Anatomy and Physiology overview

By: Aliye Kediro

(Asst. Professor)
 THE DIGESTIVE SYSTEM
2

 The digestive system is made up of the

alimentary canal (food passageway) &
accessory organs of digestion.
 THE DIGESTIVE …
3

 The main functions of the digestive system

are to:
✓ingest and carry food so that
digestion can occur.
✓eliminate unused waste material.
 THE DIGESTIVE …
4

 The alimentary canal is approximately

28 feet long in the adult and extends
from the mouth to the anus.
 THE MOUTH
5

 The mouth, or oral cavity,

is the beginning of the
digestive tract.
 Here food taken into the
body is broken into small
particles and mixed with
saliva so that it can be
swallowed.
 THE MOUTH…
6

Teeth.
 Two sets of teeth during life a:
 deciduous or temporary (20 teeth
that erupt during the 1st three yrs)
 permanent set (32 teeth)
 The primary function of the teeth
is to
 chew or masticate food and also
 help modify sound produced by
the larynx to form words.
 THE MOUTH…
7

Salivary Glands.
 Are the first accessory
organs of digestion.
 There are three pairs of
salivary glands.
 Parotid

 Submandibular &
 Sublingual gland

 They secrete saliva into

the mouth through small
ducts.
 THE MOUTH…
8

Tongue
 The tongue is a muscular organ
attached at the back of the mouth and
projecting upward into the oral cavity.
 It is utilized for taste, speech,

mastication, salivation, and swallowing.

Taste Buds
 Located on the tongue and at the back

of the mouth are special clumps of cells

known as taste buds.
 Taste buds are sensitive to substances

that are sweet, sour, bitter, and salty.

 PHARYNX
9
 The pharynx is a
musculomembranous passage
that leads from the nose and
mouth to the esophagus.
 The passage of food from the
pharynx into the esophagus is
the second stage of
swallowing.
 When food is being
swallowed, the larynx is
closed off from the pharynx
to keep food from getting into
the respiratory tract.
 THE ESOPHAGUS
10

 The esophagus is a musculomembranous

passage about 10 inches long, lined
with a mucous membrane.
 It leads from the pharynx through the
chest to the upper end of the stomach.
 Its function is to complete the act of
swallowing.
 The involuntary movement of material
down the esophagus is carried out by
the process known as peristalsis, which
is the wavelike action produced by
contraction of the muscular wall.
 THE STOMACH
11

 The stomach is an elongated pouch-like

structure lying just below the diaphragm,
with most of it to the left of the midline.
 It has three divisions:
 fundus
 body and
 pylorus
 (The cardiac sphincter is at the
esophageal opening, and the pyloric
sphincter is at the junction of the stomach
and the duodenum, the first portion of
the small intestine.)
 The cardiac sphincter prevents stomach
contents from reentering the esophagus
except when vomiting occurs.
 THE STOMACH…
12

 It acts as a store house for food, receiving fairly large amounts,

churning it, and breaking it down further for mixing with digestive
juices.
 Semiliquid food is released in small amounts by the pyloric valve into
the duodenum, the first part of the small intestine.
 The glands in the stomach lining produce gastric juices (which contain
enzymes) and hydrochloric acid.
 The enzymes in the gastric juice start the digestion of protein foods,
milk, and fats.
 Hydrochloric acid aids enzyme action.
 The mucous membrane lining the stomach protects the stomach itself
from being digested by the strong acid and powerful enzymes
 SMALL INTESTINE
13

 The small intestine is a tube about 22

feet long.
 The intestine is attached to the margin
of a thin band of tissue called the
mesentery, which is a portion of the
peritoneum, the serous membrane
lining the abdominal cavity.
 The mesentery supports the intestine,
and the vessels that carry blood to and
from the intestine lie within this
membrane.
 The other edge of the mesentery is
drawn together like a fan; the
gathered margin is attached to the
posterior wall of the abdomen.
 SMALL INTESTINE…
14

 The intestine is divided into three continuous

parts:
 Duodenum
 jejunum, and

 ileum.
 SMALL INTESTINE…
15

 Most of the absorption of food takes place in the small

intestine.
 Muscular contraction of the intestinal walls produces the
wave-like motion called peristalsis, which propels the
contents through the length of the intestines.
 The walls of the intestines are covered with small, fingerlike
projections called villi, which provide a larger surface area
for absorption.
 After food has been digested, it is absorbed into the
capillaries of the villi and carried to all parts of the body
via the circulatory system.
 SMALL INTESTINE…
16

 The small intestine

receives digestive
juices from three
accessory organs of
digestion:
 pancreas

 liver,
and
 gallbladder
 Pancreas
 The pancreas is a long, tapering
17
organ lying behind the stomach.
 The pancreas secretes a juice that

acts on all types of food.

 Pancreatic juice consists of alkaline

(chiefly bicarbonate) fluid and

enzymes; 200–800 ml is produced
each day.
 trypsin and chymotrypsin to digest
proteins
 amylase for the digestion of
carbohydrates and
 lipase to break down fats.

When food enters the stomach, these pancreatic juices are released
into a system of ducts that culminate in the main pancreatic duct.
 Liver
18

 The liver is the largest

organ in the body.
 It is located in the upper
part of the abdomen with
its larger (right) lobe to
the right of the midline.
 It is just under the
diaphragm and above the
lower end of the stomach.
 Liver…
19

 The liver has several important functions.

 One is the secretion of bile, which is stored in the
gallbladder and discharged into the small intestine
when digestion is in process.
 The bile contains no enzymes, but it breaks up the fat
particles so that enzymes can act faster.
 Liver is a storehouse for the sugar of the body
(glycogen) and for iron and vitamin B.
 It plays a part in the destruction of bacteria and
worn out red blood cells.
 Liver…
20

 Many chemicals such as poisons or medicines are detoxified

by the liver; others are excreted by the liver through bile
ducts.
 The liver manufactures part of the proteins of blood plasma.
 The blood flow in the liver is of special importance.
 All the blood returning from the spleen, stomach, intestines,
and pancreas is detoured through the liver by the portal vein
in the portal circulation.
 Blood drains from the liver by hepatic veins that join the
inferior vena cava.
 Gallbladder
21

 The gallbladder is a dark

green sac, shaped like a
blackjack and lodged in a
hollow on the underside of the
liver.
 Its ducts join with the duct of
the liver to conduct bile to the
upper end of the small
intestine.
 The main function of the
gallbladder is the storage
and concentration of the bile
when it is not needed for
digestion.
 LARGE INTESTINE (COLON)
 The large intestine, also called the colon,
22
is approx-imately 2.5 inches (6.3 cm) in
diameter and 5 feet (1.5 m) in length.
 It extends from the ileum of the small
intestine to the anus, the terminal opening..
 The cecum, located on the lower right
side of the abdomen, is the first
portion of the large intestine into
which food is emptied from the small
intestine.
 The appendix extends from the lower
portion of the cecum and is a blind
sac.
 Although the appendix usually is found
lying just below the cecum, by virtue of
its free end it can extend in several
different directions, depending upon
its mobility.
 LARGE INTESTINE (COLON)…
23 The colon extends along the right side
of the abdomen from the cecum up to
the region of the liver (ascending
colon).
 There the colon bends (hepatic flexure)
and is continued across the upper
portion of the abdomen (transverse
colon) to the spleen.
 The colon bends again (splenic flexure)
and goes down the left side of the
abdomen (descending colon).
 The last portion makes an S curve
(sigmoid) toward the center and
posterior of the abdomen and ends in
the rectum.
 LARGE INTESTINE (COLON)…
24

 The main function of the large intestine is the recovery of water and
electrolytes from the mass of undigested food it receives from the small
intestine.
 As this mass passes through the colon, water is absorbed and returned
to the tissues.
 Waste materials, or feces, become more solid as they are pushed
along by peristaltic movements.
 Constipation is caused by delay in movement of intestinal contents and
removal of too much water from them.
 Diarrhea results when movement of the intestinal contents is so rapid
that not enough water is removed.
 THE RECTUM AND ANUS
25

 The rectum is about 5 inches long and

follows the curve of the sacrum and
coccyx until it bends back into the short
anal canal.
 The anus is the external opening at the
lower end of the digestive system.
 It is kept closed by a strong sphincter
muscle.
 The rectum receives feces and
periodically expels this material
through the anus.
 This elimination of refuse is called
defecation.
 Nursing Assessment
26

 When obtaining the nursing history of a

gastrointestinal patient, a detailed interview
should be conducted.
 Nursing personnel should question the patient
about his
 dietaryhabits
 bowel habits, and

 GI complaints (signs and symptoms).

 Cont…
27

 Question the patient about the following:

 The number of meals ate per day.
 Meal times.
 Food restrictions or special diets followed.
 Changes in appetite. Increased? Decreased? No appetite?
 What foods, if any, have been eliminated from the diet? Why?
 What foods are not well tolerated?
 Alterations in taste.
 Medications used. Dosage and frequency.
 Cont …
28

✓Information about bowel patterns, especially a

change in bowel patterns, can provide clues that
will aid in the diagnosis of the problem.

 Question the patient  Stool Description.

 Constipation.
about the following:  Diarrhea.
 Frequency of bowel  Blood in stool.
movements.  Mucous in stool.
 Use of laxatives and/or  Black, tarry stools.
enemas.  Pale or clay colored
 Changes in bowel habits. stools.
 Foul smelling stools.
 Pain with stool.
 Cont…
29

 Ask the patient to describe any complaints not yet discussed in the
interview.
 For example.
 Nausea. Frequency? Duration? Associated with meals? Relieved by?
 Vomiting. Frequency? Character of emesis? Relieved by?
 Heartburn/indigestion. Frequency? Duration? Associated with
specific foods? Relieved by?
 Gas (belching and flatus). Frequency? Associated with specific
foods? Relieved by?
 Weight loss. How much? In what time period?
 30

Pain: Location? Frequency?

Duration? Character of the pain?
What does pain feel like?

▪ Steady pain inflammatory

process
▪ Crampy pain obstructive process
▪ Sharp (peritoneal irritation)
▪ Dull peritoneal stretching
31

 Was onset of pain gradual or

sudden
 Sudden
 Perforation
 Hemorrhage
 Infract

 Gradual
 Peritoneal irritation
 Hollow organ distension

 Does pain radiate?
32

 Right shoulder
 Gall bladder
 Around flank to groin
 Kidney, ureter
 Middle of back
 Pancreas
 Site of referred pain
33
 Cont…
34

 Perform a brief, general head-to-toe visual inspection of the

patient. Is height and weight within normal range for the
patient's age and body type?
 Observe the skin for the following:
 Color (pale, gray, ruddy, jaundiced).

 Bruises.

 Rashes.

 Lesions.

 Turgor and moisture content.

 Edema.
 Cont…
35

 Examine the mouth and throat.

 Look at the lips, tongue, and mucous membranes

 noting abnormalities such as

◼ Cuts
◼ sores, or
◼ discoloration.
 Observe the condition of the teeth, Note any
 discolored,
 Cracked
 Chipped
 loose, or
 missing teeth.
36

 Observe the gums. Are they healthy and pink?

Note the patient's
 breath for unusual odors
◼ Fruity
◼ Foul
◼ alcohol, and
◼ so forth).
 EXAMINATION OF THE ABDOMEN
37

 Physical examination of the abdomen involves visual inspection,

auscultation, and palpation.
 It is best to perform this examination while the patient is resting in a
 supine position
 knees slightly flexed to relax the abdominal muscles.
 In order to facilitate the referencing of location, the abdomen is
viewed as four quadrants or nine regions.
 Cont…
38

 Begin the abdominal examination by visually inspecting the

abdomen. Observe the following:
 Color.

 Pale?
 Jaundiced?
 Reddish ?
 Pigmentation. Even? Note blotches or lines of pigmentation.
 Contour. Symmetrical? Flat? Rounded? Sunken? Distended?
 Presence of: Petechiae? Scars? Rash? Visible blood vessels?
 Hair growth patterns.
 Cont…
39

 Next, auscultate the abdomen.

 Move the stethoscope in a symmetrical pattern, listening in all
four quadrants.
 Listen for bowel sounds.

 The best location is below and to the right of the umbilicus.

 Describe the sounds heard according to location, frequency, and
character of the sound.
 Abnormalities include absent bowel sounds and the peristaltic
rush of a hyperactive bowel.
 Cont…
40

 After auscultation, palpate the abdomen.

 Palpation is used to detect
 muscle guarding
 tenderness, and
 masses.
 Gently palpate the abdomen, moving in a symmetrical pattern
and covering all four quadrants.
 Record any of the following findings, noting the location.
 Rigidity or Guarding. This is the inability to relax the abdominal

muscles.
 Pain or Tenderness. Ask the patient to describe the pain if

palpation elicits a painful or tender area.

 Cont…
41

 Rebound Pain. This is pain felt upon release of

pressure, as opposed to application of pressure.
 Masses. Organs can be palpated for size and contour
by a trained examiner. Additionally, masses and
irregularities in and around the abdominal organs
may be detected.
 Diagnostic Procedures
42

The digestive tract can be outlined by x-rays

 The contrast medium is swallowed by the
patient in order to visualize the upper GI tract.
 These procedures are referred to as "barium

swallow," "upper GI," or "small bowel follow-

through."
 To visualize the lower GI tract, the contrast

medium is instilled rectally.

 This procedure is called a "barium enema."
 Diagnostic Procedures…
43

✓ Pre-Procedural Nursing Implications.

 For upper GI examinations, the patient is normally held NPO
after midnight the day before the exam in order to empty the
upper GI tract.
 Additionally, gum chewing and smoking should be discouraged the
morning of the exam, as this stimulates gastric action.
 For lower GI tract examinations, the patient's large intestine must
be free of stool.
 This is normally accomplished through the use of laxatives and
cleansing enemas.
 The patient is held NPO after midnight the day before the exam.
 The patient must be educated about the procedure, the
significance of the preparation, and any significant post-
procedural sequelae.
 Diagnostic Procedures…
44

✓ Post-Procedural Nursing Implications.

 Many patients experience constipation as a side effect of the
contrast medium.
 If so, mineral oil or a laxative may be required to relieve
constipation.
 Observe the patient for any signs of abdominal or rectal
discomfort.
 Resume diet and medications as directed by surgeon
 Diagnostic Procedures…
45

✓ Stool exam
 For
 unseen blood (occult)

 fat

 Urobilinogen

 Ova

 parasite

 bacteria, and

 other substances.
 Diagnostic Procedures…
46

 Endoscopy is a visual examination of the

interior through the use of special instruments
called endoscopes.
 In relation to the digestive system, the term

endoscopy is used to describe visual

examination of the inside of the GI tract.
 Generally, the scope consists of a hollow tube

with a lighted lens system that permits multi-

directional viewing.
 The scope has a power source and accessories
that permit both biopsy and suction.
 Diagnostic Procedures…
47

Pre-Procedural Nursing Implications.

 Endoscopic procedures are invasive, and therefore require a formal, signed
consent form.
 The patient must be educated about the procedure, the significance of any
preparation, and any post-procedural sequelae.
 Upper GI endoscopy requires that the patient be fasting.
 Sedatives are administered prior to the procedure to relax the patient and
facilitate passage of the scope.
 The physician may require the removal of the dentures prior to oral insertion of
the scope.
 Colon endoscopy requires that the bowel be free of stool to enhance
visualization.
 This is normally accomplished with laxatives and cleansing enemas.
 Diagnostic Procedures…
48

Post-Procedural Nursing Implications.

✓ Accidental perforation of the esophagus or colon may occur during
endoscopy.
✓ If pain or bleeding occur following the procedure, notify the
professional nurse. Note the following:
 Mouth or throat pain.
 Rectal pain.
 Abdominal pain.
 Bleeding from rectum.
 Bleeding from mouth or throat.
✓ Withhold foods, fluids, and p.o. medications until the patient is fully
alert and gag reflex has returned.
✓ Take vital signs as indicated.
 Diagnostic Procedures…
49

 Endoscopic examination of the

entire large bowel
 Liquid diet for 12 to 24 hr
before procedure, NPO for 6
to 8 hr before procedure
 Bowel cleansing routine
 Assessment of vital signs every
15 min
 Diagnostic Procedures
50
Proctosigmoidoscopy
 Endoscopic examination of the rectum and sigmoid
colon
 Liquid diet 24 hr before procedure
 Cleansing enema, laxative
 Position client on left side in the knee-chest posture.
 Cont…
51

 Mild gas pain and flatulence from air instilled into

the rectum during the examination
 If biopsy was done, a small amount of bleeding
possible
 Other Tests
52

 Ultrasonography
 Endoscopic ultrasonography
 Liver-spleen scan
53

Management of patient with upper gastro

intestinal disorder
54

Disorder of mouth and

related structure
 Disorders of the Teeth
55

DENTAL PLAQUE AND CARIES

 Tooth decay is an erosive process that begins with

the action of bacteria on fermentable
carbohydrates in the mouth, which produces acids
that dissolve tooth enamel
 Dental Caries: A Bacterial Infection
56

 There are two specific groups of bacteria found in the

mouth that are responsible for dental caries:
 Mutans streptococci (Streptococcus mutans)
 Lactobacilli

 They are found in relatively large numbers

in the dental plaque.
 The presence of lactobacilli in the mouth indicates a
high sugar intake.
 Dental Plaque
57

 Dental plaque is a colorless, soft, sticky coating that

adheres to the teeth.
 Plaque remains attached to the tooth despite
movements of the tongue, water rinsing, water spray,
or less than thorough brushing.
 Formation of plaque on a tooth concentrates millions
of microorganisms on that tooth.
 The Caries Process
58

 For caries to develop, three factors must occur

at the same time:
A susceptible tooth
 Diet rich in fermentable carbohydrates

 Specific bacteria (regardless of other factors,

caries cannot occur without bacteria)
59

 The extent of damage to the teeth depends on the

following:
 The presence of dental plaque
 The strength of the acids and the ability of the saliva to
neutralize them
 The length of time the acids are in contact with the
teeth
 The susceptibility of the teeth to decay
60

 Dental decay begins with a small hole, usually in a

fissure (a break in the tooth’s enamel) or in an area
that is hard to clean.
 Left unchecked, the affected area penetrates the
enamel into the dentin.
 The earliest sign of decay is decalcification

61
 Dental caries
62
 Severely decayed molar on a child
63
 Root caries

64
65

 Because dentin is not as hard as enamel, decay

progresses more rapidly and in time reaches the
pulp.
 When the blood, lymph vessels, and nerves are
exposed, they become infected and an abscess may
form, either within the tooth or at the tip of the root.
66

 Soreness and pain usually occur with an abscess.

 As the infection continues, the patient’s face may
swell, and there may be pulsating pain.
 The dentist can determine by x-ray studies the
extent of damage and the type of treatment
needed.
 Management
67

 Treatment for dental caries includes:

 Fillings

 dental implants, and

 If treatment is not successful, the tooth may need to be
extracted.
 In general, dental decay is associated with young
people, but older adults are subject to decay as
well, particularly from drug-induced or age-related
oral dryness.
 Prevention
68

 Measures used to prevent and control dental caries

include:
 practicing effective mouth care
 reducing the intake of starches and sugars (refined
carbohydrates),
 applying fluoride to the teeth or drinking fluoridated
water
 refraining from smoking and

 Controlling diabetes
 Gerontologic Considerations
69
Oral Problems
 Many medications taken by the elderly cause dry
mouth, which is uncomfortable, impairs
communication, and increases the risk of oral
infection
 These medications include the following:
◼ Diuretics
◼ Antihypertensivemedications
◼ Anti-inflammatory agents
◼ Antidepressant medications
 DENTOALVEOLAR ABSCESS
70
OR PERIAPICAL ABSCESS
 Periapical abscess, more commonly referred to as
an abscessed tooth, involves the collection of pus in
the apical dental periosteum (fibrous membrane
supporting the tooth structure) and the tissue
surrounding the apex of the tooth
71

 The abscess has two forms:

acute and
chronic.
72

 Acute periapical abscess is usually secondary to a

suppurative pulpitis (a pus-producing inflammation
of the dental pulp) that arises from an infection
extending from dental caries.
 The infection of the dental pulp extends through the
apical foramen of the tooth to form an abscess
around the apex.
73

 Chronic dentoalveolar abscess is a slowly

progressive infectious process.
 It differs from the acute form in that the process
may progress to a fully formed abscess without the
patient’s knowing it.
 The infection eventually leads to a “blind dental
abscess,” which is really a periapical granuloma.
 It may enlarge to as much as 1 cm in diameter.
 It is often discovered on x-ray films and is treated
by extraction
 Clinical Manifestations
74

 The abscess produces a dull, gnawing, continuous

pain, often with a surrounding cellulitis and edema
of the adjacent facial structures, and mobility of the
involved tooth.
 The gum opposite the apex of the tooth is usually
swollen on the cheek side.
 Swelling and cellulitis of the facial structures may
make it difficult for the patient to open the mouth.
 In well-developed abscesses, there may be a
systemic reaction, fever, and malaise.
 Management
75

 In the early stages of an infection, a dentist or

dental surgeon may perform a needle aspiration or
drill an opening into the pulp chamber to relieve
tension and pain and to provide drainage.
 Usually, the infection will have progressed to a
periapical abscess.
 Antibiotics may be prescribed.
 After the inflammatory reaction has subsided, the
tooth may be extracted or root canal therapy
performed.
 Disorders of the Salivary Glands
76

 The salivary glands consist of the

◼ parotid glands, one on each side of the face below the ear
◼ submandibular and
◼ Sublingual glands, both in the floor of the mouth; and
◼ buccal gland, beneath the lips.

 About 1200 mL of saliva are produced daily.

 The glands’ primary functions are
 Lubrication

 protection against harmful bacteria, and

 digestion.
 PAROTITIS
❑ Parotitis is
77

inflammation of the
parotid gland
❑ It is the most common
inflammatory condition
of the salivary glands

 Mumps (epidemic parotitis), a communicable

disease caused by viral infection and most
commonly affecting children
 is an inflammation of a salivary gland, usually the

parotid.
78

 Elderly

 acutely ill, or
 debilitated people

 with decreased salivary flow from general

dehydration or medications are at high risk for
parotitis.
 The infecting organisms travel from the mouth
through the salivary duct.
 The organism is usually Staphylococcus aureus
(except in mumps).
 Management
79

 Treat the underlying cause

 Analgesic for pain
 Adequate nutrition and fluid intake
 Good oral hygiene, and
 discontinuing medications that can diminish salivation
may help prevent the condition.
 (eg, tranquilizers, diuretics)
 SIALADENITIS
80

 Sialadenitis(inflammation
of the salivary glands
 may be caused by

 Dehydration

 radiation therapy
 Stress

 malnutrition,

 Salivary gland calculi (stones), or

 improper oral hygiene.

 The inflammation is associated with infection by S.

aureus, Streptococcus viridans, or pneumococcus.
81

 Symptoms include pain, swelling, and purulent

discharge.
 Antibiotics are used to treat infections.
 Massage, hydration, and corticosteroids frequently
cure the problem.
 Chronic sialadenitis with uncontrolled pain is treated
by surgical drainage of the gland or excision of the
gland and its duct.
 What is a mouth ulcer?
82

 A mouth or oral ulcer is an open sore in the

mouth, or rarely a break in the mucous
membrane or the epithelium on the lips or
surrounding the mouth.
 Epidemiology and frequency
83

 Mouth ulcer is a very common oral lesion.

 Epidemiological studies show an average prevalence
between 15% and 30%.
 Mouth ulcers tend to be more common in women and
those under 45.
 The frequency of mouth ulcers varies from fewer than 4
episodes per year to more than one episode per month
including people suffering from continuous recurrent
aphthous stomatitis
 What cause ulcers?
84

 Trauma (physical injuries)

 Chemical injuries
 Smoking
 Infection
 viral
 Bacterial
 Fungal
 protozoans
 Immunodeficiency
 Autoimmunity
 Allergy
 Dietary
 Tools for diagnosis:
85

 History
 Examination
 Further investigation
 Additional diagnostic methods – biopsy
 Traumatic lesions
86

 Mechanical trauma (acute or chronic)

 Chemical injury (acid, alcali)
 Physical injury (thermal injury, electrical injury)
 Mechanical trauma
87

 Can be:
1. Acute
2. Chronic
 caused by:
88

1. A sharp edge of a tooth

2. Accidental biting
3. Sharp, abrasive,or
excessively salty food
4. Poorly fitting dentures
5. Dental braces
6. Trauma from a tooth
brush
 Dental braces
89
 Acute trauma
90

 Single,
 can identify the cause
 should improve after
removal
 Traumatic ulcers:
91
 Clinical features of traumatic ulcers:
92

❑ They are clinically diverse, but usually appear as a single,

painful ulcer with a smooth red or whitish-yellow surface and
a thin erythematous halo.
 They are usually soft on palpation, and heal without scarring
within 6–10 days, spontaneously or after removal of the
cause.
 However, chronic traumatic ulcers may clinically mimic a
carcinoma.
 The tongue, lip, and buccal mucosa are the sites
 The diagnosis is based on the history and clinical features.
 However, if an ulcer persists over 10–12 days a biopsy must
be taken to rule out cancer.
 Treatment
93

1. Removing factors, caused trauma

2. Good hygiene of oral cavity
3. Antiseptic for 7-10 days
4. Analgetics if it is necessary
5. Topical steroids may be used for a short time.
6. Biopsy
 Leukoplakia
94

 Etiology:
-​trauma from habitual biting, dental
appliances
-​tobacco use
-​​alcohol consumption
-oral sepsis
-​local irritation
-syphilis​
-vitamin deficiency
-​endocrine disturbances​​
-actinic radiation (in the case of lip
involvement).
 Symptoms –
 painless
 fuzzy white patches on the side of the tongue or
cheeks.
 Clinical manifestation
95

 located on the tongue, mandibular alveolar ridge and buccal mucosa

in ~50%.
 palate, maxillary alveolar ridge, lower lip, floor of the mouth and the
retromolar regions are somewhat less frequently involved.
 may vary from nonpalpable, faintly translucent white areas to thick,
fissured, papillomatous, indurated lesions.
 surface is often wrinkled or shriveled in appearance and may feel
rough on palpation.
 color may be white, gray, yellowish-white, or even brownish-gray in
patients with heavy tobacco use.

Physical:
-​lesion cannot be wiped away with a gauze
96
 Differential diagnosis:
97

1. Candidiasis and aspirin burn - can be

wiped away with a gauze
 Treatment
98

 Treat dental causes such as rough teeth,

irregular denture surface, or fillings as soon as
possible.
 Stopping tobacco or/and alcohol.

 Removal of leukoplakic patches with using a

scalpel, a laser or an extremely cold probe
that freezes and destroys cancer cells
(cryoprobe).
 Chemical injures:
99

 Chemicals such
as aspirin or alcohol t
hat are held or that
come in contact with
the oral mucosa may
cause tissues to
become necrotic and
slough off creating
an ulcerated surface.
 Treatment:
100

1. Wash a mouth with lot of water

2. Analgesics
3. Antiseptics
4. Remove the cause
 Physical injures:
101

 Electric Burns to the Mouth –

 are most commonly caused

when a child bites into a cord,
improperly connected cord,
 Treatment:
102

1. Conservative
 Antiseptics
 Antibiotics
 Analgetic
2. Surgical
 Stomatitis
103

 Definition
 Inflammation of the mucous lining of any of the
structures in the mouth, which may involve the
 Cheeks
 Gums
 Tongue
 lips, and
 roof or
 floor of the mouth.
 The word "stomatitis" literally means inflammation of
the mouth.
104

 The inflammation can be caused by

conditions in the mouth itself, such as
 poor oral hygiene
 poorly fitted dentures, or
 from mouth burns from hot food or drinks, or
 by conditions that affect the entire body, such as
medications, allergic reactions, or infections.
 Herpetic stomatitis
105

 Herpetic stomatitis is
a viral infection of
the mouth that
causes ulcers and
inflammation.
 These mouth ulcers
are not the same as
canker sores, which
are caused by a
different virus.
 Symptoms:
106
 Blisters in the mouth, often on the
tongue, cheeks, palate, gums, and a
border between the lip (red colored)
and the normal skin next to it
 Decrease in food intake, even if the
patient is hungry
 Difficulty swallowing (dysphagia)
 Fever (often as high as 104
°Fahrenheit) may occur 1 - 2 days
before blisters and ulcers appear
 Irritability
 Pain in mouth
 Swollen gums
 Ulcers in the mouth, often on the
tongue or cheeks -- these form after
the blisters pop
 Causes
107

 Herpetic stomatitis is a contagious viral illness

caused by Herpes virus hominis (also herpes simplex
virus, HSV).
 It is seen mainly in young children.
 This condition is probably a child's first exposure to
the herpes virus.

 An adult member of the family may have a cold sore

at the time the child develops herpetic stomatitis.
 More likely, no source for the infection will be
discovered.
 Treatment:
108

 Good oral hygiene

 Acyclovir not later than 48 hours!
 Analgesic
 Diet (no hot or pepper food)
 Antiseptics
 Aphthous Ulcers
109

 the most common non

traumatic ulcer that
affect oral mucosa.
110

 Aphthous ulcers are also

known as canker sores.
 They are painful, temporary
sores that may occur
anywhere in the mouth.
 Usually, they show up in
several places:

 On the inside of the lips

 Inside the cheeks
 On the tongue
 At the base of the gums
 Canker sores on tongue:
111
 Etiology:
112

1. Immune system disorders

2. Other conditions cause similar sores:
 Blood and immune system diseases,
including HIV
 Vitamin and mineral deficiencies
 Allergies
 Minor ulcers:
113

 Are the most commonly

encountered form
 Single, painful oval ulcer
less than 0,6 mm, covered
by a yellow fibrinous
membrane
 Last 7 to 10 days
 Periods of freedom from
disease – 2-3 weeks to
year
 Major ulcers:
114

 Lesions are larger: more than

10 mm
 More painful
 Persist longer that minor
aphthae
 One ulcer disappears, another
one starts
 Healing generally occurs in 6
weeks and longer
 Chronic stress, common disease
can cause
 Herpetiform ulcers
115

 Recurrent crops of small

ulcers
 Healing generally occurs
in 1 to 2 weeks
 Not preceded by vesicle
and exhibit no virus-
infected cells
 Treatment:
116

 Oral hygiene
 Avoiding spicy food
 Oral rinsing with sodium bicarbonate
 Analgesics
 Antiseptics
 Anti – inflammatory agents
 Antimicrobial and corticosteroids
 Candidiasis
117

➢common oppurtunistic
oral mycotic infection
➢ develops in the presence of
one of several predisposing
factors
• immunodeficiency
• endocrine disturbances
• diabetes mellitus
• poor oral hygiene
• xerostomia
 Candidiasis
118

➢ caused by Candida albicans

➢ infection with this organism

is usually superficial, affecting
the outer aspects of
oral mucosa or skin
 Candidiasis
119

➢ in severely debilitated + immunocompromised patients

such as patients with AIDS

✓ infection may extend into alimentary tract (candidal

esophagitis

✓ bronchopulmonary tract

✓ and other organ system

 Candidiasis
120

➢ Clinical Features

✓ most common form is

acute pseudomembranous
also known, as thrush

• young infants + elderly

are commonly affected
 Candidiasis
121

➢ Clinical Features
✓ oral lesion of acute
candidiasis (thrush)

• white
• soft plaques that sometime
grow centrifugally + merge
• wiping plaques with gauze
sponge leaves a painful,
eroded, eryhtematous or
ulcerated surface
 Candidiasis
122

➢ Clinical Features

✓ Chronic Erythematous
Candidiasis

• commonly seen on
geriatric individuals

• who wear complete

maxillary denture
 Candidiasis
123

➢ Clinical Features

✓ Chronic Erythematous
Candidiasis

• bright red

• relative little
keratinization
 Candidiasis
124

➢ Clinical Features

✓ Hyperplastic Candidiasis

• usually asymptomatic

• usually discovered on
routine oral
examination
 Candidiasis
125

➢ Clinical Features

✓ Mucocutaneous Candidiasis

• long standing

• persistent candidiasis of

❑ oral mucosa
❑ skin
❑ vaginal mucosa
 Candidiasis
126

➢ Clinical Features

✓ Mucocutaneous Candidiasis

• often resistant to treatment

• begins as a pseudomembranous
type of candidiasis

• soon followed by nail +

cutaneous involvement
 Candidiasis
127

➢ Treatment
✓ majority of infections may
be simply treated with
topical applications of
nystatin suspension

• nystatin cream or
ointment often effective
when applied directly to
denture-bearing surface itself
 Candidiasis
128

➢ Treatment

✓ topical applications of either

nystatin or clotrimazole
should be continued for at
least 1 week beyond
disappearance of clinical
manifestations of disease
 Candidiasis
129

➢ Treatment

✓ Hyperplastic Candidiasis

• topical + systemic antifungal

agents may not be effective
at completely removing
lesions

▪ surgical management
may be necessary
 Candidiasis
130

➢ Treatment

✓ Chronic Mucocutaneous
Candidiasis associated
with immunosuppression

• topical agents may not

be effective
 Candidiasis
131

➢ Treatment

✓ Chronic Mucocutaneous
Candidiasis associated
with immunosuppression

• systemic administration
of medications:

▪ Ketoconazole
▪ Fluconazole
▪ Itraconazole
 Client with Oral Cancer

132

 Uncommon (5% of all cancers) but has high rate of

morbidity and mortality
 Highest among males over age 40
 Risk factors include
 smoking and using oral tobacco,
 drinking alcohol,
 marijuana use,
 occupational exposure to chemicals,
 viruses (human papilloma virus)
 Client with Oral Cancer
133

Pathophysiology
 Begin as painless oral ulceration or lesion with

irregular, ill-defined borders

 Lesions start in mucosa and may advance to involve

tongue, oropharynx, mandible, maxilla

 Non-healing lesions should be evaluated for
malignancy after one week of treatment
 Client with Oral Cancer
134

Collaborative Care
 Elimination of causative agents

 Determination of malignancy with biopsy

 Determine staging with CT scans and MRI

 Based on age, tumor stage, general health and client’s

preference, treatment may include surgery, chemotherapy,
and/or radiation therapy
 Advanced carcinomas may necessitate radical neck
dissection with temporary or permanent tracheostomy;
Surgeries may be disfiguring
 Plan early for home care post hospitalization, teaching
family and client care involved post surgery, refer to
American Cancer Society, support groups
 Gastroesophageal Reflux Disease (GERD)
135

 Gastroesophageal
reflux is the backward
flow of gastric content
into the esophagus.
 GERD common,
affecting 15 – 20% of
adults
 10% persons
experience daily
heartburn and
indigestion
 Gastroesophageal Reflux Disease (GERD)
136

Pathophysiology
 Gastroesophageal reflux results from transient relaxation or
incompetence of lower esophageal sphincter, sphincter, or
increased pressure within stomach
 Factors contributing to gastroesophageal reflux

1. Increased gastric volume (post meals)

2. Position pushing gastric contents close to
gastroesophageal juncture (such as bending or lying down)
3. Increased gastric pressure (obesity or tight clothing)
4. Hiatal hernia
 Gastroesophageal Reflux Disease (GERD)
137

Manifestations
 Heartburn after meals, while
bending over, or recumbent
 May have regurgitation of
sour materials in mouth, pain
with swallowing
 Atypical chest pain

 Sore throat with hoarseness

 Bronchospasm and
laryngospasm
138
 Gastroesophageal Reflux Disease (GERD)
139

Diagnostic Tests
 Barium swallow (evaluation of esophagus, stomach,
small intestine)
 Upper endoscopy: direct visualization; biopsies may
be done
 Gastroesophageal Reflux Disease (GERD)
140

Medications
 Antacids for mild to moderate symptoms

 H2-receptor blockers: decrease acid production; given

BID or more often, e.g. cimetidine, ranitidine, famotidine,
nizatidine
 Proton-pump inhibitors: reduce gastric secretions, promote
healing of esophageal erosion and relieve symptoms, e.g.
omeprazole (prilosec); lansoprazole (Prevacid) initially
for 8 weeks; or 3 to 6 months
 Promotility agent: enhances esophageal clearance and
gastric emptying, e.g. metoclopramide (reglan)
 Gastroesophageal Reflux Disease
141

Dietary and Lifestyle Management

 Elimination of acid foods (tomatoes, spicy, citrus foods, coffee)
 Avoiding food which relax esophageal sphincter or delay
gastric emptying (fatty foods, chocolate, alcohol)
 Maintain ideal body weight
 Eat small meals and stay upright 2 hours post eating; no eating
3 hours prior to going to bed
 Elevate head of bed
 No smoking
 Avoiding bending and wear loose fitting clothing
 Gastroesophageal Reflux Disease (GERD)
142

Surgery indicated for persons not improved by diet

and life style changes
 Laparoscopic procedures to tighten lower
esophageal sphincter
 Open surgical procedure

Nursing Care
 Pain usually controlled by treatment

 Assist client to institute home plan

 Hiatal Hernia
143
Definition
 it is a protrusion of a

portion of a stomach
through a diaphragmatic
opening to the thoracic
cavity
Predisposing factors
include:
 Increased intra-abdominal
pressure
 Increased age
 Trauma
 Congenital weakness
 Forced recumbent position
 Hiatal Hernia…
144

 Most cases are

asymptomatic;
incidence increases with
age
 There are two types of
hiatal hernia:
 Sliding (direct
esophageal hernia)
 Rolling (para
esophageal hernia)
 Hiatal Hernia…
145

Sliding hiatal hernia: gastroesophageal

junction and fundus of stomach slide through
the esophageal hiatus
✓ The most common type of hiatal hernia (90%)
 Hiatal Hernia…
146

Paraesophageal hiatal hernia:

 the gastroesophageal junction is
in normal place but part of
stomach herniates through
esophageal hiatus; hernia can
become strangulated; client may
develop gastritis with bleeding
 Cause
147

weakness of the muscle due to

 Age > 50 yrs.

 Injury with bullet [trauma]

 Thorax bullet operation

 IIAP[ Increased intra abdominal pressure]

 Hiatal Hernia…
148

Manifestations: Similar to GERD

 dysphagia

 chest discomfort

 Heart burn

 Regurgitation.

Diagnostic Tests
 Barium swallow

 Upper GI endoscopy
 Hiatal Hernia…
149

Treatment
 symptomatical RX.

 Elevate head of bed.

 Antacid

 Limitation of activity which increase intra abdominal pressure

 Dietary => small frequent diet

 Avoid irritant substance

Surgical mgt – If there is cxn.

_ If medical Rx- failed.
 Hiatal Hernia…
150

Complication
 Aspiration

 pneumonia

 obstruction

 Hemorrhage
 ACHALASIA
151

 It is a chronic
progressive motor
disorder of the lower
2/3 of esophagus.
 It is characterized by

 ineffective peristalsis
and
 in effective dilatation
 ACHALASIA
152

cause
 unknown

 but due to ineffective innervations

Clinical manifestation
 dysphagia at early solid then soft or liquid diet

 filling full ness in the chest

 halitosis [fitted odor]

 regurgitation

 Wt-loss due to malnutrition

 ACHALASIA
153

DX
 X- ray,

 Barium swallow,

 Endoscopy

CXn –
 Perforation,

 Bleeding,

 aspiration
 ACHALASIA
154

Management
 small frequent diet,
 Elevate HOB,
 Anti acid
 Correct if anemia
 Nitrate to dilate LES.
 Balloon dilation
 Complication
155

 Aspiration
 Pneumonia
 Obstruction
 Perforation
 Esophageal divertricular
156

 It is an out
pouching of the
mucosa and
sub-mucosa of
the esophageal
wall via a weak
portion of
musculature
 Types of Esophageal diverticular
157

1. Based on developmental
▪ Acquired
▪ Congenital
2. Mechanism of formation
- Traction ( fibrosis will be formed that pulls to form
diverticular)
- Pulsion (excess pressure due to neuromuscular
discoordination that causes pouch)
158

3. Based on location
- Pharyhgoesophagial (Zinker)
- Mid-esophageal
- Epiphrenic (lower esophageal)
4. Based on the layer involved
- True (contain all layer of esophageal)
Example mid esophageal
- False (contain only mucosa and submucosa)
Example Zinker
 Esophageal divertricular…
159

Types
1- Zenkers [pharyhgoesophagial]
 Acquired

 False

 pulsion

 Most common

 Common in male in ratio 3=1

 Common in age > 60 yrs-

 DM patient where the muscle is weak

 Esophageal divertricular
160

2-Midd esophageal
 True

 Traction

 fibrosis

 not common and less acute

3-lower esophageal [ epiphrenic]

 False

 Pulsion

 Associated with hiatal hernia

 less common and less acute

 Esophageal divertricular
161

Sign and symptom

- Dysphagia

- Halitosis

- Regurgitation

- Aspiration

- Atypical chest pain

Management
 surgical- diverticulectomy
 Esophageal divertricular
162

Complication
 Aspiration,

 lung abscess,

 malnutrition
 Esophageal cancer
163
 Esophageal Cancer…
164

 Relatively uncommon malignancy with high mortality rate, usually

diagnosed late
 Squamous cell carcinoma
1.Most common affecting middle or distal portion of
esophagus
2.More common in African Americans than Caucasians
3.Risk factors cigarette smoking and chronic alcohol use
 Adenocarcinoma
1.Nearly as common as squamous cell affecting distal
portion of esophagus
2.More common in Caucasians
3.Associated with Barrett’s esophagus, complication of
chronic GERD and achalasia
 Esophageal Cancer…
165

Clinical Manifestations
 Progressive dysphagia with pain while swallowing

 Choking, hoarseness, cough

 Anorexia, weight loss

Collaborative Care: Treatment goals

 Controlling dysphagia

 Maintaining nutritional status while treating carcinoma

(surgery, radiation therapy, and/or chemotherapy
 Esophageal Cancer…
166

Diagnostic Tests
 Barium swallow: identify irregular mucosal patterns or
narrowing of lumen
 Esophagoscopy: allow direct visualization of tumor and biopsy

 Chest xray, CT scans, MRI: determine tumor metastases

 Complete Blood Count: identify anemia

 Serum albumin: low levels indicate malnutrition

 Liver function tests: elevated with liver metastasis

 Esophageal Cancer…
167

Treatments: dependent on stage of disease, client’s

condition and preference
 Early (curable) stage: surgical resection of affected
portion with anastomosis of stomach to remaining
esophagus; may also include radiation therapy and
chemotherapy prior to surgery
 More advanced carcinoma: treatment is palliative and
may include surgery, radiation and chemotherapy to
control dysphagia and pain
 Complications of radiation therapy include perforation,
hemorrhage, stricture
168
169

Management of patient with gastric and

duodenal disorders
 Gastritis
170

Definition:
 It is inflammation of

the gastric or stomach

mucosa
 It is a common GI

problem.
Types
 Acute Gastritis

 Chronic gastritis
 Gastritis
171

Causes of acute gastritis

 food that is contaminated with disease-causing
microorganisms or that is irritating
 Irritants include aspirin and other NSAIDS,
corticosteroids, alcohol, caffeine
 Ingestion of corrosive substances: alkali or acid
 Effects from radiation therapy, certain
chemotherapeutic agents
 A more severe form of acute gastritis is caused by the
ingestion of strong acid or alkali, which may cause the
mucosa to become gangrenous or to perforate.
 Gastritis
172

Manifestations
 Mild: anorexia, mild epigastric discomfort, belching

 More severe: abdominal pain, nausea, vomiting,

hematemesis, melena
 If perforation occurs, signs of peritonitis
 Gastritis
173

Treatment
 NPO status to rest GI tract for 6 – 12 hours,
reintroduce clear liquids gradually and progress;
intravenous fluid and electrolytes if indicated
 Non- irritant diet when symptom subsides.
 Neutralize acid or alkaline if it is the cause.
 If symptom persists IV fluid
 CHRONIC GASTRITIS
174

 Chronic gastritis is prolonged inflammation of the

stomach.
Cause
 may be caused by either

 benign or
 malignant ulcer of stomach or

 by H-pylori.

 Chronic gastritis can be

 type A or
 type B
 Chronic Gastritis
175

Type A Chronic Gastritis

 It is auto immune [ due to change of parietal cell

antigen antibody]
 Fund’s and body are the site

 It is associated with pernicious anemia.

 Chronic Gastritis
176

 Type B Chronic Gastritis

 more common and occurs with aging
 caused by chronic infection of mucosa by
Helicobacter pylori; associated with risk of peptic
ulcer disease and gastric cancer
 Affects the remaining part of the stomach i.e.
antrum or pylorus
 Chronic Gastritis
177

Clinical Manifestations
 Type A Chronic gastritis
 Most of the time asymptomatic except symptom of
pernicious anemia
 Type B chronic gastritis
 Anorexia, Heartburn [pyrosis]
 belching

 Fulfilness, nausea and vomiting hematoemesis, sour test is

the mouth
 Chronic Gastritis
178

Collaborative Care
 Usually managed in community

 Teach food safety measures to prevent acute gastritis

from food contaminated with bacteria
 Management of acute gastritis with NPO state and
then gradual reintroduction of fluids with electrolytes
and glucose and advance to solid foods
 Teaching regarding use of prescribed medications,
smoking cessation, treatment of alcohol abuse
 Chronic Gastritis
179

Diagnostic Tests
 Gastric analysis: assess hydrochloric acid secretion
(less with chronic gastritis)
 Hemoglobin, hematocrit, red blood cell indices:
anemia including pernicious or iron deficiency
 Serum vitamin B12 levels: determine pernicious
anemia
 Upper endoscopy: visualize mucosa, identify areas of
bleeding, obtain biopsies; may treat areas of
bleeding with electro or laser coagulation or
sclerosing agent
 Chronic Gastritis
180

Treatment:
 Chronic gastritis
 Modifying patient diet
 reduce stress

 Antibiotic for H. Pylori (metronidazole (Flagyl) and

clarithomycin or tetracycline) and proton–pump inhibitor
 Vitamin B- complex
181

 MSN AND OTHER\PUD.ppt

 Cancer of Stomach
182

Incidence
 Worldwide common cancer, but less common in US
 Incidence highest among Hispanics, African Americans, Asian
Americans, males twice as often as females
 Older adults of lower socioeconomic groups higher risk
Pathophysiology
 Adenocarcinoma most common form involving mucus-producing
cells of stomach in distal portion
 Begins as localized lesion (in situ) progresses to mucosa;
spreads to lymph nodes and metastasizes early in disease to
liver, lungs, ovaries, peritoneum
 Cancer of Stomach
183

Risk Factors
 H. pylori infection

 Genetic predisposition

 Chronic gastritis, pernicious anemia, gastric polyps

 Achlorhydria (lack of hydrochloric acid)

 Diet high in smoked foods and nitrates

Manifestations
 Disease often advanced with metastasis when diagnosed

 Early symptoms are vague: early satiety, anorexia, indigestion,

vomiting, pain after meals not responding to antacids
 Later symptoms weight loss, cachexia (wasted away
appearance), abdominal mass, stool positive for occult blood
 Cancer of Stomach
184

Diagnostic Tests
 CBC indicates anemia
 Upper GI series, ultrasound identifies a mass
 Upper endoscopy: visualization and tissue biopsy of
lesion
 Cancer of Stomach
185

Treatment

Surgery, if diagnosis made prior to metastasis

 Partial gastrectomy with anastomosis to duodenum:
gastroduodenostomy
 Partial gastrectomy with anastomosis to jejunum:
gastrojejunostomy
 Total gastrectomy (if cancer diffuse but limited to
stomach) with esophagojejunostomy
 Complications associated with
186
gastric surgery
 What is dumping syndrome?
 Dumping syndrome is a medical
condition in which stomach empties its
contents into small intestine more
rapidly than it should.
 It’s also called rapid gastric
emptying.
187

 When the stomach empties too quickly, small

intestine receives uncomfortably large amounts of
poorly digested food.
 This can cause symptoms of nausea, bloating,
abdominal cramps and diarrhea.
 It can also cause sudden blood sugar changes.
188

 Stomach usually releases digestive contents into small

intestine in a gradual, controlled manner.
 The way your stomach moves food along through the
digestive process is sometimes called “gastric
motility."
 Many things are involved in gastric motility: muscles,
nerves and hormone signals coordinate together to
tell stomach how and when to empty.
 If any of these things are impaired, it can throw this
coordination off.
189

 Uncontrolled gastric emptying means that the valve

at the bottom of stomach, the pyloric valve, simply
opens and dumps everything out, before the
stomach has finished digesting.
 When the small intestine receives this mass of under-
digested food, it makes adjustments to try and
accommodate it.
 It draws in extra fluid volume and releases extra
hormones.
 These adjustments cause the symptoms that people
experience shortly after eating.
190

 Some people experience another set of symptoms a

few hours later.
 This happens because of blood sugar changes.
 If small intestine receives a concentrated serving of
sugar content, it may set off alarms in digestive system.
 The small intestine may signal the pancreas to release
extra insulin to regulate blood sugar.
 This can cause blood sugar to drop sharply
(reactive hypoglycemia).
 This drop can cause faintness, shakiness and heart
palpitations.
 Signs & symptoms of dumping
191
syndrome
 Early dumping syndrome symptoms occur within 10
to 30 minutes after finished eating.
 Nausea.
 Vomiting.
 Diarrhea.
 Abdominal pain and cramping.
 A distended abdomen.
 Feeling bloated.
 Dizzy spells.
 Heart rate accelerations.
192

 Late dumping syndrome begins to show signs about

two to three hours after the pt. finished eating.
 Weakness.
 Fatigue.
 Jitters or shakiness.
 Rapid or irregular heartbeat.
 Cold sweats.
 Face flushing.
 Brain fog (forgetfulness, confusion, lack of focus )
 Hunger.
 Dietary management
193

 Eat smaller meals more frequently. Aim for six

small meals instead of three. Eat slowly and chew
thoroughly.
 Avoid simple sugars, carbohydrates and milk
products. This will prevent rapid blood sugar shifts.
Complex carbs, such as whole grains, are better
(see below).
 Eat more protein and healthy fats to replace
carbohydrates in your diet. Fats slow down
digestion and provide a steadier form of energy.
194

 Eat more dietary fiber to add bulk to your meal

and slow down its transit time. Fiber slows down
sugar absorption in your digestive system.
 Lie down on your back for 30 minutes after
eating. This may slow down gastric emptying and
help maintain blood pressure during digestion.
 Don’t drink fluids within 30 minutes before or
after eating. Fluids encourage motility.
 Medications
195
 Certain medications can help modify the symptoms of early and
late dumping syndrome, including:
 Octreotide acetate
 Octreotide inhibits certain hormones in the digestive system,
which slows down gastric emptying and small intestinal transit
time.
 It also suppresses insulin. This medicine is given as an injection,
either daily (short-acting form) or monthly (long-acting form).
 Acarbose
 This medicine regulates blood sugar by slowing the rate at
which your body absorbs carbohydrates. This has been shown
to reduce hypoglycemia in late dumping syndrome.
 Surgery
196

 Reconstructing or modifying a part of your

stomach that isn’t functioning well.
 Reversing or converting gastric bypass operations to
a less severe alternative.
 Cancer of Stomach
197

Treatment: dietary pattern to delay gastric emptying and allow

smaller amounts of chyme to enter intestine
 Liquids and solids taken separately

 Increased amounts of fat and protein

 Carbohydrates, especially simple sugars, reduced

 Client to rest recumbent or semi-recumbent 30 – 60 minutes

after eating
 Anticholinergics, sedatives, antispasmodic medications may be
added
 Limit amount of food taken at one time
 Cancer of Stomach
198

 Nutritional problems related to rapid entry of food

into the bowel and the shortage of intrinsic factor
 Anemia: iron deficiency and/or pernicious
 Folic acid deficiency
 Poor absorption of calcium, vitamin D

Radiation and/or chemotherapy to control

metastasic spread
Palliative treatment including surgery,
chemotherapy; client may have gastrostomy or
jejunostomy tube inserted
199

Management of patient with intestinal

and rectal disorders
200

APPENDICITIS
201
 CHRONIC INFLAMMATORY BOWEL DISEASE
202

 Ulcerative colitis – It is one of chronic idiopathic

inflammatory bowel disease of the mucous and sub
mucosa.
 Sigmoid and rectum are the initial site of the
ulcerative colitis
203

 The prevalence of ulcerative colitis is highest

in Caucasians and people of Jewish heritage.
 It is typically accompanied by systemic
complications and a high mortality rate.
 Approximately 5% of patients with ulcerative

colitis develop colon cancer (NDDIC, 2012b).

 Ulcerative colitis
204

 Etiology - Idiopathic but possible theories are

 Infectious agent
 Immunologic disorder = antigen antibody rxn
 psychosomatic => emotional depression
 genetic or family
 Ulcerative colitis
205

 Incidence
 common is young [ 20-40]
 m and F attack equally
 increase in Jewish
 Pathophysiology
206

 Ulcerative colitis affects the superficial mucosa of

the colon and is characterized by multiple
ulcerations, diffuse inflammations, & desquamation
or shedding of the colonic epithelium.
 Bleeding occurs as a result of the ulcerations.
 The mucosa becomes edematous and inflamed.
207

 Abscesses form, and infiltrate is seen in the mucosa

and submucosa, with clumps of neutrophils found in
the lumens of the crypts (i.e., crypt abscesses) that
line the intestinal mucosa.
 The disease process usually begins in the rectum and
spreads proximally to involve the entire colon.
208

 Eventually, the bowel narrows, shortens, and

thickens because of muscular hypertrophy and fat
deposits.
 Because the inflammatory process is not transmural
(i.e., it affects the inner lining only), fistulas,
obstruction, and fissures are uncommon in
ulcerative colitis (NDDIC, 2012b).
 Ulcerative colitis
209

C/M
 Bloody diarrhea is cardinal sign

 S/S of DHN

 Anemia

 Anorexia, nausea and vomiting

 Cachaxia (lack of nutrition and muscle wasting)

 Ulcerative colitis
210

 Dx
 stool exam
 CBC
 Sigmidoscopy
 Biopsy
 Barium enema
 Ulcerative colitis
211

Management
 general – bed rest

- IV fluid replacement
- Rx of anemia
 Drug therapy

 Corticosteroids

 Sulfasalazine = to prevent recurrence

 Antidiarrhoeal agent

 Antibiotic
 Ulcerative colitis
212

Complication
 perforation

 hemorrhage

 anemia

 malnutrition

 colon malignancy
 Intestinal obstruction
213

 Defn- it is an interruption in the normal flow of the

intestinal content along the intestinal tract
 Intestinal obstruction…
214

 Intestinal obstruction is a potentially serous condition

in which the intestines are blocked
 The blockage may be either partial or complete
occurring in one or more locations.
Two types of processes can impede this flow:
215

 Mechanical obstruction: An intraluminal obstruction or a

mural obstruction from pressure on the intestinal wall
occurs.
 Examples are
 Intussusception
 Volvulus
 Mechanical obstruction…
216
Tumor
 Polypoid tumors and neoplasms,
 stenosis,

 strictures,

 Adhesions following abdominal surgery

 abscesses, and bezoars (i.e., foreign objects)

 Diverticulitis

 Hard fecalith,

 hematoma
217 Functional obstruction: The intestinal musculature
cannot propel the contents along the bowel.
 Examples are
 Amyloidosis (abnormal folding of normal soluble
proteins leading to fibril formation)
 muscular dystrophy,
 endocrine disorders such as diabetes, or
neurologic disorders such as Parkinson’s disease.
 Functional obstruction…
218

 Peritonitis

 Paralyticileus
 Strangulation

 Spinal cord injury

 Ischemic bowel
219

 The blockage also can be temporary and the

result of the manipulation of the bowel during
surgery.
220

 The obstruction can be partial or complete.

 Severity depends on the region of

 bowel affected,
 the degree to which the lumen is occluded, and
especially the degree to which the vascular supply
to the bowel wall is disturbed.
221

 Most bowel obstructions occur in the small

intestine.
 Small bowel obstructions are one of the most
challenging clinical situations facing surgeons and
are responsible for nearly 300,000 hospital
admissions in North America every year (Zielinski &
Bannon, 2011).
 Adhesions are the most common cause of small
bowel obstruction, followed by hernias and
neoplasms (Zielinski & Bannon, 2011).
222

✓ Most obstructions in the large bowel occur in the

sigmoid colon.
✓ The most common causes are carcinoma, diverticulitis,
inflammatory bowel disorders, and benign tumors.
 Pathophysiology
223

Blockage in the intestine

Impairment of the passage of material through the

bowel

Blockage result in distention of proximal intestine

Necrosis and perforation of the bowel

Activation of local and systemic inflammatory response

translocation of bacteria through the wall of intestine
 Clinical manifestation
224

Cardinal symptoms of intestinal obstruction

 abdominal distention
 no flatus / no defecation

 vomiting

 Colic [ crampy] abdominal pain]

pain Vomiting
 Intestinal obstruction
225

Diagnosis
Historyof symptom and physical
examination
Abdominal x-ray, CT scan
Barium enema
Endoscopic examination
CBC
 Management
226

Correction of fluid and electrolyte

Long tube decompression
Surgery depend on condition
Antibiotic should be given before
surgery
Surgery
 Intestinal obstruction
227

CXn
 DHN [dehydration]

 Perforation

 shock

 sepsis

 death
 Possible Nursing diagnosis
228

 Pain related to abdominal distension

 FVD related to fluid loss and decreased absorption
 Imbalance nutrition less than required related to
intestinal obstruction
 Anxiety related to lack of knowledge about the
disease process as evidenced by asking questions
 ABDOMINAL HERNIA
229

 hernia is a protrusion of organ or its content through a

weakened muscle.
 Hernia is often called rupture

Predisposing factor
 defect of muscle

 congenital

 Trauma

 IIAP=> cough, sneezing,

constipation, lifting heavy
things, obesity, pregnancy
230
 Classification of hernia
By site
231

 Inguinal hernia -

 More common in male

 Hernia through inguinal

canal
 Less common to be
strangulated
 Can be treated without
surgery
 Inguinal hernia can be:
◼ direct inguinal hernia
◼ Indirect inguinal hernia
232

 Direct inguinal hernia

 Bulge from the posterior wall of the inguinal canal
 Cannot descend into the scrotum
 Indirect inguinal hernia
 Hernia through the inguinal canal

 Can descend into the scrotum

233

Femoral –
 common in female

 Pass through femoral canal

 More common to be
strangulated
 Must be treated surgically
  Umbilical hernia – common in obese elderly
and multipara
234
  Ventral or incision hernia after surgery.
235
 Classification of hernia
236
By severity –
 Reducible:

 Hernia that can return

back
 Irreducible:
 Hernia that can not
return back
Incarcerated:
 irreducible associated with
237

obstruction
238

Strangulated

• Irreducible type but associated with

obstruction secondary to blood supply
blockage
 Clinical manifestation
239

 Bulging over herniated area when in

standing position and disappear when
supine
 Strangulation

 pain vomiting
 fever
 Abdominal X- ray.
240

 Physical examination
 Management
241

 Mechanically [reducible]
 truss – is an appliance with pad and belt that is
held over hernia if the Pt. is not candidate for
surgery
 Treat factors that increase Intra abdominal pressure
 Management
242

 Surgery – Removing sac replace content to its

palace then suture layer of muscle and fascia which
is called herniorrhappy
 Complication
 bowel obstruction
Nx- mgt
 Achieve contort

 Relieve pain postoperatively

 Teach the pt to hold the part of hernia while

coughing & sneezing

 post operatively, Present infection
 Complications of hernia
243

 Incarceration
 Strangulation
 Intestinal obstruction
244

 Accessery org dis.ppt

245

Thank You
246

Thank You