MEDICAL SURGICAL NURSING

NCM 112 1ST SEMESTER

-​ collapsible tube connecting the mouth to the

stomach, through which food passes as it is
ASSESSMENT OF DIGESTIVE ingested
AND GI FUNCTION Hydrochloric acid
-​ cid secreted by the glands in the stomach;
mixes with chyme to break it down into
OUTLINE absorbable molecules and to aid in the
destruction of bacteria
A.​ ANATOMIC AND PHYSIOLOGIC OVERVIEW Ingestion
B.​ ASSESSMENT OF THE GI SYSTEM -​ phase of the digestive process that occurs
a.​ Health Hx when food is taken into the GI tract via the
b.​ Physical Ax mouth and esophagus
C.​ DIAGNOSTIC EVALUATION Intrinsic factor
a.​ Serum Laboratory Studies -​ a gastric secretion that combines with vitamin
b.​ Stool Tests
B12 so that the vitamin can be absorbed
c.​ Breath Tests
d.​ Abdominal Ultrasonography Large intestine
e.​ Genetic Testing -​ the portion of the GI tract into which waste
f.​ Imaging Studies material from the small intestine passes as
g.​ Endoscopic Procedures absorption continues and elimination begins;
h.​ Manometry and Electrophysiologic consists of several parts—ascending segment,
Studies transverse segment, descending segment,
i.​ Gastric Analysis, Gastric Acid
Stimulation Test, and pH Monitoring sigmoid colon, and rectum (synonym: colon)
j.​ Laparoscopy (Peritoneoscopy) Lipase
-​ an enzyme that aids in the digestion of fats
Microbiome
-​ the collective genome of all microbes in a
GLOSSARY microbiota microbiota: the complement of
microbes in a given environment
Absorption Pepsin
-​ phase of the digestive process that occurs -​ a gastric enzyme that is important in protein
when small molecules, vitamins, and minerals digestion
pass through the walls of the small and large small intestine
intestine and into the bloodstream -​ longest portion of the GI tract, consisting of
Amylase three parts —duodenum, jejunum, and
-​ an enzyme that aids in the digestion of starch ileum—through which food mixed with all
Anus secretions and enzymes passes as it continues
-​ last section of the gastrointestinal (GI) tract; to be digested and begins to be absorbed into
outlet for waste products from the GI system the bloodstream
Chyme Stomach
-​ mixture of food with saliva, salivary enzymes, -​ distensible pouch into which the food bolus
and gastric secretions that is produced as food passes to be digested by gastric enzymes
passes through the mouth, esophagus, and Trypsin
stomach -​ enzyme that aids in the digestion of protein
Digestion
-​ phase of the digestive process that occurs
when digestive enzymes and secretions mix TYPES OF PATHOLOGIES
with ingested food and when proteins, fats, and
sugars are broken down into their component ●​ Bleeding: Common in conditions like ulcers or
smaller molecules cancer. (Overt: is seen sa naked eye, ex. Melena;
Dyspepsia Occult is dli and requires dx tests)
-​ indigestion; upper abdominal discomfort
associated with eating
Elimination
-​ phase of the digestive process that occurs after
digestion and absorption, when waste products
are evacuated from the body
Esophagus

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Common causes of gastrointestinal bleeding

Extrinsic Factors Affecting GI Function
include:
1.​ Peptic Ulcers: Sores in the stomach or
duodenum that can bleed, often caused ●​ Stress and Anxiety: Can lead to indigestion,
by Helicobacter pylori. anorexia, or bowel disturbances.
2.​ Inflammatory Bowel Disease: Crohn's ●​ Fatigue: May exacerbate GI symptoms.
disease or ulcerative colitis, which can ●​ Dietary Changes: Abrupt changes can cause
inflame the GI tract and lead to bleeding. discomfort or disorders like lactose intolerance.
3.​ Esophageal Varices: Swollen veins in
the esophagus, primarily due to liver
cirrhosis. Assessment and Education:
4.​ Tumors: Benign or malignant growths
that can erode blood vessels and cause ●​ Nurses should consider both mental and physical
bleeding. factors when assessing and educating patients
5.​ Trauma: Injury or surgery that damages about GI health.
blood vessels in the GI tract.
6.​ Vascular Anomalies: Abnormal blood
vessels that can rupture and bleed.
A ANATOMIC AND PHYSIOLOGIC
7.​ Esophagitis: Inflammation of the
OVERVIEW
esophagus from acid reflux.

●​ Perforation: Often due to ulcers or trauma.

●​ Obstruction: Can be caused by tumors,
adhesions, or congenital anomalies. Can be either
mechanical (physical blockage) or functional
(disordered movements). If there is no physical
blockage visible on imaging, the obstruction is
likely functional rather than mechanical. Functional
obstructions are caused by impaired intestinal
movements due to paralysis or inflammation, not a
physical blockage. Common mechanical causes
(as shown in image):

Figure 38-1 • Organs of the digestive system and associated

●​ Inflammation: Seen in conditions like gastritis or structures.
inflammatory bowel disease.
●​ Cancer: Affects various parts of the GI tract,
including the esophagus, stomach, and colon.

Causes of GI Abnormalities:
A1 ANATOMY
●​ Congenital: Present at birth, such as malrotation
or atresias. ●​ Length and Pathway: The GI tract extends from
●​ Inflammatory: Conditions like Crohn's disease or the mouth to the anus, measuring 7 to 7.9 meters
ulcerative colitis. (23 to 26 feet) in length.
●​ Infectious: Caused by pathogens like
Helicobacter pylori.
●​ Traumatic: Resulting from injury or surgery. ESOPHAGUS
●​ Neoplastic: Tumors, both benign and malignant.

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●​ Located in the mediastinum, anterior to the spine ●​ Anal Sphincters: A network of striated muscle
and posterior to the trachea and heart. It is forms both the internal and external anal
approximately 25 cm (10 inches) long and passes sphincters, regulating the anal outlet.
through the diaphragm at the diaphragmatic
hiatus.
BLOOD SUPPLY

●​ Arterial Supply: The GI tract receives blood from

STOMACH
arteries originating along the thoracic and
abdominal aorta, including the gastric artery and
●​ Situated in the left upper abdomen under the left superior and inferior mesenteric arteries.
lobe of the liver and diaphragm, overlaying most of ●​ Venous Return: The portal venous system
the pancreas. It is a hollow muscular organ with a includes the superior mesenteric, inferior
capacity of about 1500 mL. mesenteric, gastric, splenic, and cystic veins,
●​ Stomach Functions: Stores food during eating, which form the vena portae that enters the liver.
secretes digestive fluids, and propels partially ●​ Liver Circulation: Blood in the liver is distributed
digested food (chyme) into the small intestine. throughout and collected into the hepatic veins,
●​ Anatomic Regions of the Stomach: which then drain into the inferior vena cava.
○​ cardia (entrance), ●​ Venous Drainage: The superior mesenteric vein
○​ fundus (body), and returns blood from the small intestine, cecum, and
○​ pylorus (outlet). ascending and transverse portions of the colon.
●​ Pyloric Sphincter: Formed by circular smooth ●​ Blood Flow: Blood flow to the GI tract accounts
muscle in the pylorus, controlling the opening for about 20% of total cardiac output and
between the stomach and small intestine. increases significantly after eating.

SMALL INTESTINE

●​ The small intestine is the longest segment of the

GI tract, accounting for about two-thirds of its total
length. It provides approximately 70 meters (230
feet) of surface area for secretion and absorption.
●​ Divided into three sections:
○​ duodenum (most proximal)
○​ jejunum (middle)
○​ ileum (distal).

●​ Ileocecal Valve: Located at the end of the ileum,

this valve controls the flow of digested material
into the large intestine and prevents bacterial
Figure 38-2 • Anatomy and blood supply of the large
reflux into the small intestine.
intestine.
●​ Ampulla of Vater: The common bile duct empties
into the duodenum here, allowing the passage of
bile and pancreatic secretions. ANS AND GI TRACT

LARGE INTESTINE ●​ Innervation: Both sympathetic and

parasympathetic portions of the autonomic
nervous system innervate the GI tract.
●​ Segments: The large intestine includes cecum,
●​ Sympathetic Nervous System: Exerts an
the ascending segment on the right side of the
inhibitory effect on the GI tract, decreasing gastric
abdomen, the transverse segment extending from
secretion and motility, and causing sphincters and
right to left in the upper abdomen, and the
blood vessels to constrict.
descending segment on the left side.
●​ Parasympathetic Nervous System: Stimulates
●​ Vermiform Appendix: Attached to the cecum, it
peristalsis and increases secretory activities.
has little or no physiological function.
Sphincters relax under parasympathetic
●​ Terminal Portion: The sigmoid colon, rectum, and
stimulation, except for the upper esophageal
anus complete the terminal portion of the large
intestine.

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sphincter and external anal sphincter, which are is secreted to facilitate vitamin B12 absorption in
under voluntary control. the ileum.
●​ Peristaltic Contractions: Propels stomach
contents toward the pylorus, mechanically
breaking down large food particles.
●​ Retention Time: Food remains in the stomach for
B1 PHYSIOLOGY 30 minutes to several hours, depending on
volume, osmotic pressure, and chemical
Functions of the GI Tract composition.
●​ Breakdown of Food: The GI tract breaks down ●​ Chyme Formation: Partially digested food mixed
food into molecular forms that can be absorbed by with gastric secretions forms chyme, which enters
the body. This process involves mechanical and the small intestine for nutrient absorption.
chemical digestion. ●​ Regulation: Hormones, neuroregulators, and local
●​ Absorption: Nutrients are absorbed into the regulators in gastric secretions control secretion
bloodstream through the walls of the small rates and influence gastric motility.
intestine.
●​ Elimination: Undigested food and waste products
SMALL INTESTINE FUNCTION
are eliminated from the body through the large
intestine.
●​ Digestive Process: Continues in the duodenum
with secretions from the pancreas, liver,
CHEWING AND SWALLOWING gallbladder, and intestinal glands. These
secretions contain enzymes like amylase, lipase,
●​ Chewing Process: Begins digestion by breaking and bile.
down food into small particles that can be mixed ●​ Pancreatic Secretions: Alkaline due to
with digestive enzymes. bicarbonate, neutralizing acidic stomach contents.
●​ Salivation: Eating or the sight, smell, or taste of Enzymes include trypsin (protein), amylase
food triggers reflex salivation. Approximately 1.5 (starch), and lipase (fats).
liters of saliva are secreted daily from the parotid, ●​ Bile Function: Bile salts (a component of bile)
submaxillary, and sublingual glands. emulsifies fats for easier digestion and absorption.
●​ Saliva Composition: Contains ptyalin (salivary ●​ Sphincter of Oddi: Controls bile flow at the
amylase) for starch digestion, water, and mucus to confluence of the common bile duct and
lubricate food for swallowing. duodenum.
●​ Swallowing Process: Starts as a voluntary act ●​ Secretion Volume: Approximately 1 liter of
regulated by the swallowing center in the medulla pancreatic juice, 0.5 liter of bile, and 3 liters of
oblongata. The epiglottis covers the tracheal intestinal secretions per day.
opening to prevent food aspiration. ●​ Motility: Two types of contractions occur:
●​ Esophageal Peristalsis: Smooth muscle in the ○​ segmentation contractions (mixing
esophagus contracts rhythmically to propel food waves), and
toward the stomach. The lower esophageal ○​ intestinal peristalsis (propels contents
sphincter relaxes to allow food entry into the toward the colon).
stomach and then closes to prevent reflux. ●​ Nutrient Breakdown: Carbohydrates are broken
down into disaccharides and monosaccharides
(e.g., glucose). Proteins are broken down into
amino acids and peptides. Fats become
GASTRIC FUNCTION monoglycerides and fatty acids.
●​ Retention Time: Chyme stays in the small
intestine for 3 to 6 hours.
●​ Gastric Secretions: The stomach secretes a
●​ Villi: Small, finger-like projections that produce
highly acidic fluid, up to 2.4 liters per day, with a
digestive enzymes (esp. microvilli) and absorb
pH as low as 1, primarily due to hydrochloric acid
nutrients.
(HCl).
●​ Absorption: Major function of the small intestine.
●​ Functions of Gastric Secretions: Break down
Nutrients are absorbed through active transport
food into more absorbable components and aid in
and diffusion across the intestinal wall.
destroying ingested bacteria.
●​ Specific Absorption Sites: Carbohydrates,
●​ Enzymes and Factors: Pepsin, an enzyme for
proteins, fats, sodium, and chloride are absorbed
protein digestion, is produced from pepsinogen by
in the jejunum. Vitamin B12 and bile salts are
chief cells down in the gastric pits. Intrinsic factor
absorbed in the ileum. Magnesium, phosphate,

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and potassium are absorbed throughout the small

tty acids,
intestine.
diglycerides,
monoglycerides
THE MAJOR DIGESTIVE ENZYMES AND
Pancreatic lipase Pancreas Triglycerides→fa
SECRETION tty acids,
diglycerides,
ENZYME/SECR ENZYME DIGESTIVE monoglycerides
ETION SOURCE ACTION
Bile Liver and Fat
A. ENZYMES THAT DIGEST CARBOHYDRATES gallbladder emulsification

Ptyalin (salivary Salivary glands Starch→dextrin,

amylase) maltose, glucose THE MAJOR GI REGULATORY SUBSTANCES

Amylase Pancreas and Starch→dextrin,

intestinal maltose, glucose
mucosa

Maltase Intestinal Dextrin→maltose

mucosa , glucose

Maltose→glucos
e
COLONIC FUNCTION
Sucrase Intestinal Sucrose→glucos
mucosa e, fructose
●​ Waste Material Passage: Residual waste material
Lactase Intestinal Lactose→glucos passes from the terminal ileum into the right colon
mucosa e, galactose through the ileocecal valve within 4 hours after
eating.
B. ENZYMES/SECRETIONS THAT DIGEST PROTEIN ●​ Gut Microbes: Bacteria in the large intestine
assist in breaking down undigested proteins and
Pepsin Gastric mucosa Protein→polypep bile salts.
tides
●​ Colonic Secretions: Two types are added to the
residual material: an electrolyte solution (mainly
Trypsin Pancreas Proteins and
bicarbonate) to neutralize bacterial end products,
polypeptides→p
olypeptides, and mucus to protect the colonic mucosa and aid
dipeptides, in fecal mass adherence.
amino acids ●​ Peristalsis: Slow, weak peristalsis moves
contents along the tract, allowing for efficient water
Aminopeptidase Intestinal Polypeptides→di and electrolyte reabsorption, which is the colon's
mucosa peptides, amino major function.
acids ●​ Strong Peristaltic Waves: Occur intermittently,
often after eating, when hormones stimulate the
Dipeptidase Intestinal Dipeptides→ami
intestine, propelling contents over long distances.
mucosa no acids
●​ Rectal Distension: Waste materials reach and
distend the rectum in about 12 hours. Up to
Hydrochloric acid Gastric mucosa Protein→polypep one-fourth of waste may remain in the rectum 3
tides, amino days after ingestion.
acids

C. ENZYMES/SECRETIONS THAT DIGEST FAT WASTE PRODUCTS OF DIGESTION

(TRIGLYCERIDE)
●​ Feces Composition: Feces consist of undigested
Pharyngeal Pharynx mucosa Triglycerides→fa
foodstuffs, inorganic materials, water, and
lipase tty acids,
diglycerides, bacteria. It is approximately 75% fluid and 25%
monoglycerides solid material.
●​ Color and Odor: The brown color of feces results
Steapsin Gastric mucosa Triglycerides→fa from the breakdown of bile by intestinal bacteria.

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Chemicals produced by these bacteria contribute ○​ Digestive Enzymes: Secretes amylase,

to the fecal odor. lipase, and trypsin to aid in
●​ Gases: The GI tract contains gases like methane, carbohydrate, fat, and protein digestion.
hydrogen sulfide, and ammonia. These gases are ○​ Insulin and Glucagon: Regulates blood
either absorbed and detoxified by the liver or sugar levels.
expelled as flatus.
●​ Defecation Process: Begins with rectal ●​ Liver:
distension, which triggers reflex contractions of the ○​ Bile Production: Aids in fat digestion and
rectal musculature and relaxation of the internal absorption.
anal sphincter. ○​ Detoxification: Processes absorbed
●​ Sphincter Control: The internal anal sphincter is nutrients and detoxifies harmful
controlled by the autonomic nervous system, while substances.
the external sphincter is under conscious control.
●​ Voluntary Control: During defecation, the ●​ Gallbladder:
external sphincter relaxes voluntarily to allow ○​ Bile Storage: Releases bile into the
expulsion of colonic contents. small intestine to emulsify fats.
●​ Defecation Reflex: A spinal reflex involving
parasympathetic nerve fibers, which can be
inhibited by keeping the external sphincter closed.
●​ Facilitating Defecation: Contracting abdominal
muscles (straining) helps empty the colon.
●​ Frequency of Defecation: Typically occurs once A3 GERONTOLOGIC CONSIDERATIONS
daily, but frequency varies among individuals.
Effects of Aging on the GI Tract
●​ Mechanical and Chemical Digestion: Aging affects
GUT MICROBIOME
the mechanical disintegration of food and chemical
digestion, impacting nutrient absorption.
●​ Functions: Assists in the breakdown of waste ●​ Gastrointestinal Motor Function: Decreased
material, vitamin synthesis, and immune function, esophageal motility can lead to dysphagia and
including protection against pathogens and increased risk of aspiration.
regulation of immune responses. ●​ Food Transit: Changes in food transit times can
●​ Establishment: Colonization of the GI tract begins affect digestion and absorption.
shortly after birth, with the normal gut microbiota
established by 2 years of age. Common GI Disorders in Older Adults
●​ Influencing Factors: Composition is affected by ●​ Constipation: More common due to decreased
genetics, diet, personal hygiene, infections, colonic motility and water absorption.
vaccinations, aging, chronic diseases, and ●​ Diverticulosis: Increased prevalence with age.
medications. ●​ Gastrointestinal Ulceration: Risk increased by
●​ Impact of Antibiotics: Broad-spectrum antibiotics medications like NSAIDs and anticoagulants.
can disrupt the gut microbiota, leading to ●​ Celiac Disease: More frequent in older adults,
overgrowth of potentially pathogenic species. with challenges in adherence to gluten-free diets.
●​ Protection and Defense: The gut microbiome
protects against pathogenic invasion, produces Physiological Changes
anti-inflammatory metabolites, destroys toxins, and ●​ Taste and Smell: Decreased taste bud sensitivity
provokes an immune response. affects food enjoyment and nutrition.
●​ Immune Defense: The intestinal epithelium ●​ Saliva Production: Reduced, leading to dry mouth
contains innate immune cells like macrophages and dental issues.
and dendritic cells, playing a role in T-cell ●​ Visceral Sensitivity: Decreased, potentially
responses and antigen processing through masking severe GI conditions.
Peyer’s patches.
Nutritional Considerations
●​ Malnutrition: Increased risk due to decreased
appetite, dental issues, and altered hormone
levels.
ROLE OF ACCESSORY ORGANS ●​ Hormonal Changes: Alterations in hormones like
ghrelin and leptin affect hunger and satiety.
●​ Pancreas:
Management and Care

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●​ Dietary Solutions: Tailored dietary guidelines can

help prevent malnutrition.
●​ Monitoring: Regular assessment of GI symptoms
is crucial for early detection of disorders.

AGE RELATED CHANGES IN THE GI SYSTEM

Figure 38-3 • Common sites of referred abdominal pain.

DYSPEPSIA

●​ Definition: Dyspepsia is upper abdominal

discomfort associated with eating, commonly
referred to as indigestion. It includes symptoms
like pain, discomfort, fullness, bloating, early
satiety, belching, heartburn, or regurgitation.
●​ Prevalence: Approximately 25% of Americans
experience dyspepsia annually.
●​ GERD: Gastroesophageal reflux disease (GERD)
affects about 20% of adults in Western cultures
and often manifests with dyspepsia, particularly
heartburn.
●​ Dietary Factors: Fatty foods cause the most
discomfort due to longer digestion times. Salads,
coarse vegetables, and highly seasoned foods can
also cause GI distress.
●​ Distinction Between GER and GERD: GERD is a
more serious and longer-lasting condition
compared to GER.
B ASSESSMENT OF THE GI SYSTEM

INTESTINAL GAS

●​ Definition: The accumulation of gas in the GI tract

B1 HEALTH HISTORY can lead to belching (gas expelled through the
mouth) or flatulence (gas expelled through the
rectum).
●​ Gas Movement: Gases in the small intestine
COMMON SYMPTOMS typically pass into the colon and are released as
flatus.
●​ Symptoms: Patients may experience bloating,
PAIN
distention, or a feeling of being "full of gas," often
accompanied by excessive flatulence.
●​ Major symptom of GI disease, often presenting as
●​ Associated Conditions: These symptoms can be
abdominal pain. The character, duration, pattern,
indicative of food intolerance or gallbladder
frequency, location, and distribution of pain can
disease.
vary based on the underlying cause.

NAUSEA AND VOMITING

●​ Definition: Nausea is a vague, uncomfortable

sensation of sickness or queasiness that may or
may not be followed by vomiting.

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●​ Causes of Nausea: Common causes include

distention of the duodenum or upper intestinal PAST HEALTH, FAMILY, AND SOCIAL HX
tract, which can also be an early warning sign of a
pathologic process. Nausea can be triggered by ●​ Oral Health: Includes tooth brushing and flossing
odors, activity, medications, or food intake. habits, dental visit frequency, and awareness of
●​ Vomiting: The forceful emptying of the stomach oral lesions.
and intestinal contents through the mouth. The ●​ Nutritional Status: Assessed through dietary
vomitus may vary in color and content, containing history and laboratory tests (e.g., complete
undigested food particles, blood (hematemesis), or metabolic panel).
bilious material mixed with gastric juices. ●​ Substance Use: Details about alcohol and
●​ Characteristics of Vomitus: An acute onset of tobacco use, including type, amount, duration, and
bright red or coffee ground-like emesis is cessation date.
characteristic of a Mallory-Weiss tear, indicating ●​ Psychosocial Factors: Discussion of
upper GI bleeding. psychosocial, spiritual, or cultural factors affecting
●​ Causes of Nausea and Vomiting: Include the patient.
visceral pain, motion sickness, anxiety, medication
side effects, and torsion or trauma of organs like
the ovaries, testes, uterus, bladder, or kidney.
●​ Pathways for Vomiting Reflex: Initiated by B2 PHYSICAL ASSESSMENT
factors such as medication therapy, metabolic
abnormalities, ingested toxins, chemotherapy,
radiation therapy, inner ear disorders, motion
sickness, and anticipatory emesis. ORAL CAVITY INSPECTION AND
PALPATION

CHANGE IN BOWEL HABITS AND STOOL

CHARACTERISTICS
LIPS
●​ Diarrhea: An abnormal increase in the frequency
●​ Inspect for moisture, hydration, color, texture,
and liquidity of stool, often due to rapid movement
symmetry, and presence of ulcerations or fissures.
through the intestine and colon, leading to
Lips should be moist, pink, smooth, and
inadequate absorption of GI secretions and oral
symmetric.
contents. Typically associated with abdominal pain
●​ Buccal Mucosa: Use a tongue blade to expose the
or cramping and nausea or vomiting.
buccal mucosa for assessment of color and
●​ Constipation: A decrease in the frequency of
lesions. Stensen’s duct of each parotid gland is
stool, or stools that are hard, dry, and of smaller
visible as a small red dot next to the upper molars.
volume than typical. May be associated with anal
discomfort and rectal bleeding.
●​ Stool Characteristics: Normally, stool is light to
dark brown. Changes in stool appearance can HEALTH PROMOTION
occur due to disease processes or ingestion of
certain foods and medications. Denture Care
●​ Blood in Stool: Blood in the upper GI tract ●​ Brush dentures twice a day.
appears as melena (tarry-black), while blood in the ●​ Clean well under partial dentures, where food
lower GI tract appears bright or dark red. Lower particles tend to get caught.
●​ Consume non sticky foods that have been cut
rectal or anal bleeding is indicated by streaking of into small pieces; chew slowly.
blood on the stool surface or on toilet tissue. ●​ Remove dentures at night and soak them in
●​ Abnormal Stool Characteristics: Include bulky, water or a denture product. Never put dentures
greasy, foamy stools; light gray or clay-colored in hot water, because they may warp.
stools; stools with mucus threads or pus; small, ●​ Rinse your mouth with warm salt water in the
dry, rock-hard masses; and loose, watery stools morning, after meals, and at bedtime.
●​ See dentist regularly to assess and adjust fit.
that may be streaked with blood.

FOODS AND MEDS THAT ALTER STOOL COLOR

GUMS

●​ Inspect for inflammation, bleeding, retraction, and

discoloration. Note the odor of the breath.
●​ Hard Palate: Examine for color and shape.

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●​ Patient Positioning: The patient lies supine with

knees slightly flexed.
TONGUE ●​ Abdominal Division: The abdomen can be
divided into four quadrants or nine regions for
●​ Dorsum Inspection: Inspect the back of the examination and documentation.
tongue for texture, color, and lesions. Normal
findings include a thin white coat and large vallate INSPECTION
papillae in a "V" formation.
●​ Tongue Mobility: The patient is instructed to ●​ Visual Examination: Note skin changes, nodules,
protrude and move the tongue laterally to assess lesions, scarring, discolorations, inflammation,
size, symmetry, and strength, which helps bruising, or striae. Lesions are important as they
evaluate the integrity of the hypoglossal nerve can indicate GI diseases.
(12th cranial nerve). ●​ Abdominal Contour: Assess the contour and
●​ Ventral Surface Inspection: The patient touches symmetry of the abdomen, noting any localized
the roof of the mouth with the tip of the tongue to bulging, distention, or peristaltic waves.
inspect the ventral surface and floor of the mouth
for mucosal lesions or abnormalities involving the
frenulum or superficial veins. AUSCULTATION
●​ Pharynx Visualization: A tongue blade is used to
depress the tongue for a clear view of the pharynx. ●​ Bowel Sounds: Use the diaphragm of the
The patient is asked to tip their head back, open stethoscope to listen for soft clicks and gurgling
their mouth wide, take a deep breath, and say "ah" sounds. Normal bowel sounds occur irregularly at
to inspect the tonsils, uvula, and posterior pharynx 5-30 per minute and are designated as normal,
for color, symmetry, and signs of exudate or hyperactive, hypoactive, or absent.
ulceration. ●​ Vascular Sounds: Use the bell of the stethoscope
●​ Importance of Oral Assessment: A complete to listen for bruits in the aortic, renal, iliac, and
oral cavity assessment is crucial as many femoral arteries. Friction rubs and borborygmus
disorders, such as cancer, diabetes, and (stomach growling) are also noted.
immunosuppressive conditions, can manifest
changes in the oral cavity, including stomatitis.
PERCUSSION

ABDOMINAL INSPECTION, ●​ Purpose: To assess the size and density of

AUSCULTATION, PERCUSSION, AND abdominal organs and detect air-filled, fluid-filled,
PALPATION or solid masses.
●​ Technique: Percuss all quadrants to evaluate for
tympani (air-filled organs) and dullness (solid
DIVISION OF THE ABDOMEN INTO 4 QUADRANTS OR 9
masses).
REGIONS

PALPATION

●​ Technique: Use light palpation to identify areas of

tenderness or muscular resistance, and deep
palpation to identify masses.
●​ Sequence: Begin palpation in non-painful areas
and avoid testing for rebound tenderness due to
potential pain; instead, use light percussion to
assess peritoneal irritation.

RECTAL INSPECTION AND PALPATION

●​ Purpose: Evaluate the terminal portions of the GI

tract, including the rectum, perianal region, and
anus.

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●​ Anal Canal: Approximately 2.5 to 4 cm in length, ●​ Novel Biomarkers: Recent studies have identified
opening into the perineum, with internal and novel serum biomarkers such as IFNGR1,
external sphincters keeping it closed. TNFRSF19L, and others that may improve early
●​ Tools: Gloves, water-soluble lubrication, penlight, detection and prognosis of gastric cancer.
and drapes are necessary. ●​ Serum Autoantibodies: Panels of autoantibodies
●​ Patient Positioning: Positions include like COPS2, CTSF, NT5E, and TERF1 have
knee-chest, left lateral with flexed hips and knees, shown high sensitivity and specificity for
or standing with flexed hips and supported upper diagnosing gastric cancer.
body. Most patients prefer lying on their right side
with knees to the chest. Nursing Interventions
●​ External Examination: Inspect for lumps, rashes, ●​ Patient Education: Inform patients about the
inflammation, excoriation, tears, scars, pilonidal purpose of serum tests and any necessary
dimpling, and tufts of hair. Tenderness or preparation.
inflammation may indicate a pilonidal cyst, perianal ●​ Monitoring: Assess for signs of bleeding or clotting
abscess, or anorectal fistula/fissure. disorders based on PT/PTT results.
●​ Internal Examination: Use a gloved lubricated ●​ Follow-Up: Ensure that patients understand the
index finger to assess sphincter tone and any importance of follow-up appointments for test
nodules or irregularities of the anal ring while the results and further evaluation if needed.
patient bears down.

C1 STOOL TESTS
C DIAGNOSTIC EVALUATION
Purpose:
●​ Stool tests are diagnostic procedures that examine
a stool sample to assess the health and function of
C1 SERUM LABORATORY STUDIES the digestive system. They provide valuable
information about nutrient absorption, gut flora
Initial Diagnostic Tests: Begin with serum laboratory balance, the presence of pathogens, and potential
studies to assess various aspects of GI health. digestive disorders.

Common Tests: Types of Stool Tests:

●​ Complete Blood Count (CBC): Evaluates blood ●​ Fecal Occult Blood Test (FOBT): Detects hidden
cell counts and morphology. blood in the stool, often used in cancer screening.
●​ Complete Metabolic Panel (CMP): Assesses ●​ Fecal Immunochemical Test (FIT): More
electrolytes, glucose, and kidney function. sensitive than FOBT, detects human hemoglobin
●​ Prothrombin Time (PT) / Partial in stool.
Thromboplastin Time (PTT): Measures blood ●​ Stool DNA Test: Detects genetic material that
clotting. may indicate cancer or polyp..
●​ Triglycerides: Assesses lipid levels. ●​ Fecal Calprotectin Test: Measures calprotectin
●​ Liver Function Tests (LFTs): Evaluates liver levels to assess inflammation in the intestines,
enzymes and proteins. useful for diagnosing inflammatory bowel disease
●​ Amylase and Lipase: Measures pancreatic (IBD).
enzyme levels. ●​ Stool Culture: Identifies harmful bacteria or
parasites in the stool, aiding in the diagnosis of
Tumor Markers: infections like salmonella or giardia.
●​ Carcinoembryonic Antigen (CEA): Elevated in ●​ Ova and Parasite Exam: Looks for parasites or
colorectal cancer; used for monitoring recurrence. their eggs in the stool, helping diagnose parasitic
●​ Cancer Antigen 19-9 (CA 19-9): Elevated in infections.
pancreatic cancer; used for monitoring treatment
response. Indications:
●​ Alpha-Fetoprotein (AFP): Elevated in ●​ Gastrointestinal Infections: Stool tests can
hepatocellular carcinoma; used for monitoring diagnose bacterial, viral, or parasitic infections by
treatment response. detecting pathogens.
●​ Malabsorption Syndromes: Tests can indicate
Specific Studies for Gastric Cancer: issues with nutrient absorption.

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●​ Inflammatory Bowel Disease (IBD): Helps monitor

inflammation and disease activity. C1 ABDOMINAL ULTRASONOGRAPHY

Procedure: Abdominal Ultrasonography

●​ Collection: Patients collect a stool sample, which is ●​ Definition: A non-invasive diagnostic technique
then sent to a laboratory for analysis. using high-frequency sound waves to produce
●​ Preparation: Some tests require specific diets or images of internal body structures.
medication avoidance before collection. ●​ Usefulness: Particularly useful for detecting
conditions like an enlarged gallbladder, pancreas,
Results: gallstones, ovarian enlargement, ectopic
●​ Interpretation: Results can indicate the presence pregnancy, and appendicitis.
of infections, inflammation, or other conditions.
●​ Follow-Up: May require additional testing or Advantages
medical intervention based on findings. ●​ Non-Invasive: Does not involve ionizing radiation,
making it safe for pregnant women and others who
need to avoid radiation.
●​ Low Cost: Relatively inexpensive compared to
C1 BREATH TESTS
other imaging techniques.
●​ Immediate Results: Provides almost immediate
results, aiding in quick diagnosis and treatment
HYDROGEN BREATH TEST (HBT) planning.

Hydrogen Breath Test (HBT): Limitations

●​ Purpose: Used to diagnose conditions such as ●​ Body Type: Can be limited by patient body type,
small intestinal bacterial overgrowth (SIBO), especially if there is significant bowel gas or thick
carbohydrate malabsorption (e.g., lactose or layers of adipose tissue.
fructose intolerance), and to measure orocecal ●​ Operator Experience: Requires skilled operators to
transit time for GI motility. interpret results accurately .
●​ Procedure: Patients drink a sugary beverage (e.g.,
lactose, fructose, or glucose) and exhale into a Nursing Interventions
bag at intervals to measure hydrogen levels in the ●​ Preparation: Patients should fast for 8-12 hours
breath. before the test to reduce bowel gas.
●​ Interpretation: Elevated hydrogen levels indicate ●​ Education: Inform patients about the procedure,
malabsorption or SIBO. risks, and post-test care to reduce anxiety and
ensure compliance.
●​ Monitoring: Assess hydration status and monitor
UREA BREATH TEST (UBT) for complications, especially in patients with
comorbidities.
Urea Breath Test (UBT):
●​ Purpose: Detects Helicobacter pylori infection,
which can cause peptic ulcers.
●​ Procedure: Patients ingest a carbon-labeled urea
capsule, and a breath sample is taken 10-20 C1 GENETIC TESTING IN
minutes later to measure carbon dioxide levels.
GASTROENTEROLOGY
●​ Preparation: Patients must avoid certain
medications (e.g., antibiotics, proton pump
inhibitors) before the test. ●​ Purpose: Genetic testing helps identify genetic
variants associated with gastrointestinal (GI)
Benefits and Limitations disorders, such as inflammatory bowel disease,
●​ Benefits: Breath tests are non-invasive, celiac disease, and other conditions affecting the
inexpensive, and safe, making them a valuable digestive system.
diagnostic tool for GI disorders.
●​ Limitations: Some individuals may not produce Conditions Tested
breath hydrogen or methane, limiting the test's ●​ Inflammatory Bowel Disease (IBD): Includes
utility. Crohn’s disease and ulcerative colitis, where
genetic testing can help confirm diagnosis and
guide treatment.

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●​ Celiac Disease: Genetic testing can identify

●​ Pompe disease
individuals at risk for developing celiac disease.
●​ Zellweger syndrome
●​ Gastric Cancer: Genetic testing can identify
mutations associated with increased risk of gastric Inheritance pattern includes autosomal dominant and
cancer. autosomal recessive:
●​ Lactose Deficiency: Genetic testing can confirm ●​ Familial adenomatous polyposis
lactose intolerance by identifying mutations in the
lactase gene. X-linked:
●​ Fabry disease
●​ Colon Cancer: Genetic testing can identify
mutations associated with familial adenomatous Inheritance pattern is not distinct; however, there is a
polyposis (FAP) and Lynch syndrome, which genetic predisposition for the disease:
increase the risk of colon cancer. ●​ Crohn’s disease
●​ Type 1 diabetes
Testing Methods ●​ Celiac disease
●​ Pancreatic cancer
●​ DNA Sequencing: The most common method
used to detect specific mutations known to cause Other genetic disorders that will impact the digestive and
GI disorders. gastrointestinal system:
●​ Panel Testing: Tests multiple genes ●​ Cleft lip and/or palate
simultaneously to identify mutations associated ●​ Cystic fibrosis
with various GI conditions.

Indications for Testing

●​ Diagnostic Testing: Used to confirm a suspected C1 IMAGING STUDIES
diagnosis or establish a diagnosis when symptoms
are present.
●​ Presymptomatic Testing: For individuals with a
family history of GI disorders to identify genetic UPPER GI TRACT STUDY
risks before symptoms appear.
●​ Pharmacogenetic Testing: Helps tailor medication
therapy based on genetic variations affecting drug Definition
metabolism. ●​ An upper GI series is a radiographic examination
that uses fluoroscopy and a contrast agent
Benefits (usually barium) to visualize the esophagus,
●​ Early Detection: Allows for early identification of stomach, and duodenum.
genetic risks, enabling preventive measures and
timely interventions. Purpose
●​ Personalized Medicine: Genetic information can ●​ Diagnostic Use: This study is used to diagnose
guide treatment decisions and lifestyle conditions such as ulcers, varices, tumors,
modifications. regional enteritis, and malabsorption syndromes.

Limitations Procedure
●​ Complexity of Results: Genetic tests can yield ●​ Preparation: Patients typically need to fast for
complex results, requiring careful interpretation several hours before the test. A light evening meal
and counseling. is recommended the night before, and nothing by
●​ Cost and Accessibility: Genetic testing can be mouth after bedtime.
expensive and may not be widely available or ●​ Procedure Steps:
covered by insurance. ○​ The patient drinks a barium solution,
which coats the upper GI tract.
○​ The radiologist uses fluoroscopy to
GENETICS IN NURSING PRACTICE watch the barium move through the
digestive tract.
Autosomal dominant: ○​ The patient may be asked to change
●​ Hereditary diffuse gastric cancer
positions or have their abdomen
●​ Hereditary non-polyposis colorectal cancer
(Lynch syndrome) compressed to help spread the barium
●​ Hirschsprung disease (aganglionic megacolon) evenly.

Autosomal recessive: Variations

●​ Glucose galactose malabsorption ●​ Double-Contrast Study: Involves a thick barium
●​ Glycogen storage disease (von Gierke disease)
suspension followed by tablets that release carbon

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dioxide, providing finer detail of the esophagus ●​ Monitoring: Assess for complications
and stomach. post-procedure and educate patients on managing
●​ Enteroclysis: A detailed study of the small potential side effects like constipation or diarrhea.
intestine using a thin barium suspension and
methylcellulose, useful for detecting obstructions
or diverticula.

Nursing Interventions
●​ Preparation: Educate patients on dietary COMPUTED TOMOGRAPHY (CT) SCAN
restrictions and the importance of fasting before
the test. Definition: A CT scan is a diagnostic imaging test that uses
●​ Monitoring: Assess for hydration and monitor for X-rays to create detailed cross-sectional images of the body,
complications post-procedure. allowing for the examination of internal organs, bones, and
soft tissues.

Procedure
●​ How It Works: The patient lies on a table that
LOWER GI TRACT STUDY
slides into the CT scanner. The machine rotates
around the body, emitting X-rays that are detected
Definition: by sensors. A computer processes these data to
●​ A lower GI series, also known as a barium enema, create images that can be viewed on a monitor or
is an X-ray examination used to visualize the large printed.
intestine (colon and rectum) by filling it with barium ●​ Duration: The scan itself is quick, typically taking
contrast material. less than 30 minutes, but preparation may require
up to 1.5 hours if oral contrast is used.
Purpose
●​ Diagnostic Use: This study helps diagnose Uses
problems affecting the large intestine, such as ●​ Diagnostic Purposes: CT scans are used to
polyps, tumors, and anatomic abnormalities. diagnose a wide range of conditions, including
kidney stones, appendicitis, diverticulitis, and
Procedure various cancers affecting organs in the abdomen
●​ Preparation: Patients typically follow a low residue and pelvis.
diet and may use laxatives or enemas to clear the ●​ Emergency Situations: In emergency cases, CT
bowel before the test. scans can quickly reveal internal injuries and
●​ Procedure Steps: bleeding, aiding in timely interventions.
○​ The patient lies on a tilting X-ray table
and a flexible tube is inserted into the Advantages
anus to deliver barium. ●​ Detail and Accuracy: Provides detailed images of
○​ A balloon is inflated to prevent barium soft tissues, bones, and blood vessels, which are
leakage. superior to traditional X-rays.
○​ The patient may be asked to change ●​ Speed and Non-Invasiveness: The procedure is
positions to evenly coat the colon with painless and non-invasive, making it a preferred
barium. diagnostic tool for many conditions.
○​ If a double-contrast study is performed,
air is injected to inflate the intestine. Risks and Considerations
●​ Radiation Exposure: CT scans involve significant
Variations radiation exposure, which is a consideration for
●​ Double-Contrast Study: Uses a thicker barium patients undergoing repeated scans.
solution followed by air to provide better contrast ●​ Contrast Agents: IV contrast agents can pose risks
and detect smaller lesions. such as allergic reactions and contrast-induced
●​ Water-Soluble Contrast Study: Used if active nephropathy (CIN), requiring careful patient
inflammatory disease or perforation is suspected, screening.
using a water-soluble iodinated contrast agent.
Nursing Interventions
Nursing Interventions ●​ Preparation: Educate patients about the procedure
●​ Preparation: Ensure proper bowel cleansing and and any necessary preparations, such as fasting
dietary restrictions before the test. or avoiding certain medications.

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●​ Monitoring: Assess for hydration status and

monitor for complications post-procedure,
especially in patients with comorbidities.
POSITRON EMISSION TOMOGRAPHY
(PET) SCAN

MAGNETIC RESONANCE IMAGING (MRI)

Definition: A PET scan is a type of nuclear medicine
imaging that uses small amounts of radioactive material to
Definition: MRI is a non-invasive imaging technique that diagnose and monitor diseases such as cancer, heart
uses magnetic fields and radio waves to produce detailed disease, and brain disorders.
images of internal body structures.
How PET Scans Work
Uses in Gastroenterology ●​ Radiotracers: The most commonly used
●​ Diagnostic Applications: MRI is used to evaluate radiotracer is fluorodeoxyglucose (FDG), a
abdominal soft tissues, blood vessels, abscesses, glucose analog that accumulates in areas of high
fistulas, neoplasms, and sources of bleeding. metabolic activity, such as cancer cells.
●​ Specific Conditions: Useful for diagnosing and ●​ Procedure: The radiotracer is injected into a vein,
monitoring inflammatory bowel diseases (e.g., and the PET scanner detects the gamma rays
Crohn’s disease, ulcerative colitis), rectal cancer, emitted by the tracer, creating images of metabolic
and pelvic floor disorders. activity in the body.

Advantages Uses
●​ Soft-Tissue Contrast: Provides excellent contrast ●​ Cancer Diagnosis: PET scans are particularly
between soft tissues, aiding in the detection of useful for detecting cancer, staging it, and
tumors and inflammatory changes. monitoring treatment response.
●​ Non-Invasive: Does not involve ionizing radiation, ●​ Cardiac and Brain Imaging: Also used to assess
making it safer for repeated use, especially in heart function and diagnose conditions like
younger patients or those requiring long-term epilepsy.
monitoring.
Safety and Radiation
Limitations ●​ Radiation Exposure: PET scans involve lower
●​ Contraindications: Ferromagnetic objects can be radiation levels compared to CT scans, with an
hazardous due to the strong magnetic field; effective dose typically around 8 mSv for adults.
patients must be screened for metal implants or ●​ Safety: The radioactive tracers used are safe and
jewelry. short-acting, with no significant side effects.
●​ Claustrophobia: Some patients may experience
anxiety due to the enclosed space of the MRI Procedure Duration
machine. ●​ Total Time: Patients typically spend about 2-3
hours in the PET imaging department, although
Nursing Interventions the scan itself takes only 15-20 minutes.
●​ Preparation: Educate patients about the
procedure, including the need to remove metal
objects and potential claustrophobia.
●​ Monitoring: Assess for anxiety and provide support
during the procedure. SCINTIGRAPHY

Definition: Scintigraphy, also known as a gamma scan, is a

MRI is contraindicated in patients with any device diagnostic test in nuclear medicine that uses radioactive
containing metal because the magnetic field could cause isotopes attached to drugs to create images of internal
malfunction. MRI is also contraindicated for patients with organs and tissues. These isotopes emit gamma rays, which
internal metal devices (e.g., aneurysm clips), intraocular are detected by gamma cameras to form images.
metallic fragments, or cochlear implants. Foil-backed skin
patches (e.g., nicotine, nitroglycerin, scopolamine,
Procedure
clonidine) should be removed before an MRI because of
the risk of burns; however, the patient’s primary provider ●​ Administration of Radiotracers: A small amount
should be consulted before the patch is removed to of a radioactive substance (radiopharmaceutical)
determine whether an alternate form of the medication is administered orally, intravenously, or inhaled,
should be provided. depending on the type of test. This substance

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accumulates in the organ or tissue being ○​ Procedure: Abdominal X-rays are taken
examined. daily until all markers are passed,
●​ Detection: Gamma cameras are used to detect typically over 4-5 days.
the gamma rays emitted by the
radiopharmaceutical, creating images of the Uses
distribution within the body. ●​ Diagnostic Purposes: Helps diagnose motility
disorders by quantifying the movement of food
Types of Scintigraphy through the digestive tract.
●​ Static Acquisition: Involves obtaining a single ●​ Monitoring Treatment: Useful for assessing the
image over a certain period. effectiveness of treatments for motility disorders.
●​ Dynamic Acquisition: Involves taking multiple
images over time to observe changes in the body. Benefits
●​ Non-Invasive: These tests are non-invasive and
Common Uses relatively safe, making them suitable for repeated
●​ Bone Scintigraphy: Assesses bones for use.
conditions like cancer, infections, or fractures. ●​ Quantitative Data: Provides quantitative data on
●​ Thyroid Scintigraphy: Evaluates thyroid structure motility, aiding in precise diagnosis and treatment
and function. planning.
●​ Cardiac Scintigraphy: Assesses heart function
and detects coronary artery disease.
●​ Kidney Scintigraphy: Evaluates kidney structure
and function. C1 ENDOSCOPIC PROCEDURES

Safety Considerations
●​ Radiation Exposure: Although scintigraphy
involves radiation, the doses are generally low and UPPER GI
considered safe for most patients. However, it is FIBROSCOPY/ESOPHAGOGASTRODUOD
not recommended during pregnancy due to ENOSCOPY (EGD)
potential risks.

Definition: EGD is a diagnostic procedure that uses a

GI MOTILITY STUDIES flexible tube with a camera (endoscope) to visually examine
the esophagus, stomach, and duodenum.

Definition: These studies assess the movement of food

Procedure
through the digestive tract, helping diagnose motility
●​ Insertion: The endoscope is inserted through the
disorders such as gastroparesis or constipation.
mouth and guided down the esophagus into the
stomach and duodenum.
Types of Motility Studies
●​ Visualization: The camera at the tip of the
●​ Gastric Emptying Study: Uses radionuclide
endoscope transmits images to a monitor, allowing
markers to measure how quickly food leaves the
the doctor to inspect the mucosa for abnormalities.
stomach. This helps diagnose conditions like
●​ Biopsy: Tissue samples can be taken for further
gastroparesis or dumping syndrome.
analysis if needed.
●​ Colonic Transit Study: Evaluates how quickly
food moves through the colon, useful for
Uses
diagnosing constipation or obstructive defecation
●​ Diagnostic Purposes: Used to diagnose conditions
syndromes.
like ulcers, tumors, inflammation, and infections in
the upper GI tract.
Procedure
●​ Therapeutic Uses: Can be used to treat conditions
●​ Gastric Emptying Study:
such as bleeding ulcers or esophageal varices.
○​ Preparation: Patients ingest a meal with
radioactive tracers.
Preparation and Recovery
○​ Procedure: The patient is scanned at
●​ Preparation: Patients typically fast for several
intervals (e.g., 1, 2, and 4 hours) to
hours before the procedure and may receive
measure gastric emptying time.
sedation to reduce discomfort.
●​ Colonic Transit Study:
●​ Recovery: After the procedure, patients are
○​ Preparation: A capsule containing
monitored for complications and may experience
radionuclide markers is ingested.
temporary throat discomfort.

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Nursing Interventions for EGD

Preparation:
●​ Fasting: Patients should fast for 6-8 hours before
the procedure to reduce the risk of aspiration.
●​ Medication Management: Review medications
and follow hospital instructions regarding their use
before the procedure.
●​ Patient Education: Inform patients about the
procedure, risks, and post-procedure care to
Figure 38-5 • Patient undergoing gastroscopy. reduce anxiety.

During the Procedure:

ENDOSCOPIC RETROGRADE ●​ Sedation: Administer sedation as needed to
CHOLANGIOPANCREATOGRAPHY (ERCP) reduce discomfort and anxiety.
●​ Monitoring: Continuously monitor vital signs,
Definition: ERCP is a procedure that combines endoscopy oxygen saturation, and airway status during the
and X-ray imaging to diagnose and treat conditions affecting procedure.
the bile and pancreatic ducts.
Post-Procedure Care:
Procedure ●​ Monitoring: Assess for complications such as
●​ Insertion: An endoscope is inserted through the bleeding, perforation, or respiratory issues.
mouth, guided through the esophagus and ●​ Pain Management: Offer lozenges or analgesics
stomach, and into the duodenum. for throat discomfort.
●​ Visualization: A catheter is used to inject dye into ●​ Discharge Instructions: Provide clear verbal and
the bile and pancreatic ducts, which are then written instructions to the patient and their
visualized using X-rays (fluoroscopy). companion, as sedation may impair memory.

Uses
●​ Diagnostic Purposes: ERCP is used to diagnose
conditions such as jaundice, pancreatitis, tumors, FIBEROPTIC COLONOSCOPY
and blockages in the bile or pancreatic ducts.
●​ Therapeutic Uses: It can be used to remove Definition: Colonoscopy is a procedure that uses a flexible
gallstones, dilate narrowed ducts (stricture), place tube with a camera (colonoscope) to visually examine the
stents to keep ducts open, and collect tissue large intestine (colon and rectum) for abnormalities such as
samples for biopsy. polyps or cancer.

Indications Procedure
●​ Choledocholithiasis: Common bile duct stones are ●​ Insertion: The colonoscope is inserted through the
a primary indication for ERCP. anus and guided through the rectum and colon
●​ Pancreatitis: ERCP can help diagnose and treat ●​ Visualization: The camera at the tip of the scope
causes of pancreatitis, such as gallstones blocking transmits images to a monitor, allowing the doctor
the pancreatic duct. to inspect the colon lining.
●​ Biopsy and Polyp Removal: Instruments can be
Risks and Complications passed through the scope to take tissue samples
●​ Pancreatitis: The most common complication of or remove polyps.
ERCP, which can be severe.
●​ Bleeding: May occur after sphincterotomy or other Uses
interventions. ●​ Diagnostic Purposes: Used to diagnose conditions
like colon cancer, polyps, and inflammatory bowel
Recovery disease.
●​ Duration: The procedure typically lasts 30-60 ●​ Therapeutic Uses: Can be used to remove polyps,
minutes and is often performed on an outpatient stop bleeding, or place stents.
basis.
●​ Post-Procedure Care: Patients are monitored for Preparation
complications and usually resume normal activities
within a day.

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●​ Bowel Preparation: Patients typically follow a clear

liquid diet and use laxatives or enemas to cleanse
the bowel before the procedure.
●​ Sedation: Patients are usually sedated to reduce
discomfort during the procedure.

Recovery
●​ Duration: The procedure typically takes 30-60
minutes, and recovery from sedation usually takes
about an hour.
●​ Post-Procedure Care: Patients are monitored for
complications and may experience mild cramping
or gas discomfort. Figure 38-6 • Colonoscopy and flexible fiberoptic
sigmoidoscopy. For the colonoscopy, the flexible scope is
Other info: passed through the rectum and sigmoid colon into the
●​ Polyp Removal: Uses a special snare and cautery descending, transverse, and ascending colon. For the
to remove visible polyps, aiding in early detection flexible fiberoptic sigmoidoscopy, the flexible scope is
and prevention of colorectal cancer. advanced past the proximal sigmoid and then into the
●​ Therapeutic Uses: Can treat bleeding, strictures, descending colon.
and neoplasms using coagulators, heater probes,
sclerosing agents, or laser therapy. Nursing Interventions for Colonoscopy
●​ Positioning: The patient lies on their left side with
legs drawn up toward the chest, and their position Preparation:
may be adjusted during the procedure. ●​ The success of colonoscopy depends on how well
●​ Specimen Collection: Biopsy forceps or a cytology the colon is prepared. Adequate colon cleansing
brush can be used to obtain tissue samples for provides optimal visualization and decreases the
further examination. time needed for the procedure. Cleansing of the
●​ Complications: Potential complications include colon can be accomplished in various ways. The
cardiac arrhythmias, respiratory depression, primary provider may prescribe a laxative for two
vasovagal reactions, and circulatory issues due to nights before the examination and a Fleet or saline
hydration status. enema until the return is clear the morning of the
●​ Monitoring: Continuous monitoring of cardiac and test. However, more commonly, PEG electrolyte
respiratory function, along with oxygen saturation, lavage solutions (GoLYTELY, CoLyte, and
is performed during the procedure. NuLYTELY) are used for effective cleansing of the
●​ Duration and Discomfort: The procedure typically bowel. Current preparations include either the
lasts about an hour, and post-procedure nonsplit dose regimen, in which the entire solution
discomfort may occur due to air instillation and is ingested the night before the procedure, or the
scope movement. split-dose regimen, in which half of the dose is
ingested the night before and half is ingested the
Capsule Colonoscopy morning of the procedure, 3 hours prior to the
●​ Indications: Suitable for patients who cannot scheduled test. Tariq et al. (2019) report improved
tolerate colonoscopy or have had incomplete bowel preparation and cleansing with the split
colonoscopies. prep.
●​ Procedure: Involves swallowing a capsule with a
two-sided camera. Patient Health Considerations:
●​ Preparation: Requires more extensive bowel ●​ Patient health history and comorbidities such as
preparation compared to traditional colonoscopy. diabetes, chronic constipation, or history of opioid
●​ Follow-Up: Patients with positive results need a use, or problematic colonoscopies influence
follow-up colonoscopy on a separate day. patient preparation. Preprocedure diet instructions
include a clear liquid or a low residue diet starting
the day before the procedure; diet type has not
been shown to affect bowel preparation in patients
ingesting the split preparations (Tariq et al., 2019).
If necessary, the nurse can give the solution
through a feeding tube if the patient cannot
swallow. Patients with a colostomy can receive this
same bowel preparation. The use of lavage
solutions is contraindicated in patients with

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intestinal obstruction or inflammatory bowel ●​ Colonoscopy cannot be performed if there is a

disease. suspected or documented colon perforation, acute
severe diverticulitis, or acute colitis. Patients with
Alternative Preparation: prosthetic heart valves or a history of endocarditis
●​ A sodium phosphate tablet (OsmoPrep, Visicol) require prophylactic antibiotics before the
can be used for colon cleansing prior to procedure.
colonoscopy. Dosing consists of 32 tablets: 20
tablets (4 tablets every 15 minutes) with 8 oz of Informed Consent and Sedation:
any clear liquid (water, any clear carbonated ●​ Informed consent is obtained by the practitioner
beverage, or juice) on the evening prior to the before the patient is sedated. Before the
examination, and 12 tablets (taken in the same examination, an opioid analgesic agent or sedative
manner) on the morning of the examination. (e.g., midazolam) is given to provide moderate
sedation and relieve anxiety during the procedure.
Side Effects of Preparation: Glucagon may be given, if needed, to relax the
●​ With the use of lavage solutions, bowel cleansing colonic musculature and to reduce spasm during
is fast (rectal effluent is clear in about 4 hours) and the test. Patients who are older or debilitated may
is tolerated fairly well by most patients. Side require a reduced dosage of the analgesic agent
effects of the electrolyte solutions include nausea, or sedative to decrease the risks of oversedation
bloating, cramps or abdominal fullness, fluid and and cardiopulmonary complications.
electrolyte imbalance, and hypothermia (patients
are often told to drink the preparation as cold as Monitoring During the Procedure:
possible to make it more palatable). The side ●​ During the procedure, the patient is monitored for
effects are especially problematic for older adults, changes in oxygen saturation, vital signs, color
and sometimes they have difficulty ingesting the and temperature of the skin, level of
required volume of solution. Monitoring older consciousness, abdominal distention, vagal
patients after a bowel preparation is especially response, and pain intensity.
important because their physiologic ability to
compensate for fluid loss is diminished. Many Post-Procedure Care:
older adults take multiple medications each day; ●​ After the procedure, patients are maintained on
therefore, the nurse’s knowledge of their daily bed rest until fully alert. Some patients have
medication regimen can prompt assessment for abdominal cramps caused by increased peristalsis
and prevention of potential problems and early stimulated by the air insufflated into the bowel
detection of physiologic changes. during the procedure.

Special Considerations: Monitoring for Complications:

●​ Additionally, the nurse advises the patient with ●​ Immediately after the test, the patient is monitored
diabetes to consult with their primary provider for signs and symptoms of bowel perforation (e.g.,
about medication adjustment to prevent rectal bleeding, abdominal pain or distention,
hyperglycemia or hypoglycemia resulting from the fever, focal peritoneal signs). Because of the
dietary modifications required in preparing for the amnesic effects of midazolam, the patient may be
test. The nurse also instructs all patients, unable to recall verbal information and should
especially older adults, to maintain adequate fluid, receive written instructions. If the procedure is
electrolyte, and caloric intake while undergoing performed on an outpatient basis, someone must
bowel cleansing. transport the patient home. After a therapeutic
procedure, the nurse instructs the patient to report
Precautions for Certain Patients: Special precautions any bleeding to the primary provider.
●​ must be taken for some patients. Implantable
defibrillators and pacemakers are at high risk for
malfunction if electrosurgical procedures (i.e.,
polypectomy) are performed in conjunction with
colonoscopy. A cardiologist should be consulted ANOSCOPY, PROCTOSCOPY,
before the test is performed for device SIGMOIDOSCOPY
management. These patients require careful
cardiac monitoring during the procedure (American Definition: These procedures involve endoscopic
Society of Anesthesiology Taskforce, 2020; examination of the anus, rectum, and sigmoid and
Neubauer, Wellman, Herzog-Niescery, et al., descending colon to evaluate conditions like chronic
2018). diarrhea, fecal incontinence, ischemic colitis, and lower GI
hemorrhage.
Contraindications:

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 MEDICAL SURGICAL NURSING
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Methods: Several methods are available for visualizing the

Uses small intestine, including capsule endoscopy and
●​ Diagnostic Purposes: Used to observe for double-balloon enteroscopy.
ulceration, fissures, abscesses, tumors, polyps, or
other pathologic processes in the rectum and Capsule Endoscopy
lower colon. ●​ Procedure: The patient swallows a capsule
containing a wireless miniature camera, light
Procedure source, and image transmission system.
●​ Flexible Sigmoidoscopy: Uses a flexible fiberoptic ●​ Use: Useful for evaluating obscure GI bleeding by
sigmoidoscope to examine the colon up to 40-50 providing non-invasive visualization of the small
cm from the anus. This scope has similar intestine mucosa.
capabilities to those used for upper GI studies, ●​ Advantages: The capsule is propelled by
including still or video imaging. peristalsis, allowing inspection without patient
●​ Rigid Sigmoidoscopy: Examines the rectum and discomfort.
sigmoid colon up to 25 cm from the anus.
Double-Balloon Enteroscopy
Patient Positioning ●​ Procedure: Uses an endoscope with two balloons,
●​ Positioning: The patient assumes a comfortable one on the scope and one on a transparent
position on the left side with the right leg bent and overtube, to visualize the entire small bowel.
placed anteriorly. ●​ Technique: The balloons are alternately inflated
and deflated, causing the intestine to telescope
Biopsy and Polypectomy onto the overtube, allowing more extensive
●​ Biopsy: Performed using small biting forceps visualization.
introduced through the endoscope to remove ●​ Duration and Sedation: The procedure takes 1-3
tissue samples. hours and requires moderate sedation.
●​ Polypectomy: Polyps can be removed with a wire
snare and electrocoagulation current to prevent Nursing Interventions
bleeding. ●​ Similar to Other Endoscopic Procedures: Nursing
interventions are similar to those for other
Tissue Handling endoscopic procedures.
●​ Tissue Management: Excised tissue must be
placed in moist gauze or an appropriate
receptacle, labeled correctly, and delivered
promptly to the pathology laboratory.
ENDOSCOPY THROUGH AN OSTOMY
Nursing Interventions
●​ Preparation: Limited bowel preparation is required, Purpose: Useful for visualizing a segment of the small or
typically involving a warm tap water or Fleet large intestine through an ostomy stoma.
enema until returns are clear. Dietary restrictions
are usually not necessary, and sedation is typically Indications: Indicated to evaluate the anastomosis for
not required. recurrent disease or to visualize and treat bleeding in a
●​ Monitoring During the Procedure: The nurse segment of the bowel.
monitors vital signs, skin color and temperature,
pain tolerance, and vagal response. Nursing Interventions: Nursing interventions are similar to
●​ Post-Procedure Monitoring: After the procedure, those for other endoscopic procedures.
the nurse monitors for rectal bleeding and signs of
intestinal perforation (e.g., fever, rectal drainage,
abdominal distention, pain).
●​ Post-Procedure Care: Patients can resume regular C1 MANOMETRY AND
activities and diet after the examination. ELECTROPHYSIOLOGIC STUDIES

Definition: These studies evaluate patients with

gastrointestinal (GI) motility disorders by measuring changes
SMALL BOWEL STUDIES in intraluminal pressures and muscle activity coordination in
the GI tract.

ESOPHAGEAL MANOMETRY

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 MEDICAL SURGICAL NURSING
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●​ Purpose: Used to detect motility disorders of the ●​ Purpose: Assesses gastric motility disturbances
esophagus and upper and lower esophageal and detects motor or nerve dysfunction in the
sphincter. stomach.
●​ Diagnosis: Helpful in diagnosing conditions like ●​ Procedure: Electrodes are placed over the
achalasia, diffuse esophageal spasm, abdomen, and gastric electrical activity is recorded
scleroderma, and other esophageal motor for up to 24 hours.
disorders. ●​ Findings: Patients may exhibit rapid, slow, or
●​ Preparation: Patients must fast for 8-12 hours irregular waveform activity.
before the test and withhold certain medications
(e.g., calcium channel blockers, anticholinergic
agents, sedatives) for 24-48 hours. DEFECOGRAPHY
●​ Procedure: A pressure-sensitive catheter is
inserted through the nose, connected to a ●​ Purpose: Measures anorectal function.
transducer and video recorder, and the patient ●​ Procedure: Performed with thick barium paste
swallows small amounts of water while pressure instilled into the rectum, using fluoroscopy to
changes are recorded. assess rectum and anal sphincter function while
the patient attempts to expel the barium.
●​ Preparation: No preparation is required.
GASTRODUODENAL, SMALL INTESTINE,
AND COLONIC MANOMETRY

●​ Purpose: Evaluates delayed gastric emptying and

gastric and intestinal motility disorders such as
irritable bowel syndrome or atonic colon. C1 GASTRIC ANALYSIS, GASTRIC ACID
●​ Procedure: Often an ambulatory outpatient STIMULATION TEST, AND PH
procedure lasting 24-72 hours. MONITORING

Purpose: Gastric analysis provides information about the

ANORECTAL MANOMETRY
secretory activity of the gastric mucosa and helps diagnose
conditions like Zollinger-Ellison syndrome or atrophic
●​ Purpose: Measures the resting tone of the internal gastritis.
anal sphincter and contractibility of the external
anal sphincter. Preparation
●​ Indications: Helpful in evaluating patients with ●​ Fasting: Patients must fast for 8-12 hours before
chronic constipation or fecal incontinence and the procedure.
useful in biofeedback for treating fecal ●​ Medication Management: Medications affecting
incontinence. gastric secretions are withheld for 24-48 hours.
●​ Preparation: A dibasic sodium (Phospho-soda) or ●​ Smoking: Smoking is not allowed on the morning
saline cleansing enema is given 1 hour before the of the test due to its effect on gastric secretions.
test, and the patient is positioned prone or
laterally. Procedure
●​ Nasogastric Tube Insertion: A small nasogastric
tube is inserted through the nose and positioned in
RECTAL SENSORY FUNCTION STUDIES the stomach.
●​ Sample Collection: The entire stomach contents
●​ Purpose: Evaluates rectal sensory function and are aspirated, and gastric samples are collected
neuropathy. every 15 minutes for an hour.
●​ Procedure: A catheter and balloon are passed into
the rectum, with increasing balloon inflation until Diagnostic Information
the patient feels distention, and then the tone and ●​ Pernicious Anemia: No acid secretion under basal
pressure of the rectum and anal sphincter are conditions or after stimulation.
measured. ●​ Chronic Atrophic Gastritis or Gastric Cancer: Little
●​ Indications: Helpful in evaluating patients with or no acid secretion.
chronic constipation, diarrhea, or incontinence. ●​ Gastric Ulcer: Some acid secretion.
●​ Duodenal Ulcers: Excess acid secretion.

ELECTROGASTROGRAPHY Gastric Acid Stimulation Test

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 MEDICAL SURGICAL NURSING
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●​ Stimulation: Histamine or pentagastrin is given

subcutaneously to stimulate gastric secretions.
●​ Monitoring: Blood pressure and pulse are
REFERENCES:
monitored frequently to detect hypotension.
●​ Sample Collection: Gastric specimens are
Brunner & Suddarth’s Textbook of Medical-Surgical
collected every 15 minutes for an hour after Nursing, 15e
stimulation.

pH Monitoring
●​ Ambulatory pH Monitoring: A sensor is inserted via
endoscopy and worn for 24 hours to evaluate
esophageal reflux of gastric acid.
●​ Bravo pH Monitoring System: A capsule is
attached to the esophageal wall via endoscopy,
transmitting pH data to a receiver for up to 96
hours.

C1 LAPAROSCOPY
(PERITONEOSCOPY)

Definition: Diagnostic laparoscopy is a minimally invasive

procedure that involves creating a pneumoperitoneum by
injecting carbon dioxide into the peritoneal cavity to visualize
abdominal organs and structures.

Procedure
●​ Incision and Instrumentation: A small incision is
made lateral to the umbilicus to insert a fiberoptic
laparoscope, allowing direct visualization of
abdominal organs.
●​ Biopsy Capability: Biopsy samples can be taken
from structures and organs as needed.

Uses
●​ Diagnostic Purposes: Used to evaluate peritoneal
disease, chronic abdominal pain, abdominal
masses, and gallbladder and liver disease.
●​ Therapeutic Potential: Allows for immediate
therapeutic interventions, such as excision of the
gallbladder, if necessary.

Limitations
●​ Acute Abdominal Pain: Less commonly used for
acute abdominal pain due to the availability of less
invasive imaging tools like CT and MRI scans.

Anesthesia and Preparation

●​ General Anesthesia: Typically requires general
anesthesia.
●​ Decompression: May require decompression of
the stomach and bowel.
●​ Gas Insufflation: Carbon dioxide is used to create
a working space for visualization.

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