleen and kidneys not
felt”.
OR
• “Abdomen is flat. No bowel sounds heard. It is firm
and boardlike, with increased tenderness, guarding, and
rebound in the right midquadrant.Liver percusses to 7
cm in the midclavicular line; edge not felt. Spleen and
kidneys not felt”.
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118
Diagnostic test for common GIT problems
 Stool examination
• Inspected for color, and consistency.
• If blood in the upper GIT produce a black tarry color/ Melena.
• If blood in the lower portion of GIT will appear bright or dark

red.
• If there is streaking of blood on the surface of the stool or if blood
is noted on the toilet i.e. lower rectal or anal bleeding is
suspected.
• N.B. fecal occult blood test (FOBT) is a common stool test to
detect for CA(GI bleeding associated with colorectal cancer).
07/16/22 by Shegaw T 119

Diagnostic Modality
 Gastric analysis
• Small tube into the stomach to obtain a fluid
sample.
• Stomach contents are aspirated by suction into
the syringe.
• May be performed to diagnose gastric Ca.
07/16/22 by Shegaw T 120

Diagnostic Modality
 Radiography:
• Is a simple x-ray without contrast agents.
• It shows obstruction or paralysis of the digestive tract or
abdominal air patterns in the abdominal cavity .
• Also shows enlargements of organs like liver.
 Barium studies – A special type of X-ray
• Entire GI tract can be out lined using a contrast agent such as
barium sulfate.
 Barium swallow: ingested orally
 Barium enema: instilled rectally
07/16/22 by Shegaw T 121

Cont---
 Endoscopic procedures
• Examination of internal structures using a viewing tube
/endoscope.
• Many endoscopes have small scissors to remove tissue sample
and electric probe to destroy abnormal tissue.
 Esophago gastro duodenoscopy (EGDS)
• Allows for direct visualization of esophageal, gastric, and
duodenal mucosa through a lighted endoscopy.
• Used for both diagnosis and treatment purpose.
• Pt NPO before and after the procedure.
• Local anesthetic sprayed is indicated.
• Position : left lateral.
07/16/22 by Shegaw T 122

Cont.…
07/16/22 by Shegaw T 123

Cont---
 Laparoscopy
• Insert through the skin in the abdominal wall under spinal or
general anesthesia.
• Used to screen for tumor or other abnormalities, to obtain
sample, and to examine any organ in the abdominal cavity
 Proctoscopy and sigmoidoscopy
• Used to inspect/examine the rectum and sigmoid colon
respectively for the evidence of ulceration, tumors, polyps,
and other abnormalities.
 Colonoscopy
• Examine the colon to the cecum
07/16/22 by Shegaw T 124

Cont----
07/16/22 by Shegaw T 125

ANY QUESTION
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Oro-dental related diseases
• Adequate nutrition is related to good dental health and the
general condition of the mouth, because digestion normally
begins in the mouth.
• Changes in the oral cavity may influence the type and amount
of food ingested as well as the degree to which food particles
are properly mixed with salivary enzymes.
07/16/22 by Shegaw T 127

Cont.….
07/16/22 by Shegaw T 128

1. Dental plaque & caries
• Dental plaque is a gluey, gelatin-like substance that adheres to
the teeth.
• The initial damage to a tooth occurs under dental plaque.
• Tooth decay is an erosive process of tooth.
• Begins with the action of bacteria on fermentable carbohydrates

in the mouth.
• Produces acids that dissolve tooth enamel.
07/16/22 by Shegaw T 129

Cont.…
• Dental decay begins with a small hole, usually in a fissure that
is hard to clean.
• Left unchecked, the decay extends into the dentin.
• Dentin is not as hard as enamel, decay progresses more rapidly

and in time reaches the pulp of the tooth.
• Blood, lymph vessels, and nerves are exposed, they become
infected and an abscess may form, Soreness and pain.
07/16/22 by Shegaw T 130

Asst. and Dx:
• History taking
• P/exam
• Clinically
• X-ray
07/16/22 by Shegaw T 131

07/16/22 by Shegaw T 132
Oro dental….
 Treatment:
• Anti pain- NSAID like  Prevention:
PCM, diclofenace,
Ibuprofen, tramadol etc • Practicing effective mouth care,
• The dentist can
• Effective cleaned on a daily basis
determine the extent of
damage and type of • Reducing the intake of starches
treatment needed.
• Fillings • Applying fluoride to the teeth or
• Dental implants drinking fluoridated water,
• If treatments are not
successful the tooth • Refraining from smoking, chewing
may need to be
extracted.
07/16/22 by Shegaw T 133
2. Dento-alveolar abbesses
• Is referred to as abscessed tooth
• Collection of pus in the apical dental periosteum (fibrous

membrane supporting the tooth structure) and the tissue
surrounding the apex of the tooth. It can be:
• Acute - usually secondary to pus-producing inflammation of
the dental pulp that arises from an infection extending from
dental caries.
• Chronic (Blind dental abscess) -fully formed abscess without
the patient’s knowing it. .
07/16/22 by Shegaw T 134

Cause:
•Trauma
•Injury
•Secondary
07/16/22 by Shegaw T 135

Dental abcess……
Clinical feature:
•The abscess produces a dull,
gnawing, continuous pain.
•Surrounding cellulitis and edema
of the adjacent facial structures.
•Mobility of the involved tooth.
•In well-developed abscesses, there
may be a systemic reaction, fever,
and malaise
07/16/22 by Shegaw T 136

Managements
• Dentist or oral surgeon may perform a needle aspiration or

drill an opening into the pulp chamber to relieve pressure and
pain and to provide drainage.
• Tooth may be extracted.
• Root canal therapy.
• Analgesics and
• Antibiotics may be prescribed.
07/16/22 by Shegaw T 137

Nsg management
• The nurse assesses the patient for bleeding after treatment,
• Instructs the patient to use a warm saline or warm water mouth

rinse to keep the area clean.
• The patient is also instructed to take antibiotics
• Analgesics as prescribed, to advance from a liquid diet to a

soft diet as tolerated, and to keep follow-up appointments.
07/16/22 by Shegaw T 138

3. Parotitis
• Inflammation of the parotid gland
• Most commonly affecting children.
Cause:
• Mumps (epidemic parotitis), caused by viral infection also
causes parotitis.
• Among elderly, acutely ill and dehydrated patients
Staphylococcus aureus usually the cause.
07/16/22 by Shegaw T 139

C/m
• Fever
• The gland swells and becomes tense and tender
• Pain in the ear, and swollen glands interfere with

swallowing.
• Overlying skin soon becomes red and shiny.
07/16/22 by Shegaw T 140

Management
• Maintaining adequate nutritional and fluid intake,
• Good oral hygiene.
• Discontinuing medications (e.g. tranquilizers, diuretics) that

diminish salivation.
• Analgesics
• If antibiotic therapy is not effective, the gland may need to be

drained by a surgical procedure known as parotidectomy.
07/16/22 by Shegaw T 141

4. Leukoplakia
• It is a chronic inflammation with thick white patches of rough
hair-like projections.
• Typically found on lateral border of the tongue & mucous
membrane.
 Slowly developing changes in the oral mucosa membrane that are
characterized by thickened white, firmly attached patches.
– White patches usually on the tongue, gums, and inside of checks.
– 90% of leukoplakia lesions are benign, however, up to 7% of
lesions becomes malignant after many years.
– Lesions on the lips and tongue are more likely to progress to
malignancy.
07/16/22 by Shegaw T 142
cont---
07/16/22 by Shegaw T 143

Causes
• Chronic irritation of the mouth (poorly fitting dentures, broken
or poorly repaired teeth).
• Smoking, infected teeth.
• Very spicy foods
• Common in immunosuppressant e.g. HIV
• N.B. it can confused with oral Candida infection however,

leukoplakia can’t removed by scraping.
07/16/22 by Shegaw T 144

Cont---
• Hairy" leukoplakia of the mouth is an unusual form of
leukoplakia that is seen mostly in HIV-positive people.
• It may be one of the first signs of HIV infection.
07/16/22 by Shegaw T 145

Clinical feature
• The most commonly hairy leukoplakia are painless, fuzzy /hairy
white patches on the side of the tongue.
• The lesions have the following characteristics:-
• Location : - Usually on the tongue.
- May be on the inside of the cheeks.
• Color: - Usually white or gray
- May be red (called erythroplakia, that can lead to cancer)
• Texture : -Thick & firm
- Slightly raised
- Hardened surface
07/16/22 by Shegaw T 146

Leukoplakia…
07/16/22 by Shegaw T 147

Assessment & diagnostic
• History taking & physical exam
• Clinically
07/16/22 by Shegaw T 148

Management
• Removing the source of irritation is important and may cause the
lesion to disappear.
• Treat dental causes such as rough teeth, irregular denture surface,
etc
• Stop smoking and do not drink alcohol.
• Some times surgery may require to remove the lesion.

Prognosis
• Lesions often clear up in a few weeks or months after the source
of irritation is removed.
07/16/22 by Shegaw T 149

4. Oral candidiasis /Trush
07/16/22 by Shegaw T 150

oral candidacies….
07/16/22 by Shegaw T 151

Cont---
07/16/22 by Shegaw T 152

Cont---
 S/ Sx:
• Cheesy white plaque
• Erythematous /reddened/and often bleeding gums and

scraping off
 Asst & dignostic
• History, Clinically and Histological exam
 Mgt: Antifungal medications
– Nystatin, grisufulvin
– Clotrimazole or ketoconazole for wks-months

07/16/22 by Shegaw T 153
5. Stomatitis
• Is the general term for inflammation of the oral cavity.
• The most common are canker sore & HSV-1.
• Shallow ulcer with a white center and red border.
• The sore usually forms on the soft, loose tissues particularly

on the inside of the lips or cheek, tongue, soft palate and
sometimes in the throat.
• It can be: Small or large canker sore
07/16/22 by Shegaw T 154

Possible causes
 Vitamin deficiency (B-complex,  Chemotherapy or

folic acids, Zink, iron) radiation therapy.
 Infection (bacterial, viral or  Allergies, acidic foods
fungus)
 It is also associated with
 Systemic diseases (HIV, DM,
emotional or mental
leukemia)
stress, fatigue, or
 Irritants ( tobacco, and
hormonal factors
alcohol)
07/16/22 by Shegaw T 155

Sign and symptoms
• Oral pain lasts 4-10 days • Tongue may be dry,
• Fever and dry mouth cracked, contain masses or
• Shallow ulcer with or gray exudates.
center and red border. • Sensitivity to hot and spicy
• It begins with burning or foods.
tingling sensation and slight • Oral bleeding
swelling.
07/16/22 by Shegaw T 156

Management
 Conservative mgt.:
 Medications
• Control or remove causes
• Analgesics for pain,
– Improve diet
• Topical/systemic steroids.
– Rx of underlying infections • Antibiotic
• Good oral hygiene • Antiviral:
• Antifungal.
• Rest: to promote tissue repair
07/16/22 by Shegaw T 157

See it??
• Gingivitis
• Oral cancer
07/16/22 by Shegaw T 158

Esophageal disorders
 There are many pathologic conditions of the
esophagus, including:
– Esophagitis
– Achalasia
– Hiatal hernias, and
– Diverticula,
07/16/22 by Shegaw T 159

1. Esophagitis
• It is an acute or chronic inflammation of the
esophagus.
• It also called gastro esophageal Reflux disease
(GERD).
07/16/22 by Shegaw T 160

Cont--
 Causes:
– Gastric reflux
– Inappropriate relaxation of LES
– Infection
– Trauma – Delayed gastric emptying
– Chemicals: medication, – Swallowing of foreign bodies

acids, alkalis – Prolonged nasogastric intubation
– Repeated vomiting
07/16/22 by Shegaw T 161

Cont---
 C/M:
– Dyspepsia/indigestion – Dysphagia or odynophagia

– Heart burn (pain on swallowing).
– A sensation of acidic or – Pain on drinking/alcohol,

bitter regurgitation hot or cold fluid.
associated with nausea – Worsen w/n the client
– Bleeding (acute or chronic) bends over, strain, or in
recumbent position.
07/16/22 by Shegaw T 162
Cont---
 Dx:
– Using c/m
– Esophagoscopy
07/16/22 by Shegaw T 163

Management
Depends on the cause of esophagitis:
1. Life style changes

– The patient is instructed to eat slowly and chew foods
thoroughly (to avoid belching).
– Avoid caffeine, beer /alcohol and smoking
– Avoid acidic foods e.g. orange juice, tomatoes etc.
– Raising the head of the bed /15-20cm
07/16/22 by Shegaw T 164

Cont---
- Remain upright 1-2hrs after meal.
- No food or drink with in 2-3hrs of bed time.
- Avoid lifting of heavy objects or straining and working in bent

over position.
- Avoid heavy meal / a low-fat diet.
- Encourage small and frequent diet 4-6 times than large foods 3
times /day.
- Left lateral position.
07/16/22 by Shegaw T 165

Cont---
2. Medication
• Antacids after each meal and before bed time.
• Accelerate gastric emptying /prokinetic drugs.
• Anti secretory agents.
• Antibiotics if associated with infection.
07/16/22 by Shegaw T 166

2. Achalasia
• It is a motility disorder
• It is absent or ineffective peristalsis of the distal esophagus

accompanied by failure of the esophageal sphincter to relax in
response to swallowing.
• Narrowing of the esophagus just above the stomach
• The exact cause is unknown.
07/16/22 by Shegaw T 167

Cont---
07/16/22 by Shegaw T 168

Clinical manifestation
• Difficulty in swallowing (both liquid and solid): the 1st
symptom.
• Sensation of food sticking in the lower portion of the
esophagus.
• Food is commonly regurgitated,
• May have chest pain and heart burn
• Halitosis
• Pain may or may not be associated with eating

07/16/22 by Shegaw T 169
Diagnostic Evaluation
• Radiological studies - show esophageal dilation above the
narrowing at the gastro esophageal junction.
• Barium swallow and endoscopy may be used to diagnosis.
• CT scan
• Clinically
07/16/22 by Shegaw T 170

Radiological: "Bird's beak image" appearance
07/16/22 by Shegaw T 171
Management
• Instructed to take slowly and drink fluids with meals and avoid
foods that aggravate the condition.
• Mild cases can be treated by:
– Ca++ channel blockers
– B-blokers and
– Nitrates
• Injection of botulinum toxin.
07/16/22 by Shegaw T 172

Cont---
• If this is unsuccessful
• Pneumatic (forceful) dilation: by passing a tube into the

esophagus i.e. large metal stents may be used to keep esophagus
open for longer duration.
• Has 75% success rate and a 3% incidence of perforation
07/16/22 by Shegaw T 173

Dilation of narrowed esophagus
07/16/22 by Shegaw T 174

Cont---
• Surgical separation of the, muscle fibers may be
recommended /esophagomyotomy /LES incised.
07/16/22 by Shegaw T 175

3. Esophageal Diverticula /pouches
• Diverticulum: is an out pouching of mucosa and sub mucosa that
protrudes through a weak portion of the musculature.
• Esophageal diverticula: is a sacs resulting from the herniation of
esophageal mucosa and sub mucosa into the surrounding tissue.
 It may occur in one of the three areas of the esophagus:-
– The pharyngo/ Zenker’s on upper area of the esophagus (most
common),
– The mid esophageal area or
– Epiphrenic or lower area of the esophagus
07/16/22 by Shegaw T 176

Cont---
07/16/22 by Shegaw T 177

Cont---
07/16/22 by Shegaw T 178

Clinical feature
• Difficulty swallowing
• Fullness in the neck (feeling that food stops before

reaching in to the stomach)
• Belching, Halitosis
• Regurgitation of undigested foods
• Diverticulum /pouch filled with food or fluid
07/16/22 by Shegaw T 179

Dx. Cont---
• Esophago gastro dodunoscopy
 Management
• The only means of cure is surgical removal of the diverticulum

/diverticullectomy
• After surgery foods and fluids are withheld until x-ray is
confirm no leakage at surgical site.
07/16/22 by Shegaw T 180

readddd
• MALLORY-WEISS TEAR
• ESOPHAGEAL VARICES
• Esophageal Ca
07/16/22 by Shegaw T 181

Hiatal hernia
• Hiatus a Latin word w/c means gap, cleft/ opening.
• Hiatus is an opening in the diaphragm; the esophagus passes

through
• It is a protrusion of the upper portion of the stomach through an
esophageal opening in the diaphragm or the lower portion of the
thorax. Also called diaphragmatic hernia
• Normally, the opening in the diaphragm encircles the esophagus
tightly and the stomach lies completely with in the abdomen.
07/16/22 by Shegaw T 182

causes
• Increased abdominal pressure
• Muscle weakness in the
– bending.
– Straining, esophageal hiatus
– pregnancy, – age,
– strenuous exercises,
– trauma,
– coughing,
– obesity, tight cloth & – congenital weakness,
ascites.
– surgery
Incidence: It occurs more often in women than men
07/16/22 by Shegaw T 183

Classification
• Type I - sliding
• Type II -paraesophageal
• Type III - para and sliding component
• Type IV - other viscera involved
07/16/22 by Shegaw T 184

Con…
07/16/22 by Shegaw T 185

Cont---
• There are four types of hiatal hernia
1) Axial, Sliding or type 1: occurs when the upper stomach and

the gastroesophageal junction (GEJ) are displaced upward and
slide in and out of the thorax.
• The most common type of hernia.
• Accounts approximately 90 % of all hiatal hernias.
07/16/22 by Shegaw T 186

Cont---
07/16/22 by Shegaw T 187

Cont---
2) Para esophageal hernia: occurs when all or part of the
stomach pushes/rolls through the diaphragm beside the
esophagus.
• Less common
• The GEJ remains in its normal location
• Reflux is a rare concern
07/16/22 by Shegaw T 188

Con…
07/16/22 by Shegaw T 189

Con…
3. Sliding- para esophageal hiatal hernia
•Occurs when all part of stomach and the gastro esophagel
junction (GEJ) are displaced upward in or out the thorax and
besides the esophagus.
4. Other viscera involved hiatal hernia

•Occurs when all part of stomach , gastroesophagel junction
(GEJ) and other viceral are displaced upward in or out the thorax
and besides the esophagus.
07/16/22 by Shegaw T 190

Con….
07/16/22 by Shegaw T 191

C/manifestation
• A small hernia may not produce any
discomfort or require treatment.
• However, a large hernia can cause pain,
heartburn, a feeling of fullness, or reflux,
which can injure the esophagus with possible
ulceration and bleeding.
07/16/22 by Shegaw T 192

C/ms
• Paraesophageal hernia:
• Sliding hernia
 feeling of fullness after eating,
 heart burn,
Breathlessness after eating,
 Regurgitation,
Feeling of suffocation,
 Dysphagia, Chest pain that mimics angina,
 Chest pain and belching Worsening of manifestations in
 May be asymptomatic recumbent position,
Reflux usually doesn’t occur,
junction sphincter is intact.
07/16/22 by Shegaw T 193
Con..
 Sliding-paraesophageal hiatal hernia
 heart burn,
 regurgitation,
 Dysphagia
 feeling of fullness after eating,
 breathlessness after eating,
 feeling of suffocation,
 chest pain that mimics angina, and

07/16/22 by Shegaw T 194
Dx. Cont---
 Assessment
 Confirmed by radiographic studies and
 Fluoroscopy.
07/16/22 by Shegaw T 195

Surgical Management
• Fundoplication, in which the stomach fundus is wrapped

around the lower part of the esophagus, is the most common
surgical procedure performed
07/16/22 by Shegaw T 196

Nursing Management
– Avoid strenuous exercise.
– Medications: antacids,
antiemetic's, stool softeners,
gastric acid inhibitors.
– 15% of patients require
surgery.
07/16/22 by Shegaw T 197

Reading assignment???
• Umbilical hernia
• Femoral hernia
• Inguinal hernia
07/16/22 by Shegaw T 198

Gastric and duodenal disorders
1. Gastritis
 Inflammation of the gastric or stomach mucosa.
 It is a common GI problem.
 It may be acute, lasting several hours to few days, or chronic ,
resulting from repeated exposure to irritating agents or
recurring episodes of acute gastritis.
07/16/22 by Shegaw T 199

Cont---
 Acute gastritis : inflammation of the gastric mucosa after exposure
to local irritants.
 Causes:
• It is often caused by dietary indiscretion.
• The person eats too much, too rapidly or eats food that is
contaminated or too highly seasoned or infected.
• Others include alcohol, aspirin, bile reflux, radiation, infection
• More severe form caused by ingestion of strong acids or alkalis.
• Gastritis also may be the 1st sign of an acute systemic infection

07/16/22 by Shegaw T 200
Gatritis…
 C/M - Acute gastritis
• Rapid onset of gastric pain or discomfort
• Dyspepsia/heart burn
• Abdominal discomfort
• Headache
• Nausea, anorexia
• Vomiting / hematemesis
• Some patients, however, are asymptomatic.

07/16/22 by Shegaw T 201
Cont---
 Chronic gastritis: occurs over time
• Classified as type A or type B.
Type A:
• It is often referred to as autoimmune gastritis and
occurs in the fundus (body of stomach).
• It may also be associated with dietary factors such as
hot drinks or spices, use of drugs, alcohol, smoking or
reflux of intestinal contents in to the stomach.
07/16/22 by Shegaw T 202
Cont---
Type B
•Type B chronic gastritis affects the antrum and pylorus
(lower end of the stomach near the duodenum) and
•It is associated with Helicobacterpylori bacterial infection.
•Type B is the most common type of chronic gastritis.
07/16/22 by Shegaw T 203

Gastritis…
 C/ms - chronic gastritis:
• Heartburn/ epigastric pain

• Anorexia
• Belching
• Sour taste in the mouth
• Vomiting and nausea
• Pernicious anemia due to not secret internsic factor.

07/16/22 by Shegaw T 204
Cont---
 Diagnosis
• History
• Hyper chlorhydria
• Endoscopy
• X-ray
• Serologic test (Ab for h.pylori )
07/16/22 by Shegaw T 205

Management
• The gastric mucosa is capable of repairing itself after a bout of
gastritis
• Avoid foods /drinks that cause distress coffee, tea ,chocolate,
alcohol and smoking etc.
• Instruct the patient to refrain from alcohol and food until
symptoms subside
• Encourage non irritating diet
• Bed rest
07/16/22 by Shegaw T 206
Cont---
 For Chronic gastritis
• Is managed by modifying the patient’s diet
• Promoting rest,
• Reducing stress and
• Initiating pharmacotherapy (antacids, sucralfate, and

triple therapy).
07/16/22 by Shegaw T 207

Nursing intervention
• Assess and document s/s and reactions to treatments
• Monitor intake and out put.
• Provide the prescribed diet.
• Administer medication as prescribed and monitor for side effects.
• Note amount and character of emesis, diarrhea and Monitor IV

fluids.
• Educate patent and family concerning drug therapy, diet activities

and any restrictions.
•
07/16/22 by Shegaw T 208
2. Peptic ulcer diseases (PUD)
• A peptic ulcer is an excavation (hollowed-out area) that forms in
the mucosal wall of the stomach, in the pylorus (opening between
stomach and duodenum) in the duodenum or in the esophagus.
• It is frequently referred to as gastric, duodenal or esophageal
ulcer, depending on its location or as a peptic ulcer disease.
(PUD)
07/16/22 by Shegaw T 209

Cont---
• Erosion of a circumscribed area of mucus membrane is occurred.
• This erosion may extend as deeply as the muscle layers or

through the muscle to the peritoneum
• Peptic ulcers are more likely to be in the duodenum than in the
stomach
07/16/22 by Shegaw T 210

Gastric and duodenal ulcer
07/16/22 by Shegaw T 211

Gastric and duodenal ulcer
07/16/22 by Shegaw T 212

Cont...
 Causes:
– Increase secretion of Hcl and pepsin acid
– Gram-negative bacteria H. pylori

 Predisposing factors
– Stress (occupational stress ,and emotionally stress
– Emotional tense persons/anger
– Hereditary link persons with Blood group O are 35% more
susceptible than others
– Other predisposing factors associated with peptic ulcer
include caffeine, smoking, alcohol ingestion, use of
NSAIDS.
07/16/22 by Shegaw T 213
Pathophysiology
 The erosion is due to an increase in concentration or activity
of acid – pepsin or due to a decrease in the normal resistance
of the mucosa.
 Damaged mucosa is unable to secrete enough mucus to act as
a barrier against HCl acid.
 W/n a break in mucosal barrier; the Hcl injuries the
epithelium.
 Rapidly emptying of food from stomach reduces the buffering
effects of food and delivers a large acid bolus to the duodenum
leading to duodenal ulcer.
07/16/22 by Shegaw T 214
Cont---
07/16/22 by Shegaw T 215

Clinical manifestation
• Symptoms ulcer may last for a few days, weeks, months may
even not disappear.
• Dyspepsia/indigestion: discomfort centered around the
epigastrium or upper abdomen is the most common reported
symptoms
• Pain – dull, gnawing pain, or a burning sensation in the mid
epigatrium or in the back.
• It is believed that pain occurs w/n the increased acid content of
the stomach and duodenum.
07/16/22 by Shegaw T 216

Cont…
• Sharply localized tenderness can be elicited by applying gentle
pressure to the epigastrium or slightly to the right of the midline
• May relief by applying local pressure on the epigastrium
• Pyrosis ( heart burn) some patients experience a burning sensation

in the esophagus and stomach
• Vomiting : is rare in uncomplicated duodenal ulcers
• Constipation and bleeding: perforation or hemorrhage may

occur with any preceding manifestations
• Abdominal distention/fullness
07/16/22 by Shegaw T 217
Comparing Duodenal and Gastric Ulcer
 Duodenal Ulcer
• Age 30-60
• Take 80%
• Hyper secretion of HCL
• Pain occurs after 2-3hrs of a
meal
• Ingestion of food relives pain
• May have wt gain
• Vomiting uncommon
07/16/22 by Shegaw T 218

DU GU
• Hemorrhage less likely than with • Hemorrhage more likely to
G.U occur than with duodenal
• but if present melena more ulcer;
common than hematemesis
• hematemesis more common
• More likely to perforate than G.U
than melena
• Malignancy : rare
• less likely to perforate

• Occasionally
07/16/22 by Shegaw T 219

Diagnostic Evaluation
• History and physical examination/bowel sound may be absent
• Barium study of the upper GI tract may show an ulcer - X-ray

• Endoscopy: is the preferred diagnostic procedure to detect those
lesions not evident in x ray studies
• Stool- for occult blood
• Gastric secretion studies
• Urea breath test - having patient drink carbon-labeled urea
• Serologic test for antibodies of H.pylori Ag.
• Biopsy - most conclusive test
07/16/22 by Shegaw T 220

Management of PUD
A) Nondrug management
• Stress reduction and rest
• Smoking cessation
 Dietary modification: avoid foods that increase secretion of acid
e.g. coffee, alcohol, cola, milk,
• Small and frequent foods
• Food it self acts as an antacid by neutralizing gastric acid for 30-
60 minutes then an increased gastric secretion follows.
• Follow up care
07/16/22 by Shegaw T 221
Cont---
B) Drug management
I. Antacids
• Magnesium hydroxide and or Aluminum hydroxide 50-80
MEq 1hr and 3 hr after meal and at bed time.
II. H2 Receptors antagonist ( anti histamine)
• Cimetidine 200mg IV, IM /PO Qid for 4-6 week (400mg BID
and 800 mg once) or
• Ranitidine150 mg PO BID for 4-6 week (300mg PO at bed
time) or
• Famotidine 40 mg po once a day for 4-6 week or
• Nizatidine 150 mg PO BID or 300mg at bed time.
07/16/22 by Shegaw T 222

Cont---
III. Antisecrotary agents ( proton pump inhabitor)
– Omeprazole 20mg PO BID or 40mg at bed time
– Lansoprazole 15 or 30 mg PO at bed time.
– Panto prazole 40mg PO IV daily
– Esomeprazole 20mg or 40 mg PO daily.
IV. Mucosal barrier fortifiers

– Sucralfate 1gm PO QID or 2gm twice daily.
07/16/22 by Shegaw T 223

Cont---
V. Triple therapy:
– Omeprazol 20mg po BID plus
– Clarithromycin 500 mg PO BID plus
– Amoxicillin 1 gm PO BID for 10-14 days
or
- Metrindazole 500 mg PO BID for penicillin allergy.
07/16/22 by Shegaw T 224

Cont---
C) Surgical management
• Surgical intervention for peptic ulcers is less common
• It usually recommended for patient with intractable ulcers, life

threatening hemorrhage, perforation, obstruction
 It includes:
A)Vagotomy: Severing of the vagus nerve. Decreases gastric
acid by diminishing cholinergic stimulation to the parietal
cells, making them less responsive to gastrin.
 reduce gastric acid secretion
07/16/22 by Shegaw T 225
Cont---
B) Billroth I : antrectomy with anastmosis to the duodenum /
gastro- duodenostomy.
• Removal of the lower portion of the antrum of the stomach
(which contains the cells that secrete gastrin) as well as a
small portion of the duodenum and pylorus. The remaining
segment is anastomosed to the duodenum (Billroth I)
07/16/22 by Shegaw T 226

Cont---
07/16/22 by Shegaw T 227

Cont---
c) Billroth II: antrectomy with anastmosis to the jejunum
/gastro- jejunostomy.
• Removal of distal third of stomach; anastomosis with
jejunum.
• Removes gastrin -producing cells in the antrum and part of
the parietal cells
07/16/22 by Shegaw T 228

Cont---
07/16/22 by Shegaw T 229

Nursing intervention
• Pain level on scale of 0 to 10 every 3 hours.
• Identify factors precipitating and relieving pain.
• Administer antiulcer medications as ordered.
• Provide small, frequent meals four to six times a day.
• Encourage nonacidic fluids between meals.
• Monitor for signs and symptoms of hemorrhage such as
hematemesis (vomiting blood) and melena (blood in the stool).
• Maintain intravenous infusion as ordered.
• Monitor hematocrit and hemoglobin levels as ordered.
07/16/22 by Shegaw T 230

Cont---
• Potential complications
– Hemorrhage
– Perforation
– Pyloric obstruction (it occurs when the area distal to the

pyloric sphincter becomes scarred and stenosis from spasm
or edema)
– Intractable ulcers
– Dumping Syndrome
07/16/22 by Shegaw T 231

PUD Video
PUD_44.FLV
07/16/22 by Shegaw T 232

Reading ???
• Stress Ulcers
• Gastric Bleeding
• Gastric Cancer
07/16/22 by Shegaw T 233

Nursing Care of Patients with Lower
Gastrointestinal Disorders
07/16/22 by Shegaw T 234

1. Intestinal disorders
 Intestinal Obstruction
• It exists when the intestinal blockages prevents the normal

flow of intestinal contents through the intestinal tract.
• Two types of process can impede flow:
1. Mechanical obstruction
2. Functional obstruction
1) Mechanical obstruction - an intraluminal obstruction from

pressure on the intestinal walls.
07/16/22 by Shegaw T 235

Cont--
 Mechanical obstruction can be caused by:
• Intussusceptions: one part of the intestine slips in to the

another part located below it like a telescope shortening.
• Adhesions: loops of the intestine become adherent to areas that
heal slowly or scar after abdominal surgery.
• Volvulus: bowel twist and turns upon it
• Hernias: protrusion of intestine through a weakened area in

the abdominal muscle or wall.
• Tumors and neoplasm,
07/16/22 by Shegaw T 236
Mechanical obstruction
07/16/22 by Shegaw T 237

Cont---
2) Functional obstruction: the intestinal musculature cannot
propel the contents along the bowel.
• E.g. muscular dystrophy, endocrine disorders such as DM, or
neurological disorders such as Parkinson’s disease
• The obstruction can be partial or complete.
• Its severity depends:

• On the region of bowel affected
• The degree to which lumen is occluded and
• Especially the degree to w/c vascular supply is disturbed
•
07/16/22 by Shegaw T 238
A. Small bowel obstruction (SBO)
• Most bowel obstructions occur in the small intestine- 85%
• Adhesion is the most common cause of SBO,
• Hernias and neoplasms – next most common
• Followed by inflammatory bowel disease, foreign bodies,

strictures, volvulus, and intussusception.
07/16/22 by Shegaw T 239

SBO…
Pathophysiology
•In SBO when the intestinal tract obstruct, intestinal contents, fluid,
and gas accumulate above the obstruction .
•The abdominal distension and retention of fluid reduce the
absorption of fluids and Stimulate more gastric secretion.
•This caused edema, congestion, necrosis and eventually rupture or
perforation of the intestinal wall, with resultant peritonitis.
•Reflux vomiting may be caused by abdominal distension.
•Dehydration and acidosis develop from loss of water and sodium.
•With acute fluid losses hypovolemic shock may occur.
07/16/22 by Shegaw T 240
SBO…
 C/M-
• Initially abdominal cramp pain that is wavelike and colicky.
• Blood and mucus may pass, but no fecal matter and flatus.
• Abdomen becomes distended
• If obstruction is complete- the peristaltic wave become reverse
direction so intestinal content come to the mouth .
• If obstructions is in the ileum- fecal vomiting
• First the patient vomits the stomach contents then the bile stained
contents of the duodenum and the jejunum and finally with each
paroxysm of pain, the darker, fecal like contents of the ileum.
07/16/22 by Shegaw T 241

Cont---
 Sign of DHN become evident i.e.
• Hypovolemic shock from DHN and loss of plasma volume and
• Fluid and electrolytes loss
• Constipation
• Intense thirst
• Drowsiness
• Generalized malaise
07/16/22 by Shegaw T 242

SBO…
 Diagnostic Evaluation
• Patient Hx and P/E
• Ultrasonography
• X-ray findings (shows abnormal quantities of gas, fluid or

both in the bowel).
• CT scan finding
• Laboratory studies (electrolyte studies and CBC)
07/16/22 by Shegaw T 243

Cont---
 Management
• Keep NPO
• Decompression of the bowel through a nasogastric tube is
successful in most cases.
• IV fluid therapy to replace the depleted water, and electrolyte
• Complete obstruction needs surgical intervention /depends on
the cause of obstruction i.e. if adhesion dividing the adhesion
to which intestine is attached , if hernia: repairing of hernia.
• Prophylactic antibiotics
• Monitor intake and out put
• Supportive care
07/16/22 by Shegaw T 244

• In most cases, the patient is kept NPO
• Insert and maintaining the function of the NG tube
• Administering IV solution
• Assessing for fluid and electrolyte imbalance
• prepare the pt’ for surgery
• Assess and document S/S and response toward treatments
• Monitor V/S at least Q 4 hrs
07/16/22 by Shegaw T 245

Nursing intervention…
• Record intake and out put
• Administered prescribed medication and monitor for side

effects
• Maintain NPO
• Monitor the state of distention and hydrations
• Provide routine post operative care if patient undergoes surgery

07/16/22 by Shegaw T 246

Con…..
“Never let the sun rise or set on

small-bowel obstruction”
07/16/22 by Shegaw T 247

B) Large bowel obstruction (LBO)
• About 15% of intestinal obstruction occur in the large bowel

and the most common causes are carcinoma, diverticulitis,
inflammatory bowel diseases and benign tumors.
• The most are found in sigmoid colon.
07/16/22 by Shegaw T 248

Pathogenesis
• As in small bowel obstruction, large bowel obstruction results in

an accumulation of intestinal contents, fluid and gas proximal to
the obstruction.
• Even if the obstruction is complete, it may be undramatic if the

blood supply to the colon is not disturbed.
• If the blood supply is cut off, however strangulation and necrosis

(i.e. tissue death) occur, this condition is life threatening.
07/16/22 by Shegaw T 249

c/ms
• LBO differs clinically from small bowel obstruction in that
symptoms develop slowly relative to SBO .
• Constipation (if obstruction in sigmoid colon or the rectum).
• Abdomen becomes markedly distended.

• Loops of large bowel becomes visibly outlined through the
abdominal wall.
• Eventually, cramp lower abdominal pain
• High pitched tinkling sound heard, localized tenderness
• Dehydration occurs more slowly than in the small intestine.
07/16/22 by Shegaw T 250

Characteristics of SBO & LBO
LBO
SBO • Prevalence 15%
• Prevalence 85%
• Onset slowly
• Onset rapid
• Dehydration less likely
• Dehydration more common
• Fecal stained vomiting
• Stomach content vomiting
• Marked abdominal
• Abdominal distension distension( visible distended
• Pre rectal exam rarely / bowel)
absence of fecal/mucosa • Pre rectal exam fecal/ bloody
• Constipation less common mucosa present
• Constipation more common
07/16/22 by Shegaw T 251

Cont---
 Diagnosis
• Based on sign /symptoms
• Ultrasonography
• X-ray studies (show distended colon)
• CT scan
• Endoscopy
N.B - Barium enema is contraindicated
07/16/22 by Shegaw T 252

Management
• Colonoscopy may be performed to untwist and decompress
• Rectal tube to decompress.
• The usual Rx, however, is surgical resection to remove the

obstructing lesion.
• Cecostomy /surgical opening of the cecum / may be performed.
• Temporary or permanent colostomy may be necessary /is the
surgical creation of an opening into the colon to drainage or
evacuation colon contents to the outside of the body.
07/16/22 by Shegaw T 253

Management
Nsg dx.: Acute pain related to abdominal distention.
Intervention:
•Assess pain level using rating scale
•Give medication for pain as ordered.
•Semi-Fowler’s position to reduce tension on the abdomen.
•Maintain nasogastric tube on low intermittent suction as
ordered
•Maintain NPO status
•Provide frequent mouth care
07/16/22 by Shegaw T 254

Cont…
Nsg dx.: Deficient fluid volume related to vomiting.
Intervention:
•Accurately monitor intake and output
•Maintain fluid replacement
•Monitoring electrolyte imbalance and metabolic
alkalosis occur
07/16/22 by Shegaw T 255

Nursing management
• Each quadrant of the abdomen is auscultated
• Palpated for distention, firmness, and tenderness.
• Documented amount and character of stool
• Pain is assessed and manage.
• Daily weight and intake and output are monitored.
• Skin turgor is assessed for fluid deficit.
• If a nasogastric tube is in place, the amount, color, and character

of drainage is documented.
• Vital signs are monitored for signs of infection or shock
07/16/22 by Shegaw T 256
Acute inflammatory intestinal disorders
• Any part of the lower gastrointestinal tract is susceptible to
acute inflammation caused by infection due to bacteria, virus,
or fungus.
• The two sever situations are appendicitis and diverticulitis.
and
• Others include peritonitis and gastroenteritis.
07/16/22 by Shegaw T 257

A) Appendicitis
• Appendix is a small, finger like appendage about 10 cm long that
is attached to the cecum just below the ileocecal valve.
• Has no known function
• The appendix fills with food and empties regularly in to the

cecum
• Because it empties inefficiently and its lumen is small, the
appendix is prone to obstruction and is particularly vulnerable to
infection.
07/16/22 by Shegaw T 258

Cont…
• Appendicitis: It is an inflammation of the appendix.
• Is the most common cause of acute inflammation in the RLQ of

abdominal cavity.
• Is the most common reason for emergency surgery.
• People consume a diet low in fiber and high in refined

carbohydrates are more liable.
07/16/22 by Shegaw T 259

Pathophysiology
• As a result of either becoming kinked or occluded by a fecalith
(hardened mass of stool), tumor, or foreign body =
• The appendix becomes inflamed and edematous.
• The inflammation process increases intraluminal pressure

initiating progressively sever abdominal pain; localized in the
RLQ (McBurney’s) of the abdomen within a few hrs.
• The inflamed appendix fills with pus and then likely to perforate.
07/16/22 by Shegaw T 260

Appendicitis
07/16/22 by Shegaw T 261

C/M
• Right lower quadrant pain and is usually accompanied by a fever
and nausea and vomiting and anorexia.
• Local tenderness noted in McBurney's point. (Located 2/3 way
from the umbilicus and 1/3 from anterior spine of the ileum).
• Slight abdominal muscular rigidity (guarding), normal bowel
sounds, and local rebound tenderness (intensification of pain
when pressure is released after palpation).
• If it is ruptured, the pain becomes more diffuse.
• Abdominal distention, develops as a result of paralytic ileus
• 07/16/22
Constipation can also occur.by Shegaw T 262
Mcburney’s point
07/16/22 by Shegaw T 263

Cont---
 Complications
• The major complication of appendicitis is perforation of the
appendix, which can lead to peritonitis or abscess
• Incidence of perforation is 10-32%
• It generally occurs 24hrs after the onset of pain
• Symptoms include a fever of 37.7oC or higher, and continued

abdominal pain or tenderness.
07/16/22 by Shegaw T 264

Diagnosis
• Patient Hx. & P/exam.
• Lab studies particularly WBC count /elevated WBC.
• Ultrasonography
• X-ray findings
07/16/22 by Shegaw T 265

Physical examination
 Tests of appendicitis
• Rovsing’s sign: pain elicited when left lower quadrant is

palpated/apply pressure.
• Rebound tenderness: pain recognized after removal of
pressure at RLQ.
• Psoas sign: up on flexing at hip and knee ask the client
against the pressure.
• Obturator sign: flex and rotating at hip through internally.
07/16/22 by Shegaw T 266

DDx
– Peritonitis
– Diverticulitis
– Cholicysitities
– Cholilithiasis
– Ovarian abscess
07/16/22 by Shegaw T 267

Management
1) Supportive treatment 2) Surgery is the best

• Correct fluid and electrolyte treatment of abscessed
imbalance and DHN. appendicitis /appendectomy.
• Antibiotics
• If surgery is undecided avoid

analgesic/antipain.
07/16/22 by Shegaw T 268

• Kept NPO and surgery is done immediately if it acute

• Ice to the site of pain and maintaining semi-Fowler’s position
• Prepare for an appendectomy by emergency department
• If the appendix has ruptured, intravenous fluids and antibiotic
therapy are started and surgery may be delayed for 8 hours or +
• Laxatives and enemas are avoided; may trigger rupture
• The use of a heating pad on the abdomen is avoided because the
warmth may increase inflammation and risk of rupture.
• Initiate diet with clear fluids
• Vital signs and Pain control
• Promote early ambulation, coughing, deep breathing
07/16/22 by Shegaw T 269

B) Peritonitis
• Peritoneum is the serous membrane lining the abdominal cavity

and covering the viscera.
• Peritonitis is an acute inflammation of the peritoneum.
• It can be classified as primary (TB) and secondary (secondary to

trauma, bile leakage ) and localized and generalized.
07/16/22 by Shegaw T 270

Pathophysiology
• Trauma, ischemia, tumor perforation in any abdominal organ causes
leakage of the organ’s contents into the peritoneal cavity.
• Most common cause of peritonitis -ruptured appendix, but
• Also occur after perforation of PUD, gangrenous gallbladder,

diverticulitis, incarcerated hernia or obstruction, dialysis.
• Peritonitis results from the inflammation or infection.
• The tissues become edematous and leaking fluid blood, protein,

cellular debris and white blood cells.
• Initially, the intestinal tract responds with hyper motility, but this is
soon followed by paralysis (paralytic
07/16/22 by Shegaw T ileus) 271
Etiology
• Bacterial infection (coli, streptococcus, staphylococcus,
Gonococcus etc ).
• Bacteria gain entry into the peritoneum by perforation or from
external penetrating wound.
• The most common causes of bacteria peritonitis are appendicitis,
perforation associated with PUD, diverticulitis, and bowel
obstruction.
• It can also result from external sources such as injury or trauma
(ex. Gunshot wound, stab wound), or inflammation that extend
from an organ outside peritoneal area.
07/16/22 by Shegaw T 272

C/ms
• It depends on the location and extent of inflammation
• The cardinal signs of peritonitis are abdominal pain /
tenderness localized or generalized) and progressive
abdominal distention.
• At first, diffuse type of pain is felt
• Guarding pain
• The pain tends to become constant, localized and more intense
near the site of inflammation
• The affected area of the abdomen becomes extremely tender
and distended and the muscles become rigid.
07/16/22 by Shegaw T 273

Cont---
 Others:
– Fever
– N/V/anorexia
– Diminished bowel sounds
– Inability to pass flatus or feces
– Pulse rate increase
– Dehydration
– Respiratory difficulty
07/16/22 by Shegaw T 274
Cont---
 Diagnostic Evaluation
– Clinically
– Lab, increase WBC(> 20,000/mm3)
– Abdominal X-ray
– Peritoneal dialysis (positive for peritonitis if more than 500

WBC/ml of fluid or more than 50,000 RBCs/ml of fluid or
Presence of bacteria).
07/16/22 by Shegaw T 275

Management
• The patient is NPO because of the impaired peristalsis
• Fluid and electrolyte replacement –hypovolemic
• Abdominal distention relieved -nasogastric tube
• Antibiotics are used to treat or prevent sepsis
• Surgery to excise, drain, or repair the cause
• An ostomy to divert feces, allowing resolution of the infection.
• Pain control is essential to overall recovery.
• Severely compromised patients may receive total parenteral
nutrition (TPN).
07/16/22 by Shegaw T 276
Cont---
• Positioning: Semi fowlers position to promote drainage of
peritoneal contents in to inferior region and abdominal cavity
and also to it facilitate adequate respiration.
• Surgical if critically needed: exploratory laparotomy; to
remove or repair the inflamed or perforated organ;
07/16/22 by Shegaw T 277

Cont---
 Complication
• Sepsis is the major cause of death from peritonitis
• Shock – from septicemia or hypovolemic
• Intestinal obstruction – from inflammatory process 10 from

development of bowel adhesions .
07/16/22 by Shegaw T 278

C) Diverticulosis and Diverticulitis
• Diverticula are congenital or acquired pouch like herniations of
the mucosa through the muscular wall of the intestine.
• Diverticula can occur in any part of the small or large intestine
but they occur most commonly in the sigmoid colon
• Diverticulosis is the presence of many diverticula without
inflammation or symptoms.
• Diverticulitis is the term used to describe an inflammation of
one or more diverticula.
07/16/22 by Shegaw T 279

07/16/22 by Shegaw T 280
Pathophysiology
• Undigested foods or bacteria can become trapped in the
diverticulum =
• Diverticulum becomes inflamed and local abscess forms =
• Diverticulitis
• Abscess develops and may eventually perforate =
• Leading to peritonitis
07/16/22 by Shegaw T 281

Causes
• It forms when the mucosa and sub mucosal layer of the colon
herniated through the muscular wall because of:
– High intraluminal (abdominal) pressure and
– Decreased muscle strength in the colon wall (i.e.

muscular hypertrophy from hardened fecal masses or
w/n blood supply interrupt ).
– Chronic constipation precedes the development of
diverticulosis by many years
– Eating diet with low fiber can increased the risk of
diverticula.
07/16/22 by Shegaw T 282
C/M
• Generally asymptomatic
• Possibly alternating between constipation and diarrhea
• Bowel irregularity and intervals of diarrhea
• Abrupt onset, steady or crampy pain in the LLQ - most common
• Fever
• V/N, anorexia and abdominal distension

• Bleeding, weakness, fever, fatigue, and anemia
• If untreated, septicemia develop
07/16/22 by Shegaw T 283

Diagnostic methods
• Confirmed with sigmoidoscopy, colonoscopy,
or barium enema.
• Occult blood test /FOBT
• Ultrasonography
• x –ray
• CT scan
07/16/22 by Shegaw T 284

Management
• Diverticulosis is managed by preventing constipation
• In acute case hospitalized - antibiotics and pain control
• A nasogastric tube, intravenous fluids, and NPO status
• If the acute period is over, a progressive diet is started
• Whether or not perforation occurs, surgical resection with

anastomosis or a temporary colostomy to the inflammation subside
and the diseased portion of the colon to rest.
07/16/22 by Shegaw T 285

Cont---
• Dietary considerations include foods that are soft but high in
fiber, such as prunes, raisins, and peas.
• Unprocessed bran can be added to soups, cereals, and salads to
give added bulk to the diet.
• Fiber should be increased in the diet slowly to prevent excess gas
and cramping.
• Surgical management :- immediate surgical intervention is
necessary if complications (Ex. Perforation/rupture , abscess
formation, hemorrhage, peritonitis and bowel obstruction).
07/16/22 by Shegaw T 286
D) Gastro enteritis
• It is the inflammation of the mucosal membrane of the gastro

intestinal tract.
• Is an increase in the frequency and water contents of stool or
vomiting as result of the inflammation of mucous membrane of
the intestinal tract .
• It can be viral (e.g. rota virus) or bacterial ( e.g. E.coli,
shigellosis),protozoa & helmenthiasis in origin.
• Usually self limiting if no complication
07/16/22 by Shegaw T 287

Cont…
C/M
•Frequent watery content stool loss
•Urgency to defecate & tensmus
•Abdominal discomfort
•Nausea, vomiting
•S/S of dehydration may be
Diagnostic
•Stool exam
07/16/22 by Shegaw T 288

Mgt
• Symptomatic treatment
• Drug therapy depends on the lab result e.g. if bacterial Abs

(Norfloxacillin 400mg PO BID, or ciprofloxacin 500mg PO
BID for 3days)
• If viral only supportive treatment (Rx of DHN,
antiemetic/antispasmodic, anticholinergics to suppress intestinal
motility).
07/16/22 by Shegaw T 289

Chronic inflammatory Bowel Disease (IBD)
• Is disorders of the lower GIT, and it refers to two

chronic inflammatory GI disorders:-
– Ulcerative colitis
– Regional enteritis (crohn’s disease) or granulomatous

colitis.
07/16/22 by Shegaw T 290

A) Ulcerative Colitis
• It is a recurrent ulcerative and inflammatory disease of the

mucosal and sub mucosal layers of the left colon and rectum.
07/16/22 by Shegaw T 291

Etiology
• Unknown cause but may trigger by:
– Infection, allergy, and autoimmune response
– Environmental agents such as pesticides, tobacco, radiation,

and food additives may precipitate an exacerbation
– Psychological stress may trigger or worsen an attack of
symptoms
07/16/22 by Shegaw T 292

Pathophysiology…
• Following bowel infection, Autoimmune (antibody against
bowel epithelium) can be a contributory factors.
• It affects the superficial mucosa of the colon and characterized
by multiple ulcerations, diffuse inflammations.
• Mucosal inflamed, edematous and results extensive ulceration.
• Bleeding occurs as a result of the ulcerations.
• It usualy begins in the rectum & spreads to the entire colon.
• Eventually 10-15 % of the pt develop carcinoma of the colon
• It accompanied by systemic complication and high MM

07/16/22 by Shegaw T 293
C/M Ulcerative…
• Diarrhea (10 to 20 times /day), dehydration, fluid and electrolyte
imbalance, fecal urgency, Intermittent tensemus
• LLQ abdominal pain, Anorexia, weight loss, vomiting, fever
• and rectal bleeding are the predominant symptoms.
• Arthritis, skin lesions, inflammatory disorders of the eyes, and

abnormalities of liver function with intermittent remissions
lasting from months to years.
• S/s of Anemia; rectal bleeding and Serum albumin reduced
07/16/22 by Shegaw T 294

Diagnostic evaluation
• Stool is +ve for blood
• Low Hgb and HCT and increases WBC
• X-ray (abdominal).
• Sigmoidoscopy, or colonoscopy
• Stool examination for parasites and other microbes (to rule out
dysentery caused by common intestinal organisms like
E.histolytica)
• Biopsy
07/16/22 by Shegaw T 295
Management
 Pharmacologic therapy
• Antidiarrheal & anti peristaltic medications - rest the bowel
• Aminosalicylate - mild or moderate inflammation
• Corticosteroids - treat severe disease
 Surgical management may recommend when medical

measurement fail to relive the severe symptoms.
• e.g. Total proctocolectomy /colectomy with permanent ileostomy
• The colon rectum and anus are removed and closure of anus.
07/16/22 by Shegaw T 296

Management…
 Nutritional therapy:
• Oral fluids and a low-residue, high protein, high-calories diet

with supplemental vitamin therapy and iron replacement are
prescribed to meet nutritional needs,
• Reduce inflammation, and control pain and diarrhea
• Any foods that exacerbate diarrhea are avoided ex. Milk, may
contribute to diarrhea in those with lactose intolerance.
07/16/22 by Shegaw T 297

B) Regional Enteritis /Crohn’s disease
• Regional enteritis is a sub acute and chronic inflammation of the

bowel that affects cecum & right colon.
• Extends through all layers (i.e., trans mural lesion) of the bowel
wall from the intestinal mucosa.
Etiology:
• Although the exact cause unknown, familial tendency
• Autoimmune processes and infectious agents
• Physical or psychological stress may trigger exacerbations

07/16/22 by Shegaw T 298
Pathophysiology
• The disease process begins with inflammation of the bowel
mucosa.
• Edema and thickening of the mucosa.
• Ulcers begin to appear on the inflamed mucosa.
• These lesions are not in continuous contact with one another and
are separated by normal tissue.
• The bowel wall thickens and becomes fibrotic, and the intestinal
lumen narrows.
• Later on obstruction occurs
07/16/22 by Shegaw T 299
C/ms
• In RE, the onset of symptoms is usually insidious.
• Right lower quadrant abdominal pain.
• Abdominal pain and diarrhea unrelieved by defecation.
• Cramp abdominal pain
• Abdominal tenderness and spasm.
• Because eating stimulates peristalsis, the crampy pain occur after
meals
• Weight loss as a reason of to avoids the crampy pain,
malnutrition and
• Secondary anemia due to limit normal nutritional requirement.
• Sever diarrhea and mal absorption.
07/16/22 by Shegaw T 300

Diagnostic
• Endoscopy (colonoscopy and sigmoidoscopy)
• A barium enema shows a classic “cobblestoning” effect and,
as the disease progresses, areas of narrowing in the intestine
• A newer test, optical coherence tomography, allows the layers
of the bowel to be examined for microscopic inflammation to
differentiate this disease from ulcerative colitis.
• An elevated sedimentation rate and leukocytosis are present,
• Serum albumin levels may be low because of malnutrition or
poor absorption of protein.
• A stool examination may reveal fat content and occult blood
• Biopsies specimen.
07/16/22 by Shegaw T 301

Management
 Similar to UC
07/16/22 by Shegaw T 302

Comparison b/n RE and UC
Ulcerative colitis Regional enteritis
• LLQ pain • RLQ pain
• Begins in the rectum and • Most often in the terminal ileum
proceeds in a continuous to colon
manner toward the colon. • All layers of the bowel
• Inner layer of the mucosa. • Un known
• Etiology: Un known • 5-6 soft loose stools / day
• 10-20 liquid stool/ day • rarely bloody
• Bloody  complications:
 complications: • Rarely hemorrhage, anemia
• Hemorrhage, anemia • Fistula and nutritional
• perforation, fistula and deficiency
nutritional deficiency
07/16/22 by Shegaw T 303
Reading???
 Irritable Bowel Syndrome
 Absorption Disorders
 Lower Gastrointestinal Bleeding
 Colon Cancer
07/16/22 by Shegaw T 304

Hemorrhoids
• Are dilated portions of veins in the anal canal.
• Hemorrhoids are varicose veins in the anal canal
• They are very common.
• By the age of 50, 50% of people have hemorrhoids to some

extent.
07/16/22 by Shegaw T 305

Cont---
 Predisposing factors
• Straining during bowel movements
• Prolonged sitting or standing, obesity,
• Increased intra abdominal pressure
• Portal hypertension
• Pregnancy, chronic constipation,
• Internal abdominal tumors = pressure in rectal and anus veins =

dilation occurs.
07/16/22 by Shegaw T 306

Cont---
 They are classified into two types:-
• Internal hemorrhoids:- if it occurs above the internal

sphincter.
• External hemorrhoids: - those appearing outside the external
sphincter.
07/16/22 by Shegaw T 307

Fig. internal and external hemorrhoids
07/16/22 by Shegaw T 308

C/ms
• Hemorrhoids cause itching and pain and are the most common
cause of bright red bleeding with defection.
• Feeling of mass or pressure in the anal canal.
• Edema and inflammation
• External hem: are associated with itching and severe pain from
the inflammation and edema caused by thrombosis(i.e. clotting
of blood within the hemorrhage).
• Prolapsed
• Internal hem: are not usually painful until they bleed or
prolapsed when they became enlarged.
07/16/22 by Shegaw T 309
Management
• Good personal hygiene, and avoiding excessive straining
• Alternating ice and heat application
• Warm compress, Sitz bath – circulation, comfort and healing
• A high residue diet and increased fluid intake 2 to 3 L of fluid/d
• Laxatives , steroid creams or suppositories
• Sclerotherapy involves the injection of a sclerosing agent
• Rubber band ligation
• Bed rest.
07/16/22 by Shegaw T 310
Management…
 Surgical Rx is applied according to the progress:
• The rubber band legation procedure: the hemorrhoid portion

above the mucocutaneous lines is grasped with an instrument and
a small rubber band.
• Sclerotherapy, cryosurgery
• Hemorrhoidectomy, or surgical excision, can be performed to

remove all the redundant tissue.
07/16/22 by Shegaw T 311

Reading ???
• Anal Fissures
• Anorectal Abscess
• Rectal Ca
07/16/22 by Shegaw T 312

.
D !
E N
H E
T
07/16/22 by Shegaw T 313

GIT accessory organ disorders
07/16/22 by Shegaw T 314

Overview
• The liver is located behind the ribs in the upper right portion
of the abdominal cavity. It weighs about 1,500 g and is
divided into four lobes.
• The liver, the largest gland of the body, can be considered a
chemical factory that manufactures, stores, alters, and excretes
a large number of substances involved in metabolism.
07/16/22 by Shegaw T 315

Cont…
• The gallbladder, a pear-shaped, hollow, saclike organ,
• It is 7.5 to 10 cm (3 to 4 in) long,
• It lies on the inferior surface of the liver,
• The capacity of the gallbladder is 30 to 50 mL of bile.
• Its wall is composed largely of smooth muscle.
• The gallbladder functions as a storage for bile.
• Bile is composed of water and electrolytes (sodium, potassium,

calcium, chloride, and bicarbonate) and significant amounts of
lecithin, fatty acids, cholesterol, bilirubin, and bile salts.
07/16/22 by Shegaw T 316
Cont…..
• The pancreas, located in the upper abdomen,
• It has endocrine & exocrine functions .
• The secretion of pancreatic enzymes into the gastrointestinal

tract through the pancreatic duct represents its exocrine
function.
• The secretion of insulin, glucagon, and somatostatin directly
into the bloodstream represents its endocrine function.
07/16/22 by Shegaw T 317

Common GIT accessory organ disorders
 Hepatitis & liver cirrhosis
 Cholicystitis & cholilithiasis
 Pancreatitis
07/16/22 by Shegaw T 318

Hepatitis
• Hepatitis is an inflammation of the liver.
• Viral hepatitis is the most common cause of hepatitis.
• The types of viral hepatitis are A, B, C, D, E, and G.
07/16/22 by Shegaw T 319

Cont….
Hepatitis A
–Hepatitis A is an RNA virus that is transmitted through the
fecal-oral route.
–The mode of transmission of HAV is mainly transmitted by
ingestion of food or liquid infected with the virus and rarely
parenteral.
–sometimes called infectious hepatitis
07/16/22 by Shegaw T 320

Cont…
• Hepatitis B
– HBV is a DNA virus that is transmitted perinatal by mothers
infected with HBV; percutaneous (e.g., IV drug use); or
horizontally by mucosal exposure to infectious blood, blood
products, or other body fluids.
– sometimes called serum hepatitis
– HBV is a complex structure with three distinct antigens: the

surface antigen (HBsAg), the core antigen (HBcAg), and the
e antigen (HBeAg).
07/16/22 by Shegaw T 321
Cont…
• Hepatitis C
– HCV is an RNA virus that is primarily transmitted
percutaneous.
– The most common mode of HCV transmission is the
sharing of contaminated needles and paraphernalia
(equipment's) among IV drug users.
– There are 6 genotypes and more than 50 subtypes of HCV.
– sometimes called non-A, non-B (NANB) hepatitis
07/16/22 by Shegaw T 322

Hepatitis D
• Transmitted through blood or body fluids as with HBV
• Strongly linked as a confection with HBV
• Clinically Similar to HAV and HBV but more severe
• Diagnose with Elevated serum liver enzymes (ALT,

AST), elevated serum bilirubin, HDV antigen HBIG
Same as HBV
07/16/22 by Shegaw T 323

Signs and Symptoms
• Hepatitis usually shows a typical pattern of loss of liver function.
• There are generally three stages:
1. The prodromal or preicteric (prejaundice), stage lasts about 1 wk

 Complains of flulike symptoms of malaise, headache, anorexia, low-
grade fever, possibly dull right upper quadrant (RUQ) pain, nausea,
vomiting, and diarrhea or constipation.
2. The icteric stage peaks at 2 weeks and lasts 2 to 6 weeks.

 Continues to have fatigue, anorexia, nausea, vomiting

07/16/22 by Shegaw T 324
C/f…
 The patient is also likely to have jaundice or noticeable.
• Yellowing of the skin, sclera and mucous membranes; dark amber
urine; and clay colored stools
• The liver is usually enlarged and tender on examination.
3. Posticteric or convalescent, stage lasts from 2 to 6 weeks with
complete recovery in 6 months if relapse does not occur.
• The patient usually feels well, but full recovery measured by the
return to normal liver function tests may take 1 yr.
• Hepatitis is considered a reversible process if the patient complies
with a medical regimen of adequate rest, good nutrition, and
abstinence from alcohol or other liver-toxic agents for at least 1
year after liver function laboratory values return to normal.
07/16/22 by Shegaw T 325
Diagnosis
• Physical examination may reveal hepatomegaly,
lymphadenopathy, and sometimes splenomegaly.
• Serum liver enzymes are elevated.
• Serum bilirubin and urobilinogen may be elevated
• The erythrocyte sedimentation rate, prothrombin time is

usually elevated from the inflammatory process.
• Serological tests to determine the specific virus
• Abdominal x-ray examination show an enlarged liver.
07/16/22 by Shegaw T 326

Mgt.
• There is no specific treatment or therapy for acute viral hepatitis
• Drug therapy for chronic HBV and HCV is focused on decreasing

the viral load, aspartate aminotransferase (AST) and alanine
aminotransferase (ALT) levels, and the rate of disease
progression.
• Chronic HBV drugs include interferon (antibody), lamivudine
(Epivir), adefovir (Hepsera), entecavir (Baraclude), and
telbivudine (Tyzeka).
• Treatment for HCV includes pegylated -interferon (Peg-Intron,
Pegasys) given with ribavirin (Rebetol, Copegus).
07/16/22 by Shegaw T 327
Cont..
• Both hepatitis A vaccine and immune globulin (IG) are used
for prevention of hepatitis A.
• Immunization with HBV vaccine is the most effective method
of preventing HBV infection.
• For post exposure prophylaxis, the vaccine and hepatitis B
immune globulin (HBIG) are used.
07/16/22 by Shegaw T 328

Acute (Fulminant) Liver Failure
• Acute (fulminant) liver failure is an uncommon
but gravely serious complication of liver disease
and has a mortality rate as high as 50%.
07/16/22 by Shegaw T 329

Pathophysiology and Etiology
• It results from the sudden massive loss of liver
tissue, or necrosis.
• The cause of liver damage is usually drug
toxicity or HBV in the presence of HDV.
• The outcome of the disease may be decided
within 48 to 72 hours of diagnosis.
• Possible outcomes are reversal, need for
transplantation, or death.
07/16/22 by Shegaw T 330

Signs and symptoms
• Hepatic encephalopathy, or central nervous system dysfunction
• Suddenly lapse into extremely serious illness, starting with

confusion and progressing to coma.
• In a matter of hours the liver shows a rapid reduction in size; a
typical sign of onset of acute liver failure.
• In addition, sudden elevation of liver enzymes and bilirubin.
• Prothrombin time is elevated.
• Marked elevation in the prohrombin time is an ominous sign.
07/16/22 by Shegaw T 331

Dx.
• Levels of ALT and AST may rise from 1000 mU/mL to as high as
4000 mU/mL.
• The serum bilirubin level is more than 2.5 mg/dL. Urobilinogen levels
may be elevated.
• Serum potassium levels drop below 3.5 mEq/L.
• Blood glucose drops below 70 mg/dL.
• The prothrombin time is elevated above 25 seconds.
• An abdominal x-ray examination may document the change in size of

the liver
07/16/22 by Shegaw T 332

Therapeutic Interventions
• Medical treatment is directed toward stopping and reversing the
damage to the liver.
• An attempt is made to put the liver completely at rest.
• The patient is put on complete bed rest.
• All drugs are discontinued, since they are metabolized by the
liver.
• Dialysis may be ordered if the liver damage is a result of an
overdose of a hepatotoxic substance.
• The patient is ordered a high-calorie, low-sodium, low-protein
diet.
• Lactulose, neomycin, magnesium citrate, or sorbitol may be given
to decrease ammonia levels, but they are not always effective.
07/16/22 by Shegaw T 333
Chronic Liver cirrhosis
• Cirrhosis is a chronic progressive disease characterized by
extensive degeneration and destruction of the liver parenchymal
cells and the replacement of normal liver tissue with diffuse
fibrosis that disrupts the structure and function of the liver.
• It is called Laënnec’s cirrhosis, or portal, nutritional, fatty, or
alcoholic liver disease.
• The disease usually has an insidious onset and
• It is the tenth leading cause of death among the total population
and is more common among men
• Occasionally proceeding over a period of 30 or more years.
07/16/22 by Shegaw T 334
Type of cirrhosis based on Etiology
1. Alcoholic cirrhosis,
• scar tissue characteristically surrounds the portal areas.
• This is most frequently due to chronic alcoholism and is the
most common type of cirrhosis.
2. Post necrotic cirrhosis

• scar tissue as a late result of a previous bout or massive
exposure to hepatotoxins, viral hepatitis, or infection.
07/16/22 by Shegaw T 335

Con…
3 . Biliary cirrhosis- scarring occurs in the liver around the bile
ducts.
• This type usually is the result of chronic biliary obstruction and
infection (cholangitis).
• It is much less common than the other two types.
• Biliary liver failure is caused by chronic inflammation and

obstruction of the gallbladder and bile ducts
4. Cardiac cirrhosis: caused by chronic severe congestion of the

liver from heart failure. The liver congestion causes death of liver
cells from lack of nutrients and oxygen.
07/16/22 by Shegaw T 336
causes
• Malnutrition
• Biliary obstruction, and
• Right-sided heart failure.
• Chemicals-(carbon tetrachloride, chlorinated naphthalene,

arsenic)
• Infectious– viral, bacteria, protozoa & helmenthaisis.
• Excessive alcohol ingestion is the single most common cause

of cirrhosis followed by chronic hepatitis (B and C).
07/16/22 by Shegaw T 337

Pathophysiology
 Chronic liver failure is a progressive disease.
 Healthy liver cells respond to toxins such as alcohol by becoming
inflamed.
 The liver cells are infiltrated with fat and white blood cells and
are then replaced by fibrotic tissue.
 As the disease progresses, more and more liver cells are replaced
by fatty and scar tissue.
 The lobes of the liver are disrupted and the liver becomes
hardened and lumpy. Early in the disease, the liver is enlarged,
firm, and hard from the inflammatory process.
 Later, the liver shrinks and is covered with gray connective tissue
07/16/22 by Shegaw T 338

C/m
• Irreversible chronic injury of the hepatic parenchyma.
• Extensive fibrosis - distortion of the hepatic architecture
• Formation of regenerative nodules
• skin for petechial or ecchymosis areas (bruises)
• skin lesions (spider angiomas), peripheral neuropathy
• Failure of the liver to synthesize proteins, clotting factors,
• Portal hypertension (ascites and varices)
• GASTROINTESTINAL VARICES: collateral blood vessel distension in

the abdomen.
07/16/22 by Shegaw T 339
c/m…
• Varices are varicosities that develop from elevated pressures
transmitted to all of the veins that drain into the portal system.
• hematologic problems (thrombocytopenia, leucopenia,
anemia, coagulation disorders).
• Lassitude, Jaundice , Asterixis, Pigment gallstones
• Hepatomegaly, Splenomegaly
• Tapping the lower right thorax briskly may elicit tenderness.
07/16/22 by Shegaw T 340

07/16/22 by Shegaw T 341
Complications
 Hepatorenal Syndrome:
• It is a secondary kidney failure that occurs in about one-third of
liver failure patients.
• Characterized by oliguria without detectable kidney damage,
reduced GFR and sodium retention.
• It is considered as an ominous sign
 Clotting Defects:
• It may develop because of impaired prothrombin and fibrinogen
production in the liver.
• Also results from absence of bile salts prevents the absorption of
fat-soluble vitamin K, blood clotting factors.
• Have a tendency to bruise easily and may progress to
disseminated intravascular coagulation (DIC) or hemorrhage.
07/16/22 by Shegaw T 342
Complication…
 Ascites:
• It is an accumulation of serous fluid in the abdominal cavity.
• The fluid accumulates primarily because of low production of
albumin by the failing liver.
• The accumulated fluid causes a markedly enlarged abdomen.
• The fluid may cause severe respiratory distress as a result of
elevation of the diaphragm.
07/16/22 by Shegaw T 343

Ascites formation
07/16/22 by Shegaw T 344

Complication…
 Portal Hypertension:
• It is a persistent blood pressure elevation in the portal circulation
• Liver damage causes a blockage of blood flow in the portal vein.
• Increased resistance from delayed drainage causes enlargement of
the visible abdominal veins around the umbilicus (caput
medusae), rectal hemorrhoids, enlarged spleen, and esophageal
varices .
• The most serious result of portal hypertension is bleeding
esophageal varices.
• he walls of the esophageal veins are thin and tear easily from
sudden excessive pressure, such as the intraabdominal pressure
that results from coughing, lifting, or straining, causing severe
bleeding
07/16/22 by Shegaw T 345
Complication…
 Hepatic Encephalopathy:
• It is caused by the accumulation of noxious substances in the
circulation, ammonia, a by-product of protein metabolism.
• Characterized by a progressive confusion; asterixis, or flapping
tremors and fetor hepaticus, or foul breath.
• Stages of hepatic encephalopathy:
1. Early: The patient exhibits subtle changes in personality, fatigue,
drowsiness, and changes in handwriting (best asst. for early stage).
2. Stuporous and confused: often belligerent and irritable and
asterixis, muscle twitch, hyperventilation, and marked confusion.
3. Comatose: Patient gradually loses consciousness and comatose.
• If levels of toxic substances can be decreased and managed, patient
gradually regains consciousness.
• It represents end-stage liver failure and has a MR of 90% once
coma begins.
07/16/22 by Shegaw T 346
Assessment
• History taking:
– Identification data
– C/concern of pt.
– HPI & Past medical illness
– Psychosocial & personal hx is important.
P/E: IAPP
07/16/22 by Shegaw T 347

Diagnostic
• Serum albumin level decline
• Prothrombin time is prolonged.
• Liver biopsy.
• Ultrasound, Esophagogastroduodenoscopy (EGD), Laparoscopy.
• CT scan & MRI.
• Serum liver enzyme test
• Enzyme tests (principally the serum aminotransferases, alkaline

phosphatase, and gamma glut amyl trans peptidase
07/16/22 by Shegaw T 348

• It is a removal or treat the underlying causes, support liver
regeneration and treat the complications.
• Ascites is treated with diuretics, albumin infusions, fluid and
sodium restrictions.
• Paracentesis as an emergency measure to remove
• Trans jugular intrahepatic Porto systemic shunt
• Antacids to decrease gastric distress and minimize GI bleeding.
• Vitamins and nutritional supplements promote healing of damaged

liver cells and improve the general nutritional status.
07/16/22 by Shegaw T 349
• Colchicine is believed to reverse the fibrotic
processes in cirrhosis, and this has improved survival
• Anti inflammatory agent

• Salt restriction
• High carbohydrate, low fat and protein
• Rest
• Finally surgery - Lobectomy
- Transplantation of liver
07/16/22 by Shegaw T 350

Nursing Process for the Patient
Nsg. Dx: Excess fluid volume related to portal hypertension
(ascites).
Intervention:
•Daily weights are a good measure
•Measure and record abdominal girth (circumference) daily.
•This monitors the amount of ascites.
•Monitoring vital signs every 4 hours.
07/16/22 by Shegaw T 351

NCP…
Nsg dx.: Imbalanced nutrition: less than body requirements related to
anorexia.
Interventions:
•Assess the patient’s bowel sounds, abdominal distention, and evidence
of bleeding
•Monitor the patient’s diet
•Offer the patient frequent, small, high-calorie meals to reduce feeling

of fullness
•Administer vitamins or supplements as ordered to correct deficiencies.
07/16/22 by Shegaw T 352
Gallbladder disorder
• Several disorders affect the biliary system and interfere with
normal drainage of bile into the duodenum.
• These disorders include inflammation of the biliary system and
carcinoma that obstructs the biliary tree.
• The commonly exist are: cholecystitis and cholelithiasis
• Gallbladder disease with gallstones is the most common disorder

of the biliary system
07/16/22 by Shegaw T 353

Cholecystitis and cholilithiasis
• Cholecystities is the inflammation of gallbladder/bile ducts .
• Cholelithiasis is obstruction of gallbladder/bile duct by

gallstone.
• More than 90% of patients with acute cholecystitis have
gallstones or due to cholilithiasis.
07/16/22 by Shegaw T 354

Risk factor
Idiopathic or due to:
• Hemolytic disorders,
• Cystic fibrosis,
• Obesity, Elderly
• Pregnancy: predisposes cholelithiasis but rarely cholecystitis.
• 4 F‘s:
 Forty
 Family
 Fat
 Four times in women to men.
07/16/22 by Shegaw T 355

Cholecystitis
• Bile constituents
– Water (80%). • Cholesterol (70%)
– Bile acids (10%). – Radiolucent (lower
– Lecithin & other content calcium )
phospholipids (4-5%). – Pigment (20%)
– Cholesterol (1%).
– Radiopaque (more
– Conjugated bilirubin
calcium)
– Electrolytes
– Mucous • Mixed (10%)
– Various proteins
07/16/22 by Shegaw T 356

Pathophysiology
• Cholesterol stones account for most of the remaining cases of
gallbladder disease .
• Cholesterol, a normal constituent of bile, is insoluble in water.
• Its solubility depends on bile acids and lecithin (phospholipids) in
bile.
• In gallstone-prone patients, there is decreased bile acid synthesis
• Increased cholesterol synthesis in the liver, resulting in bile super
saturated with cholesterol,
• Which precipitates out of the bile to form stones.
• The cholesterol-saturated bile predisposes to the formation of
gallstones and
• Acts as an irritant, producing inflammatory changes in the
gallbladder.
07/16/22 by Shegaw T 357
C/features
• Evidence of inflammation, such as an elevated temperature,
pulse, and respirations; vomiting
• Epigastric pain, RUQ tenderness
• Positive Murphy’s sign
• Biliary colic; steady, aching, severe pain in the RUQ
• Pain begins suddenly after a fatty meal and lasts for 1 to 3 hours
• Jaundice – more in acute choledocholithiasis.
• In chronic cholecystitis heartburn, indigestion, and flatulence are

more common
07/16/22 by Shegaw T 358
ddx
 Gastritis
 GERD
 Pancreatitis
 Hepatitis
 PUD
 Atypical MI
 Pyelonephritis
 Appendicitis
 PID
 Pneumonia/pleural effusion
07/16/22 by Shegaw T 359

Assessment & diagnostic evaluation
• Clinically
• WBC may be elevated
• Serum amylase or Lipase level may be elevated
• Urine to r/o pyelo, UTI, kidney stones
• Ultrasonography commonly use in hospital.
• Abdominal x-ray.
• CT scan, MRI
• Nuclear scan
07/16/22 by Shegaw T 360
Complication
• Cholangitis,
• Necrosis or perforation of the gallbladder,
• Empyema
• Fistulas and
• Adenocarcinoma of the gallbladder
• Acute pancreatitis
07/16/22 by Shegaw T 361

Treatment
• Approximately 80% of the patients with acute gallbladder
inflammation achieve remission with rest
• IV fluids If pt. presents in shock or dehydration.
• Broad spectrum Abx.
• Antispasmodic agents propantheline bromide and dicyclomine
hydrochloride.
• Pain control using opiate analgesics (meperidine)
• Antiemetic's (promethazine).
• NSAIDS
• NGT (if protracted vomiting)
• Placed on high protein, low-fat diets after the nausea and
vomiting.
07/16/22 by Shegaw T 362

Con…
• Oral dissolution agents (ursodeoxycholicacid, chenodeoxycholic
acid).
• Extracorporeal shockwave lithotripsy followed by medical
litholytic therapy .
• Extracorporeal Lithotripsy
• Atraditional cholecystectomy-long, transverse, right subcostal
incision
• Surgery - To decompress biliary tree
- To remove ischemia
• Risk of perforation -> surgery
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Figure:
cholecystectomy
07/16/22 by Shegaw T 364

Pancreatitis
• Pancreatitis is an inflammation of the pancreas.
• It may be either acute or chronic.
• The two forms of pancreatitis have different courses and are

considered two different disorders.
07/16/22 by Shegaw T 365

Acute Pancreatitis
• Pancreatitis (inflammation of the pancreas
• Acute pancreatitis can be a medical emergency associated with

a high risk for life-threatening complications and mortality,
whereas chronic pancreatitis often goes undetected until 80%
to 90% of the exocrine and endocrine tissue is destroyed.
07/16/22 by Shegaw T 366

Pathophysiology
• Inflammation of the pancreas - auto digestion
• Pancreas normally secretes digestive enzymes.
• The enzymes can be activated while they are still within
the pancreas.
• In addition, large amounts of the enzymes are released
by inflamed cells.
• Trypsin destroys pancreatic tissue and vasodilation.
• As capillary permeability increases, fluid is lost to the
retroperitoneal space, causing shock.
• conversion of prothrombin to thrombin, so that clots
form. The patient may develop DIC.
07/16/22 by Shegaw T 367
Etiology
 Biliary tract disease especially stones
 Alcoholism-most common
 Drugs (furosemide, valproic acid, sulfasalazine)
 Infection (e.g. mumps)
 Hypertriglyceridemia
 Structural abnormalities of pancreatic duct (stricture, cancer,
 Abnormalities of common bile duct and ampullary region
 Surgery of stomach, biliary tract
 Vascular disease
 Trauma
 Hyperparathyroidism, hypercalcemia
07/16/22 by Shegaw T 368

Sign and symptoms
• Dull abdominal pain, guarding, a rigid abdomen,
hypotension or shock and respiratory distress from
accumulation of fluid in the retroperitoneal space.
• The abdominal pain in the midline below the sternum,
with radiation to the spine, back, and flank
• Eating makes the pain worse
• Low-grade fever, dry mucous membranes, and
tachycardia, nausea and vomiting, and jaundice.
• The islets of Langerhans in the terminal one-third of the
pancreas are usually not impaired.
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Diagnosis
• Serum amylase and serum lipase, urine amylase rise
• Glucose, bilirubin, alkaline phosphatase, lactic dehydrogenase,

ALT, AST, cholesterol, and potassium are all elevated.
• Decreases serum albumin, calcium, sodium, and magnesium.
• X-ray examination
• Computed tomography and ultrasonography
07/16/22 by Shegaw T 370

Management
 Mild oedematous pancreatitis:
• Keep patient NPO (nothing per os).
• Give sufficient intravenous fluids
• Insert nasogastric tube.
• Anti pain meperidine (Demerol) ,but not morphine.
 Severe acute pancreatitis:
• Refer to hospitals for admission to intensive care unit.
• Vital signs and urine output are monitored at least every 1 hr.
• Accurate metabolic flow sheet which should be checked every 8 hrs.
• Arterial blood gases are determined as necessary,
• Keep patient NPO with NG tube insertion .
• Fluids may be given up to 6 - 8 L/d.
07/16/22 by Shegaw T 371

Con…
Surgery is indicated for:
•Trauma
•Uncontrolled biliary sepsis's
•Laparotomy to establish pancreatic drainage, or to resect or
débride a necrotic pancreas.
•The patient who undergoes pancreatic surgery may have
multiple drains in place postoperatively as well as a surgical
incision that is left open for irrigation and repacking every 2 to 3
days to remove necrotic debris .
07/16/22 by Shegaw T 372

Chronic pancreatitis
• It is a continuing pancreatic cellular damage
and decreased pancreatic enzyme functioning
usually following repeated occasions of acute
pancreatitis.
07/16/22 by Shegaw T 373

Pathophysiology
• It is a continuous, progressive disease that replaces functioning
pancreatic tissue with fibrotic tissue as a result of inflammation.
• Pancreatic ducts become obstructed, dilated and finally atrophied.
• The acinar or enzyme-producing, cells of the pancreas ulcerate in

response to inflammation.
• The ulceration causes further tissue damage and tissue death.
• The pancreas becomes smaller and hardened, and progressively

smaller amounts of pancreatic enzymes are produced.
07/16/22 by Shegaw T 374

Etiology and Incidence
• Excessive alcohol ingestion

• Chronic obstructive biliary disease
• Prolonged malnutrition,
• Cancer of the pancreas or duodenum, and
• Prolonged use of enteral feedings,
07/16/22 by Shegaw T 375

Signs and symptoms
• Less severe but more long term.
• Remissions and exacerbations over time
• Epigastric or LUQ pain, weight loss, and anorexia.
• Malabsorption and fat intolerance
• Later on diabetes mellitus symptom may occure.
07/16/22 by Shegaw T 376

Complication
• Abscesses and fistulas and tissue necrosis.
• Malabsorption syndrome
• Biliary obstruction
• Type 1 DM
07/16/22 by Shegaw T 377

Diagnostic Tests
• Serum amylase and serum lipase
• Fecal fat analysis
• Hyperglycemia
• Serum calcium is decreased.
• Bilirubin may be increased.
• Abdominal x-ray
• Computed tomography and
• Ultrasonography
• Endoscopic retrograde cholangiopancreatography (ERCP)
07/16/22 by Shegaw T 378

Therapeutic intervention
• Treatment is aimed at promoting comfort

• Maintaining adequate nutrition.
• Pain is managed with analgesics.
• Nutrition is maintained
• Surgery may be necessary to repair fistulas,
drain cysts, or repair other damage.
• In other instances, part or all of the pancreas
may be removed.
07/16/22 by Shegaw T 379
NCP
• Nsg dx.: Pain related to edema and inflammation.
• Intervention:
• Administer analgesics as ordered, before pain becomes severe.
• Assist the patient to a position of comfort, usually high

Fowler’s or leaning forward slightly.
• Keep the environment free from excessive stimuli.
07/16/22 by Shegaw T 380

NCP
Nsg Dx: Imbalanced nutrition: less than body requirements related

to pain, medical restrictions (NPO), and treatment (suction).
Intervention:
•Weighing the patient every other day.
•Monitoring serum albumin levels as ordered.
•Auscultating for bowel sounds.
•Observing for nausea or vomiting.
07/16/22 by Shegaw T 381

Cont…..
Read :
Liver abscess
chronic pancreatitis.
07/16/22 by Shegaw T 382

Thank you!
07/16/22 by Shegaw T 383

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Chapter –Five

Gastro Intestinal Tract Disorders (GITDs)

•Perform physical examination for patient with GIT disorders

•Identify common GIT diseases, pathophysiology, cause & C/

•Managing patient with GIT disorder

•Prepare Nursing care plan of each problem.

• The GIT tract is pathway (23-to-26 feet or 7-8 meter

• Digestion normally begins in the mouth,

• At the upper end of the esophagus there is a sphincter i.e.

• Location: is a J- shaped saclike structure situated in the upper

• The inlet of the stomach is

• The ileocecal value is located at this junction.

• The vermiform appendix is located near this junction and it

 Digestion – break down

 Absorption - in to the blood stream

 Elimination- undigested and unabsorbed food stuffs and waste

• Wash your hands, preferably while the patient is

• Exposing only the area that

Right lumbar Left lumbar

Right iliac region Left iliac region

 Standing at the right side

Note the skin, including:

• More conspicuous in the thin than in the fat

• Greater in the old than in the young.

• Increased in thyrotoxicosis, hypertension, or aortic

• In those who have a mass joining the aorta to the

• Normal sounds are due

• After silence the

• Presence of a bruit on the

• Dull sounds that

6-12 cm from right

Percussion at Castell’s Spot

• Technique • Liver edge

 First warm your hands by rubbing them together.

 Abdominal wall depressed approximately 1-2 cm.

two-handed deep palpation

• Ask the patient to take a

2. From left anterior axillary to costal margin:

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• Murphy’s Sign • Re bound Tenderness

• McBurney’s Point • Costovertebral

• Rovsing’s Sign tenderness

• Psoas Sign • Shifting Dullness

• Obturator Sign • Fluid wave

• Anatomic basis for the

• Internally rotate right leg at the hip with the knee at

If the patient has ascites, the area of

An easily palpable impulse suggests ascites.

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• Inspected for color, and consistency.

• If blood in the upper GIT produce a black tarry color/ Melena.

• If blood in the lower portion of GIT will appear bright or dark

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• Tooth decay is an erosive process of tooth.