Introduction: Gastrointestinal Disorders
The GI tract, also known as the alimentary canal, is a long, hollow, musculomembranous tube consisting of glands and accessory organs (salivary glands, liver, gallbladder, and pancreas). (See Reviewing GI anatomy and physiology, page 684, and Histology of the GI tract, page 685.) The GI tract breaks down food — carbohydrates, fats, and proteins — into molecules small enough to permeate cell membranes, thus providing cells with the necessary energy to function properly; it prepares food for cellular absorption by altering its physical and chemical composition. (See Primary source of digestive hormones, pages 686 and 687.) Consequently, a malfunction along the GI tract can produce far-reaching metabolic effects, eventually threatening life itself. The GI tract is an unsterile system filled with bacteria and other flora; these organisms can cause superinfection from antibiotic therapy or they can infect other systems when a GI organ ruptures. A common indication of GI problems is referred pain, which makes diagnosis especially difficult.
Accurate assessment vital
Your assessment of the patient with suspected GI disease must begin with a careful history that includes occupation, family history, and recent travel. The medical history should include previous hospital admissions; surgical procedures (including recent tooth extraction); family history of ulcers, colitis, or cancer; and current medications, whether prescribed, over-the-counter, or herbal remedies, with particular attention to aspirin, steroids, or anticoagulants.
Have the patient describe his chief complaint in his own words. Does he have abdominal pain, indigestion, heartburn, or rectal bleeding? How long has he had it? What relieves these symptoms or makes them worse? Has he experienced nosebleeds or difficulty in swallowing recently? Has he had recent weight loss or gain? Is he on a special diet? Does he drink alcoholic beverages or smoke? If yes to either, how much and how often? Ask about bowel habits. Does he regularly use laxatives or enemas? If he experiences nausea and vomiting, what does the vomitus look like? Does changing his position relieve nausea?
Next, try to define and locate any pain. Ask the patient to describe the pain. Is it dull, sharp, burning, aching, spasmodic, or intermittent? Where is it located? Does it radiate? How long does it last? When does it occur? What triggers it? What relieves it?
Visual assessment
Observe how the patient looks and note appropriateness of behavior. Changes in fluid and electrolyte balance, severe infection, drug toxicity, and hepatic disease may cause abnormal behavior. Your visual examination should check:
❑ Skin: loss of turgor, jaundice, cyanosis, pallor, diaphoresis, petechiae, bruises, edema, and texture (dry or oily)
❑ Head: color of sclerae, sunken eyes, dentures, caries, lesions, tongue (color, swelling, dryness), and breath odor
❑ Chest: shape (asymmetrical, barrel, or sunken)
❑ Lungs: rate, rhythm, and quality of respirations
❑ Abdomen: size and shape (distention, contour, visible masses, and protrusions), abdominal scars or fistulae, excessive skin folds (may indicate wasting), and abnormal respiratory movements (inflammation of diaphragm).
Auscultation, palpation, and percussion
Auscultation provides helpful clues to GI abnormalities. For example, absence of bowel sounds over the area to the lower right of the umbilicus may indicate peritonitis. High-pitched sounds that coincide with colicky pain may indicate small bowel obstruction. Less intense, low-pitched rumbling noises may accompany minor irritation.
Palpating the abdomen after auscultation helps detect tenderness, muscle guarding, and abdominal masses. Watch for muscle tone (boardlike rigidity points to peritonitis or hemorrhage; transient rigidity suggests severe pain) and tenderness (rebound tenderness may indicate peritoneal inflammation).
Percussion helps detect air, fluid, and solid matter in the abdominal region.
Diagnostic tests
After physical assessment, several tests can identify GI malfunction.
❑ A barium or gastrografin swallow is used primarily to examine the esophagus. Gastrografin may be used instead of barium. Like barium, gastrografin facilitates X-ray imaging. However, if gastrografin escapes from the GI tract, it’s absorbed by the surrounding tissue, whereas escaped barium isn’t absorbed and can cause complications.
❑ In an upper GI series, swallowed barium sulfate travels through the esophagus, stomach, and duodenum to reveal abnormalities. The barium outlines stomach walls and delineates ulcer craters and defects.
❑ A small-bowel series, an extension of the upper GI series, visualizes barium flowing through the small intestine to the ileocecal valve.
❑ A barium enema (lower GI series) allows X-ray visualization of the colon.
❑ A stool specimen is useful to detect suspected GI bleeding, infection, or malabsorption as well as the presence of parasites. Guaiac test for occult blood, microscopic stool examination for ova and parasites, and tests for fat require several specimens.
❑ In esophagogastroduodenoscopy, insertion of a fiber-optic scope allows direct visual inspection of the esophagus, stomach, and duodenum. These structures are examined for varices, tumors, inflammation, hernias, polyps, ulcers, and obstruction.
❑ Proctosigmoidoscopy permits inspection of the rectum and distal sigmoid colon; colonoscopy is used for inspection of the descending, transverse, and ascending colon. These tests help visualize tumors, polyps, hemorrhoids, or ulcers.
❑ Gastric analysis examines gastric secretions for the presence of high levels of gastrin and the amount of acid produced.
❑ Endoscopic retrograde cholangiopancreatography directly visualizes the esophagus, stomach, proximal duodenum, and fluoroscopic visualization of the pancreatic, hepatic, and biliary ducts. This test can help visualize duct obstruction, benign structures, cysts, anatomic variations, and malignant tumors.
Intubation
Certain GI disorders require nasogastric (NG) intubation to empty the stomach and intestine, to aid diagnosis and treatment, to decompress obstructed areas, to detect and treat GI bleeding, and to administer medications or feedings. Tubes generally inserted through the nose are the short NG tubes (the Levin, the Salem Sump, and the specialized Sengstaken-Blakemore) and the long intestinal tubes (Cantor and Miller-Abbott). The larger Ewald tube is usually inserted orally.
When caring for the patient with a tube:
❑ Explain the procedure before intubation.
❑ Maintain accurate intake and output records. Measure gastric drainage every 8 hours; record the amount, color, odor, and consistency. When irrigating the tube, note the amount of saline solution instilled and aspirated. Check for fluid and electrolyte imbalances.
❑ Provide good oral and nasal care. Brush the patient’s teeth frequently and provide mouthwash. Make sure that the tube is secure, but isn’t causing pressure on the nostrils. Change the tape to the nose every 24 hours. Gently wash the area around the tube, and apply a water-soluble lubricant to soften crusts. These measures help prevent sore throat and nose, dry lips, nasal excoriation, and parotitis.
❑ Ensure maximum patient comfort. After insertion of a long intestinal tube, instruct the patient to turn from side to side to facilitate its passage through the GI tract. Note the tube’s progress. Never attach an intestinal tube to a patient’s gown, bed linens, side rails of the bed, and so forth.
❑ With both types of tubes, tell the patient to expect a feeling of dryness or a lump in the throat; if he’s allowed, suggest that he chew gum or eat hard candy to relieve discomfort.
❑ Always keep scissors taped to the wall near the bed when the patient has a Sengstaken-Blakemore tube in place. If the tube should dislodge and obstruct the bronchus, cut the lumen to the balloons immediately. Sometimes the tube is taped to the face piece of a football helmet worn by the patient to prevent the tube from dislodging and to put traction on the tube.
❑ After removing the tube from a patient with GI bleeding, watch for signs and symptoms of recurrent bleeding, such as hematemesis, decreased hemoglobin level, pallor, chills, diaphoresis, hypotension, and rapid pulse.
❑ Provide emotional support because the patient may panic at the sight of a tube. A calm, reassuring manner can help minimize his fear.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Digestive symptoms
» Next page: Irritable bowel syndrome (Professional Guide to Diseases (Eighth Edition))
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