1.

Mouth
For Mastication (CN5) Trigeminal Nerve
Ptyalin Production- converts starch into sugar
2. Esophagus- passage way
(Lower esophageal sphincter/ cardiac sphincter= GERD)
3. Stomach
food digestion
Storage (stores 30min to 1hr)
GASTRECTOMY: 2 implications: Pernicious Anemia and Dumping Syndrome
4. Small Intestine
Nutrient absorption
a. Duodenum (first part of small intestine immediately after beyond stomach)
b. Jejunum (between duodenum and ileum)
c. Ileum (between jejunum and cecum)
3 Accessory Organs for Nutrient Absorption
***Liver- bile production
***Gallbladder- stores bile
***Pancreas- acinar cells produce enzyme juice: LIPASE (fat absorption), TRYPSIN
(CHON Absorption), AMYLASE (CHO absorption)
5. Large Intestine
Water reabsorption and stool formation
a. Rectum
b. Cecum
c. Ascending colon
d. Transverse colon
e. Descending colon

Radiographic: USE OF FLOUROSCOPE-real time; moving images

Upper GI
Contrast Medium: Barrium Swallow
Position: High fowler’s
Pre: NPO 6-8HRS
Post: S/E: chalk-like stool, constipation (NI: inc OFI, inc fiber, laxative per MD order)
Complications: Anaphylactic shock; WOF: urticaria, itchiness, facial flushing, throat swelling,
dyspnea, DOB

LOWER GI
Contrast Medium: Barrium Enema
Position: Sim’s lateral (change position to distribute dye)
Pre: NPO 6-8HRS; clear liq diet 3 days PTOR
Post: SAME
Complications: SAME
“Scopy”
UPPER GI (assesses esophagus, duodenum, and stomach)
Contrast Medium: NONE
Position: Sim’s Lateral
Pre: NPO 6-12hrs PTOR, local anesthesia (lidocaine spray) Atropine SO4 (antimuscarinic) to
decrease secretions and relax smooth muscle, Midaz IV
Post: Check for gag reflex
Complications: Perforation. WOF: shock
LOWER GI (assesses colon)
Contrast Medium: NONE
Position: Sim’s Lateral
Pre: NPO 6-12HRS
Post: NONE
Complication: Perforation. WOF: Bleeding
Sigmoidoscopy- rectum through nearest part of colon; fasting not needed; cleansing enema only.
GASTROESOPHAGEAL REFLUX DISEASE/ HIATAL HERNIA (defective cardiac sphincter)
HALLMARK: Heartburn
Chronic Sign: Hematemesis
Position: HOB Elevated/ high fowler’s/ upright

3. Hiatal Hernia (part of the stomach pushes up through the diaphragm muscle)
Obesity
Weak diaphragm
Tear in thorax
*** fundoplication- (LAPAROSCOPIC SURGERY) fundus wrapped around esophagus to
strengthen sphincter

Problems:
1. HCl backflow- heart burn/pyrosis
Mgt: Avoid irritants, meds
2. Fullness
Mgt: small frequent meals, sips of water
3. N&V
Mgt: antiemetics (metoclopramide and ondansetron)
4. Dysphagia
Mgt: flex neck upon swallowing, thicken food and fluid
5. Ptyalism- increased saliva
Mgt: toothbrush, gum/candy
PEPTIC ULCER- wound in mucosal lining

Gastric Ulcer (wound in stomach)

HCl: N or decreased
Cause: Long term NSAID> Decreased mucosal lining
Pain: during meals; Relieved by vomiting
 Hematemesis (+)
Hypokalemia (U wave elevation, ST sagging, Twave depression)

Duodenal Ulcer
HCl increased
Cause: Stress, H. Pylori> damage mucosal lining
Pain: relieved during meals; Pain present 2-4 hours after meal
Wt gain
Black tarry stool- melena

Mgt:
***monitor Hgb, avoid irritants.
COMPLICATION: Perforation; WOF: shock, shoulder pain (due to compression of phrenic
nerve, board like rigidity)
 GASTRECTOMY
1. Total- removal of entire stomach
Complication:
Pernicious Anemia (Vit B12 deficiency; caused by inability of body to absorb vit
b12 needed for healthy rbc production)
Dumping Syndrome
2. Partial- removal of antrum (part of stmach inside pylorus) and pyloric sphincter
A. Biltroth I- remaining part of stomach is anastomosed to duodenum;
gastroduodenostomy
B. Bilroth II- anastomosed to jejunum; gastrojejunostomy
VAGOTOMY
Removal of vagus nerve (CN 10)- parasympathetic control of heart, lungs,
digestive tract (parasympathetic responsible for activities when body is at rest)
Vagus Nerve- stimulates parietal cells= HCL secretion (parietal cells is located in
gastric glands found in the lining of fundus and stomach)
Vagotomy is indicated for patients who develop acute complications from peptic ulcer
disease (ie, bleeding, perforation, obstruction) or chronic intractable symptoms such as pain,
despite being on maximally tolerated medical therapies.

DUMPING SYNDROME:
Rapid gastric emptying
Early s: diaphoresis, tachycardia, dizziness
Problems:
Bloatedness (NI: small frequest ,eal, sips of water)
N&v, Diarhhea, DHN, Wt loss, Fatigue
 Increased CHO (undigested) (Increased undigested food in small intestine>
increased peristalsis> diarrhea)
Hypoglycaemia
AVOID: irritants and fiber
Mgt:
During meal: Low Fowler’s
After meal: Supine at least 30min
Diet: Decreased CHO, Increased CHON and fat, Avoid drinking during meal

PERNICIOUS ANEMIA
Stomach is removed> absent parietal cells> decreased vit b12 absorption> decreased
RBC production
Hallmark: Beefy tongue due to blood pooling to small vessels
Brain Affectation:
Numbness
Paralysis
Mgt:
Vit B12 (IM qmonth FOR LIFE)
RBC Affectation:
Macrocytic Anemia= decreased O2
SOB
Dx: Schilling’s Test (N: 8-40% Vit b12); normal if you urinate 8-40percent of radiolabeled
VitB12 within 24HRS
Preprocedure:
No VIT B12 injections 3 days before the test
NPO 8hrs before the test
SPECIME: 24HR Urine collection

NGT INSERTION
Position: High Fowler’s
Measure: tip of nose to earlobe to xyphoid process (N.E.X.)
Assess: patency of nose
Lubricate: KY jelly/ Lidocaine gel
Nasopharynx (tube location) hyperextend neck
Oropharynx (tube location) flex the neck and instruct px to swallow or sips of water via a
straw

*Levine Tube- single lumen; for intermittent suctioning

*Salem sump tube- double lumen; for continuous suctioning; WOF: oversuctioning (met alka,
hypoK)

FEEDING/GIVING MEDICATION
Sustained release/ enteric coated meds: DO NOT GIVE per NGT (example: aspirin and
potassium chloride are enteric coated and irritant so it should only be dissolved in the small
intestine.
Buccal or SL meds: as prescribed
Give drugs separately
Position: Semi folwer’s
Assess: Bowel sound> offer clear liq> if tolerated, inform MD
Placement
Check: Residual volume, N: <100ml
Flush 30 cc distilled water
Give meds/feed: WOF cramps (hold feeding until pain subsides)
Reflush with 60cc water

Tube patency:
Instill air= whooshing, gurgling sound
Aspirate gastric content= N 1-5pH

ROLE OF LIVER:
1. Converts CHON by product (Ammonia) to urea (thru liver); ammonia needs to be
converted because it is extremely toxic to the body.
2. ADEK Absorption (Liver produces bile needed for fat emulsification))
Diagnostic test: Liver biopsy
Removal of small tissue from liver to detect dx or damage
Pre:
****Assess for prothrombin time; to rule out bleeding problems
****Local anesthesia
Position: L sidelying with right hand under head; inhale, exhale and hold breath 5-10 seconds (to
prevent lung puncture)

Post:
***WOF bleeding
Position: R Sidelying (affected) for atleast 4h to prevent bleeding

HEPATITIS
Hepa A and E= fecal-oral route
Hepa BCDEG- blood borne
Diet: decreased CHON and fat, increased CHO
Mgt:
a. Interferon Ig
3-5x/week SQ (usually 6mos)
Can’t cure but prevent proliferation
b. Cholestyramine (Questran, Questran light, Prevalite)
Bile acid sequestrant (removes bile acid in the body)
Relieves pruritus
S/E: constipation, decreased ADEK absorption

Cause:
Alcohol- laennec’s
Stages:
1. Pre-icteric
2weeks after exposure
Liver inflammation
RUQ pain
Increased ALT and AST (Alanine Transaminase and Aspartate Aminotransferase)
Flu-like sx (fever, anorexia, n&v, body malaise)
2. Icteric phase
120 days after exposure (due to RBC lysis) Waste product: Bilirubin
RBC dies> unconjugated bilirubin= gives N color to U and F
If there is hepatitis there is increased unconjugated bilirubin
LIVER converts bilirubin to conjugated form> increased unconjugated bilirubin in the
blood> pruritus, clay colored stool, tea colored urine
3. Post Icteric
Generalized fatigue
Cessation of sx

LIVER CIRRHOSIS
Causes:
Chronic alcoholism or liver dx> scarring of liver> fibrosis (heals itself- forms connective
tissues)> obstruction at portal vein circulation> PORTAL HTN

If with portal HTN

> no ADEK absorption (increased bleeding)
>decreased oncotic pressure due to fluid leak from interstitial to abdominal cavity=>
ascites
>ammonia is not converted to urea (increased in brain)= confusion; NEOMYCIN is
given to decrease ammonia level
>esophageal varices

ESOPHAGEAL VARICES
Dilated esophagus> rupture> bleeding> airway obstruction and shock
Mgt:
Vasopressin IV- prevent further dilation; vasoconstriction
Sengstaken Blakemore Insertion (2 balloons)
a. Esophageal balloon: control bleeding; N pressure 25-40mmHg
b. Gastric balloon- serves as an anchor; inflate 100-200cc air
*** surgical scissors at bedside in case of balloon rupture (gastric)

ASCITES
Increased hydrostatic pressure (pushing force)> decreased oncotic pressure (pulling
force)>ascites
***Oncotic pressure keeps fluid in circulatory system
Mgt:
1. Diuretic- K sparing
2. Albumin IV to increase oncotic pressure
3. Paracentesis
Prep: Empty bladder
 Position: sitting or supine
Local anes
Needle inserted around umbilicus
Assess VS esp BP during procedure
Neomycin prophylaxis
Albumin IV after

HEPATIC ECEPHALOPATHY
CHON Metabolism> ammonia> crosses blood brain barrier (because not converted to
urea)

S and sx:
Brain: altered LOC, coma

Spinal cord: hyperreflexia

Hallmark: Asterixis
Mgt:
Lactulose- osmotic laxative. Excretes ammonia
Neomycin- eliminates N bacteria in the intestine because their byproduct is ammonia

CHOLELITHIASIS
Risk: Fat, female, forty, fair, fertile

Colelithiasis>obstruction in CBD> increased bilirubin serum> Pruritus, jaundice, tea

colored urine, clay colored stool
Diet: decrease fat
DOC: ursodiol- dissolves gallstones
Cholecystectomy: T Tube 300-500cc
 1. Laparoscopic Chole= preferred; inflated by CO2>irritates phrenic nerve> shopulder
pain (expected)

CHOLECYSTITIS
Inflammation of gallbladder; can be caused by cholelithiasis
RUQ Pain> continuous right shoulder pain> increased fat> right shoulder scapula pain
“BOA’s sign”

1. Boas’ Sign- right shoulder scapula pain

2. Murphy’s sign:
Palpate RUQ
Px inhale upon palpation
Px stops breathing due to pain
Meperidine (demerol) for pain control

PANCREATITIS (decreased Ca, Increase enzyme: lipase, amylase)

Decrease calcium bcoz of precipitation of calcium soaps in abdominal cavity
Causes:
Alcoholism
Cholelithiasis
***Causes destroy acinar cells> decreased enzymatic juice found in small intestine>
malabsorption> steatorrhea
***Causes destroy acinar cells> increase enzyme inside pancreas> autodigestion
Assessment:
LUQ pain
Bleeding
UMBILICUS: Cullen’s sign
FLANK: Turner’s sign
Fat lipolysis> fatty acid biproduct> binds to ca> hypocalcemia
Priority: Spasm (due to decrease Ca)
Mgt:
lifestyle changes
Meds: Pancreatin Pancrealipase (they are enzyme substitutes) > take with meals
DOC for PAIN: Demerol
Isotonic IV to expand blood volume thereby prevent shock

DIAGNOSTIC TEST: ERCP endoscpic retrograde CholangioPancreatography

Dx test for:
CBD
Pancreas
Gallbladder
Pre:
1. Local anes
2. NPO 6-12Hrs
3. Atropine So4
4. Midazolam IV
CONTRATS MEDIUM IS USED
Post:
Assess gag reflex

APPENDICITIS
Appendix: RLQ
Causes: Trapped seed, fecalith
S and Sx: fever, increased WBC, Pain radiating at McBurny’s point
Psoas Sign= right thing flexion towards hips, upon extension= PAIN
Rovsing’s Sign= Palpate LLQ, RLQ pain
If ruptured= peritonitis; Markle’s Sign= Px stand on R foot and drop right heel= jarred landing
and localized pain
Mgt:
Avoid heating pads
No enema
No laxative, decrease fiber
No pain meds
Appendectomy

CROHN’s Dx/ Regional Enteritis:

Location: Small intestine and large intestine
GI Lining: ALL Linings: Mucosa, submucosa
Presenting S and Sx: Steatorrhea
Common Site: Ileum
Bleeding: None
Diarrhea: 5-6x/day
ULCERATIVE COLITIS
Location: Large intestines only
GI Lining: Mucosa only
Presenting S and Sx: Ulcer
Common Site: Rectum
Bleeding: Hematochezia (fresh)
Diarrhea: 10-20x/day
IBD diet: Low fiber; avoid fatty and oily food, avoid butter, seeds, gas forming.
Abx if infection occurs: Metronidazole, Ciprofloxacin

DIVERTICULOSIS
Outpouching of colon
Cause:
Decreased fiber
 Aging
Trapped fecalith
Increased meat in diet

Focus: Prevent complication

Diet: Increase Fiber
DIVERTICULITIS
Infection> fever, increase WBC
Inflammation, LLQ pain, Diarrhea> rupture> peritonitis

Mgt: Colon resection> stoma

Diet: decreased fiber

STOMA
Bacterial Prophylaxias: Neomycin
Expected Post-op Color: Brick red/ beefy red
2-3 weeks: pinkish (+heal): mucus

ILEOSTOMY:
Stool: Watery ( no water absorption in ilum)
Risk for: Skin breakdown
Drain pouch: Continuous> DHN
Health Teaching:
-avoid fiber
-increase OFI
NO SWIMMING
NO ODOR
Empty pouch if 1/3 full or every 4-6HRS
Colostomy
Ascending- watery
Transverse- semi-mushy
Descending- mushy
Sigmoid- formed

ODOROUS
Health Teaching:
Food to lessen odor: parsley, beets, yogurt
Can do swimming
Avoid gas forming food and raw food
Functional: (+) flatus
Patient is ready if:
a. Looking at the stoma
b. Asking for equipment
c. Active participation

Important Points
 Try to irrigate at the same time each day.
 Don’t irrigate if you have diarrhea.
 Don’t irrigate if you notice a bulge (hernia) around your stoma. If you notice a bulge or
hernia, call your doctor.
 Check with your doctor before irrigating while you are getting chemotherapy or radiation
therapy. Irrigation is not recommended during these treatments.
 The amount of returns will vary from irrigation to irrigation.

PEG:
Indications:
1. Unable to swallow
2. Long term feeding
Sequence:
1. Explain procedure
2. Wash hands
3. Provide privacy
4. Assemble materials
5. Position: semifowlers
6. Wear clean gloves
7. Place a towel on px’s abdomen
8. Check for signs of infxn
9. Auscultate bowel sounds
10. Unclamp and aspirate gastric residual volume; N <100cc
11. Pinch proximal end of feeding tube to prevent air
12. Flush 30cc of distilled water
13. Feed
14. Reflush 60cc
15. Clamp tube