DIGESTIVE AND GASTROINTESTINAL FUNCTION

I. Anatomy of the Digestive System

The digestive system is made up of the gastrointestinal tract and accessory organs that help the
body break down and absorb food.

Gastrointestinal tract - The GI tract is a 23- to 26-foot-long (7 m to 7.9 m) pathway that extends
from the mouth to the esophagus, stomach, small and large intestines, and rectum to the terminal
structure, the anus .

Upper GI:

1. Esophagus

2. Stomach

3. Duodenum

Lower GI

1. Small Intestine

2. Large Intestine

Oral cavity

• It receives food and begins the mechanical breakdown of food by the action of chewing an
grinding the food

1. Lips

2. Cheeks

3. Palate

4. Tongue

5. Teeth

Salivary glands

• The oral cavity is permanently moist due to a continuous coating of saliva.

• Saliva makes swallowing easier.

1. parotid

2. submandibular

3. sublingual.
Pharynx

1. nasopharynx,

2. oral pharynx and

3. laryngeal pharynx

Esophagus

• located in the mediastinum, anterior to the spine and posterior to the trachea and heart.

• receives food from your mouth when you swallow.

• at the bottom, contains the esophageal sphincter that controls the flow of food.

Stomach

• Situated in the left upper portion of the abdomen.

• Has four anatomic regions: the cardia (entrance), fundus, body, and pylorus (outlet).

• A hollow muscular organ with a capacity of approximately 1500 mL.

• Stores food during eating

• Secretes digestive fluids

• Gastrin is secreted when food enters the stomach and secretion stops when the stomach pH
drops below 1.5

• Propels chyme (consisting of gastric juices and partly digested food) into the small intestine
through the pyloric sphincter.

Small Intestine

• The longest segment of the GI tract.

• Breaks down food using enzymes released by the pancreas and bile from the liver.

• Has three sections: duodenum, jejunum and ileum.

• The duodenum continues the process of mechanical digestion by the action

of peristalsis

• The jejunum is to further break down the nutrients coming from the duodenum.

• The Ileum is the longest section of small intestine. Main function is absorption of nutrients

Large intestine

• Consists of cecum, ascending colon, transverse colon, descending colon, sigmoid colon.

• absorption of water, electrolytes and vitamins (vitamin K and some B complexes (B 1 , B 2 and
folic acid)
• Responsible for processing waste passing by means of peristalsis.

• Stool is stored in the sigmoid (S-shaped) colon.

• Normally takes about 36 hours for stool to get through the colon.

Rectum

• Chamber that connects the colon to the anus.

• Receive stool from the colon.

• When anything (gas or stool) comes into the rectum, sensors send a message to the brain.

Anus

• Consists of the pelvic floor muscles and the two anal sphincters (internal and external).

• The lining of the upper anus is able to detect rectal contents.

• The internal sphincter is always tight, except when stool enters the rectum.

Accessory Organs for Digestion

Pancreas

• Exocrine function - pancreatic juice (1500 mL of pancreatic juice are produced per day)

• pancreatic amylase (carbohydrates)

• Trypsin (Protein)

• Lipase (fats)

• Endocrine function

• glucagon from pancreatic alpha cells – increases blood glucose levels

• insulin from pancreatic beta cells – lowers blood glucose levels

• somatostatin from pancreatic delta cells – regulates both glucagon and insulin levels.

Liver

• carbohydrate, protein and fat metabolism

• modifies waste products and toxic substances, i.e. drugs such as paracetamol, aspirin and
alcohol

• produces and stores glycogen (maintains blood glucose levels)

• converts ammonia into urea, which is a waste product

• stores minerals such as iron and copper, fat-soluble vitamins A, D, E and K, and water-soluble
vitamin B 12
• manufactures plasma proteins such as prothrombin

• production of bile, which emulsifies fats in the diet for absorption

Gallbladder

• Stores and concentrates bile from the liver and releases it into the duodenum.

Cholecystitis, Choledocholithiasis, Cholelithiasis, cholangitis

II. Function of the Digestive System

A. Mouth function

Chewing (Mastication ) and Swallowing (Deglutition)

• The process of digestion begins with the act of chewing.
• Eating—or even the sight, smell, or taste of food—can cause reflex salivation.
• Ptyalin, or salivary amylase, is an enzyme that begins the digestion of starches.
• Water and mucus, also contained in saliva, help lubricate the food.
• Swallowing begins as a voluntary act to esophageal peristalsis.

B. Gastric Function

• The stomach secretes a highly acidic fluid (HCl, up to pH1) in response to the ingestion of food:

1. to break down food into more absorbable components

2. to aid in the destruction of most ingested bacteria.

• Pepsin, an important enzyme for protein digestion in gastric juice

• Intrinsic factor combines with dietary vitamin B12.

C. Small Intestine Function

• Duodenal secretions come from the accessory digestive organs and the glands in the wall of the
intestine itself.

• Secretions contain digestive enzymes: amylase, lipase, (secreted by the pancreas) and bile
(liver)

• Pancreatic secretions have an alkaline pH due to their high concentration of bicarbonate.

• Bile aids in emulsifying ingested fats, making them easier to digest and absorb.

• The sphincter of Oddi controls the flow of bile.

• Two types of contractions in the small intestine:

 1. Segmentation contractions produce mixing waves that move the intestinal contents back and
forth in a churning motion.

2. Intestinal peristalsis propels the contents of the small intestine toward the colon.

• Both movements are stimulated by the presence of chyme.

• Villi (small, finger-like projections that extend into the lumen of the small intestine) line the
entire intestine and function to produce digestive enzymes as well as to absorb nutrients.

D. Colonic Function

• Bacteria assist in completing the breakdown of waste material.

• Two types of colonic secretions are added to the residual material:

1. an electrolyte solution

2. mucus.

• Slow transport allows for efficient reabsorption of water and electrolytes.

E. Elimination Function (Defecation)

• Feces consist of undigested foodstuffs, inorganic materials, water, and bacteria.

• The brown color of the feces results from the breakdown of bile by the intestinal bacteria.

• Chemicals formed by intestinal bacteria are responsible in large part for the fecal odor.

• The internal sphincter is controlled by the autonomic nervous system; the external sphincter is
under the conscious control of the cerebral cortex.

The average frequency of defecation in humans is once daily, but this varies among people.

III. Assessment of the Gastrointestinal System

A. Health History

1. Common Symptoms

Dyspepsia (INDIGESTION)

• Upper abdominal discomfort associated with eating.

• The most common symptom of patients with GI dysfunction.

• Fatty foods cause the most discomfort because they remain in the stomach for digestion longer
than proteins or carbohydrates.

Intestinal Gas (Flatus)

• flatulence is a medical term for releasing gas from the digestive system through the anus.
• The accumulation of gas in the GI tract may result in belching or flatulence.

• Patients often complain of bloating, distention, or feeling “full of gas” with excessive flatulence
as a symptom of food intolerance or gallbladder disease.

• Colic is severe, often fluctuating pain in the abdomen caused by intestinal gas or obstruction in
the intestines and suffered especially by babies.

Nausea and Vomiting

• Nausea is a vague, uncomfortable sensation of sickness or “queasiness” that may or may not be
followed by vomiting.

• The emesis or vomitus may vary in color and content (e.g. hematemesis).

• May result from:

1. visceral afferent stimulation

2. CNS disorders

3. irritation of the chemoreceptor trigger zone

• Distention of the duodenum or upper intestinal tract is a common cause of nausea.

• Vomiting is a physiologic protective response.

Change in Bowel Habits and Stool Characteristics

• May signal colonic dysfunction or disease.

• Diarrhea - an abnormal increase in the frequency and liquidity of the stool.

• Constipation - a decrease in the frequency of stool, or stools that are hard, dry, and of smaller
volume than typical.

• Blood in the stool can present in various ways and must be investigated:

1. Tarry-black color (melena) - upper GI tract bleeding.

2. Bright or dark red - lower GI tract bleeding.

3. Streaking of blood on the surface of the stool (or in the tissue) - Lower rectal or anal bleeding

• Other common abnormalities in stool:

1. Steatorrhea - bulky, greasy, foamy stools that are foul in odor and may or may not float –
malabsorption

2. Light-gray or clay-colored stool - caused by a decrease or absence of conjugated bilirubin -

blockage in the bile ducts

3. Stool with mucus threads or pus that may be visible on gross inspection of the stool - irritable
bowel syndrome (IBS), ulcerative colitis (UC), or Crohn's disease
4. Small, dry, rock-hard masses occasionally streaked with blood - constipation

5. Loose, watery stool that may or may not be streaked with blood - diarrhea

Pain (Referred pain) can be a major symptom of GI disease.

6. With radiating pain, the pain travels from one part of the body to another. The pain literally
moves through the body.

7. With referred pain, the source of pain doesn't move or get larger. The pain is simply felt in areas
other than the source.

2. Past Health, Family, and Social History

The nurse asks about the patient’s:

a. normal toothbrushing and flossing routine;

b. frequency of dental visits;

c. awareness of any lesions or irritated areas in the mouth, tongue, or throat;

d. recent history of sore throat or bloody sputum;

e. discomfort caused by certain foods;

f. daily food intake;

g. the use of alcohol and tobacco

h. Past and current medication use

i. Previous diagnostic studies, treatments, or surgery

j. Changes in appetite or eating patterns

k. Unexplained weight gain or loss over the past year.

l. Psychosocial, spiritual, or cultural factors that may be affecting the patient.

B. Physical assessment

Oral Cavity Inspection and Palpation

• Dentures should be removed to allow good visualization of the entire oral cavity.

1. Lips

• the presence of ulcerations or fissures.

• buccal mucosa for an assessment of color and lesions.

• Stensen’s duct of each parotid gland is visible as a small red dot in the buccal mucosa next to
the upper molars.

2. Gums

• inspected for inflammation, bleeding, retraction, and discoloration. (Gingivitis)

• The odor of the breath is also noted. (halitosis)

• The hard palate is examined for color and shape.

3. Tongue

• The dorsum (back) of the tongue is inspected for texture, color, and lesions.

• Frenulum, roof of the mouth, tonsils, uvula, and posterior pharynx.

Rectal Inspection and Palpation

• Gloves, water-soluble lubrication, a penlight, and drapes are necessary tools for the evaluation.

• Positions include knee-chest, left lateral with hips and knees flexed, or standing with hips flexed
and upper body supported by the examination table.

• The patient is asked to bear down, allowing the ready appearance of fistulas, fissures, rectal
prolapse, polyps, and internal hemorrhoids.

• Digital Rectal Exam (DRE) - Internal examination is performed with a gloved lubricated index
finger inserted into the anal canal while the patient bears down.

The abdomen can be divided into either four quadrants or nine regions.

Inspection

• Lesions are of particular importance, GI diseases often produce skin changes.

• noting skin changes, nodules, lesions, scarring, discolorations, inflammation, bruising, or striae.

• The contour and symmetry of the abdomen are noted and any localized bulging, distention, or
peristaltic waves are identified.

Auscultation

• The frequency and character of the sounds are usually heard as clicks and gurgles that occur
irregularly and range from 5 to 30 per minute.

• Normal (sounds heard about every 5 to 20 seconds),

• hypoactive (one or two sounds in 2 minutes),

• hyperactive (5 to 6 sounds heard in less than 30 seconds), or

• absent (no sounds in 3 to 5 minutes)

 • Borborygmi (“stomach growling”) is heard as a loud prolonged gurgle.

• All quadrants are percussed for overall tympani and dullness. To know the location of organs.

• Light palpation is appropriate for identifying areas of tenderness or muscular resistance.

• Deep palpation is used to identify masses.

IV. Diagnostic Evaluation

Overview

• GI diagnostic studies can confirm, rule out, stage, or diagnose various disease states, including
cancer.

• After the diagnosis, time should be allotted for discussion with the patient.

General nursing interventions

1. Establishing the nursing diagnosis

2. Providing needed information about the test and the activities required of the patient

3. Providing instructions about post-procedure care and activity restrictions

4. Providing health information and procedural education to patients and significant others

5. Helping the patient cope with discomfort and alleviating anxiety

6. Informing the primary provider of known medical conditions or abnormal laboratory values that
may affect the procedure

7. Assessing for adequate hydration before, during, and immediately after the procedure, and
providing education about maintenance of hydration

Diagnostic test

Serum Laboratory Studies

• Initial diagnostic tests begin with serum laboratory studies.

• These include:

• CBC,

• complete metabolic panel, (electrolytes)

• prothrombin time (ability to clot)

• partial thromboplastin time, (for blood thinning therapy effecticity)

• triglycerides,
 • liver function tests, aspartate transaminase (AST) or SGOT, alanine transaminase (ALT)
or SGPT

• amylase, and lipase (pancreas function)

• Specific studies may be indicated, such as carcinoembryonic antigen (CEA), cancer antigen (CA)
19–9, and alpha-fetoprotein, which are sensitive and specific for colorectal and hepatocellular
carcinomas, respectively.

Stool Tests

• Include inspecting the specimen for consistency, color, and occult (not visible) blood.

• Stool samples are usually collected on a random basis.

• Random specimens should be sent promptly to the laboratory for analysis.

• Fecal occult blood testing (FOBT) is one of the most commonly performed stool tests to detect
blood in the stool

Breath Tests

• Hydrogen breath test - determines the amount of hydrogen expelled in the breath after it has
been produced in the colon (on contact of galactose with fermenting bacteria) and absorbed
into the blood to evaluate carbohydrate absorption.

• bacterial overgrowth, or intolerances to lactose, fructose, or sucrose.

• Urea breath tests - detect the presence of Helicobacter pylori. After the patient ingests a
capsule of carbon-labeled urea, a breath sample is obtained 10 to 20 minutes later.

• gastritis (inflammation of the mucous membrane of the stomach) or ulcers in the

stomach and small intestine

Abdominal Ultrasonography

• A noninvasive diagnostic technique in which high-frequency sound waves are passed into
internal body structures.

• Useful in the detection of an enlarged gallbladder or pancreas, the presence of gallstones, an

enlarged ovary, an ectopic pregnancy, or appendicitis.

• Advantages of abdominal ultrasonography include an absence of ionizing radiation, no

noticeable side effects, relatively low cost, and almost immediate results.

• The patient is instructed to fast for 8 to 12 hours before ultrasound testing to decrease the
amount of gas in the bowel.

Genetic Testing

• To identify people who are at risk for certain GI disorders.

 • People who are identified as being at risk for certain GI disorders may choose to have genetic
counseling to learn about the disease and options for preventing and treating the disease, and
to receive support in coping with the situation.

Upper Gastrointestinal Tract Study

a. Upper GI fluoroscopy - delineates the entire GI tract after the introduction of a contrast agent
(radiopaque liquid).

Nursing consideration:

- Clear liquid diet, with NPO from midnight the night before the study.

Lower Gastrointestinal Tract Study

a. Barium enema – can detect the presence of polyps, tumors, or other lesions of the large
intestine and demonstrate any anatomic abnormalities or malfunctioning of the bowel.

Nursing consideration:

- low-residue diet 1 to 2 days before the test, a clear liquid diet and a laxative the evening before,
NPO after midnight, and cleansing enemas until returns are clear the following morning.

Computed Tomography

- A CT scan may be performed with or without oral or intravenous (IV) contrast.

Magnetic Resonance Imaging

- contraindicated in patients with any device containing metal because the magnetic field could
cause malfunction.

Nursing Consideration:

- NPO status 6 to 8 hours before the study and removal of all jewelry and other metals.

- May induce feelings of claustrophobia, and the machine will make a knocking sound during the
procedure.

Positron Emission Tomography

• Produces images of the body by detecting the radiation emitted from radioactive substances.

• PET scan looks at their function and shows unusual cellular activity.

Nursing Consideration:

• The radioactive substances are injected into the body IV and are usually tagged with radioactive
isotopes of oxygen, nitrogen, carbon, or fluorine

Scintigraphy
 - Scintigraphy (radionuclide testing) relies on the use of radioactive isotopes (i.e., technetium,
iodine, and indium) to reveal displaced anatomic structures, changes in organ size, and the
presence of neoplasms or other focal lesions such as cysts or abscesses.

Nursing Consideration:

- A sample of blood is removed, mixed with a radioactive substance, and reinjected into the
patient.

- Abnormal concentrations of blood cells are then detected at 24- and 48-hour intervals.

Gastrointestinal Motility Studies

a. Gastric emptying studies - the liquid and solid components of a meal (typically scrambled eggs)
are tagged with radionuclide markers.

- After ingestion of the meal, the patient is positioned under a scinti scanner.

b. Colonic transit studies - used to evaluate colonic motility and obstructive defecation syndromes.

- The patient is given a capsule containing 20 radionuclide markers and instructed to follow a
regular diet and usual daily activities.

- Abdominal x-rays are taken every 24 hours (4-5 days) until all markers are passed.

G. Endoscopic Procedures

1. Upper Gastrointestinal Fibroscopy/Esophagogastroduodenoscopy

2. Endoscopic retrograde cholangiopancreatography (ERCP)

3. Fiberoptic Colonoscopy

4. Anoscopy, Proctoscopy, and Sigmoidoscopy

5. Endoscopy Through an Ostomy

6. Laparoscopy (Peritoneoscopy)

Upper Gastrointestinal Fibroscopy/Esophagogastroduodenoscopy

- allows direct visualization of the esophageal, gastric, and duodenal mucosa through a lighted
endoscope (gastroscope).

- valuable when esophageal, gastric, or duodenal disorders or inflammatory, neoplastic, or

infectious processes are suspected.

- the gastroenterologist views the GI tract through a viewing lens and can obtain images through
the scope to document findings.

Endoscopic retrograde cholangiopancreatography (ERCP)

 - uses the endoscope in combination with x-rays to view the bile ducts, pancreatic ducts, and
gallbladder.

Endoscopy Through an Ostomy

- useful for visualizing a segment of the small or large intestine.

- may be indicated to evaluate the anastomosis for recurrent disease

- To visualize and treat bleeding in a segment of the bowel

Fiberoptic Colonoscopy

- Direct visual inspection of the large intestine (anus, rectum, sigmoid, transcending and
ascending colon) is possible by means of a flexible fiberoptic colonoscope.

- Still and video recordings can be used to document the procedure and findings.

- The procedure can be used to remove all visible polyps with a special snare and cautery through
the colonoscope.

- Colonoscopy is performed while the patient is lying on the left side with the legs drawn up
toward the chest.

- Adequate colon cleansing provides optimal visualization and decreases the time needed for the
procedure.

Anoscopy, Proctoscopy, and Sigmoidoscopy

- Biopsies and polypectomies can be performed during this procedure.

- These examinations require only limited bowel preparation, including a warm tap water or Fleet
enema until returns are clear.

Laparoscopy (Peritoneoscopy)

• a small incision is made lateral to the umbilicus, allowing for the insertion of the fiberoptic
laparoscope.

• permits direct visualization of the organs and structures within the abdomen

• permits visualization and identification of any growths, anomalies, and inflammatory processes.

• biopsy samples can be taken from the structures and organs as necessary.

• after visualization of a problem, excision can then be performed at the same time, if
appropriate.

V. Digestive and Gastrointestinal Treatment Modalities

Gastrointestinal Intubation

• insertion of a flexible tube into the stomach, or beyond the pylorus into the duodenum or the
jejunum.
 • The tube may be inserted through the mouth, the nose, or the abdominal wall.

• GI intubation may be performed in order to:

1. Decompress the stomach and remove gas and fluid

2. Lavage the stomach and remove ingested toxins or other harmful materials

3. Diagnose GI disorders

4. Administer tube feedings, fluids, and medications

5. Compress a bleeding site

6. Aspirate GI contents for analysis

Type of tubes:

1. Orogastric tube - a large-bore tube inserted through the mouth into the stomach that contains a
wide outlet for removal of gastric contents.

2. Gastric tube (nasogastric (NG) tube) - introduced through the nose into the stomach, often
before or during surgery or at the bedside, to remove fluid and gas from the upper GI tract.

Enteral nutrition is delivered through a tube to your stomach or the small intestine,

Enteral Nutrition

1. A gastrostomy is a procedure in which an opening is created into the stomach either for the
purpose of administering nutrition, fluids, and medications via a feeding tube, or for gastric
decompression.

• preferred over a nasally inserted tube to deliver enteral nutrition support longer than 4 weeks.

• also preferred over nasogastric or orogastric feedings in the patient who is comatose because
the gastroesophageal sphincter remains intact.

• a permanent gastric stoma (an artificially created opening) is created surgically.

2. A jejunostomy is a surgically placed opening into the jejunum for the purpose of administering
nutrition, fluids, and medications.

• indicated when the gastric route is not accessible, or to decrease aspiration risk when the
stomach is not functioning adequately to process and empty food and fluids.

Percutaneous endoscopic gastrostomy or jejunostomy

is the placement of a feeding tube using an endoscope.

Parenteral nutrition. "Parenteral" means "outside of the digestive tract.“

Parenteral Nutrition

• a method of providing nutrients to the body by an IV route.

 • The nutrients are a complex admixture containing proteins, carbohydrates, fats, electrolytes,
vitamins, trace minerals, and sterile water in a single container.

• to improve nutritional status, establish a positive nitrogen balance, maintain muscle mass,
promote weight maintenance or gain, and enhance the healing process.

• The indications for PN include an inability to ingest adequate oral food or fluids within a 7- to
10-day timeframe.

There are two primary types of PN:

(Partially) PPN is generally used for patients who need supplementary nutrition,

(Total) TPN is for patients who require all of their dietary needs replaced.