Gastrointestinal disease

1. Management of the patient with Chronic GIT
Disorders
1

2. Learning Objectives
• At the end of this session, learners will be able to:
– Define and identify causes/risk factors for GERD,
PUD, Hernia, Constipation, Hemorrhoid, CLD.
– Describe pathophysiology and C/M for GERD,
PUD, Hernia, Constipation, Hemorrhoid, CLD
– Identify appropriate diagnostic methods and
possible differentials for GERD, PUD, Hernia,
Constipation, Hemorrhoid, CLD
– Manage the patient using medical and nursing
approaches.
2

3. Brainstorming
• Being in a group of FIVE and discuss the following
points:
– Definitions, causes/risk factors, pathophysiology,
C/M, diagnosis methods, DDX, medical and
nursing management for:
• GERD, PUD, Hernia, Constipation, Hemorrhoid,
CLD
– Discussion: Fifteen minutes
– Presentation: Five minutes for each group
3

4. Gastro Esophageal Reflux Disease
(GERD)
4

5. Gastro Esophageal Reflux Disease (GERD)
• Is a digestive disorder that occurs when acidic
stomach juices, or food and fluids back up from the
stomach into the esophagus and irritates the food
pipe lining.
• Acid reflux and heartburn more than twice a week
may indicate GERD.
5

6. Epidemiology
• GERD affects people of all ages: from infants to older
adults.
• It’s prevalence is 20% in USA.
• Men are at greater risk than women to develop the
disease (general overview), but no association with
sex in North America and Europe.
• People with asthma are at higher risk of developing
GERD.
6

7. Causes / Risk factors
• Occasional acid reflux is quite common, often
occurring as a result of eating a large meal, lying
down after eating (2-3Hrs), or eating particular
foods.
• People with obesity or people who are overweight
because of increased pressure on the abdomen.
• Mothers who are pregnant, affecting around 40–85%
of mothers during pregnancy.
7

8. Causes / Risk factors
• People who are taking certain medications, including
some asthma medications, calcium channel blockers,
antihistamines, sedatives, and antidepressants.
• People who are smokers and those who use alcohol,
caffeine.
• Using fatty foods, using large meals at night.
• People with hiatal hernia.
8

9. Clinical manifestations
• Heartburn (usually after eating, during night/ while
lying down)
• Backwash (regurgitation) of food / fluid
• Chest pain
• Trouble swallowing (dysphagia)
• Sudden excess of saliva
• Chronic sore throat
• Bad breath
• A recurrent or chronic cough
9

10. Diagnostic studies
• X-ray of the upper digestive system
• Endoscopy (examines the inside of the esophagus)
• Ambulatory acid (pH) test (monitors the amount of
acid in the esophagus)
• Esophageal impedance test (measures the
movement of substances in the esophagus)
• Transnasal esophagoscopy (done to look for any
damage in esophagus)
• Esophageal manometry test (measures muscle
contractions in the esophagus during swallowing)
10

11. DDX
• PUD
• Achalasia
• Dyspepsia
• Gastritis
11

12. Management
• Antacids (antacids which contains calcium carbonate)
• H2 blockers (Reduces the amount of acid in the
stomach but are not as good at healing the lining of the
esophagus: Cimetidine, Famotidine, Nizatidine)(not fast
act as antacids but longer stay (12hr)
• PPIs (block acid production: Omeprazole, Lansoprazole)
• Emptying stomach faster (E.g. use Erythromycin)
• Surgery (fundoplication- wrapping and tightening the
sphincter)
12

13. Management
• Lifestyle changes to treat GERD :
• Elevate the head of the bed 6-8 inches
• Lose weight
• Stop smoking
• Decrease alcohol intake
• Limit meal size and avoid heavy evening meals
• Do not lie down within two to three hours of eating
• Decrease caffeine intake
• Avoid theophylline (if possible for asthma patient)
13

14. Prognosis/outlook
• Extremely good with 80-90% of the affected
individuals recovering with the help of antacids.
14

15. Complications of GERD
• Esophagitis
• Esophageal stricture (Repeated irritation can cause
scarring in the esophagus, making it narrow).
• Barrett’s esophagus (The cells lining the esophagus can
change into cells similar to the lining of the intestine
which can develop into esophageal cancer.
• Respiratory problems: It is possible to breathe
stomach acid into the lungs, which can cause a range
of problems, such as chest congestion, hoarseness,
asthma, laryngitis, and pneumonia.
15

16. Prevention of GERD
– Eat small meals frequently (avoid large meals)
– Stay upright after eating
– Finish eating 2–3 hours before going to bed
– Quit or avoid smoking, avoid using caffeine,
– Avoid strenuous activities after eating
– Lose weight if overweight
– Minimize wearing tight clothing around the
abdomen
– Sleep at a slight angle with the head slightly
elevated
– Avoid using greasy and spicy food
16

17. Nursing Diagnosis
• Imbalanced nutrition less/more than body
requirement
• Acute pain
• Risk for aspiration
• Deficient knowledge
17

18. Nursing Interventions
• Measuring the weight of the patient
• Encourage small and frequent meals
• Instruct the patient to remain upright after eating
• Instruct patient to eat slowly and masticate food well
18

19. Peptic
Ulcer
Disease
(PUD)
19

20. Peptic Ulcer Disease
• Peptic ulcers are sores/excavation that develop in
the lining mucosal wall of the stomach, pylorus,
lower esophagus, or small intestine.
• Sites:
– Lower esophagus
– Stomach
– Duodenum
– 10% of men, 4% of women
20

21. Types (Based on the duration)
 Acute (shorter)
• Superficial erosion
• Minimal erosion
 Chronic (longer)
• Muscular wall erosion with formation of fibrous
tissue
• Present continuously for many months or
intermittently
21

22. Types (based on site of involvement)
• Gastric ulcer –in the lesser curvature of the stomach
• Duodenal ulcer –in the duodenum
• Esophageal ulcer – lower parts of esophagus because
of HCl back flow
22

23. Epidemiology
• One in 10 people develops an ulcer.
• Occurs with greatest frequency between 40-60 years
of age.
• Relatively uncommon in women of child bearing age.
• After menopause the incidence is equal in male and
female.
23

24. Causes /Risk factors/
• Helicobacter pylori (H. pylori)
• Use of NSAIDS
• Smoking
• Drinking too much alcohol
• Radiation therapy
• Stomach cancer, illnesses like chronic pancreatitis, ...
• Family history and blood type (Gastric-A, Duodenal-O)
• Excessive HCl secretion
• Irritants (caffeine, milk, ...accelerate gastric empting)
24

25. Pathophysiology
25

26. Disruption of Gastric Mucosal Barrier
26

27. Pathophysiology
• Erosion - caused by increased concentration of acid
pepsin/decreased resistance of mucosa.
• Damage – damaged mucosa cannot act as a barrier
against HCl.
• Acid secretion – duodenal ulcers secrete more acids
whereas in gastric ulcers hypo/normal acid secretion.
• Decreased resistance - infections from H/pylori can
easily occur.
27

28. Gastric Ulcers (Characteristics)
• A normal to low secretion of gastric acid
• Back diffusion of acid is greater (chronic )
• Critical pathologic process is amount of acid able to
penetrate mucosal barrier
• H pylori is present in 50% to 70%
• Factors: Drugs users like aspirin, corticosteroids,
NSAIDs, Chronic alcohol users, chronic gastritis,...
• Pain intensifies after meal
28

29. Duodenal Ulcers
• Common: between ages of 35 to 45 years
• Account for 80% of all peptic ulcers
• Associated with ↑HCl acid secretion
• H.pylori associated in 90- 95 % of cases
• Diseases with ↑risk of duodenal ulcers: COPD,
cirrhosis of liver, chronic pancreatitis,
hyperparathyroidism, chronic renal failure
• Pain improves after meal
29

30. Clinical Manifestations /Common/
• Changes in appetite
• Nausea
• Bloody or dark stools
• Unexplained weight loss
• Indigestion
• Vomiting, sometimes with blood
• Epigastric abdominal pain
• Bloating, gas,
• Trouble breathing
30

31. 31

32. Diagnostic Studies
• Hx and Physical examination (tenderness, distension)
• Endoscopy-Determines degree of ulcer healing after
treatment, is preferred test
• H. Pylori tests- A breath test is the easiest way to
discover H. pylori
• Esophagogastroduodenoscopy (for biopsy, to r/o cancer)
• Barium contrast studies - widely used
• Occult blood
• Carbon 13 (13C) urea breath test-reflects activity of
H/Pylori
32

33. DDX
• Gastritis
• GERD
• Acute pancreatitis
• Cholelithiasis
• MI
• Pleural empyema
• Primary biliary cirrhosis
33

34. Management
• Medical regimen consists of:
• Adequate rest
• Dietary modification
• Drug therapy
• Elimination of smoking
• Long-term follow-up care
• Aim of treatment program:
• ↓ degree of gastric acidity
• Enhance mucosal defense mechanisms
• Minimize harmful effects on mucosa
34

35. Management
• Proton pump inhibitors (PPI): These drugs reduce
acid flow, which allows the ulcer to heal
(Omeprazole,Lansoprazole,Rabeprazole,
pantoprazole)
• Histamine receptor blockers (H2 blockers): These
drugs also reduce acid production (Famotidine,
Cimetidine, Nizatidine)
• Antibiotics: These medications kill bacteria
(Amoxacillin, Clarithromycin,Metronidazole,..).
35

36. Management
• Protective medications: Like a liquid bandage, these
medications cover the ulcer in a protective layer to
prevent further damage from digestive acids and
enzymes (misoprostol, sucralfate).
• Antacids – Increase gastric PH (Aluminum hydroxide
and Magnesium hydroxide)
• Anticholinergic – Decrease HCl secretion stimulation
(Glycopyrrolate)
• Combination of drugs during treatments:
– PPIs + clarithromycin/or/bismuth compound +
amoxicillin/or/ metronidazole/
36

37. Management /Surgical Procedures/
• < 20% of patients with ulcers need surgical intervention
• Indications for surgical interventions:
• History of hemorrhage, ↑ risk of bleeding
• Prepyloric or pyloric ulcers
• Multiple ulcer sites
• Drug-induced ulcers
• Possible existence of a malignant ulcer
• Obstruction
37

38. Management /Surgical procedures/
• Gastroduodenostomy
• Gastrojejunostomy
• Vagotomy
• Pyloroplasty
38

39. Nutritional Therapy
• Dietary modifications may be necessary so that foods
and beverages irritating to patient can be avoided
• Nonirritating or bland diet consisting of 6 small
meals a day during symptomatic phase
• Protein considered best neutralizing food
• Stimulates gastric secretions
• Carbohydrates and fats are least stimulating to HCl
acid secretion
• Do not neutralize well
• Stress reduction and rest
39

40. Complications of a Peptic Ulcer Disease
• Perforation
• Internal bleeding
• Scar tissue
• Seek urgent medical attention if the patient
experiences the following symptoms:
• Sudden, sharp abdominal pain
• Fainting, excessive sweating, or confusion, as
these may be signs of shock
• Blood in vomit or stool
• Abdomen that’s hard to the touch, abdominal
pain
40

41. Nursing Diagnosis
• Acute pain
• Anxiety
• Imbalanced nutrition
• Deficient knowledge
41

42. Nursing Interventions
• Administer prescribed medication
• Encourage relaxation methods
• Encourage patient to eat regularly,
• Health education:
– Nature of the disease
– Preventive methods
– Treatment modalities
42

43. Preventions of PUD
• Avoid tobacco products
• Avoid irritant foods
• Avoid alcohol
• Don’t ignore any symptoms of ulcer
• Washing your hands frequently to avoid infections
• Use caution with aspirin, and/or NSAIDS
• Reduce stress
• Practice relaxation exercise
43

44. Outlook / Prognosis
• Are ulcers curable?
• For most people, treatment that targets the
underlying cause (usually H. pylori bacterial infection
or NSAID use) is effective at eliminating peptic ulcer
disease.
• Ulcers can reoccur, though, especially if H. pylori isn’t
fully cleared from system or you continue to smoke
or use NSAIDs.
• How long does it take an ulcer to heal?
• It generally takes several weeks of treatment for an
ulcer to heal.
44

45. Questions?
• Will drinking milk help an ulcer?
– No. Milk may temporarily soothe ulcer pain because it coats
the stomach lining. But milk also causes your stomach to
produce more acid and digestive juices, which can make ulcers
worse.
• Is it safe to take antacids?
– Antacids temporarily relieve ulcer symptoms. However, they
can interfere with the effectiveness of prescribed medications.
Check with your doctor to find out if antacids are safe to take
while undergoing treatment.
• What should ulcer patients eat?
– No foods have been proven to negatively or positively impact
ulcers. However, eating a nutritious diet and getting enough
exercise and sleep is good for your overall health.
45

46. Hernia
• A hernia occurs when an organ pushes through an
opening in the muscle or tissue that holds it in place.
• Many hernias occur in the abdomen between your
chest and hips, but they can also appear in the upper
thigh and groin areas.
• Most hernias aren’t immediately life threatening, but
they don’t go away on their own.
46

47. Common Types
• Inguinal hernia: fatty tissue or a part of the intestine pokes into
the groin at the top of the inner thigh.
• Is the most common type, and affects men more than women.
• Femoral hernia: Fatty tissue or part of the intestine protrudes
into the groin at the top of the inner thigh.
• It is much less common than inguinal and mainly affect older
women.
• Umbilical hernia: Fatty tissue or part of the intestine pushes
through the abdomen near the navel (belly button).
• Hiatal (hiatus) hernia: Part of the stomach pushes up into the
chest cavity through an opening in the diaphragm.
47

48. Common Types
• Incisional hernia: Tissue protrudes through the site
of an abdominal scar from a remote abdominal or
pelvic operation.
• Epigastric hernia: Fatty tissue protrudes through the
abdominal area between the navel and lower part of
the sternum (breastbone).
• Spigelian hernia: The intestine pushes through the
abdomen at the side of the abdominal muscle, below
the navel.
• Diaphragmatic hernia: Organs in the abdomen move
into the chest through an opening in the diaphragm.
48

49. How common are hernias?
• Of all hernias that occur:
– 75 to 80% are inguinal or femoral.
– 2% are incisional or ventral.
– 3 to 10% are umbilical, affecting 10 to 20% of
newborns; most close by themselves by 5 years of
age.
– 1 to 3% are other types.
49

50. 50

51. Causes /Risk factors
• Damage from an injury or surgery
• Strenuous exercise or lifting heavy weights
• chronic coughing or COPD
• Pregnancy, especially having multiple pregnancies
• Constipation, /which causes straining/
• Being overweight or having obesity
• Ascites
• Being older
• Cystic fibrosis
• Smoking, which leads to the weakening of connective
tissue
• A personal or family history of hernias
51

52. Clinical Manifestation
• A bulge or lump (more likely to be felt through touch
when standing up, bending down, or coughing).
• Discomfort or pain in the area around the lump may
also be present
• Some types of hernia, such as hiatal hernias, can
have more specific symptoms like heartburn, trouble
swallowing, and chest pain.
• In many cases, hernias have no symptoms.
52

53. Diagnostic Studies
• History
• Abdominal ultrasound: uses high-frequency sound waves
to create an image of the structures inside the body.
• Abdominal CT scan: combines X-rays with computer
technology to produce an image.
• Abdominal MRI scan: uses a combination of strong
magnets and radio waves to create an image.
• X-rays: The patient will drink a liquid containing
gastrografin or a liquid barium solution.
• These liquids help digestive tract appear highlighted on X-
ray images.
• Endoscopy: During an endoscopy, a healthcare professional
threads a small camera attached to a tube down the throat
and into esophagus and stomach.
53

54. Management
• The only way to effectively treat a hernia is through
surgical repair (open surgery, laparoscopic surgery).
• Whether or not patient need surgery depends on the
size of hernia and the severity of symptoms.
• If the patient have a hiatal hernia, over-the-counter
(OTC) and prescription medications that reduce
stomach acid can relieve the discomfort and improve
symptoms (Antacids, H2 receptor blockers, and
proton pump inhibitors).
54

55. Home remedies for hernia
• Increasing fiber intake may help relieve constipation.
• Constipation can cause straining during bowel movements,
which can aggravate a hernia.
• Some examples of high fiber foods include whole grains,
fruits, and vegetables….
• Dietary changes can also help with the symptoms of a hiatal
hernia.
• Try to avoid large or heavy meals, don’t lie down or bend over
after a meal, and keep your body weight in a moderate range.
• To prevent acid reflux, avoid foods that may cause it, such as
spicy foods and tomato-based foods.
• Additionally, giving up cigarettes may also help, for smokers.
55

56. Complications
• Strangulation (leading to ischemia, cell death)
• Bowl obstruction
• Scrotal swelling
• Infection
• Numbness at surgical site
• Back pain
• Groin pain
• Inner thigh pain
56

57. Prevention
• If you smoke, consider quitting
• See a health professionals when you’re sick to avoid
developing a persistent cough.
• Maintain a healthy /moderate body weight.
• Try not to strain while having a bowel movement or during
urination.
• Eat enough high fiber foods to prevent constipation (fruits,
vegetables, whole grains).
• Perform exercises that help to strengthen the muscles of your
abdomen.
• Avoid lifting weights that are too heavy for you.
57

58. Nursing Diagnosis
• Acute pain
• Deficient knowledge
• Risk for injury
• Risk for fluid volume deficit
• Risk for infection
58

59. Nursing Interventions
• Administering antipain
• Health education on the nature of the disease,
prevention methods and managements
• Providing support/comfort/
• Monitoring IP vs OP
• Wound care
59

60. Constipation
• Technically defined as: Having fewer than three bowel
movements a week; However, how often you “go” varies
widely from person to person.
• Some people have bowel movements several times a day
while others have them only one to two times a week.
• Whatever the bowel movement pattern is, it’s unique and
normal for everybody.
• Other key features that usually define constipation include:
– Stools are dry and hard
– Bowel movement is painful and stools are difficult to pass
– You have a feeling that you have not fully emptied your
bowels
60

61. Epidemiology
• Constipation is one of the most frequent
gastrointestinal complaints in the United States.
• At least 2.5 million people see their doctor each year
due to constipation.
• People of all ages can have an occasional attack of
constipation.
• There are also certain people and situations that are
more likely to lead to becoming more consistently
constipated (“chronic constipation”).
61

62. Epidemiology (Risk groups)
• These include:
– Older age
– Being a woman, especially during pregnancy and
after childbirth.
– Those not eating enough high-fiber foods.
– Those taking certain medications
– Having certain neurological (diseases of the brain
and spinal cord) and digestive disorders
62

63. Causes of constipation
• Eating foods low in fiber
• Not drinking enough water (dehydration)
• Not getting enough exercise
• Changes in regular routine, such as traveling or eating or
going to bed at different times
• Eating large amounts of milk or cheese
• Stress
• Resisting the urge to have a bowel movement
• Medications: NSAIDS, Strong antipain, antidepressant,
antacids, allergy medication, certain anti HTN drugs
• Diseases: hypothyroidism, DM, colorectal Cancer, stroke,
intestinal obstruction, pregnancy (though not a disease)
63

64. How does constipation happen?
• Constipation happens because colon absorbs too much water
from waste (stool/poop), which dries out the stool making it
hard in consistency and difficult to push out of the body.
• To back up a bit, as food normally moves through the digestive
tract, nutrients are absorbed.
• The partially digested food (waste) that remains moves from the
small intestine to the large intestine, also called the colon.
• The colon absorbs water from this waste, which creates a solid
matter called stool.
• During constipation, food may move too slowly through the
digestive tract.
• This gives the colon more time to absorb water from the waste.
• The stool becomes dry, hard, and difficult to push out.
64

65. Clinical manifestations
• Fewer than three bowel movements a week
• Stools are dry, hard and/or lumpy
• Stools are difficult or painful to pass
• Stomach ache or cramps
• Feeling bloated and nauseous
• Feeling that you haven’t completely emptied your
bowels after a movement
65

66. Diagnostic studies
• Medical history
– What are your current and past diseases/health
conditions?
– Have you lost or gained any weight recently?
– Have you had any previous digestive tract surgeries?
– What medications and supplements do you take for
other disorders and for the relief of constipation?
– Does anyone in your family have constipation or
diseases of the digestive tract or a history of colon
cancer?
– Have you had a colonoscopy?
66

67. Diagnostic studies
• Bowel movement history
– How often do you have a bowel movement?
– What do your stools look like?
– Have you noticed any blood or red streaks in your
stool?
– Have you ever seen blood in the toilet bowl or on the
toilet paper after you wipe?
• Lifestyle habits and routines
– What food and beverages do you eat and drink?
– What is your exercise routine?
67

68. Diagnostic studies
• Lab tests: Blood and urine tests for ( hypothyroidism, anemia,
and diabetes).
• Imaging tests: CTS, MRI may be ordered to identify other
problems that could be causing constipation.
• Colonoscopy: To test for cancer or other problems and any
found polyps will be removed.
• Colorectal transit studies: These tests involve consuming a
small dose of a radioactive substance, either in pill form or in
a meal, and then tracking both the amount of time and how
the substance moves through your intestines.
68

69. Management
• Fiber supplements (calcium ploycarbophil)
• Stimulants (bisacodyl)
• Osmotic laxatives (oral magnesium hydroxide)
• Lubricants (mineral oils)
• Stool softeners (docusate sodium)
• Enema
• Suppositories (glycerin)
• Serotonin 5-hydroxytryptamine 4 receptors (helps move
stool through the colon)
• Surgery (if the cause is rectocele or stricture)
69

70. Managements
• Increase fluid intake
• Increase fiber intake (fruits, vegetables whole grains )
• Exercise most days of the week
• Don’t ignore the urge to have a bowl movement
• Training pelvic muscles
70

71. Complications of constipation
• Hemorrhoids
• Infections like diverticulitis
• Fecal impactions
• Bowel incontinence
• Stress urinary incontinence (during straining)
71

72. Preventions of constipation
• Eat a well-balanced diet with plenty of fiber.
• Good sources of fiber are fruits, vegetables, legumes, and
whole-grain breads and cereals.
• Fiber and water help the colon pass stool.
• Most of the fiber in fruits is found in the skins, such as in
apples. Fruits with seeds you can eat, like strawberries,
have the most fiber.
• People with constipation should eat between 18 and 30
grams of fiber every day.
• Drink eight 8-ounce glasses of water a day. (Note: Milk can
cause constipation in some people.) Liquids that contain
caffeine, such as coffee and soft drinks, can dehydrate you.
• Exercise regularly.
• Move your bowels when you feel the urge. Do not wait.
72

73. Nursing diagnosis
• Constipation related to immobility secondary to hip
fracture surgery as evidenced by difficulty to pass
stool and no bowl movement for 4 days post surgery.
• Constipation related to reduced muscle control
secondary to neurologic disease as evidenced by
reduced bowl movement, verbalization of having to
strain when on the toilet.
73

74. Nursing interventions
• Administer recommended fluid and food
• Provide time to use toilet
• Provide privacy
• Encourage high fiber diets
74

75. Hemorrhoid
• Hemorrhoids also called piles, are swollen veins in anus
and lower rectum, similar to varicose veins.
• It can develop inside the rectum (internal hemorrhoids)
or under the skin around the anus (external
hemorrhoids).
• Nearly three out of four adults will have hemorrhoids
from time to time.
• It has a number of causes, but often the cause is
unknown.
• Many people get relief with home treatments and
lifestyle changes.
75

76. Causes
• Hemorrhoids can develop from increased pressure in the
lower rectum due to:
– Straining during bowel movements
– Sitting for long periods of time on the toilet
– Having chronic diarrhea or constipation
– Being obese, Being pregnant
– Having anal intercourse
– Eating a low-fiber diet, Regular heavy lifting
• Risk factors
– Family hx, sedentary life style, episiotomy, rectal surgical
procedures, spinal cord injury, rectal muscle tone loss
76

77. Types of hemorrhoid
Internal
• Occurs within rectum
• Usually not visible or
uncomfortable
• May bleed / bright red
blood/
• Can get out during straining,
child birth, heavy lifting
...which can cause
prolapsed hemorrhoid
/greater discomfort/
External
• Found outside of rectum
• Can easily bleed and pain
• Walking or sitting can cause
irritation
• Pool blood /clot/
77

78. Clinical manifestation
External hemorrhoids
• These are under the skin
around your anus.
• Itching or irritation in anal
region
• Pain or discomfort
• Swelling around anus
• Bleeding /clotting/
Internal hemorrhoids
• They rarely cause
discomfort.
• But straining or irritation
when passing stool can
cause:
– Painless bleeding during
bowel movements.
– Small amounts of bright red
blood on toilet tissue or in the
toilet.
– Perception/urge to defecate
78

79. Diagnostic studies
• Physical examination
• DRE /Digital Rectal Examination/
• Anoscopy ... To detect internal hemorrhoid
• Sigmoidoscopy ... Examines inside section of large
intestine (sources of pain, diarrhea, constipation)
• Colonoscopy .. To examine abnormal growths,
inflamed tissues, ulcers,
79

80. Pharmacological and non pharmacological
managements
• Consume high fiber diets
• Soak in a warm bath or sitz bath regularly
• Analgesics and NSAIDS
• Sclerotherapy... Destroying the tissues by injecting
chemicals.
• Electrocoagulation ... Cut off blood flow to
hemorrhoid with electric current.
• Hemorrhoidectomy... Surgical removal (all type)
• Hemorrhoid stapling ...removes internal type and
retains if prolapsed.
80

81. Complications
• Anemia: Rarely, chronic blood loss from hemorrhoids may
cause anemia.
• Strangulated hemorrhoid: If the blood supply to an internal
hemorrhoid is cut off, the hemorrhoid may be "strangulated,"
which can cause extreme pain.
• Blood clot: Occasionally, a clot can form in a hemorrhoid
(thrombosed hemorrhoid).
• Although not dangerous, it can be extremely painful and
sometimes needs to be cut and drained.
• Sepsis
• Perianal thrombosis
81

82. Prevention
• Eat high-fiber foods: Eat more fruits, vegetables and whole grains.
• Drink plenty of fluids: Drink six to eight glasses of water and other
liquids (not alcohol) each day to help keep stools soft.
• Consider fiber supplements: Most people don't get enough of the
recommended amount of fiber — 20 to 30 grams a day — in their
diet.
• Don't strain
• Go as soon as you feel the urge. If you wait to pass a bowel
movement and the urge goes away, your stool could dry out and be
harder to pass.
• Exercise. Stay active to help prevent constipation and to reduce
pressure on veins, which can occur with long periods of standing or
sitting.
• Avoid long periods of sitting. Sitting too long, particularly on the
toilet, can increase the pressure on the veins in the anus.
82

83. Nursing Diagnosis
• Impaired tissue integrity
• Constipation
• Acute pain
• Deficient knowledge
• Impaired comfort
83

84. Nursing Intervention
• Apply topical treatments / antibiotics, lotions/
• Administer stool softeners / laxatives/
• Administer analgesics
• Health education: the nature of the disease,
treatments, complications, prevention
• Providing the patient comfort environments
84

85. Gastric Cancer
• Gastric cancer refers to malignant lesions found in the
stomach.
• It is more common in men than in women.
• H. pylori infection plays a role in gastric cancer
development.
• Other factors that may be associated with gastric cancer
development include pernicious anemia; exposure to
occupational substances such as lead dust, grain dust,
glycol ethers, or leaded gasoline; and a diet high in smoked
fish or meats.
• A poor prognosis is often associated with gastric cancer
because most patients have metastasis at the time of
diagnosis
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86. Clinical manifestation
• Gastric cancer is rarely diagnosed in its early stages
because symptoms do not appear until late in the
disease
• In the early stages, there may not be any symptoms at
all, and metastasis to another organ, such as the liver,
may have already occurred.
• The symptoms of gastric cancer are often mistaken for
peptic ulcer disease: indigestion, anorexia, pain
relieved by antacids, weight loss, and nausea and
vomiting.
• Anemia from blood loss commonly occurs, and occult
blood in the stool may be present.
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87. Diagnostic studies
• X-ray examination
• Gastroscopy
• Gastric fluid analysis
• Measurement of serum gastrin levels
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88. Management
• There is little effective medical treatment available for
gastric cancer.
• Surgical removal of the cancer is the most effective
treatment for gastric cancer.
• Most often the cancer has already metastasized, and
surgery is performed only to relieve the symptoms.
• Chemotherapy and radiation are sometimes used in
conjunction with surgery.
• New cytotoxic agents
• Total parenteral nutrition is a method for providing
nutrition to the patient who has had a total gastrectomy.
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89. Nursing Diagnosis
• Acute pain
• Fear
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90. Nursing intervention
• Administer medications as ordered
• Apply relaxation therapy
• Regular positioning (after procedures)
• Monitor vital signs
• Psychotherapy (assuring the patient)
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91. Chronic Liver Failure /Disease/ (CLD)
• Chronic liver failure is also called Laennec’s cirrhosis,
or portal, nutritional, fatty, or alcoholic liver disease.
• Chronic liver failure is the tenth leading cause of
death among the total population and is more
common among men than women.
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92. Causes
• Laennec’s cirrhosis is caused by chronic excessive
alcohol ingestion, especially when excess alcohol is
combined with a lack of dietary protein.
• Post necrotic liver failure may result from massive
exposure to hepatotoxins, viral hepatitis, or infection.
• Biliary liver failure is caused by chronic inflammation
and obstruction of the gallbladder and bile ducts.
• Cardiac liver failure is caused by chronic severe
congestion of the liver from heart failure (liver
congestion causes death of liver cells from lack of
nutrients and oxygen).
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93. Pathophysiology
• Chronic liver failure is a progressive disease.
• Healthy liver cells respond to toxins such as alcohol by
becoming inflamed.
• The liver cells are infiltrated with fat and white blood cells
and are then replaced by fibrotic tissue.
• As the disease progresses, more and more liver cells are
replaced by fatty and scar tissue.
• The lobes of the liver are disrupted and the liver becomes
hardened and lumpy.
• Early in the disease, the liver is enlarged, firm, and hard
from the inflammatory process.
• Later, the liver shrinks and is covered with gray connective
tissue.
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94. Clinical manifestations
• Malaise, anorexia, indigestion, nausea, weight loss,
diarrhea or constipation, and dull, aching RUQ pain.
• The liver may be enlarged, firm, and tender.
• Bruising of the skin, bleeding gums, anemia, and
jaundice, also known as icterus, may be present.
• Jaundice is a common finding with hepatitis.
• The patient’s skin may be dry or contain abnormal
pigmentation.
• The patient may complain of severe pruritus (itching).
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95. Complications (CHEAP)
• Hepatorenal syndrome
• blood clotting defects
• Ascites
• Portal hypertension
• Hepatic encephalopathy.
95

96. Complications (Hepatorenal Syndrome)
• Hepatorenal syndrome is a secondary kidney failure
that occurs in about one-third of liver failure
patients.
• Symptoms of Hepatorenal syndrome include oliguria
without detectable kidney damage, reduced
glomerular filtration rate (GFR) with essentially no
urine output or less than 200 mL per day, and nearly
total sodium retention.
• Hepatorenal syndrome is considered an ominous
sign.
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97. Complications (Clotting Defects)
• Blood clotting defects may develop because of
impaired prothrombin and fibrinogen production in
the liver.
• Further, the absence of bile salts prevents the
absorption of fat-soluble vitamin K, which is essential
for some blood clotting factors.
• Patients with chronic liver failure have a tendency to
bruise easily and may progress to disseminated
intravascular coagulation (DIC) or hemorrhage.
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98. Complications (Ascites)
• Ascites is an accumulation of serous fluid in the
abdominal cavity.
• The fluid accumulates primarily because of low
production of albumin by the failing liver.
• An insufficient amount of protein in the capillaries
causes plasma to leak into the abdominal cavity.
• The accumulated fluid causes a markedly enlarged
abdomen.
• The fluid may cause severe respiratory distress as a
result of elevation of the diaphragm.
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99. Complications (portal hypertension)
• Portal hypertension is a persistent blood pressure
elevation in the portal circulation of the abdomen.
• Liver damage causes a blockage of blood flow in the
portal vein.
• Increased resistance from delayed drainage causes
enlargement of the visible abdominal veins around the
umbilicus (called caput medusae), rectal hemorrhoids,
enlarged spleen, and esophageal varices (dilated veins)
• The most serious result of portal hypertension is
bleeding esophageal varices.
• The walls of the esophageal veins are thin and tear
easily.
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100. Complications (Hepatic Encephalopathy)
• Hepatic encephalopathy is caused by the accumulation of
noxious substances in the circulation.
• The failing liver is unable to make the toxic substances water
soluble for excretion in the urine.
• Ammonia, a by-product of protein metabolism, is most
commonly the substance causing symptoms.
• Signs and symptoms of hepatic encephalopathy include
progressive confusion; asterixis, or flapping tremors in the
hands caused by toxins at peripheral nerves; and fetor
hepaticus, or foul breath caused by metabolic end products
related to sulfur.
• Stages of hepatic encephalopathy are early, stuporous and
confused, and comatose.
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101. Diagnostic Studies
• History and P/E
• LFT
• Liver serum enzymes, serum bilirubin, urobilinogen,
serum ammonia, and prothrombin times are all
elevated in chronic liver failure.
• CT Scans
• X rays
• MRI
• Biopsy
• Increased WBC
101

102. 102

103. Management
• Ascites is treated with diuretics, albumin infusions,
and fluid and sodium restrictions.
• Paracentesis is sometimes considered as an
emergency measure to remove accumulated
abdominal fluid,
• Bleeding varices are treated with vasoconstrictors
such as vasopressin, with tamponed (direct pressure
on the bleeding veins), or with emergency
sclerotherapy to close the veins.
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104. Management
• Transplantation
• Anti emetics
• Rest
• Vitamin supplements
• Avoid causes/risk factors/ like alcohol
• Maintaining fluid and electrolyte balances
104

105. Nursing Diagnosis
• Fluid volume excess
• Imbalanced nutrition less than body requirement
• Pain
• Risk for disturbed thought processes
• Risk for infection
105

106. Nursing interventions
• Monitor vital signs
• Check IP/OP
• Maintain low sodium diet
• Assist the patient during feeding
• Providing ant pains
• Providing comfort
• Health educations
106

107. Prevention
• Chronic liver failure may be prevented by:
– Abstinence from alcohol
– Eating a balanced diet with adequate amounts of
protein
– Avoiding exposure to infections or hepatotoxic
chemicals.
107

108. Exercise
108

109. Reading Assignment
• Reading Assignment: Definitions, Causes,
pathophysiology, clinical manifestations, Dx methods,
DDx, Cxn, medical management, nursing
management, prevention methods.
– IBD (Crohn’s disease and ulcerative colitis)
– Periodontal abscess
– Motility disorder of esophagus
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