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1. Digestive System
By-RUPAM BHOWMIK
Nursing Officer AIIMS

3. The Digestive system consists of two
groups of organ
1. Gastrointestinal Tract (GIT) or Alimentary
Tract or Primary Digestive Organ :
• The organ where actual digestion takes place
called primary digestive organ.
• GIT is a 5-7 meter long continuous tube from
mouth to anus.

4. The length of GIT in a cadaver (a dead human
body preserved for anatomical study) is about
7- 9 meter (23-30 feet), but in living person it
is much shorter (5-7 meter) because of
muscles are in contracted state
2. Accessory Digestive Organ :
• It help primary digestive organ in the process
of digestion, examples are teeth, tongue,
salivary gland, pancreas, liver, gall bladder etc.

5. FUNCTION OF DIGESTIVE SYSTEM
The digestive system perform following 6 basic
process –
 Eating or Ingestion - Taking food and liquid into
mouth.
 Secretion – The cells of GIT or accessory organs
secrete about 7 liter of water, acid, buffer and
enzymes.
 Mixing & Propulsion - GIT mix food & secretion
and then propel toward the anus.

6.  Digestion -Break down of ingested food into
small and simple chemical molecules by
mechanical and chemical process called
digestion.
A. Mechanical digestion-Cutting & churning of
foods.
B. Chemical digestion-Breaking up of larger
molecules into smaller molecules by digestive
enzymes.

7.  Absorption – Taking up small digested
molecules (glucose amino-acid, fatty acid
etc.) into blood through epithelial cells of GIT
called absorption.
 Defecation- Wastes, undigested substance,
bacteria and cells sloughed from lining of GIT
leave the body through the anus called
defecation.

9. Layers of GIT
• INNER To OUTER : Is mucosa, submucosa,
muscularis and serosa/adventitia.
• Mucosa:- inner most layer, contain goblet cell
which secrete mucus.
• Submucosa :- contain nerves, blood vessels.
• Muscularis :- helps in peristalsis.
• Serosa/adventitia:- prevent any frictional
damage from the intestine rubbing against
other tissue.

10. MUCOSA
• Mucosa is consisting of stratified
squamous epithelium (mouth, pharynx,
upper part of esophagus and anal canal)
and columnar epithelium (lower part of
esophagus, stomach and intestine).
• Within every 5-7 days, epithelial cells of
GIT are replaced by new cells.

11. SUB-MUCOSA
• Extensive networks of neurons are also
located in submucosa which called
submucosal plexus (Meissner's plexus).
• Vagus nerve also supplies most of part of
GI tract but last half of the large intestine
supplied by nerve of sacral spinal cord.

12. MUSCLE LAYER
• Muscles of mouth, pharynx, upper part of
esophagus and external anal sphincter contain
skeleton muscles (voluntary in nature) and rest of
tract contains smooth muscles (involuntary in
nature).
• A Muscle layer help in mixing and propulsion of
food by peristalsis.
• Between layers of muscles, nerve tissue present
which called myenteric plexus (Auerbach's
plexus).

13. SAROSA/ADVENTITIA
• Prevent any frictional damage from the
intestine rubbing against other tissue.

14. Mouth or Oral Cavity or Buccal Cavity
• The roof of month formed by palates.
• Anterior part of palate called hard palate
(formed by maxilla & palatine bone) and
posterior part called soft palate (formed by
muscles).

15. • Posterior free hanging border of soft palate
called uvula, which during swallowing close
naso-pharynx to prevent entry of food and
liquid into nasal cavity.

16. • Pain upon swallowing- called odynophagia.
• Inflammation of the mouth (including the lips,
tongue and mucous membranes) called
stomatitis.
• Normal flora or commonsale microbes of oral
cavity mainly contain lactobacillus acidophilus,
bacteria that produces lactic acid by
fermenting the sugars present in milk

17. TEETH
1. Primary Teeth or Temporary Teeth or
Deciduous Teeth or Baby Teeth or Milk
Teeth:
• Total numbers are 20 (10 in each jaw).
• It starts to erupt at 6 month of age (lower
central incisor) and completed at 24 month
(second molar).
• It lost between 6 year to 12 year of life.

19. • Formula - 2102/2102 (sequence from
anterior to posterior : 2 incisor, 1 canine, 0
premolar, 2 molar).
• These teeth called diphyodont (having two
sets of teeth) because erupt two times in the
life.

20. 2. Secondary Teeth or Permanent Tecth:
 It starts to erupt in 6 year of age (first molar)
and complete 32 teeth in 24 years (3rd molar).
Formula - 2123/2123 (sequence from anterior
to posterior : 2 incisor, 1 canine, 2 premolar, 3
molar).

21. Incisor and canine are called- cutting teeth
and premolar and molar are called- grinding,
crushing or chewing teeth.
3rd molar teeth called wisdom teeth.
3rd molar and premolar teeth called
monophyodont (having a single permanent
set of teeth) because erupt one times in the
life.

22. Structure of Teeth
• A tooth has three major region
1. Crown- Visible portion of teeth.
2. Root - Embedded portion in sockets.
3. Neck - Constricted junction of crown and
root near the gum.

24. • Teeth are composed of dentin (calcified
connective tissue composed of 70% calcium
salt).
• The dentin encloses a cavity within crown
called pulp cavity, which contain blood vessels
and nerves.

25. • The dentin in crown is covered by a hardest
substance of body (composed of about 95% of
calcium salt) called enamel.
• Inflammation of the gums or gingiva
characterized by redness, swelling and
tendency to bleed called Gingivitis.

26. Salivary Gland
• 3 pairs of the glands secrete saliva called
salivary gland :
1. PAROTID GLAND (25% SECRETION OF
SALIVA)
• Largest salivary gland, weight 20-30gm
• Secretion of these glands comes in to oral
cavity by parotid duct or Stensen's duct (40
mm long) and it open at upper second molar
teeth.

27. • Ptyalin secreted by only parotid gland.
• A Inflammation and enlargement of parotid
gland by paramyxovirus called mumps or
epidemic parotitis or parotiditis.

28. 2. SUBMANDIBULAR (70% secretion of saliva) :
• Situated beneath the base of tongue.
• Weight 8-10gm. Opens by submandibular
duct or Wharton's duct (40 mm long) at side
of frenulum of tongue.

30. 3. SUBLINGUAL GLAND (5% secretion of saliva) :
• Smallest salivary gland, Weight 2-3gm.
• Open their secretion by 5-15 ducts called
minor sublingual duct (duct of Rivinus) or a
large sublingual duct (Bartholin's ducts).

31. • Volume of Saliva: 1000 -1500 ml/day or 1
ml/minute .
• Excessive secretion of saliva called ptyalism or
sialorrhea.
• Xerostomia (mouth dryness) means decreased
production or lack of saliva.

32. • Composition of Saliva :
• 99.5%- H2O
• 0.5% Solutes like Na+ , K+, Cl-,
Phosphate,HCO3,
• Immunoglobulin A, lysozyme (bactericidal) &
enzymes.
• pH of saliva - 6.35 to 6.85
• Specific gravity-1.002 to 1.012.

33. • Food may remain in the fundus of stomach
about an hour without mixing with gastric
juice, during this time, digestion by salivary
amylase is continues. A

34. • Tongue Tongue is a voluritary muscular organ.
• It attached to floor of mouth or hyoid bone by
frenulum (a thin fold of mucosa in middle of
floor of the mouth).
• If a person's lingual frenulum is abnormally
short or rigid which called Ankyloglossia
(tongue tied) result into speech impairment.

37. • A Inflammation of tongue called glossitis.
• Superior surface of tongue consist of stratified
squamous epithelium with numerous papillae
(little projections).

38. • Papillae containing taste buds (nerve ending
for sense of taste, sensory branch of
glossopharyngeal nerve).
• Types of papillae There are three types of
papillae based on their shape -

39. • 1) Vallate (circum-vallate) papillae:
• It arranged in inverted V shape at the base of
tongue.
• These are larger papillae, can most ensily seen
on tongue.
• 2) Filiform papillae (thread-like) : Smallest
type and situated on anterior 2/3 of tongue.
• 3) Fungiform papillae(mushroom-like):
Situated mainly at tip & edges of tongue.

40. TASTE BUDS
• Sweet and salty taste buds situated mainly on
tip.
• Sour taste buds situated at the edge & side of
tongue.
• Bitter taste buds situated at the back of
tongue.

41. QUESTIONS
• Al of the following accessory organs help in
digestion except:
(a) Liver
(b)Gall bladder
(c) Pancreas
(d)Duodenum

42. • The process of taking food into the digestive
system is
(a) Ingestion
(b)Propulsion
(c) Digestion
(d)Elimination

43. • Inflammation of mucus membrane of the
teeth is called:
(a) Stomatitis
(b)Halitosis
(c) Gingivitis
(d)Cheilosis

44. • Halitosis means offensive odor of the breath.
• Cheilosis means a condition in which lips
become reddened and develop fissures at the
angles, mainly due to vitamin B complex
deficiencies, especially riboflavin.

45. • Commonest commonsale microbes present
into oral cavity
(a) Helicobacter pylori
(b)E. Coli
(c) Bacillus acidophilus
(d)All of above

46. • Lactobacillus acidophilus is a species of
bacteria that produces lactic acid by
fermenting the sugars present in milk.
• It is found in milk, feces of bottle-fed infants,
adults whose diets include high milk content.
• It is also part of oral and vaginal commonsale
mierobes (flora).
• Helicobacter pylori mainly present in stomach
and E. coli into colon,

47. • Which acid convert milk into curd
(a) Citric acid
(b)Mallic acid
(c) Lactic acid
(d)Tartaric acid

48. • Which of the following taste is one most
limited to the tip of the tongue?
(a) Bitter
(b)Sweet
(c) Salty
(d)Sour

49. • Taste buds for sensing bitterness are located
on which part of the tongue?
(a) Anterior part of the tongue
(b)Posterior part of the tongue
(c) Lateral part of the tongue
(d)Under surface of the tongue

50. • Which one of the following enzymes is found/
secreted in the Saliva?
(a) Rennin
(b)Tenin
(c) Ptyalin
(d)Resin milk. .

51. • Saliva contains an enzyme, ptyalin (salivary
amylase), which start to digest carbohydrates
like starch and glycogen to maltose and
glucose into mouth.
• The optimum pH for ptyalin activity is 6.8.
• Saliva also contains an enzyme, lingual lipase,
which digest pre-emulsified fat present into
milk.
• Rennin or chymosin is an enzyme present in
the gastric juice of young ruminants that
curdles milk.

52. • Which part of food first start to digest into
mouth?
(a) Carbohydrate
(b)Fat
(c) Protein
(d)Vitamin

53. • Digestion of food in human starts from
(a) Small intestine
(b)Mouth
(c) Duodenum
(d)Large intestine

54. • The salivary gland secretes saliva which
contains the enzyme
(a) Pepsin
(b)Renin
(c) Lipase
(d)Ptyalin

55. • Amount of saliva produced in one day is:
(a) 0.5 liter
(b)1.5 liter
(c) 1 liters
(d)2 liter

56. • Deficient salivation is called
(a) Xerophthalmia
(b)Xerostomia
(c) Ptyalism
(d)Halitosis

57. ESOPHAGUS
• Esophagus is a 25cm long collapsible muscular
tube that lies posterior to the trachea.
• Laryngo-pharynx continues to esophagus at
2nd thoracic vertebrae.

59. • Through esophageal hiatus (an opening for
esophagus), esophagus cross the diaphragm
and ends in the superior portion of the
stomach.

61. • Sometimes part of the stomach protrudes
above the diaphragm through esophageal
hiatus called hiatal hernia.

62. • A sphincter between upper part of esophagus
and laryngopharynx called upper esophageal
sphincter or cricopharyngeal sphincter.

63. • A sphincter between the lower end of
esophagus and stomach called lower
esophageal sphincter (LES) or cardiac
sphincter.

64. • If LES or cardiac sphincter fails to close
adequately after entering the food into
stomach, the stomach content can reflux or
back up into esophagus; this condition is
known as gastroesophageal reflex disease
(GERD).

67. • Pharmacological Management of GERD: -
• H2 histamine receptor antagonists (decrease
acidity) .
• Reduce gastric acidity: Ranitidine.
• Proton pump inhibitors (decrease acidity and
increase lower esophageal sphincter
tone):Pantoprazole and Omeprazole.
• Gastric emptying: Prokinetic agents: Reglan.

68. • Management of GERD :
• Dietary modification: Encourage low fat diet;
avoid caffeine, tobacco, beer, carbonated
beverages and milk.
• Avoid eating and drinking 2 hours before the
bed time Maintain normal body weight .
• Avoid tight fitting clothes.
• Elevate head end of the bed and elevate
upper part of the body over a pillow

69. • Hcl (hydrochloric acid) from stomach content
irritate the esophageal wall, causes burning
sensation which is termed heart burn or
pyrosis.
• Drinking alcohol & smoking cause cardiac
sphincter to relax, which result into heart
burn.

70. • Pharynx continues to esophagus at :
(a) 2nd cervical vertebra
(b)3rd cervical vertebra
(c) 2nd thoracic vertebra
(d)3rd thorneic vertebra

71. • These tissues are found in stomach:
(a) Longitudinal fibres
(b)Circular fibers
(c) All of these Nurse
(d)Oblique fibers

72. • The muscular layer of stomach contains three.
layers of smooth muscle fibers; an outer layer
contain longitudinal fibers, a medial layer
circular and an inner layer oblique fiber of
muscles.
• These three layer of smooth muscles of
stomach are responsible for mechanical
digestion of food.

73. • Mechanical Digestion in the stomach is
accomplished by which of the following
structures?
(a) Mucosa
(b)Smooth muscle layer
(c) Striated muscle layer
(d)Gastric glands

74. • Chyme is called:
(a) Food in the mouth
(b)Food in stomach
(c) Food reaches in duodenum
(d)Food reaches in the rectum

75. • The mixture of partially digested food
digestive secretions in the stomach, or
partially digested food which is entering into
first part of small intestine (duodenum) called
chyme.

77. • Food reservoir is known as:
(a) Oesophagus
(b)Small intestine
(c) Stomach
(d)Large intestine

78. • Stomach is a "J" shaped distensible muscular
sac like part of the alimentary tube, serve as
reservoir of food.
• Fatty food remains longest time, protein less
than fat and carbohydrate least into stomach.

79. • Identify the part of Human Stomach which
connects/joins with Oesophagus
(a) Fundus
(b)Body
(c) Cardia
(d)Pylorus

81. • Human body needs a constant supply of
proteins to survive. The first part of digestive
system to begin digesting proteins is
(a) Mouth
(b)Small intestine
(c) Stomach
(d)Large intestine

82. • The process of digestion of protein first
started into stomach by proteolytic enzyme
pepsin (an enzyme that catalyzes the
conversion of proteins into peptides and
amino acids).
• Pepsin secreted by chief cells of gastric glands
in inactive form of pepsinogen

83. STOMACH
• Stomach is a J- shaped distensible enlarged
part of GIT.
• It is situated just inferior to diaphragm in the
epigastric, umbilical & left hypochondriac
region.
• Stomach serves as a mixing chamber (make
chyme) or food reservoir (maximum capacity
1.5 liter).

84. • Cardia – Region around the opening of lower
esophageal sphincter or cardiac sphincter.
• Fundus - A dome shaped part above the
cardiac sphincter.
• Body - Central largest part (80%) of stomach.
• Pylorus – Lower part of stomach which
connects the body of stomach to the
duodenum.

85. • It has two parts- Pyloric antrum, which
connect to the body of stomach.
• Pyloric canal, which open into duodenum.

86. Region of stomach Stomach has
divided in four main region-

87. • The sphincter between stomach & duodenum
called pyloric sphincter.

88. • Major clinical manifestation :
• Non-bilious projectile vomiting .
• Dehydration and electrolyte imbalance
• Olive like mass on palpation of right upper
quadrant of the abdomen - Left to right
peristaltic movement across the abdomen

89. • Management - Pyloromyotomy known as
Ramstedt's procedure: Dividing the muscle of
the pylorus to open up the gastric outlet.

90. • Narrowing of pyloric sphincter called pyloric
stenosis.
• Projectile vomiting is a hallmark symptom of
pyloric stenosis.

91. • Surface mucosa of stomach is renewed about
every 3 day, but steroids decrease cell
renewal.
• Prostaglandins are protective for gastric
mucosa, which synthesis inhibit when patient
taking NSAID.

92. • Gastric glands contains 3 types of exocrine
giand cells that secrete different content of
gastric juice, like-
1. Chief cells – it secrete pepsinogen (digest
protein )to peptone and gastric lipase (digest
fat).

93. 2. Parietal cells - It produce intrinsic factor and
hydrochloric acid (HCI).
• Intrinsic factor is needed for absoption of
vitamin B12 & HCl convert pepsinogen
(inactive) to pepsin (active form).

94. 3. Mucus neck cells - It secrete mucus.
• Mucus protects the wall from HCl and
pepsinogen.

95. About 2-3 liter of gastric juice secreted per day
by exocrine cells of gastric glands.
The pH of gastric juice is 1.5 to 3.5 (strongly
acidic), which destroys pathogens.

96. Gastric gland also contains enteroendocrine
cells (c.g. G cells) which secrete gastrin
hormone directly into blood stream.
Rennin (chymosinin, an enzyme that curdles
milk) in human present only in newborn, in
adult curdling of milk occurs by Hcl.

97. Small Intestine
• Small intestine has three parts:
1. Duodenum (25 cm),shortest part.
2. Jejunum (8 feet)
3. Ileum (12 feet), Absorption of vitamin B12
take place in ileum.

101. HEPATIC BILIARY SYSTEM
 Liver is the largest gland in the body, located
in the right upper quadrant.
It weighs about 1500 gm and divided into 4
Lobes
Lobes are further divided into lobules.
Kupffer cells are the phagocytic cells present
in the liver.
Smallest bile duct called canaliculi are located
between the lobules of liver.

102. Canaliculi carry bile secreted by hepatocytes
to larger bile duct, which eventually become
hepatic duct.
Hepatic duct from liver and cystic duct from
gallbladder join to form common bile duct
which empties bile into the duodenum of
small intestine.

104. Functions of Liver
• Glucose metabolism: After digestion, glucose is
converted to glycogen and whenever the body
requires, glycogen is converted to glucose.
• Glycogenesis: Glucose is converted and stored as
glycogen.
• Glycolysis: Glycogen is converted back to glucose.
• Gluconeogenesis: Glucose is synthesized from
non-carbohydrate substances such as protein and
amino acids.

105. • Ammonia conversion: Protein and amino acid
metabolism leads to ammonia generation.
Liver converts this highly toxic ammonia to
urea for excretion.
• Protein metabolism: Liver synthesizes all
plasma protein (except gamma globulin) such
as albumin, alpha and beta globulins.

106. • Fat metabolism: When glucose is not available
fatty acids are broken down for the production
of energy.
• Vitamin and iron storage: Liver store large
amount of vit A, D, E, K and vit. B12 and it also
store iron and copper.
• Drug metabolism: Liver is a major site for drug
metabolism
• Bile formation: Hepatocytes synthesizes bile
and store in gallbladder. Bile salts are formed
from cholesterol.

108. • Between small intestine and large intestine is
the caecum which is located in the right lower
quadrant. Ileocecal valve located here.
• Ileocecal valve control the entry of content
into the large intestine as well as it prevent
the reflex of bacteria from large to small
intestine.

110. •Vermiform appendix is located near to ileocecal
junction in the right lower quadrant.
Deficiency of vitamin B12 results in pernicious
anaemia.

111. Large Intestine
• 5 feet (1.5 metre) long.
• Absorbs water and eliminate waster.
• Intestinal bacteria play a vital role in the
synthesis of some vitamins and vitamin K .
• The large intestine is divided into three parts
caecum, colon and rectum.

113. • Colon is further divided as :
1. Ascending: shortest person of colon
2. Transverse
3. Descending
4. Sigmoid
• Rectum continuous in an external opening
called anus.

115. Waste Product of Digestion
• The brown colour of the fecal matter is due to
breakdown of bile by intestinal bacteria.
• Chemical formed by intestinal bacteria such as
indole and skatole are responsible for fecal
odor.
• Internal anal sphincter is under automatic
nervous system control.
• External anal sphincter is under voluntary
control.

116. Stomatitis: inflammation of
oral/buccal mucosa.

118. • Surgery: Neissan fundoplication; Wrapping of
the gastric fundus around the sphincter area
of the esophagus.

119. Hiatal hernia
• Eesophagus enter into the stomach through
an opening in the diaphragm known HIATUS.
• In Hiatal hernia this opening becomes large
and upper portion of the stomach moves into
lower thorax.
• A condition in which part of the stomach
pushes up through the diaphragm muscle

122. Peptic Ulcer Disease
• It is the erosion of the mucosal wall of
stomach, duodenum or in esophagus.
• Based upon the location, it is also called as
esophageal ulcer, gastric ulcer or duodenal
ulcer.
• Peptic ulcer is more commonly seen in
duodenum.

124. Etiology
1. Hyper-secretion of gastric juice, by-
• Increase stimulation of vagus nerve.
• Increase number or capacity of parietal cells
to secrete acids.
2. Impair mucosal barrier protection.

125. Risk factor
• Use of alcohol, smoking and ulcerogenic drugs
like aspirin, NSAID & steroids (so it never gives
empty stomach).
• Infection by helicobacter pylori bacteria (gram-
negative bacteria that causes 90% of peptic
ulcers.
• Family history of peptic ulcer & blood group O.
• Zollinger- Ellison syndrome (ZES) - Abnormal
secretion of gastrin from tumor of pancreatic
islets, which cause excessive secretion of gastric
juice.

126. • Stress especially cause duodenal ulcer (due to
vasoconstriction).
• Curling's ulcer (ulcer caused by severe burn).
• Cushing's ulcer (ulcer caused by increased
secretion of gastric acid due to vagus nerve
stimulation in increased ICP during head injury
cause).

127. GASTRIC ULCER DUODENAL ULCER
Age- 50 or more
Male : Female – 1:1
Clinical manifestation : Normal
or hyposecretion of HCL.
Wt loss.
Pain occur 30-60 min after a
meal.
Pain Relieved by Vomiting.
Ingestion of food may increase
the pain.
Vomiting and Hematemesis
seen.
Age- 30 -60
Male : Female – 2-3:1
Clinical manifestation : Hyper
secretion of HCL.
May Wt gain
Pain occur 2-3 hours after a
meal.
Wakes up in the night due to
pain.
Pain Relieved by Vomiting.
Ingestion of food may decrease
the pain.
Vomiting is uncommon.
Malena is coomon.

128. • Client education :
1. Avoid consuming alcohol and substances that
contain caffeine or chocolate.
2. Avoid smoking.
3. Avoid aspirin or NSAIDS.
4. Obtain adequate rest and reduce stress.

129. • Management - Histamine blocker such as
ranitidine or cimetidine is used to decrease
gastric acid production.
• Proton pump inhibitor such as omeprazole,
lansoprazole, pantoprazole is used to suppress
acid production.
• Avoid smoking, alcohol use and caffeinated
beverages and coffee.

130. Surgical management
• Total gastrectomy: removal of entire stomach
and some portion of esophagus attached to it
and anastomosis of esophagus to jejunum or
duodenum.
• So it is also called as esophagojejunostomy or
esophagoduodenostomy.

131. • Vagotomy: Removal of the vagus nerve supply
to stomach and there by decreases the stimuli
for gastric acid secretion Gastric resection:
Removal of the lower portion of the stomach
usually along with vagotomy. It is also called
as antrectomy.

132. • Billroth I: Partial gastrectomy and anastomosis
of remaining stomach to duodenum. It is also
called as gastroduodenostomy.

133. • Billroth II: Reconstruction after a partial
gastrectomy, the duodenal stump is closed
and a gastrojejunostomy is created.

135. • Pyloroplasty: Enlargement of pylorus to
prevent or decrease pyloric obstruction and
thereby enhancing gastric emptying.

136. • Postoperative interventions:
• Monitor vital signs.
• Place in a Fowler's position for comfort and to promote drainage.
• Administer fluids and electrolyte replacements intravenously as
prescribed; monitor intake and output.
• Assess bowel sounds.
• Monitor NG suction as prescribed.
• Maintain NPO status as prescribed for 1 to 3 days until peristalsis
returns.
• Progress the diet from NPO to sips of clear water to 6 small bland
meals a day, as prescribed when bowel sounds return.
• Monitor for postoperative complications of hemorrhage, dumping
syndrome, diarrhea, hypoglycemia, and vitamin B12 deficiency.

137. Dumping Syndrome
• Also called rapid gastric emptying. Occurs
when food moves from stomach to intestine
too quickly.
• It is one of the major complications of patients
who underwent partial or complete resection
of stomach.

138. • Manifestations:
• Sensation of fullness, weakness, faint,
dizziness, palpitation, diaphoresis, cramping
pain, diarrhea and borborygmi (loud gurgles
indicating hyperperistalsis).

139. • Patient education to prevent dumping
syndrome :
• Avoid sugar, salt and milk.
• Eat high protein, high fat low carbohydrate
food items.
• Eat small meals and avoid consuming fluids
along with meal.
• Lie down after eating.

140. • The part of the large intestine that is joined to
the rectum is called
a) Ascending colon
b) Descending colon
c) Transverse colon
d) Sigmoid colon

141. • The basic general layout of the gastrointestinal
tract wall from inside to outside follows this
sequence:
a.Submucosa → mucosa → muscular → serosa
b. Muscular → serosa → mucosa → submucosa
c. Mucosa → submucosa → muscular → serosa
d. Serosa → muscular → submucosa → mucosa

142. • In the liver, bacteria that found their way into
portal circulation is destroyed by : (ESIC 2019)
a) Hydrochloric acid
b) Kupffer cells
c) Cilia
d) Leukocytosis

143. APPENDICITIS
• Appendix is a small finger like projection
attached to cecum below ileo-cecal valve.
• Inflammation of this projection is knows as
appendicitis.
• Fecalith is the most common cause of
appendicitis.
• Most commonly occur in adolescents

144. Clinical Manifestation
• Low grade fever, nausea and vomiting
• Rebounding tenderness on palpation at Mc
Burney's point. (it is a point 2/3rd of the way
umbilicus to Anterior Superior Iliac Spine).
• Rovsing sign: Palpation of left lower quadrant
paradoxically elicit pain in the right lower
quadrant.

145. Diagnosis
• Blood test: Elevation of WBCS
• Abdominal X-ray, USG, CT
• Complication : Perforation of appendix which
leads to peritonitis

146. Management
• Appendectomy.

147. • KEY POINTS
1. Enema, laxatives and hot applications are
contraindicated in case of appendicitis. It
may lead to rupture of appendix and
peritonitis.
2. Fowler's position to minimize pain.
3. After surgery, place the client ina semi
fowler's position. This will help to reduce
tension in suture and abdominal organ.

148. PERITONITIS
• Inflammation of peritoneum, the serous
membrane covering the abdominal cavity.
• Content of abdominal organ leaks into the
abdominal cavity as a reşult of trauma,
perforation, infection, or inflammation
• Immediate response of intestinal tract in
peritonitis is hyper motility followed by
paralytic ileus.

149. Manifestations
• Diffused pain in the abdomen which becomes
constant and localized.
• Movement may aggravate the pain.
• Rebound tenderness and paralytic ileus may
be present.
• Elevated leukocyte count and electrolyte
abnormalities.

150. Diagnosis
• X-ray shows air and fluid levels and distended
bowel loops.
• Culture and sensitivity of peritoneal fluid to
identify the cause.

151. Management Manifestations
• Fluid and electrolyte replacement is the major
focus of management.
• Lung expansion is compromised due to the
compression of intra-abdominal fluid over the
lung. So oxygen therapy or intubation is often
necessary for airway management.
• Massive antibiotic therapy.

152. • Surgical management is needed if peritonitis
occurred as a result of appendicitis,
perforation etc.
• Peritonitis patients placed on side with knee
flexed. This position will reduce the tension on
the abdominal organs.

153. Pancreatitis
• Inflammation of the pancreas due to the any
etiological factor which causes injury to
pancreatic cells or activation of pancreatic
enzyme into pancreas rather than intestine
that may result in auto digestion of pancreas
by its own enzymes.
• Types -There are two types of pancreatitis.

154. 1. ACUTE PANCREATITIS :
• Sudden and single attack of inflammation of pancreas.
• Attack may be recurrent with resolution also called
acute pancreatitis.
Etiology :
• Alcohol abuse (may be increase secretion of pancreatic
enzyme) and obstructions of the pancreatic duct by
gallstones are the most common causes.
• Biliary tract discase (most common in female) such as
gall bladder stone and cystic fibrosis.
• Viral infection e.g. HIV, mumps and coxsackievirus.
• Some drugs like corticosteroids, NSAID and oral
contraceptive.

155. diagnosis
• Elevated serum level of WBC, bilirubin, lipase
(diagnostic marker) & amylase.

156. C/M
• Sudden abdominal pain in left upper quadrant
then radiates to back.
• Pain increase by intake of alcohol and fatty
foods.
• Abdominal tenderness & guarding.
• Cullen Sign and Turner's Sign

157. • Cullen's sign is superficial edema and
bruisingin the subcutaneous fatty tissue
around the umbilicus.
• It is a sign hemorrhage.
• It is also a sign of rupture of fallopian tube or
ectopic Pregnancy.

158. • Grey Turner's sign refers to bruising of the
flanks, the part of the body between the last
rib and the top of the hip.
• It is a sign of retroperitoneal hemorrhage, or
bleeding behind the peritoneum.
• Gray turner's sign (flank ecchymosis) may also
be rupture of aneurysm.

159. 2. CHRONIC PANCREATITIS :
• After repeated attack of acute pancreatitis,
the inflammatory process results in scarring
and calcification of pancreatic tissue.
• The damage is irreversible & affects both
endocrine & exocrine function of pancreas.

160. • Etiology – Excessive and chronic intake of
alcohol.
• Biliary tract disease like cholelithiasis, which
cause inflammation of sphincter of oddi (most
common cause).
• C/M – Sign symptoms of diabetes mellitus.
Jaundice, weight loss.
• Steatorrhea (fats in stool) which cause foul
smelling stool.
• Abdominal pain & tenderness which radiate to
back.

161. MANAGEMENT
• The patient should receives nothing by mouth until pain, nausea
and vomiting resolved.
• Total parenteral nutrition, fluid & electrolytes for patients with
severe pancreatitis.
• Administer somatostatin for inhibition of gastric motility and gastric
acid secretion, blockage of the exocrine and endocrine function of
the pancreas in the patient with acute pancreatitis.
• Administer pancreatin (a mixture of enzymes, chiefly amylase,
lipase and protease; used in patients with chronic pancreatitis, who
do not secrete adequate amounts of their own pancreatic
enzymes).
• Meperidine (pethidine) is a kind of opioid analgesic which is
believed to induce less biliary spasm (spasm of pancreatic duct and
sphincter of oddi) than morphine and codeine, so meperidine is
preferred analgesic in to cholecystitis, pancreatitis and biliary colic.

162. • Morphine causes spasm of biliary duct, so it is
contraindicated in pancreatitis as an analgesic.
• A nasogastric tube may be inserted and placed on
low, intermittent suctioning to reduce
hydrochloric acid levels or relieve gastric
distention, because increase level of gastric juice
or gastric distension may cause pancreatic
stimulation.
• Advice to avoid alcohol consumption and limited
intake of fats & protein.

163. Surgical Interventions:
1. Pancreaticojejunostomy: Anastomosis of
pancreatic duct to jejunum.
2. Whipple resection (Pancreaticoduodenectomy)
The head of the pancreas. the first part of the
small intestine (duodenum), the gallbladder and
the bile duct will be removed. The remaining
organs are reattached to allow digestion of food
normally after surgery.

165. PANCREAS
• It is a pale grey, retroperitoneal gland.
• It situated into epigastric and left
hypochondriac region.
• Its weight is about 60gm.
• The pancreas consists of a head, a body and a
tail.
• The head is expanded portion which lies into
curve of duodenum.

166. Structure of Pancreas
• 99% part of pancreas is exocrine and
remaining 1% part is endocrine (pancreatic
islets or islets of Langerhans).
• "Islets of Langerhans" are concentrated in to
tail portion of pancreas.
• The acinar cells of Pancreas secrete
"pancreatic juice".

167. • Just before entering the duodenum the
pancreatic duct join the common bile duct to
form Hepato-Pancreatic ampulla (Vater's
ampulla or papilla of Vater).
• Vater's ampulla opens into duodenum by
hepato-pancreatic sphincter or Sphincter of
Oddi.
• pH- alkaline (8 to 8.9) due to high
concentration of HCO3, (110-115mEq/liter).

168. Exocrine gland :
1. Secretes sodium bicarbonate to neutralize
the acidity of the stomach contents that
enter the duodenum.
2. Pancreatic juices contain enzymes for
digesting carbohydrates, fats, and proteins.

169. Endocrine gland :
1. "Secretes glucagon to raise blood glucose
levels and secretes somatostatin to exert
hypoglycemic effect .
2. The islets of Langerhans secrete insulin.
3. Insulin is secreted into the bloodstream and
is important for carbohydrate metabolism.

170. Pancreatic Enzyme in Pancreatic Juice
• Protein - digesting enzyme :
• Trypsinogen (converted to active trypsin ) and
chymotrypsinogen (convert to active
chymotrypsin).
• Both trypsin and chymotrypsin digest protein
and forms amino-acids.

171. • Fat - digesting (lipolytic) enzyme :
• Pancreatic lipase (powerful lipolytic enzyme)
digests triglyceride in to fatty acid & glycerol.

172. • Carbohydrate digesting enzyme :
• Pancreatic amylase digests starch into
oligosaccharide, disaccharides &
monosaccharide.
• Note - Protein digesting enzymes such as
trypsin or chymotrypsin are produced in
inactive form in pancreas as trypsinogen and
chymotrypsinogen, so do not digest cells of
pancreas.

173. Portal Circulation or entero-hepatic
circulation
• In the portal circulation venous blood from
capillaries of digestive system, spleen & pancreas
to passes through a Secondary capillaries bed
(hepatic sinusoids) in the liver before entering
into the IVC.
• It is essential because high concentration of
digested nutrients absorbed by digestive system
must first göes to liver.
•

174. • Portal Veins - Portal vein is formed by union of
following 5 veins
• 1) Splenic vein - Drain blood from spleen and
pancreas.
• 2) Inferior mesenteric vein - Drain blood from a
part of transverse colon, descending colon &
rectum.
• 3) Superior mesenteric vein - Drain blood from
small intestine, ascending colon and part of
transverse colon.
• 4) Gastric vein - Drain blood from stomach.
• 5) Cystic vein - Drain blood from gall bladder.

175. • Secretion of bile Volume 500 to 1000 ml/day.
COMPOSITION OF BILE :
• Water, mineral salt, mucus, bile pigment (bilirubin is most
common bile pigment) bile salts (derived from bile acid).
• Bile acids are the complex acid that occurs as salts in bile.
• It reabsorbed from the intestine to be used again by the
liver, so the circulation of bile acids is called enterohepatic
circulation.
• Bile does not contain any digestive enzyme so it called
pseudodigestive juice.
• Bile salts into small intestine helping in fat digestion.

176. Diagnostic Procedure
Upper GI tract study (barium swallow)
1. Description: Examination of the upper GI tract under
fluoroscopy after the client drinks barium sulfate
2. Preprocedure: Withhold foods and fluids for 8 hours
prior to the test.
3. Postprocedure:
• A laxative may be prescribed.
• Instruct the client to increase oral fluid intake to help
pass the barium.
• Monitor stools for the passage of barium stools will
appear chalky white for 24 to 72 hours
postprocedure) because barium can cause a bowel
obstruction.

177. Fiberoptic colonoscopy
• Fiberoptic endoscopy study in which the lining
of the large intestine is. visually examined;
biopsies can be performed.
• Cardiac and respiratory function is moni-
tored continuously during the test.
• Colonoscopy is performed with the client lying
on the left side with the knees drawn up to
the chest; position may be changed during the
test to facilitate passing of the scope.

178. • Preprocedure :
• A clear liquid diet is started on the day before
the test. Red, orange, and purple (grape)
liquids are to be avoided.
• The client receiving oral liquid bowel cleansing
prep- arations or enemas is at risk for fluid and
electrolyte imbalances.

179. Signs of Bowel Perforation and
Peritonitis
• Guarding of the abdomen
• Increased temperature and chills
• Pallor
• Progressive abdominal distention and
abdominal pain
• Restlessness
• Tachycardia and tachypnea

180. Liver biopsy
• A needle is inserted through the abdominal wall
to the liver to obtain a tissue sample for biopsy
and microscopic examination.
Preprocedure :
• Assess results of coagulation tests
(prothromtime, partial thromboplastin time,
platelet count).
• Adminbin ister a sedative as prescribed
• The client is placed in the supine or left lateral
position during the proce- dure to expose the
right side of the upper abdomen.

181. Post procedure :
• Assess vital signs
• Assess biopsy site for bleeding.
• Monitor for peritonitis
• Maintain bed rest for several hours as prescribed.
• Place the client on the right side with a pillow under
the costal margin for 2 hours to decrease the risk of
bleeding, and instruct the client to avoid coughing and
straining
• Instruct the client to avoid heavy lifting and strenuous
exercise for 1 week.

182. UREA BREATH TEST
• The urea breath test detects the presence of
Helicobacter pylori, the bacteria that cause peptic ulcer
disease.
• The client consumes a capsule of carbon-labeled urea
and provides a breath sample 10 to 20 minutes later.
• Certain medications may need to be avoided before
testing. These may include antibiotics for 1 month
before the test; 15 days sucralfate and omeprazole for
1 week before the test; and ranitidine, and nizatidine
for 24 hours before breath testing.
• H. pylori can also be detected by assessing serum
antibody levels. and

183. Liver and pancreas laboratory studies
• Liver enzyme levels (alkaline phosphatase
[ALP], aspartate aminotransferase [AST], and
alanine aminotransferase [ALT]) are elevated
with liver damage or bilary obstruction.
• Normal reference intervals: ALP, 0.5 to 2.0
mckat/L (35 to 120 U/L); AST, O to 35 U/L (0 to
35 U/L); ALT, 4 to 36 U/L(4 to oibo 36 U/L).

184. • Prothrombin time is prolonged with liver dam-
age.
• Normal reference interval: 11 to 12.5 seconds.
• An increase in cholesterol level indicates
pancreatitis or biliary obstruction.
• Normal reference interval: <200 mg/dL (<5.0
mmol/L).

185. • An increase in bilirubin level indicates liver
damage or biliary obstruction.
• Normal reference intervals: Total, 0.3 to 1.0
mg/dL, indirect 0.2 to 0.8 mg/dL, direct 0.1 to
0.3 mg/dL
• Increased values for amylase and lipase levels
indicate pancreatitis

186. CHOLECYSTITIS
Inflammation of the gallbladder that may occur
as an acute or chronic process
Acute inflammation is associated with gallstones
(cholelithiasis).
 A Chronic cholecystitis results when inefficient
bile emptying and gallbladder muscle wall
disease cause a fibrotic and contracted
gallbladder.
Acalculous cholecystitis occurs in the absence of
gallstones and is caused by bacterial invasion via
the lymphatic or vascular system.

187. • Assessment :
 Nausea and vomiting
 Indigestion
 Flatulence
 Epigastric pain that radiates to the right shoulder
or scapula
 Pain localized in right upper quadrant and trig-
gered by high-fat or high-volume meal
 Guarding, rigidity, and rebound tenderness Mass
palpated in the right upper quadrant

188.  Murphy's sign (cannot take a deep breath
when the examiner's fingers are passed below
the hepatic margin because of pain)
 Elevated temperature
 Tachycardia
 Signs of dehydration

189. • In case of Biliary obstruction :
 Jaundice
 Dark orange and foamy urine
 Steatorrhea (Oily, smelly stools) and clay-
colored feces
 Pruritis

190. Interventions :
 Maintain NPO status during nausea and
vomiting episodes.
Maintain NG decompression as prescribed for
severe vomiting.
Administer antiemetics as prescribed for
nausea and vomiting.
Administer analgesics as prescribed to relieve
pain and reduce spasm.

191. Administer antispasmodics (anticholinergics)
as prescribed to relax smooth muscle.
Instruct the client with chronic cholecystitis to
eat small, low-fat meals.
Instruct the client to avoid gas-forming foods.
Prepare the client for nonsurgical and surgical
procedures as prescribed.

192. Surgical interventions
• Cholecystectomy is the removal of the
gallbladder.
• Choledocholithotomy requires incision into
the common bile duct to remove the stone.
• Surgical procedures may be performed by
laparoscopy.

193. • Postoperative interventions :
1. Monitor for respiratory complications caused by
pain at the incisional site.
2. Encourage coughing and deep breathing.
3. Encourage early ambulation.
4. Instruct the client about splinting the abdomen
to prevent discomfort during coughing.
5. Administer antiemetics as prescribed for nausea
and vomiting.

194. • Administer analgesics as prescribed for pain
relief.
• Maintain NPO status and NG tube suction as
prescribed.
• Advance diet from clear liquids to solids when
prescribed and as tolerated by the client.
• Maintain and monitor drainage from the T-
tube, if present.

195. THANK YOU