Asrat Woldeyes Health Science

Campus
School of Nursing and Midwifery
Department of Nursing

GIS disorders
By Getachew. M (MSc in AHN)
 Learning Objectives
✓ Describe the structure and function of the organs of the

gastrointestinal (GI) tract.

✓ Discriminate between normal and abnormal assessment

findings identified by inspection, auscultation, percussion,

and palpation of the gastrointestinal system.

✓ Recognize and evaluate the major symptoms of

gastrointestinal dysfunction by applying concepts from the
patient’s health history and physical assessment findings.

✓ Identify the diagnostic tests used to evaluate GI tract

function and related nursing implications.

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 Anatomy and physiologic overview GIT
 The GI tract is a pathway that extends from the mouth to the ter

minal structure, the anus .

 The GIT lumen is also composed of four layers.

 Mucosa (inner layer)

 sub mucosa

 Muscularies

 Serosa.

❖ Muscularies (longitudinal and circular )

❖ The largest serosa is peritoneum

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❖ Most of abdominal organs are covered by peritoneum.
 Anatomy and physiologic over view …
 The digestive system is made up of the

➢ Alimentary canal (food passageway), and

• Is a hollow tube lined with mucous membrane.

➢ The accessory organs of digestion.

 The products of the accessory organs help to prepare food

for its absorption and use by the tissues of the body.

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 Anatomy and physiologic over view…
➢ The alimentary canal ➢ Accessory organs

Mouth Teeth,

Esophagus Tongue,

Stomach Salivary glands,

Small intestine Liver,

Large intestine and Pancreas,

Rectum Gallbladder, and

Ducts.
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 Anatomy and physiology over view…
 Major functions of gastrointestinal system :

 Ingestion (intake) of food and mechanical processing

 Transportation or propulsion

 Secretion

 Digestion of food

 Absorption of nutrients, and

 Elimination of solid waste (Defecation).

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 Anatomy and physiology over view…
 For simplicity and understanding, the alimentary canal can be

divided into three parts:

➢ The Upper gastrointestinal tract → the Mouth, Oesophagus

and Stomach.

➢ The Middle GIT → Small Intestine.

➢ The Lower GIT → Large Intestine.

 The Fourth part (Accessory Structures) - Salivary glands,

Liver, Gallbladder, and Pancreas

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 Functions of Oral Cavity/Mouth
 Sensory analysis

• Before swallowing

 Mechanical and chemical digestio

n processes begin in the mouth.

 Lubrication

• Mixing with mucus and salivary

gland secretions.

 Limited digestion

• Carbohydrates.
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 Mouth - Protective Action

 Defense against invading microorganisms

 Contains specific antimicrobial proteins like lysosomes

, lactoferrin and lactoperoxidase, but also mucin, IgA,

and nitric oxide-donating substances such as nitrates

 Mucus covers food and follows it to colon. It can attach

to mucosal surfaces and forms protective barrier.

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 The Teeth
According to the location
and function, they are divi
ded into:
✓Incisors
✓Canine
✓Premolars
✓Molars

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 The Teeth …
• A person develops two sets of teeth during his life
•A deciduous (or temporary) set, and
•A permanent set.
➢There are 20 temporary teeth and these erupt during t
he first 3 years of life.
➢They are replaced during the period between the
6th and 14th years by permanent teeth.
➢There are 32 permanent teeth in the normal mouth.

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 The Teeth …
The primary function of the teeth is:-

✓To chew or masticate food.

✓Also help modify sound produced by the larynx to form

words.

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 The Salivary Glands
 There are three pairs of (parotid, submandibular and sub
lingual) salivary glands.

 They secrete saliva into the mouth through small duct.

 Saliva contains two major types of secretion:

1. Serous secretion: contains ptyalin (an α amylase), which is

an enzyme for digesting starches, and

2. Mucus secretion: contains mucin for lubricating and for surf

ace protective purposes.

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 The Tongue
➢The tongue is a muscular organ attached at the back of
the mouth and projecting upward into the oral cavity.
➢ It is utilized for
➢Taste,
➢Speech,
➢Mastication,
➢Salivation, and
➢Swallowing.

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 Pharynx
 The pharynx is a musculo membranous passage that

leads from the nose and mouth to the esophagus.

 The passage of food from the pharynx into the esophagus

is the second stage of swallowing.

 When food is being swallowed, the larynx is closed off

from the pharynx to keep food from getting into the

respiratory tract.

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 Esophagus
✓ A hollow muscular tube located in the thoracic cavity,

Posterior to the trachea & larynx

✓ About 25 cm (10 in.) long and 2 cm (0.80 in.) wide.

✓ The esophagus extends from the oropharynx to the

stomach.

✓ Conveys solid food and liquids to the stomach.

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 Esophagus …
 At the top of the esophagus is the upper esophageal sp

hincter (UES).

▪ This prevent the influx of air into the esophagus

during respiration.

 At the bottom of the esophagus is the lower esophageal

sphincter (LES)

▪ This prevent the reflux of acid from the stomach into

the esophagus.

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 The Stomach
 The stomach is an elongated pouch-like structure lying ju

st below the diaphragm.

 Is the most dilated part of the GIT and has a J-like shape

 Receive esophagus from above and continues to the first

part of the small intestine, duodenum

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 Parts of the Stomach
 The Cardia- surrounds the opening of the esophagus

 The fundus- the highest dome shaped region of the stomach

And above the entrance of the esophagus;

 The body of stomach- the largest and central region

 The pyloric part- continuation site to the small intestine which

is divided into the pyloric antrum and pyloric canal and is the
distal end of the stomach

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 The Stomach…
✓ The cardiac sphincter: is at the esophageal opening
 The contents of the esophagus empty into the stomach thro
ugh the cardiac sphincter.
 Prevents stomach contents from reentering the esopha
gus except when vomiting occurs
✓ Circular sphincter muscles that act as valves guard
the opening of the stomach.
✓ The pyloric sphincter is at the junction of the stoma
ch and the duodenum, the first portion of the small int
estine).
 Controls the opening between stomach & small intestine

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 Gastric Secretion
 The stomach mucosa has two important types of tubular g
lands:
➢ oxyntic glands (also called gastric glands)

➢ pyloric glands.

 The gastric (acid-forming) glands: secrete hydrochloric aci

d, pepsinogen, intrinsic factor, and mucus.

 The pyloric glands: secrete mainly mucus for protection of

the pyloric mucosa from the stomach acid. They also secrete
the hormone gastrin.
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 Secretions from the Oxyntic (Gastric) Glands

 A typical stomach oxyntic gland is composed of three

types of cells:

1. Mucous neck cells, which secrete mainly mucus;

2. Peptic (or chief) cells, which secrete large quantities of

pepsinogen; and

3. Parietal (or oxyntic) cells, which secrete hydrochloric

acid and intrinsic factor.

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 Pyloric Glands Secretion

 The pyloric glands are structurally similar to the oxyntic gla

nds but contain few peptic cells and almost no parietal cells
Instead, they contain mostly mucous cells.

 These cells secrete a small amount of pepsinogen, and an

especially large amount of thin mucus that helps to

lubricate food movement.

 The pyloric glands also secrete the hormone gastrin, which

plays a key role in controlling gastric secretion.

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 Liver

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 Liver
 The liver is a very vascular organ located in the RUQ of
the abdomen under the diaphragm.
 It has two main lobes that are comprised of smaller lobules.
 Function:
Stores a variety of vitamins (A, B12, D, E & K) and minerals.
Metabolizes proteins;
Synthesizes plasma proteins, fatty acids and triglycerides
Stores and releases glycogen.
Detoxifies foreign substances such as alcohol, drugs or che
micals.
Forms and secretes bile to aid in digestion of fat

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 Anatomy and physiology over view…
Gall bladder: is a small receptacle located on the inferior
aspect of the liver that holds bile until it is needed.
Pancreas: is located retro-peritoneally (posterior wall) in the
upper abdomen near the stomach
It extends from just right of midline(duodenum) to the left to
ward the spleen.
The pancreas has both endocrine and exocrine functions.
The endocrine functions
 Secretion of insulin
 Secretion of glucagon
The exocrine function includes
 Secretion of trypsin, lipase, amylase, and chymotrypsin to
aid in digestion.
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 Pancreas
 Pancreatic Enzymes
 Pancreatic alpha-amylase
 Breaks down starches
 Pancreatic lipase
 Breaks down complex lipids
 Nucleases
 Break down nucleic acids.
 Proteolytic enzymes
 Proteases break large protein complexes.
 Peptidases break small peptides into amino acids.
 70% of all pancreatic enzyme production.
 Secreted as inactive proenzymes
 Activated after reaching small intestine.
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 Small Intestine
 Is the longest part of the gastrointestinal tract
 Is approximately 6 -7 m long with a narrowing diameter
from beginning to end
Consists of:
 The duodenum
 The jejunum and
 The ileum
 Is the primary site for absorption
(90%)
 Extends from the pylorus to the
ileocecal junction where the ileum j
oins the cecum
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 Small Intestine Cont’d
 The small intestine is responsible for the digestion and

absorption of nutrients, vitamins, minerals, fluids,

and electrolytes.

 The digestive chyme (mixture of partially digested food

and secretions) travels to small bowel by segmental

contractions and peristaltic waves.

 Substances that are well tolerated move through the

bowel relatively slowly; foods or drugs that are toxic

or irritable to the small bowel are evacuated rapidly.
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 Duodenum
 The first and shortest (25 cm) part of the small intestine

 Is also the widest and most fixed part

 Pursues a C - shaped course around the head of the pancreas

 Begins at the pylorus on the right side and ends at the

duodenojejunal junction on the left side

Functions of the duodenum

 To receive chyme from stomach.

 To neutralize acids before they can damage the absorptive

surfaces of the small intestine.

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 Jejunum
 The jejunum represents the proximal 2/5th of the small intes

tine

 It is larger in diameter and has a thicker wall than the ileum

 The less prominent arterial arcades and longer vasa re

cta (straight arteries) compared to those of the ileum are

a unique characteristic of the jejunum.

 Is the location of most

 Chemical digestion

 Nutrient absorption
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 Ileum
 Makes up the distal 3/5th of the small intestine
 Compared to the jejunum, the ileum has thinner walls, shor
ter vasa recta, more mesenteric fat, and more arterial arc
ades
 Has two flaps projecting into the lumen of the cecum which
serve as sphincters to prevent the back flow of feces fro
m the large intestine to the ileum
 Opens into the cecum OR ends at the ileo-cecal valve,
 This valve works in conjunction with ileocecal sphincter to
control emptying of contents from the small intestine
into the colon and to prevent regurgitation of digestive
chyme from the large to small bowel.
 It is in this area that the vermiform appendix is located.

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 Large Intestine
 Extends from the cecum to the anus
 Is approximately 1.5 m in length
 Absorbs fluids and salts from the gut contents, thus forming feces
Consists of:
 Cecum is about 6cm
- Appendix is about 10 cm
 Colon
 Ascending colon is about 25 cm
 Desending colon is about 25 cm
 Transverse colon is about 50 cm
 Sigmoid colon is about 14 cm
 Rectum is about 12 cm
 Anal canal is about 8 cm

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 The Colon
Ascending colon Descending colon
 Cecum to right colic flexure  Splenic flexure to sigmoid
(hepatic flexure)  Runs downward, on left (left
 Runs upward , on right side to the iliac fossa)
 Retroperitoneal  Retroperitoneal
 mid gut  Hind gut
Transverse colon Sigmoid ( pelvic ) colon
 Hepatic flexure to left colic  Descending colon to rectum
flexure (splenic flexure)  S-shaped course
 Runs almost horizontally(R-L)  Intraperitoneal ( sigmoid
 Intraperitoneal( transverse mesocolon)
mesocolon)  Hind gut( distal 1/3)
 Mid gut( proximal 2/3)
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Abdominal Assessment
 Assessment cont..
❑ History taking

❑ Physical examination

❑ Laboratory tests

▪ CBC and electrolyte

▪ stool examination

▪ Occult blood

▪ Ova and parasites

▪ Stool culture

▪ Stool for lipids

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Abdomen
Sub-division of abdomen
❖Right upper quadrant - RUQ
❖Right lower quadrant – RLQ
❖Left upper quadrant – LUQ
❖Left lower quadrant - LLQ

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 Four Abdominal Quadrants

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 9 Abdominal regions

Right hypocho Left hypochon

ndriac region driac region

Right lumbar re
gion Left lumbar region

Right iliac re
gion Left iliac region

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 Think Anatomically

• When looking, listening,

percussing and feeling i
magine what orga
ns live in the area that
you are examining.

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Right Upper Quadrant
❖ Liver

❖ Gallbladder

❖ Duodenum

❖ Head of pancreas

❖ Right kidney and adrenal

❖ Hepatic flexure of colon

❖ Part of ascending and transverse colo

n
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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 Upper Quadrant (LUQ)
❖ Stomach

❖ Spleen

❖ Left lobe of liver

❖ Body of pancreas

❖ Left kidney and adrenal

❖ Splenic flexure of colon

❖ Parts of transverse and descending col

on
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 Left Lower Quadrant (LLQ)

❖Part of descending colon

❖Sigmoid colon

❖Left ovary and tube

❖Left ureter

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 History and Physical Examination Of
Abdomen
❖70% of diagnoses can be made based on history

alone.

❖90% of diagnoses can be made based on

➢History and

➢Physical exam.

❖Expensive tests often confirm what is found during

the history and physical examination.

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 Abdominal Health History
❑Ask the pt. about

✓Indigestion, Nausea, Vomiting, Anorexia,

✓Hematemesis

✓How is his/her appetite, distress associated with

eating

✓Heartburn ----sense of burning or warmth that

is retrosternal and may radiate to the neck

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 CONT…
✓Excessive gas: frequent belching, distention or flatulence

,Abdominal fullness.
 Dysphagia: difficulty in swallowing: difficulty in swallowing,

with a variety of possible causes

 Odynophagia: severe pain on swallowing due to disorder o

f esophagus
✓Change in bowel function

✓Constipation or diarrhea

✓Jaundice
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 CONT…
❑Bowel Habits

❑Past Abdominal History

❑Medications

➢ Aspirin

➢ Smoking

❑Nutritional Assessment

➢ 24 hour recall

➢ Nutritional patterns

➢ Weight change
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Abdominal Pain
 Visceral :pain arise from visceral layer of serous
membrane
❖ Burning

❖ Dull pain
❖ Aching ,
❖ Difficult to localize,
❖ Varies in quality

❖ E.g. Pain in RUQ from liver distention

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 Abdominal pain cont ….
Parietal pain: Arise from parietal layer of serous membrane
❑Caused by inflammation,

✓Sharp
✓Steady,
✓More sever,
✓Localized,
✓Increase by movement or coughing
❑Referred pain

❖ Felt at more distant site, well localized,

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 General principles of exam
❖ Good light

❖ Relax the patient

❖ Full exposure of abdomen from above the xiphoid proce

ss 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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 General principles of exam cont.. .
❖ Before the exam, ask the

patient to identify painful

areas so that you can examine
those areas last

❖ During the exam pay attention

to their facial expression to

assess for sign of discomfort

❖ Distract the patient if

necessary with conversation

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or questions.
 General principles of exam cont.. .
❖ Use warm hand, warm stethoscope, and have short

finger nails

❖ Approach the patient slowly and deliberately explaining

what you will be doing

❖ Stand right side of the bed

❖ Examine with right hand

❖ Head just a little elevated

❖ Ask the patient to keep the mouth partially open and

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breathe gently
 General principles of exam cont.. .
❖ If muscles remain tense, patient may be asked to

rest feet on table with hips and knees flexed

❖ 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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 Abdominal Exam
The four Steps of abdominal examination

1. Inspection

2. Auscultation

3. Percussion

4. Palpation

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 Special Abdominal Exam
➢ Murphy’s Sign ➢ Rebound Tenderness

➢ Rovsing’s Sign ➢ Costovertebral tenderness

➢ Psoas Sign ➢ Cutaneous hyperesthesia

➢ Obturator Sign ➢ Carnett`s sign

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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 inspir

atory effort shows 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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 Assessing Possible Appendicitis
➢ Rovsing’s Sign

➢ Psoas Sign

➢ Obturator Sign

➢ Tenderness

➢ Rebound Tenderness

➢ Referred rebound tenderness

✓ Are special exam/tests which are helpful in assessing p

ossible appendicitis .

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Rovsing’s Sign
❖ Sign of appendicitis

❖ Patient will experience right lower quadrant (RLQ) pain

(in region of McBurney’s Point) when left lower quadra

nt (LLQ) is palpated.

➢ Referred rebound tenderness: right lower quadrant

pain on quick withdrawal of the LLQ pressure.

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 Iliopsoas Sign
Psoas Sign: 2 methods

1st Method

 Place your hand just above the patient’s right knee

 Ask the patient to raise that thigh against your hand (extending

right thigh)

2nd Method

 Ask the patient to turn onto the left side

 Then extend the patient’s right leg at the hip

❖ Flexion of the leg at the hip makes the psoas muscle contr
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act; extension stretches it
 Iliopsoas Sign cont..

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 Obturator Sign
❖ Internally rotate right leg at the hip with the knee at 9

0 degrees of flexion will produce pain if inflamed appen

dix is in pelvis.

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 Rebound tenderness
❖ Warn the patient what you are ab

out to do.
✓ Press deeply on the abdomen

with your hand.

✓ After a moment, quickly releas

e pressure.
✓ If it hurts more when you relea

se, the patient has rebound ten

derness.
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Cost vertebral Tenderness
(Often with renal disease)
❖ Done in R & L CVA to assess kidney
tenderness
❖ Warn the person what you are about
to do
❖ Have the person sit up on the exam
table
❖ Use the heel of your closed fist to
strike the patient firmly over the
costovertebral angles (the angle
formed by the lower border of the
12th rib and the transverse
processes of the upper lumbar
vertebrae).
❖ Compare the left and right sides.
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 Diagnostic procedures of GI disorder
Complete blood count (CBC) and electrolyte
❖ Red blood cells-
✓4.2 to 5.4 million/mm3 (women)
✓4.5 to 6.2 million /mm3 (men)
❖ Haemoglobin
✓12 to 16g/dl (Women) AND 14 to 18 g/dl (Men).
❖ Hematocrit-
✓38 to 46% (Women) AND 42 to 54% (Men)
❖ Decreased value indicates possible anaemia or haemorrhage.
❖ Increased value indicates possible hemo-concentration, caused
by dehydration.
Electrolyte
 Potassium 3.5 to 5 mg/d, decreased value indicates possible G
I suction, diarrhoea, vomiting, intestinal fistula

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 Diagnostic procedures of GI disorder
Stool examination
o Occult blood
o Ova and parasites
o Stool culture
o Stool for lipids (Normally → 2 to 5gm/24h(Normal diet))

 Steatorrhea :the excretion of abnormal quantities of fat with the

faeces owing to reduced absorption of fat by the intestine
Color of stool
➢ Melena / tarry black/  upper GI bleeding
➢ Bright red blood  lower GI bleeding
➢ Blood streaking on surface of stool  lower rectal or anal
bleeding
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 Diagnostic …
➢ Radiographic tests
 X-ray study is performed to visualize abdominal organs.
 This test can reveal abnormalities such as tumours, obstruc
tion, abnormal gas collectives and strictures.

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 Diagnostic …
 Upper gastro-intestinal series (Barium) swallow.
➢ An upper series permits radiologic visualization of the oeso
phagus, stomach, duodenum and jejunum.
➢ It can aid in the detection of structures, ulcers, tumors, polyp
s, hiatal hernias and motility problems.
 Preparation:
➢ Instruct the patients NPO for 6 to 8 hours before test.
➢ Procedure: clients drink a radiopaque contrast medium
(barium) while standing in front of a fluoroscopy.

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 Diagnostic …
❖ Nursing interventions
✓ Instruction regarding dietary changes prior to the study shou
ld include a clear liquid diet, with nothing by mouth (N
PO) from midnight the night before the study
✓ The patient is advised to not smoke or chew gum during
the NPO period because these can increase gastric secretion
s and salivation
✓ Follow-up care is provided after the upper GI procedure to e
nsure that the patient has eliminated most of the ingest
ed barium.
✓ Fluids may be increased to facilitate evacuation of stool and b
arium

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 Diagnostic …
❖ Lower gastrointestinal series (Barium enema)
Is performed to visualize the position, movements, and filli
ng of the colon.
This test aid in the detection of tumors, diverticulum, stenosis,
obstruction, inflammation, ulcerative colitis and polyps.
 Preparation:
Adequate bowel preparation
Placing the client on a low-residue, clear liquid
NPO for 6 to 8 hrs.
Laxative
Cleansing enema.

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 Diagnostic …
❖ Nursing interventions
✓ Preparation of the patient includes emptying and cle
ansing the lower bowel.
 (low-residue diet 1 to 2 days before the test, a clear liquid
diet and a laxative the evening before, NPO after midnig
ht, and cleansing enemas until returns are clear the follo
wing morning).
✓ Making sure that barium enemas are scheduled before a
ny upper GI studies.
 If the patient has active inflammatory disease of the colo
n, patients with signs of perforation or obstruction, Active
GI bleeding are contraindicated for use of laxatives and
barium enema
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 Diagnostic …
✓ Postprocedural patient education includes

 Information about increasing fluid intake,

 Evaluating bowel movements for evacuation of

barium, and

 Noting increased number of bowel movements,

because barium, due to its high osmolarity, may draw
fluid into the bowel, thus increasing the intraluminal
contents and resulting in greater output.
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Diagnostic …
➢ Endoscopy

Is the direct visualization of the GI system by means of a

lighted, flexible tube.

More accurate than radiologic examination because the p

hysician can directly observe source of bleeding and surf

ace lesions and determine the status of healing tissue.

include fibroscopy/esophagogastroduodenoscopy (EGD),

colonoscopy, anoscopy, sigmoidoscopy, small bowel ente

roscopy, and endoscopy through an ostomy.
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