NCLEX: Gastrointestinal disorders

Gastrointestinal disorders: A look at gastrointestinal disorders

Focus topic: Gastrointestinal disorders

As the site of the body’s digestive processes, the GI system has the critical task of supplying essential nutrients to fuel the brain, heart, and lungs. GI function also profoundly affects the quality of life through its impact on overall health.

Gastrointestinal disorders: Anatomy and physiology

Focus topic: Gastrointestinal disorders

The GI system’s major functions include ingestion and digestion of food and elimination of waste products. When these processes are interrupted, the patient can experience problems ranging from loss of appetite to acid-base imbalances.
The GI system consists of two major divisions: the GI tract and the accessory organs.

Gastrointestinal disorders

Gastrointestinal disorders: GI tract

Focus topic: Gastrointestinal disorders

The GI tract is a hollow tube that begins at the mouth and ends at the anus. About 25 (7.5 m) long, it consists of smooth muscle alternating with blood vessels and nerve tissue. Specialized circular and longitudinal fibers contract, causing peristalsis, which helps propel food through the GI tract. The GI tract includes the pharynx, esophagus, stomach, small intestine, and large intestine.

Move into the mouth

Focus topic: Gastrointestinal disorders

Digestive processes begin in the mouth with chewing, salivating, and swallowing. The tongue provides the sense of taste. Saliva is produced by three pairs of glands: the parotid, submandibular, and sublingual.

Proceed to the pharynx

Focus topic: Gastrointestinal disorders

The pharynx, or throat, allows the passage of food from the mouth to the esophagus. The pharynx assists in the swallowing process and secretes mucus that aids in digestion. The epiglottis —a thin, leaf-shaped structure made of fibrocartilage — lies directly behind the root of the tongue. When food is swallowed, the epiglottis closes over the larynx, and the soft palate lifts to block the nasal cavity. These actions keep food and fluid from being aspirated into the airway.

Enter the esophagus

Focus topic: Gastrointestinal disorders

The esophagus is a muscular, hollow tube about 10 (25.5 cm) long that moves food from the pharynx to the stomach. When food is swallowed, the upper esophageal sphincter relaxes, and the food moves into the esophagus. Peristalsis then propels the food toward the stomach. The gastroesophageal sphincter at the lower end of the esophagus normally remains closed to prevent reflux of gastric contents. The sphincter opens during swallowing, belching, and vomiting.

Slide into the stomach

Focus topic: Gastrointestinal disorders

The stomach, a reservoir for food, is a dilated, saclike structure that lies obliquely in the left upper quadrant below the esophagus and diaphragm, to the right of the spleen, and partly under the liver. The stomach contains two important sphincters: the cardiac sphincter, which protects the entrance to the stomach, and the pyloric sphincter, which guards the exit.
The stomach has three major functions. It:

  • stores food
  • mixes food with gastric juices (hydrochloric acid, pepsin, gastrin, and intrinsic factor)
  • passes chyme — a watery mixture of partly digested food and
  • digestive juices — into the small intestine for further digestion and absorption. An average meal can remain in the stomach for 3 to 4 hours.
  • Accordion-like folds in the stomach lining called rugae allow the stomach to expand when large amounts of food and fluid are ingested.

Slip through the small intestine

Focus topic: Gastrointestinal disorders

The small intestine is about 20 (6 m) long and is named for its diameter, not its length. It has three sections: the duodenum, the jejunum, and the ileum. As food passes into the small intestine, the end products of digestion are absorbed through its thin mucous membrane lining into the bloodstream.
Carbohydrates, fats, and proteins are broken down in the small intestine. Enzymes from the pancreas, bile from the liver, and hormones from glands of the small intestine all aid digestion. These secretions mix with the food as it moves through the intestines by peristalsis.

Last stop, the large intestine

Focus topic: Gastrointestinal disorders

The large intestine, or colon, is about 5 (1.5 m) long and is responsible for:
• absorbing excess water and electrolytes
• storing food residue
• eliminating waste products in the form of feces.
The large intestine includes the cecum; the ascending, transverse, descending, and sigmoid colons; the rectum; and the anus — in that order. The appendix, a fingerlike projection, is attached to the cecum. Bacteria in the colon produce gas or flatus.

Gastrointestinal disorders: Accessory organs

Focus topic: Gastrointestinal disorders

Accessory GI organs include the liver, pancreas, gallbladder, and bile ducts. The abdominal aorta and the gastric and splenic veins also aid the GI system.

Look at the liver

Focus topic: Gastrointestinal disorders

The liver is located in the right upper quadrant under the diaphragm. It has two major lobes, divided by the falciform ligament.  The liver is the heaviest organ in the body, weighing about 3 lb(1.5 kg) in an adult.
The liver’s functions include:

  • metabolizing carbohydrates, fats, and proteins
  • detoxifying blood
  • converting ammonia to urea for excretion
  • synthesizing plasma proteins, nonessential amino acids, vitamin A, and essential nutrients, such as iron and vitamins D, K, and B12.
    The liver also secretes bile, a greenish fluid that helps digest fats and absorb fatty acids, cholesterol, and other lipids. Bile also gives stool its color.

Gaze at the gallbladder

Focus topic: Gastrointestinal disorders

The gallbladder is a small, pear-shaped organ about 4 (10 cm) long that lies halfway under the right lobe of the liver. Its main function is to store bile from the liver until the bile is emptied into the duodenum. This process occurs when the small intestine initiates chemical impulses that cause the gallbladder to contract.

Presenting the pancreas

Focus topic: Gastrointestinal disorders

The pancreas, which measures 6 to 8 (15 to 20 cm) in length, lies horizontally in the abdomen behind the stomach. It consists of a head, tail, and body. The body of the pancreas lies in the right upper quadrant, and the tail is in the left upper quadrant, attached to the duodenum. The tail of the pancreas touches the spleen. The pancreas releases insulin and glycogen into the bloodstream and releases pancreatic enzymes into the duodenum for digestion.

Behold the bile ducts

Focus topic: Gastrointestinal disorders

The bile ducts provide a passageway for bile to travel from the liver to the intestines. Two hepatic ducts drain the liver, and the cystic duct drains the gallbladder. These ducts converge into the common bile duct, which then empties into the duodenum.

View the vasculature

Focus topic: Gastrointestinal disorders

The abdominal aorta supplies blood to the GI tract. It enters the abdomen and then splits into many branches that supply blood to the length of the GI tract.
The gastric and splenic veins drain absorbed nutrients into the portal vein of the liver. After entering the liver, the venous blood circulates and then exits the liver through the hepatic vein, emptying into the inferior vena cava.

Gastrointestinal disorders: Assessment

Focus topic: Gastrointestinal disorders

GI disorders can have many baffling signs and symptoms. To help sort out significant symptoms, you’ll need to take a thorough patient history. Then you’ll probe further by conducting a thorough physical examination, using inspection, auscultation, palpation, and percussion.

Gastrointestinal disorders: History

Focus topic: Gastrointestinal disorders

To help track the development of relevant signs and symptoms over time, you’ll need to develop a detailed patient history.

Current health status
Ask the patient about changes in appetite, difficulty chewing or swallowing, indigestion, nausea, vomiting, diarrhea, constipation, and abdominal pain. Has he noticed a change in bowel movements? Has he ever seen blood in his stool?

Drug difficulties

Focus topic: Gastrointestinal disorders

Ask the patient if he’s taking any medications. Some drugs — including aspirin, sulfonamides, nonsteroidal anti-inflammatory drugs (NSAIDs), and some antihypertensives — can cause GI signs and symptoms.
Don’t forget to ask about laxative use; habitual use may cause constipation. Also ask the patient if he’s allergic to medications or foods. Such allergies commonly cause GI symptoms.

Previous health status
To determine if your patient’s problem is new or recurring, ask about past GI illnesses, such as ulcers, gallbladder disease, inflammatory bowel disease, gastroesophageal reflux, or GI bleeding. Also ask if he has had abdominal surgery or trauma.

Family history
Because some GI disorders are hereditary, ask the patient whether anyone in his family has had a GI disorder. Disorders with a familial link include:
• ulcerative colitis
• GI cancer
• stomach ulcers
• diabetes
• alcoholism
• Crohn’s disease.

Lifestyle patterns
Inquire about your patient’s occupation, home life, financial situation, stress level, and recent life changes. Be sure to ask about alcohol, caffeine, and tobacco use as well as food consumption, meal frequency, exercise habits, and oral hygiene. Also ask about sleep patterns. How many hours of sleep does he feel he needs? How many does he get?

Gastrointestinal disorders: Physical examination

Focus topic: Gastrointestinal disorders

Physical assessment of the GI system includes evaluation of the mouth, abdomen, liver, and rectum. To perform an abdominal assessment, use this sequence: inspection, auscultation, percussion, and palpation. Palpating or percussing the abdomen before you auscultate it can change the character of the patient’s bowel sounds and lead to an inaccurate assessment.

Mouth
Use inspection and palpation to assess the mouth.

Open wide

Focus topic: Gastrointestinal disorders

First, inspect the patient’s mouth and jaw for asymmetry and swelling. Check his bite, noting malocclusion from an overbite or underbite. Inspect the inner and outer lips, teeth, and gums with a penlight. Note bleeding, gum ulcerations, and missing, displaced, or broken teeth. Palpate the gums for tenderness and the inner lips and cheeks for lesions.

Now, stick out your tongue

Focus topic: Gastrointestinal disorders

Assess the tongue, checking for coating, tremors, swelling, and ulcerations. Note unusual breath odors. Finally, examine the pharynx, looking for uvular deviation, tonsillar abnormalities, lesions, plaques, and exudate.

Abdomen
Have the patient lie in the supine position, with knees slightly flexed. Use inspection, auscultation, percussion, and palpation to examine the abdomen. Assess painful areas last to help prevent the patient from experiencing increased discomfort and tension.

Inspection
Begin by mentally dividing the abdomen into four quadrants and then imagining the organs in each quadrant.

Gastrointestinal disorders

Learn the lingo

Focus topic: Gastrointestinal disorders

You can more accurately pinpoint your physical findings at the midline by knowing these three terms:

  • epigastric — above the umbilicus and between the costal margins
  • umbilical — around the navel
  • suprapubic — above the symphysis pubis.

The shape of things

Focus topic: Gastrointestinal disorders

Observe the abdomen for symmetry, checking for bumps, bulges, or masses. Also note the patient’s abdominal shape and contour.Assess the umbilicus, which should be located mid-line in the abdomen and inverted. If his umbilicus protrudes, the patient may have an umbilical hernia.

Scanning the skin

Focus topic: Gastrointestinal disorders

The skin of the abdomen should be smooth and uniform in color. Note stretch marks, or striae, and dilated veins. Record the length of any surgical scars on the abdomen.

Riding the peristaltic wave

Focus topic: Gastrointestinal disorders

Note abdominal movements and pulsations. Usually, waves of peristalsis can’t be seen; if they’re visible, they look like slight, wavelike motions. If you observe visible rippling waves, report them immediately; they may indicate bowel obstruction. In thin patients, pulsation of the aorta is visible in the epigastric area. Marked pulsations may occur with hypertension, aortic aneurysm, and other conditions causing widening pulse pressure.

Auscultation
Lightly place the stethoscope diaphragm in the right lower quadrant, slightly below and to the right of the umbilicus. Auscultate in a clockwise fashion in each of the four quadrants, spending at least 2 minutes in each area. Note the character and quality of bowel sounds in each quadrant. In some cases, you may need to auscultate for 5 minutes before you hear sounds. Be sure to allow enough time for listening in each quadrant before you decide that bowel sounds are absent.
Before auscultating the abdomen of a patient with a gastric or an abdominal tube connected to suction, such as a nasogastric (NG) tube, briefly clamp the tube or turn off the suction. Suction noises can obscure or mimic actual bowel sounds.

Pardon my borborygmus

Focus topic: Gastrointestinal disorders

In a normal bowel, you’ll hear high-pitched, gurgling noises caused by air mixing with fluid during peristalsis. The noises vary in frequency, pitch, and intensity and occur irregularly from 5 to 34 times per minute. They’re loudest before mealtimes. Borborygmus, or stomach growling, is the loud, gurgling, splashing bowel sound heard over the large intestine as gas passes through it.
Bowel sounds are classified as normal, hypoactive, or hyperactive.

Humming along

Focus topic: Gastrointestinal disorders

Auscultate for vascular sounds with the bell of the stethoscope. Using firm pressure, listen over the aorta and renal, iliac, and femoral arteries for bruits. Check for venous hums over the portal vein, inferior vein cava, and common iliac veins.

Gastrointestinal disorders

Percussion
Direct or indirect percussion is used to determine the size and location of abdominal organs and to detect air or fluid in the abdomen, stomach, or bowel. In direct percussion, strike your hand or finger directly against the patient’s abdomen. In indirect percussion, use the middle finger of your dominant hand or a percussion hammer to strike a finger resting on the patient’s abdomen. Begin percussion in the right lower quadrant and proceed clockwise, covering all four quadrants. Don’t percuss the abdomen of a patient with an abdominal aortic aneurysm because doing so can precipitate a rupture.

Tympany: Never a dull moment

Focus topic: Gastrointestinal disorders

Normally, you’ll hear two sounds during percussion of the abdomen: tympany and dullness. When you percuss over hollow organs, such as an empty stomach or bowel, you’ll hear a clear, hollow sound like a drum beating. This sound, tympany, predominates because the stomach and bowel normally contain air. The degree of tympany depends on the amount of air and gastric dilation. When you percuss over solid organs — such as the liver, kidney, or feces-filled intestines — the sound changes to dullness. Note where percussed sounds change from tympany to dullness.

Sounding out the liver

Focus topic: Gastrointestinal disorders

Percussion of the liver can help you estimate its size. Hepatomegaly is commonly associated with hepatitis and other liver diseases. Liver borders may be obscured and difficult to assess.

Dull, yes — but never boring!

Focus topic: Gastrointestinal disorders

The spleen is located at about the level of the 10th rib, in the left midaxillary line. Percussion may produce a small area of dullness, generally 7 (18 cm) or less in adults. However, the spleen usually can’t be percussed because tympany from the colon masks the dullness of the spleen. To assess a patient for splenic enlargement, ask him to breathe deeply. Then percuss along the 9th to 11th intercostal spaces on the left, listening for a change from tympany to dullness. Measure the area of dullness.

Palpation
Palpate all four quadrants, leaving painful and tender areas for last.

Gastrointestinal disorders

Light touch

Focus topic: Gastrointestinal disorders

Light palpation helps identify muscle resistance and tenderness as well as the location of some superficial organs. To palpate, put the fingers of one hand close together, depress the skin about 1/2 (1.3 cm) with your fingertips, and make gentle, rotating movements. Avoid short, quick jabs.
The abdomen should be soft and nontender. As you palpate the four quadrants, note organs, masses, and areas of tenderness or increased resistance.

In deep

Focus topic: Gastrointestinal disorders

To perform deep palpation, push the abdomen down about 2 to 3 (5 to 7.5 cm). In an obese patient, put one hand on top of the other and push. Palpate the entire abdomen in a clockwise direction, checking for tenderness, pulsations, organ enlargement, and masses.
If the patient’s abdomen is rigid, don’t palpate it. He could have peritoneal inflammation, and palpation could cause pain or could rupture an inflamed organ.
Palpate the patient’s liver to check for enlargement and tenderness. Unless the spleen is enlarged, it isn’t palpable. To attempt to palpate the spleen, stand at the patient’s right side. Use your left hand to support his back left lower rib cage, and ask him to take a deep breath. Then, with your right hand on his abdomen, press up and in toward the spleen. If you do feel the spleen, stop palpating immediately because compression can cause rupture.

Gastrointestinal disorders

Rectum and anus
If the patient is age 40 or older, perform a rectal examination as part of your GI assessment. Explain the procedure to him before you begin.
First, inspect the perianal area. Put on gloves and spread the buttocks to expose the anus and surrounding tissue, checking for fissures, lesions, scars, inflammation, discharge, rectal prolapse, and external hemorrhoids. Ask the patient to strain as if he’s having a bowel movement; this may reveal internal hemorrhoids, polyps, or fissures. The skin in the perianal area is normally somewhat darker than that of the surrounding area.
Next, palpate the rectum. Apply a water-soluble lubricant to your gloved index finger. Tell the patient to relax, and warn him that he’ll feel some pressure. Then insert your finger into the rectum, toward the umbilicus. To palpate as much of the rectal wall as possible, rotate your finger clockwise and then counterclockwise.
The rectal walls should feel soft and smooth, without masses, fecal impaction, or tenderness.

Gastrointestinal disorders

Inspect and test

Focus topic: Gastrointestinal disorders

Remove your finger from the rectum, and inspect the glove for stool, blood, and mucus. Test fecal matter adhering to the glove for occult blood using a guaiac test.

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