Chapter 42: Nursing Management: Upper Gastrointestinal Problems

NAUSEA AND VOMITING

• Nausea and vomiting are found in a wide variety of gastrointestinal (GI) disorders.

• They are also found in conditions that are unrelated to GI disease, including pregnancy,
infectious diseases, central nervous system (CNS) disorders (e.g., meningitis),
cardiovascular problems (e.g., myocardial infarction), metabolic disorders (e.g., diabetes
mellitus), side effects of drugs (e.g., chemotherapy, opioids), and psychologic factors (e.g.,
fear).

• Vomiting can occur when the GI tract becomes overly irritated, excited, or distended.
o It can be a protective mechanism to rid the body of spoiled or irritating foods and
liquids.
o Pulmonary aspiration is a concern when vomiting occurs in the patient who is
elderly, is unconscious, or has other conditions that impair the gag reflex.
o The color of the emesis aids in identifying the presence and source of bleeding.

• Drugs that control nausea and vomiting include anticholinergics (e.g., scopolamine),
antihistamines (e.g., promethazine [Phenergan]), phenothiazines (e.g., chlorpromazine
[Thorazine], prochlorperazine [Compazine]), and butyrophenones (e.g., droperidol
[Inapsine]).

• The patient with severe or prolonged vomiting is at risk for dehydration and acid-base and
electrolyte imbalances. The patient may require intravenous (IV) fluid therapy with
electrolyte and glucose replacement until able to tolerate oral intake.

Upper Gastrointestinal Bleeding

• The mortality rate for upper GI bleeding remains at 6% to 10% despite advances in intensive
care, hemodynamic monitoring, and endoscopy.

• The severity of bleeding depends on whether the origin is venous, capillary, or arterial.

• Bleeding ulcers account for 50% of the cases of upper GI bleeding.

• Drugs such as aspirin, nonsteroidal antiinflammatory agents, and corticosteroids are a major
cause of upper GI bleeding.

• Although approximately 80% to 85% of patients who have massive hemorrhage

spontaneously stop bleeding, the cause must be identified and treatment initiated
immediately.

• The immediate physical examination includes a systemic evaluation of the patient’s

condition with emphasis on blood pressure, rate and character of pulse, peripheral perfusion
with capillary refill, and observation for the presence or absence of neck vein distention.
Vital signs are monitored every 15 to 30 minutes.

• The goal of endoscopic hemostasis is to coagulate or thrombose the bleeding artery. Several
techniques are used including thermal (heat) probe, multipolar and bipolar
electrocoagulation probe, argon plasma coagulation, and neodymium:yttrium-aluminum-
garnet (Nd:YAG) laser.
 • The patient undergoing vasopressin therapy is closely monitored for its myocardial, visceral,
and peripheral ischemic side effects.

• The nursing assessment for the patient with upper GI bleeding includes the patient’s level of
consciousness, vital signs, appearance of neck veins, skin color, and capillary refill. The
abdomen is checked for distention, guarding, and peristalsis.

• The patient who requires regular administration of ulcerogenic drugs, such as aspirin,
corticosteroids, or NSAIDs, needs instruction regarding the potential adverse effects related
to GI bleeding.

• During the acute bleeding phase an accurate intake and output record is essential so that the
patient’s hydration status can be assessed.

• Once fluid replacement has been initiated, the older adult or the patient with a history of
cardiovascular problems is observed closely for signs of fluid overload.

• The majority of upper GI bleeding episodes cease spontaneously, even without intervention.

• Monitoring the patient’s laboratory studies enables the nurse to estimate the effectiveness of
therapy.

• The patient and family are taught how to avoid future bleeding episodes. Ulcer disease, drug
or alcohol abuse, and liver and respiratory diseases can all result in upper GI bleeding.

Oral Infections and Inflammations

• May be specific mouth diseases, or they may occur in the presence of systemic disorders
such as leukemia or vitamin deficiency.

• The patient who is immunosuppressed (e.g., patient with acquired immunodeficiency

syndrome or receiving chemotherapy) is most susceptible to oral infections. The patient on
oral corticosteroid inhaler treatment for asthma is also at risk.

• Management of oral infections and inflammation is focused on identification of the cause,

elimination of infection, provision of comfort measures, and maintenance of nutritional
intake.

Oral (or Oropharyngeal) Cancer

• May occur on the lips or anywhere within the mouth (e.g., tongue, floor of the mouth,
buccal mucosa, hard palate, soft palate, pharyngeal walls, tonsils).

• Head and neck squamous cell carcinoma is an umbrella term for cancers of the oral cavity,
pharynx, and larynx. Accounts for 90% of malignant oral tumors.

• The overall goals are that the patient with carcinoma of the oral cavity will (1) have a patent
airway, (2) be able to communicate, (3) have adequate nutritional intake to promote wound
healing, and (4) have relief of pain and discomfort.

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

• There is no one single cause of gastroesophageal reflux disease (GERD). It can occur
 when there is reflux of acidic gastric contents into the esophagus.

• Predisposing conditions include hiatal hernia, incompetent lower esophageal sphincter,

decreased esophageal clearance (ability to clear liquids or food from the esophagus into the
stomach) resulting from impaired esophageal motility, and decreased gastric emptying.

• A complication of GERD is Barrett’s esophagus (esophageal metaplasia), which is

considered a precancerous lesion that increases the patient’s risk for esophageal cancer.

• Most patients with GERD can be successfully managed by lifestyle modifications and drug
therapy.

• Drug therapy for GERD is focused on improving LES function, increasing esophageal
clearance, decreasing volume and acidity of reflux, and protecting the esophageal mucosa.

• Because of the link between GERD and Barrett’s esophagus, patients are instructed to see
their health care provider if symptoms persist.

HIATAL HERNIA
• The two most common types of hiatal hernia are sliding and paraesophageal (rolling).

• Factors that predispose to hiatal hernia development include increased intraabdominal

pressure, including obesity, pregnancy, ascites, tumors, tight girdles, intense physical
exertion, and heavy lifting on a continual basis. Other factors are increased age, trauma,
poor nutrition, and a forced recumbent position (e.g., prolonged bed rest).

Esophageal Cancer
• Two important risk factors for esophageal cancer are smoking and excessive alcohol intake.

Gastritis
• Gastritis occurs as the result of a breakdown in the normal gastric mucosal barrier.

• Drugs such as aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), digitalis, and

alendronate (Fosamax) have direct irritating effects on the gastric mucosa. Dietary
indiscretions can also result in acute gastritis.

• The symptoms of acute gastritis include anorexia, nausea and vomiting, epigastric
tenderness, and a feeling of fullness.

Peptic Ulcer Disease

• Gastric and duodenal ulcers, although defined as peptic ulcer disease (PUD), are different
in their etiology and incidence.

• Duodenal ulcers are more common than gastric ulcers.

• The organism Helicobacter pylori is found in the majority of patients with PUD.

• Alcohol, nicotine, and drugs such as aspirin and nonsteroidal antiinflammatory drugs play a
role in gastric ulcer development.

• The three major complications of chronic PUD are hemorrhage, perforation, and gastric
 outlet obstruction. All are considered emergency situations and are initially treated
conservatively.

• Endoscopy is the most commonly used procedure for diagnosis of PUD.

• Treatment of PUD includes adequate rest, dietary modifications, drug therapy, elimination
of smoking, and long-term follow-up care. The aim is to decrease gastric acidity, enhance
mucosal defense mechanisms, and minimize the harmful effects on the mucosa.

• The drugs most commonly used to treat PUD are histamine (H2)-receptor blockers, proton
pump inhibitors, and antacids. Antibiotics are employed to eradicate H. pylori infection.

• The immediate focus of management of a patient with a perforation is to stop the spillage of
gastric or duodenal contents into the peritoneal cavity and restore blood volume.

• The aim of therapy for gastric outlet obstruction is to decompress the stomach, correct any
existing fluid and electrolyte imbalances, and improve the patient’s general state of health.

• Overall goals for the patient with PUD include compliance with the prescribed therapeutic
regimen, reduction or absence of discomfort, no signs of GI complications, healing of the
ulcer, and appropriate lifestyle changes to prevent recurrence.

• Surgical procedures for PUD include partial gastrectomy, vagotomy, and/or pyloroplasty.

STOMACH Cancer
• Stomach (gastric) cancers often spread to adjacent organs before any distressing symptoms
occur.

• The nursing role in the early detection of stomach cancer is focused on identification of the
patient at risk because of specific disorders such as pernicious anemia and achlorhydria.

E. coli O157:H7O157:H7
• It is the organism most commonly associated with food-borne illness.

• It is found primarily in undercooked meats, such as hamburger, roast beef, ham, and turkey.

****Chapter 43: Nursing Management: Lower Gastrointestinal Problems

Diarrhea
• Diarrhea is most commonly defined as an increase in stool frequency or volume, and an increase in the
looseness of stool.

• Diarrhea can result from alterations in gastrointestinal motility, increased secretion, and
decreased absorption.

• All cases of acute diarrhea should be considered infectious until the cause is known.

• Patients receiving antibiotics (e.g., clindamycin [Cleocin], ampicillin, amoxicillin,

cephalosporin) are susceptible to Clostridium difficile (C. difficile), which is a serious
 bacterial infection.

Fecal Incontinence
• Fecal incontinence, the involuntary passage of stool, occurs when the normal structures that
maintain continence are disrupted.

• Risk factors include constipation, diarrhea, obstetric trauma, and fecal impaction.

• Prevention and treatment of fecal incontinence may be managed by implementing a bowel

training program.

CONSTIPATION
• Constipation can be defined as a decrease in the frequency of bowel movements from what
is “normal” for the individual; hard, difficult-to-pass stools; a decrease in stool volume;
and/or retention of feces in the rectum.

• The overall goals are that the patient with constipation is to increase dietary intake of fiber
and fluids; increase physical activity; have the passage of soft, formed stools; and not have
any complications, such as bleeding hemorrhoids.

• An important role of the nurse is teaching the patient the importance of dietary measures to
prevent constipation.

Abdominal Pain, Trauma, and Inflammatory Disorders

• Acute abdominal pain is a symptom of many different types of tissue injury and can arise
from damage to abdominal or pelvic organs and blood vessels.

• Pain is the most common symptom of an acute abdominal problem.

• The goal of management of the patient with acute abdominal pain is to identify and treat the
cause and monitor and treat complications, especially shock.

• Bowel sounds that are diminished or absent in a quadrant may indicate a complete bowel
obstruction, acute peritonitis, or paralytic ileus.

• Expected outcomes for the patient with acute abdominal pain include resolution of the cause
of the acute abdominal pain; relief of abdominal pain and discomfort; freedom from
complications (especially hypovolemic shock and septicemia); and normal fluid, electrolyte,
and nutritional status.

• Common causes of chronic abdominal pain include irritable bowel syndrome (IBS),
diverticulitis, peptic ulcer disease, chronic pancreatitis, hepatitis, cholecystitis, pelvic
inflammatory disease, and vascular insufficiency.

• The abdominal pain or discomfort associated with IBS is most likely due to increased
visceral sensitivity.

Abdominal Trauma
• Blunt trauma commonly occurs with motor vehicle accidents and falls and may not be
obvious because it does not leave an open wound.
 • Common injuries of the abdomen include lacerated liver, ruptured spleen, pancreatic trauma,
mesenteric artery tears, diaphragm rupture, urinary bladder rupture, great vessel tears, renal
injury, and stomach or intestine rupture.

Appendicitis
• Appendicitis results in distention, venous engorgement, and the accumulation of mucus and
bacteria, which can lead to gangrene and perforation.

• Appendicitis typically begins with periumbilical pain, followed by anorexia, nausea, and
vomiting. The pain is persistent and continuous, eventually shifting to the right lower
quadrant and localizing at McBurney’s point.

• Until a health care provider sees the patient, nothing should be taken by mouth (NPO) to
ensure that the stomach is empty in the event that surgery is needed.

Peritonitis
• Peritonitis results from a localized or generalized inflammatory process of the peritoneum.

• Assessment of the patient’s abdominal pain, including the location, is important and may
help in determining the cause of peritonitis.

Gastroenteritis
• Gastroenteritis is an inflammation of the mucosa of the stomach and small intestine.

• Clinical manifestations include nausea, vomiting, diarrhea, abdominal cramping, and distention. Most cases are
self-limiting and do not require hospitalization.

• If the causative agent is identified, appropriate antibiotic and antimicrobial drugs are given.

• Symptomatic nursing care is given for nausea, vomiting, and diarrhea.

Inflammatory Bowel Disease

• Crohn’s disease and ulcerative colitis are immunologically related disorders that are
referred to as inflammatory bowel disease (IBD).

• IBD is characterized by mild to severe acute exacerbations that occur at unpredictable intervals over many
years.

• Ulcerative colitis usually starts in the rectum and moves in a continual fashion toward the
cecum. Although there is sometimes mild inflammation in the terminal ileum, ulcerative
colitis is a disease of the colon and rectum.

• Crohn’s disease can occur anywhere in the GI tract from the mouth to the anus, but occurs
most commonly in the terminal ileum and colon. The inflammation involves all layers of the
bowel wall with segments of normal bowel occurring between diseased portions, the so-
called “skip lesions.”

• With Crohn’s disease, diarrhea and colicky abdominal pain are common symptoms. If the small intestine is
involved, weight loss occurs due to malabsorption. In addition, patients may have systemic symptoms such as
 fever. The primary symptoms of ulcerative colitis are bloody diarrhea and abdominal pain.

• The goals of treatment for IBD include rest the bowel, control the inflammation, combat infection, correct
malnutrition, alleviate stress, provide symptomatic relief, and improve quality of life.

• Nutritional problems are especially common with Crohn’s disease when the terminal ileum
is involved.

• The following five major classes of medications are used to treat IBD:
o Aminosalicylates
o Antimicrobials
o Corticosteroids
o Immunosuppressants
o Biologic therapy
• Surgery is indicated if the patient with IBD fails to respond to treatment; exacerbations are
frequent and debilitating; massive bleeding, perforation, strictures, and/or obstruction occur;
tissue changes suggest that dysplasia is occurring; or carcinoma develops.

• During an acute exacerbation of IBD, nursing care is focused on hemodynamic stability,

pain control, fluid and electrolyte balance, and nutritional support.

• Nurses and other team members can assist patients to accept the chronicity of IBD and learn
strategies to cope with its recurrent, unpredictable nature.

Intestinal Obstruction
• The causes of intestinal obstruction can be classified as mechanical or nonmechanical.

• Intestinal obstruction can be a life-threatening problem.

• Cancer is the most common cause of large bowel obstruction, followed by volvulus and
diverticular disease.

• Emergency surgery is performed if the bowel is strangulated, but many bowel obstructions
resolve with conservative treatment.

• With a bowel obstruction, there is retention of fluid in the intestine and peritoneal cavity,
which can result in a severe reduction in circulating blood volume and lead to hypotension
and hypovolemic shock.

Polyps
• Adenomatous polyps are characterized by neoplastic changes in the epithelium and are
closely linked to colorectal adenocarcinoma.

• Familial adenomatous polyposis (FAP) is the most common hereditary polyp disease.

Colorectal Cancer
• Colorectal cancer is the third most common form of cancer and the second leading cause of
cancer-related deaths in the United States.

• Most people with colorectal cancer have hematochezia (passage of blood through rectum) or
 melena (black, tarry stools), abdominal pain, and/or changes in bowel habits.

• The American Cancer Society recommends that a person who has no established risk factors
should have a fecal occult blood test (FOBT) or a fecal immunochemical test (FIT) yearly, a
double-contrast enema every 5 years, a sigmoidoscopy every 5 years, or a colonoscopy
every 10 years starting at age 50.

• Colonoscopy is the gold standard for colorectal cancer screening.

• Surgery for a rectal cancer may include an abdominal-perineal resection. Potential

complications of abdominal-perineal resection include delayed wound healing, hemorrhage,
persistent perineal sinus tracts, infections, and urinary tract and sexual dysfunctions.

• Chemotherapy is used both as an adjuvant therapy following colon resection and as primary
treatment for nonresectable colorectal cancer.

• The goals for the patient with colorectal cancer include normal bowel elimination patterns,
quality of life appropriate to disease progression, relief of pain, and feelings of comfort and
well-being.

• Psychologic support for the patient with colorectal cancer and family is important. The
recovery period is long, and the cancer could return.

• An ostomy is used when the normal elimination route is no longer possible.

• The two major aspects of nursing care for the patient undergoing ostomy surgery are (1)
emotional support as the patient copes with a radical change in body image, and (2) patient
teaching about the many aspects of stoma care and the ostomy.

• Bowel preparations are used to empty the intestines before surgery to decrease the chance of
a postoperative infection caused by bacteria in the feces.

• Postoperative nursing care includes assessment of the stoma and provision of an appropriate
pouching system that protects the skin and contains drainage and odor.

• The patient should be able to perform a pouch change, provide appropriate skin care, control
odor, care for the stoma, and identify signs and symptoms of complications.

• Colostomy irrigations are used to stimulate emptying of the colon in order to achieve a
regular bowel pattern. If control is achieved, there should be little or no spillage between
irrigations.

• The patient with an ileostomy should be observed for signs and symptoms of fluid and
electrolyte imbalance, particularly potassium, sodium, and fluid deficits.

• Bowel surgery can disrupt nerve and vascular supply to the genitals. Radiation therapy,
chemotherapy, and medications can also alter sexual function.

• Concerns of people with stomas include the ability to resume sexual activity, altering
clothing styles, the effect on daily activities, sleeping while wearing a pouch, passing gas,
the presence of odor, cleanliness, and deciding when or if to tell others about the stoma.
Diverticular Disease
• Diverticular disease covers a spectrum from asymptomatic, uncomplicated diverticulosis to
diverticulitis with complications such as perforation, abscess, fistula, and bleeding.

• Diverticular disease is a common disorder that affects 5% of the U.S. population by age 40
years and 50% by age 80 years.

• The majority of patients with diverticular disease are asymptomatic.

• Symptomatic diverticular disease can be further broken down into the following:
o Painful diverticular disease
o Diverticulitis (inflammation of the diverticuli)

• Complications of diverticulitis include perforation with peritonitis.

• A high-fiber diet, mainly from fruits and vegetables, and decreased intake of fat and red
meat are recommended for preventing diverticular disease.

HERNIA
• A hernia is a protrusion of a viscus through an abnormal opening or a weakened area in the
wall of the cavity in which it is normally contained.

• If the hernia becomes strangulated, the patient will experience severe pain and symptoms of
a bowel obstruction, such as vomiting, cramping abdominal pain, and distention.

MALABSORPTION SYNDROME
• Malabsorption results from impaired absorption of fats, carbohydrates, proteins, minerals,
and vitamins.

• Causes of malabsorption include the following:

o Biochemical or enzyme deficiencies
o Bacterial proliferation
o Disruption of small intestine mucosa
o Disturbed lymphatic and vascular circulation
o Surface area loss

Celiac Disease
• Three factors necessary for the development of celiac disease (gluten intolerance) are
genetic predisposition, gluten ingestion, and an immune-mediated response.

• Early diagnosis and treatment of celiac disease can prevent complications such as cancer
(e.g., intestinal lymphoma), osteoporosis, and possibly other autoimmune diseases.

• Celiac disease is treated with lifelong avoidance of dietary gluten. Wheat, barley, oats, and
rye products must be avoided.

LACTASE DEFICIENCY
• The symptoms of lactose intolerance include bloating, flatulence, cramping abdominal pain,
and diarrhea. They usually occur within 30 minutes to several hours after drinking a glass of
milk or ingesting a milk product.
 • Treatment consists of eliminating lactose from the diet by avoiding milk and milk products
and/or replacement of lactase with commercially available preparations.

Other Lower GI Disorders

• Short bowel syndrome (SBS) results from surgical resection, congenital defect, or disease-related loss of
absorption.
o SBS is characterized by failure to maintain protein-energy, fluid, electrolyte and micronutrient
balances on a standard diet.
o The length and portions of small bowel resected are associated with the number and severity of
symptoms. Short bowel syndrome is characterized by failure to maintain protein-energy, fluid,
electrolyte, and micronutrient balances on a standard diet.

• Hemorrhoids are dilated hemorrhoidal veins. They may be internal (occurring above the
internal sphincter) or external (occurring outside the external sphincter). Nursing
management for the patient with hemorrhoids includes teaching measures to prevent
constipation, avoidance of prolonged standing or sitting, proper use of over-the-counter
(OTC) drugs, and the need to seek medical care for severe symptoms of hemorrhoids (e.g.,
excessive pain and bleeding, prolapsed hemorrhoids) when necessary.

• An anal fissure is a skin ulcer or a crack in the lining of the anal wall that is caused by
trauma, local infection, or inflammation.

• A pilonidal sinus is a small tract under the skin between the buttocks in the sacrococcygeal
area. Nursing care for the patient with a pilonidal cyst or abscess includes warm, moist heat
applications.