Transcript Chapter_039

Assisting in Gastroenterology
Chapter 39
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
1
Learning Objectives
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Define, spell, and pronounce the terms listed in the
vocabulary.
Apply critical thinking skills in performing patient
assessment and care.
Describe the primary functions of the gastrointestinal
system.
Identify the anatomic structures that make up the
system, and describe the physiology of each.
Differentiate among the abdominal quadrants and
regions.
Summarize the typical symptoms and characteristics
of gastrointestinal complaints.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
2
Learning Objectives
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Perform telephone screening for patients with
gastrointestinal complaints.
Distinguish among cancers of the
gastrointestinal tract.
Explain common esophageal and gastric
disorders, their signs and symptoms, diagnostic
tests, and treatments.
Define intestinal disorders and their signs and
symptoms, diagnostic tests, and treatments.
Classify disorders of the liver and gallbladder
and their signs and symptoms, diagnostic tests,
and treatments.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
3
Learning Objectives
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Describe the similarities and differences among the
various forms of infectious viral hepatitis.
Summarize the medical assistant’s role in the
gastrointestinal examination.
Explain the common diagnostic procedures for the
gastrointestinal system.
Perform the procedural steps for assisting with the
collection of a fecal specimen, including the necessary
patient education for preparation for the examination
and collection of stool samples at home.
Describe the medical assistant’s role in the proctologic
examination.
Demonstrate assisting with an endoscopic colon
examination.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
4
Anatomy and Physiology
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The gastrointestinal system prepares, digests,
absorbs, and excretes nutrients and waste
materials.
The gastrointestinal system begins at the
mouth and ends at the anal canal.
Terms to remember
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Mastication
 Bolus
 Peristalsis
 Emulsification
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5
Digestion
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The digestive process starts in the mouth with
mastication and enzyme action.
The bolus of food is swallowed and passed from the
esophagus into the stomach, where digestion
continues with the mixing of chyme with hydrochloric
acid, enzyme action, and intrinsic factor.
It ends in the duodenum with pancreatic juices and
emulsification of fat by bile, which is excreted by the
liver and stored in the gallbladder. Digestion of fat,
protein, and CHO is completed in the duodenum.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
6
Absorption
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Absorption of nutrients takes place in the ileum
and jejunum, with absorption of fluids and
electrolytes in the large intestine.
Waste materials (feces) are excreted through
the anus (defecation).
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
7
Anatomy of Digestive System
From Gould B:
Pathophysiology for the
health professions, ed 3,
Philadelphia, 2006,
Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
8
Four Quadrants and Regions
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The abdominal cavity can be divided into four
sections or quadrants, the right and left upper
quadrants and right and left lower quadrants.
Another, more specific method of dividing the
abdominal cavity is with nine regions:
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Right hypochondriac, epigastric, and left hypochondriac
 Right lumbar, umbilical, and left lumbar
 Right inguinal, hypogastric, and left inguinal
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These anatomic markers can clearly identify the
location of the gastrointestinal problem.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
9
Abdominal Quadrants and Regions
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
10
Anatomic Markers
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Peritoneum—covers abdominal organs
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Mesentery—posterior peritoneum that
attaches the jejunum and ileum to the posterior
abdominal wall
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Omentum—fatty peritoneal tissue, contains
lymph nodes, hangs like apron from stomach
to colon; inflammation causes adhesions
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11
Diseases of the Gastrointestinal System:
Common Signs and Symptoms
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Nausea with pallor, diaphoresis, and tachycardia
Vomiting because of pain, stress, GI upset, or an
inner ear or intracranial pressure disturbance
Diarrhea resulting from an infection, allergy, or
malabsorption problem
Constipation because of a low-fiber diet or
inadequate fluids, side effect of medication, or a
bowel obstruction or tumor
Abdominal pain that varies in intensity and quality
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12
Recording of Symptoms
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Identify the location of the patient’s discomfort
by using either abdominal quadrants or
regions, and note the onset, duration, and
frequency of all symptoms.
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13
Critical Thinking Application
Two days a week Joan works in the telephone
screening area of the practice, where she is responsible
for the initial management of calls from Dr. Sahani’s
patients. The following problems from patients are
typical of a call day. What are some of the questions
Joan should ask and subsequently document on each
patient’s chart?
 The mother of a 7-year-old patient is concerned
because her son has been vomiting since yesterday.
 The father of an 18-month-old infant reports that the
child has had diarrhea for 2 days.
 A 72-year-old patient is concerned about constipation
that is not relieved with laxatives.
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14
Gastrointestinal System Medications
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Histamine stimulates acid-secreting cells to release
hydrochloric acid; histamine (H-2) blockers decrease the
amount of hydrochloric acid released into the stomach;
prescription or OTC medications including ranitidine
(Zantac), famotidine (Pepcid), cimetidine (Tagamet), and
nizatidine (Axid).
OTC antacids neutralize existing stomach acid; provide
rapid pain relief.
Proton pump inhibitors reduce acid by blocking the action
of "pumps" within acid-secreting cells; omeprazole
(Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex),
esomeprazole (Nexium), and pantoprozole (Protonix).
Cytoprotective agents help protect tissues lining the
stomach and small intestine; include prescription
medications sucralfate (Carafate) and misoprostol
(Cytotec) and OTC Pepto-Bismol.
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15
Cancers of the Gastrointestinal Tract
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GI tumors can include:
 Oral tumors, seen as either a white mass or an
ulcer
 Esophageal tumors, causing dysphagia
 Gastric tumors, causing anorexia and weight loss,
asymptomatic in the early stages
 Liver tumors, usually secondary to metastasis
from another cancerous site with hepatomegaly
and portal hypertension
 Pancreatic cancer, usually advanced when
diagnosed
 Colorectal cancer (develops from polyps) with
changes in bowel function and anemia
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
16
Esophageal and Gastric Disorders
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Esophageal and gastric disorders include:
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Hiatal hernias—Part of stomach pushes through
the hiatal sphincter of the diaphragm, causing
GERD. Treatment: Prilosec, Nexium, Pepcid,
Zantac; avoid caffeine and cigarettes, eat six small
meals.
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Hiatal Hernias
From Damjanov I: Pathology for the health-related professions, ed 3, Philadelphia, 2006, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
18
Gastrointestinal Disorders
Peptic ulcers
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May be in the duodenum or stomach
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Associated with H. pylori infections
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First signs positive hemoccult, hematemesis,
melena
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Treated with combination of antibiotics and proton
pump inhibitors (Prilosec or Pepcid)
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May also occur as a complication of medications
such as prednisone
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19
Endoscopy of the Stomach
From Phipps WJ, Sands JK,
Marek JF, editors: Medicalsurgical nursing: health and
illness perspectives, ed 7,
Philadelphia, 2003, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
20
Gastrointestinal Disorders
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Pyloric stenosis—seen most frequently in
first-born male infants. Causes projectile vomiting.
Must be surgically corrected.
These disorders are usually diagnosed
symptomatically and with the use of a barium
swallow, upper GI series of radiographs, or
endoscopy.
Medical treatment includes the use of Propulsid,
Nexium, Pepcid, Tagamet, or Zantac. Surgery may
be indicated for repair of a hiatal hernia or gastric
ulcers if perforation occurs.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
21
Food Poisoning
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Intestinal disorders include a variety of food
poisonings, all of which cause mild to severe
gastroenteritis, with antiemetics (Tigan or
Compazine) and antidiarrheal (Lomotil)
medications used to control symptoms.
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Require a comprehensive patient history; stool
or blood cultures may be done to determine
causative agent.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
22
Dumping Syndrome
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Dumping syndrome may occur as a postsurgical
complication to weight-loss surgery and results in
widespread gastrointestinal complaints.
Signs and symptoms include nausea, abdominal
cramps, diarrhea, vertigo, tachycardia, and
diaphoresis.
Patients should eat small frequent meals high in
protein and low in simple sugars and should
drink fluids between rather than with meals to
prevent syndrome.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
23
IBS
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Irritable bowel syndrome (IBS) is a recurrent functional
bowel disorder causing alternating bouts of diarrhea,
flatulence, and constipation lasting at least 3 months.
Common problem (9% to 20% adult population).
More common in women; starts in late adolescence or
early adulthood.
IBS is treated pharmaceutically with bulk-forming agents
(Metamucil), antidiarrheals (Imodium), antispasmodics
(Bentyl), and anticholinergics (Levsin) and Mylicon for
bloating and flatulence.
Patient should keep food diary to determine causative
foods.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
24
Weight Loss Surgery
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Bariatric surgeries create a smaller stomach pouch (about
the size of an egg) and bypass the duodenum, where the
majority of digestion is completed
Most common gastric bypass surgery is the Roux-en-Y
procedure; smaller stomach is anastomosed to the jejunum
Option for patients who have a BMI of 40 or higher or have a
BMI greater than 35 with a serious medical condition such as
diabetes, hypertension, and sleep apnea
Weight loss after surgery can drastically improve diabetes
mellitus
Most lose 60% to 80% of excess body weight; helps resolve
weight-related health issues including heartburn,
musculoskeletal discomforts, breathing, sleep apnea, and
hypertension
Patients develop vitamin B12 deficiencies; iron deficiency
anemia; lack of calcium absorption; and other vitamin and
mineral deficiencies
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
25
Acute Appendicitis
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Appendix becomes inflamed and infected from
fecalith obstruction, causing ischemia and
necrosis of appendix wall.
If infection leaks out, peritonitis can develop.
Signs and symptoms include RLQ pain, nausea
and vomiting, positive McBurney’s sign (rebound
tenderness between umbilicus and right anterior
superior iliac spine), low-grade fever, leukocytosis.
Treatment includes appendectomy and antibiotics.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
26
Crohn’s Disease
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Regional enteritis, or Crohn’s disease, causes localized areas
of ulceration in the intestinal tract, usually in the small intestine
and ascending colon.
Inflammation causes localized areas of ulceration that invade
into the wall of the intestine.
Can cause decreased absorption of nutrients if in the intestine
or increased mobility and decreased absorption of fluids if in
the colon.
Scar tissue forms at site, causing a bowel obstruction or
adhesions; possible perforation of the ulcer.
Treated medically to decrease inflammation, manage
symptoms, and maintain nutritional status; anastomosis may
be needed.
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27
Ulcerative Colitis
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Ulcerative colitis causes inflammatory ulcers from
the anus proximally through the colon.
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Causes ulcer formation that is continuous and
invades mucosal linings but does not go through
the entire colon wall.
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It is treated like Crohn’s disease, but surgical
removal of the colon with an ileostomy is curative.
Screened annually with colonoscopy because of
the increased risk factor for cancer of colon.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
28
Ulcerative Colitis
From Damjanov I: Pathology for the health-related professions, ed 3, Philadelphia, 2006, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
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Diverticular Disease
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Caused by small herniations of the muscular lining
of the colon.
Diverticula develop from chronic constipation
and muscular hypertrophy of the colon.
Diverticulosis is the presence of multiple diverticuli
that are asymptomatic; diverticulitis is present
when they become inflamed from a fecalith.
Managed with dietary changes (high roughage, no
seeds or kernels) and plenty of fluids; surgery if
perforation occurs.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
30
Celiac Disease
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Malabsorption disorder: Celiac disease is caused by
a genetic defect in the ability to metabolize gluten.
Gluten found in all grains—all products made of
wheat, barley, rye, or oats.
Can tolerate rice and small amount of corn flour.
Gluten-containing product causes an
antigen-antibody reaction that destroys the villi of
the small intestine; intestine cannot absorb nutrients,
so malnutrition occurs.
Symptoms—steatorrhea, abdominal pain,
weight loss.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
31
Hernias and Varicose Veins
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If the abdominal muscles are weakened, hernias
can develop; named by location of occurrence.
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Sign is an abnormal lump with mild pain
Severe pain indicates strangulation and possible
gangrene
Surgically repaired with herniorrhaphy
Hemorrhoids—varicose veins of the anus;
treated with stool softeners (Colace), high-fiber
diets, analgesic ung, or surgical repair by
sclerotherapy, cryosurgery, or ligation.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
32
Disease of the Liver and Gallbladder
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Disorders of the liver include hepatitis, either
from viral infection or chemical reaction,
including alcohol abuse and a complication of
drug metabolism.
Mild inflammation temporarily impairs function,
but severe inflammation may lead to necrosis
and serious complications including jaundice,
cirrhosis, and portal hypertension.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
33
Nonalcoholic Fatty Liver Disease
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Accumulation of fat in the liver causes inflammation
that may lead to scar formation, cirrhosis, and liver
cancer.
Affects all age groups, including children, but seen
most frequently in middle-aged people who are
overweight or obese, and may be diabetic.
Symptoms rare in early stages; often detected
because of abnormal liver blood tests.
Treatment – weight loss, exercise, improved
diabetes control and anticholesterol medications.
Can be life-threatening; approximately 25% of
patients developing serious liver disease that
requires a transplant.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
34
Viral Hepatitis
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Acute infection of the liver; hepatocytes can regenerate,
so depending on degree of liver involvement patient may
recover or develop necrosis, cirrhosis, and liver failure.
Chronic inflammation (lasting longer than 6 months) can
occur with hepatitis B, C, and D; causes liver damage,
increased risk of liver cancer, and potential for becoming
an asymptomatic carrier of the disease.
Diagnosis: blood testing, liver biopsy; LFTs periodically to
determine extent of liver damage.
Treatment: possible interferon, bed rest, high-protein diet.
All healthcare workers should have HBV immunizations.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
35
Viral Hepatitis
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Typical signs and symptoms of all forms are
malaise, arthralgia, anorexia, nausea and
vomiting, fever, hepatomegaly, jaundice,
lymphadenopathy
HAV—fecal-oral route; contaminated water or food
HBV—blood and body fluids
HCV—blood and body fluids; most frequent
posttransfusion hepatitis; very serious; more
fatalities, increased risk of liver cancer, and carrier
state
HDV—seen only with HBV; blood and body fluids
HEV—can be fatal for pregnant women
HGV—similar to HCV
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
36
Groups at Risk
For Hepatitis A, B, and C
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Hepatitis A: Day care workers and clients,
institutionalized residents, individuals
traveling to infected areas
Hepatitis B: Intravenous drug users,
homosexual men, hemodialysis patients,
hemophiliacs, healthcare personnel, those
with a history of frequent sexual partners
Hepatitis C: Patients receiving frequent blood
transfusions, homosexual men, intravenous
drug users, healthcare personnel
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
37
Critical Thinking Application
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As a healthcare worker who has the potential
for being exposed to blood and body fluids,
Joan is quite concerned about contracting
viral hepatitis. What types of hepatitis is she
at risk for in Dr. Sahani’s office? What can
she do to reduce her risk and protect herself
from contracting these diseases?
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
38
Cholelithiasis or Cholecystitis
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Gallbladder stores bile excreted by the liver to
aid in fat metabolism.
Cholelithiasis occurs in gallbladder; stones
may lodge in gallbladder or duct system;
women at greater risk.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
39
Cholelithiasis or Cholecystitis
From Phipps WJ, Sands JK, Marek JF, editors: Medical-surgical nursing: health and illness
perspectives, ed 7, Philadelphia, 2003, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
40
Cholelithiasis or Cholecystitis
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Most are asymptomatic; biliary pain occurs if
stones obstruct duct; radiating upper quadrant
pain.
Diagnosis: CT or MRI of gallbladder to
visualize stones; cholescintigraphy (HIDA
nuclear scan).
Treatment: cholecystectomy by laparoscopy or
lithotripsy to fragment stones.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
41
The Medical Assistant’s Role in the
Gastrointestinal Examination
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Providing patient support and education
Gathering and recording complaints—sample
interview questions
Instilling rectal medications (procedure)
Assisting with the examination and diagnostic
procedures
Terms:
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Striae
Petechiae
Ascites
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42
Critical Thinking Application
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Joan is responsible for initially questioning
patients about complaints and clearly
documenting this information on the patient
chart. What information should Joan include
that details each patient’s problem and would
be helpful in determining the patient’s
diagnosis?
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
43
Diagnostic Procedures
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Diagnostic procedures:
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Laboratory studies such as liver panels, urinary
tests for bilirubin and amylase
Stool tests for occult blood, intestinal parasites, and
fat excretion
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
44
Diagnostic Tests
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Radiologic and endoscopic tests (refer to
Table 39-5)
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Barium swallow
 Upper GI series
 Barium enema
 HIDA scan
 Sigmoidoscopy
 Colonoscopy
 Endoscopy
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
45
Flexible Colon Fiberscopes
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46
Proctoscopy Procedure
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The role of the medical assistant in the
proctologic examination:
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Supporting and preparing the patient
 Positioning and draping the patient
 Monitoring vital signs before and during the
procedure
 Assisting the physician with the procedure
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
47
Sigmoidoscopy
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Done in the physician’s office; patient does not receive
anesthesia
Patient positioned in a left-lying Sims’ position and draped
appropriately
Physician inserts a short, flexible, lighted tube into the
rectum and slowly guides it into the sigmoid colon
Scope transmits image of inside of the rectum and colon;
blows air into colon to inflate organ and aid in visualization
Physician may remove polyps or take samples of tissue
for biopsy
Procedure takes 10 to 20 minutes
Patient may complain of pressure and slight cramping in
the lower abdomen (see Procedure 39-3)
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48
Patient Education
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Listen to the patient’s concerns, and report any
findings to the physician.
Learn to perform and assist with diagnostic
procedures in order to aid the physician in the
diagnostic sequence and assist the patient in
maintaining a healthy gastrointestinal system.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
49