Pathophysiology Of The Gall Bladder

Gall bladder diseases can either be short-term and easily manageable or longer-term and debilitating. Generally diseases of the biliary system present during middle age. In individuals aged 20-50, diseases of the biliary tract are six times more common in women than in men, but over the age of 50 the incidence in men and women becomes equal (Summerfield 2000). Biliary tract disorders that are examined in this section include cholelithiasis, cholecystitis, choledocholithiasis, cholangitis and...

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders in medical practice and can account for approximately 50 of referrals to gastroenterology outpatient clinics. Between 10 and 15 of the general population may have IBS and it affects females more than males. However, it is estimated that only 10 of people with irritable bowel syndrome seek medical advice and most of those who do are managed in primary care. Those who do consult report more severe gastrointestinal...

Useful Addresses

Local addresses are usually listed in the telephone directory or Yellow Pages under Social Services, Welfare Organisations and Charitable Organisations. Provides information and support to colostomy patients before and after surgery. British Liver Trust Portman House 44 High Street Ringwood Hampshire BH24 1AG Provides information, support and advice concerning liver disease. Encourages education, training and clinical audit in the field of gastroenterology. Cancer BACUP 3 Bath Place Rivington...

Colonoscopy

Colonoscopy gives information about the lower gastrointestinal tract and is performed to examine the entire colon and rectum, almost always under sedation. Modern colonoscopes are similar in design to upper gastrointestinal endoscopes but are longer, ranging from 1.2 to 1.8 m. Diagnostic colonoscopy is indicated in the following situations Evaluation of active or occult lower gastrointestinal bleeding. Unexplained faecal occult blood. Unexplained iron deficiency anaemia. Confirmation of...

Control of absorption in the small intestine

Various factors are involved in the control of water and electrolyte absorption by the cells near the tip of the villi. These include endocrine, paracrine and nervous influences. Glucocorticoids stimulate electrolyte and water absorption in both the small and large intestines. Somatostatin stimulates electrolyte and water absorption in the ileum. Absorption can be inhibited by inflammatory mediators such as histamine and prostaglandins, which are released from cells of the gastrointestinal...

Flexible sigmoidoscopy

Flexible sigmoidoscopy employs a flexible instrument to examine the rectum, sigmoid and a variable length of more proximal colon. The flexible sigmoidoscope measures up to 65 cm in length and its flexibility allows the endoscopist to reach the descending colon in up to 80 of patients. One additional benefit of flexible sigmoidoscopy is that it is better tolerated than rigid protosigmoidoscopy in many patients. Flexible sigmoidoscopy is generally indicated for Screening of asymptomatic patients...

Historical perspective of psychological influences in IBD

Crohn made several links between psychological variables and Crohn's disease. Since the first recognition of Crohn's disease in the 1930s, gastroenter-ologists, surgeons, psychologists and psychiatrists have striven to find a relationship between psychological variables and physical symptoms. This link has been examined in four ways (3) relationship with interpersonal factors (4) stressful life events leading to onset and exacerbation of IBD

The scope of gastrointestinal nursing

Gastrointestinal nursing is a distinct specialism within nursing in which nurses work alongside their medical and surgical colleagues in gastroenterology. Therefore gastroenterology nurses work with a wide range of patients from those suffering from minor and acute gastrointestinal disorders through chronic conditions to those requiring major surgery and treatment for malignant disease. Gastrointestinal nurses therefore support patients with distressing symptoms and those requiring endoscopic...

Clinical presentation of coeliac disease

The clinical presentation of coeliac disease is highly variable, depending on the severity and extent of small bowel involvement. Symptoms include recurrent attacks of diarrhoea, steatorrhoea, abdominal distension, flatulence and stomach cramps. Coeliac disease is associated with autoimmune disorders (thyroid disease, insulin-dependent diabetes mellitus, IgA deficiency, Down's syndrome and inflammatory bowel disease). The pathology of coeliac disease also varies considerably in severe cases the...

General wellbeing

The most comprehensive definition of HRQoL is provided by the World Health Organisation Quality of Life Group (WHOQOL 1995), which provided a definition including individual perceptions and relationships with the environment 'Quality of life is defined as an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept, affected in a complex...

Gastrointestinal haemorrhage

Frank gastrointestinal bleeding is very distressing for patients, especially from the upper tract, and the nurse has an important role to play in remaining calm and reassuring the patient about any action that needs to be taken. This, combined with good first-aid skills, will save lives and lead to effective treatment of any underlying gastrointestinal conditions. In general, bright red blood comes from low in the tract, and dark, altered blood from higher up the gastrointestinal tract....

Gastroscopy

Gastroscopy, or oesophogastroduodenoscopy, uses a flexible endoscope less than 10 mm in diameter, which is passed directly into the upper gastrointestinal tract. The entire oesophagus and stomach and proximal duodenum can be visualised. Larger diameter gastroscopes with larger suction channels are used for therapeutic procedures. Gastroscopy allows the physician or nurse endoscopist to diagnose and document gastrointestinal disorders through the use of direct vision and video photography....

Pancreatic enzymes

There are three main types of enzyme present in pancreatic juice Amylases, which break down carbohydrates into glucose and maltose. Lipases, which are important in the early stages of fat breakdown. Proteases, including trypsinogen, the precursor of proteolytic trypsin. These enzymes are released from the pancreatic acinar cells and are involved in the digestion of foodstuffs. The acinar cells contain zymogen granules, in which enzyme or enzyme precursor proteins are stored. The enzyme...

Acidpepsin versus mucosal resistance

An ulcer forms when there is an imbalance between aggressive factors, i.e. from the digestive power of gastric acid and pepsin, and defensive factors, i.e. the ability of the gastric and duodenal mucosa to resist this digestive power. This mucosal resistance constitutes the gastric mucosal barrier. Ulcers occur only in the presence of acid and pepsin they are never found in achlorhydric patients such as those with pernicious anaemia. On the other hand, severe intractable peptic ulceration...

Anatomy And Physiology

The pancreas is both an endocrine and an exocrine gland. It is a wedge-shaped elongated gland which lies in the abdominal cavity. It is approximately 15 cm long and 5 cm wide and it weighs about 80-90 g. Structurally the pancreas can be divided into three regions the head, which lies over the vena cava in the C-shaped curve of the duodenum the body, which lies behind the duodenum and the tail, which is situated under the spleen (see Figure 9.1). The pancreatic duct (duct of Wirsung) runs the...

Anatomical arrangement of the oesophagus

The structure of the oesophagus is made up of three layers the mucosa, submucosa and the muscularis. Unlike the bulk of the gastrointestinal tract, the oesophagus is not surrounded by serosa. The innermost mucosal layer is composed of stratified squamous epithelium. Beneath the epithelium is the lamina propria, which is composed of connective tissue. At the upper and lower ends of the oesophagus the mucosa contains mucus-producing glands. A thin band of smooth muscle, the muscularis mucosa,...

Achalasia

Achalasia is a condition that involves chronic and progressive obstruction to the passage of contents through the lower oesophageal sphincter. It is characterised by defective peristalsis in the oesophagus combined with an elevated lower oesophageal sphincter pressure which fails to relax in response to the oesophageal swallowing wave. Patients with achalasia present with dysphagia to solids and liquids, sometimes associated with pain, regurgitation and weight loss. It is an unusual disease...

Acute gastritis

This may involve the gastric body and antrum of the stomach and is often erosive and haemorrhagic. The response of the gastric mucosa to trauma is similar to that in other tissues with the release of an array of physiologically active substances. Erythema and oedema are predominant features. Acute gastritis often produces no symptoms but may cause dyspepsia, anorexia, nausea or vomiting, haematemesis or melaena. Many cases resolve quickly and do not merit investigation in others endoscopy and...

Background Reading

Additional reading to support the material in this chapter can be found in the relevant sections of the following texts Alexander, M., Fawcett, J.N. and Runciman, P. (2000) Nursing Practice Hospital and Home - the Adult. Churchill Livingstone, Edinburgh (Chapter 4). Brooker, C. and Nicol, M. (2003) Nursing Adults the Practice of Caring. Mosby, London (Chapter 22). Clancy, J. and McVicar, A.J. (2002) Physiology and Anatomy a Homeostatic Approach, 2nd edition. Arnold, London (Chapter 10). Clancy,...

As a registered nurse midwife or health visitor you must maintain your professional knowledge and competence

6.1 You must keep your knowledge and skills up-to-date throughout your working life. In particular, you should take part regularly in learning activities that develop your competence and performance. 6.2 To practise competently, you must possess the knowledge, skills and abilities required for lawful, safe and effective practice without direct supervision. You must acknowledge the limits of your professional competence and only undertake practice and accept responsibilities for those activities...

Antibiotics

Antibiotics are prescribed in gastroenterology for severe cases of infectious diarrhoea, Crohn's disease and treatment for bacterial infections, including Helicobacter pylori. Bacterial infectious organisms that respond to antibiotics include Escherichia coli, Shigella, Helicobacter, Vibrio cholerae and Clostridium difficile. Antibiotics that are prescribed for patients with infectious diarrhoea are ampicillin, metranidazole, tetracycline and vancomycin. The specific drug prescribed depends...

Antiemetics

Anti-emetics are drugs that prevent or modify nausea and vomiting. Anti-emetics comprise a diverse range of drugs, including dopamine receptor antagonists, antihistamines, anticholinergics, and 5HT3 receptor antagonists. Dopamine receptor antagonists are used to control nausea and vomiting. They antagonise dopamine receptors involved in the vomiting reflex, and they affect dopamine receptors in peripheral pathways, thereby increasing peristalsis and decreasing reflux, by facilitating gastric...

Assessment of disease activity in Crohns disease

Objective scoring of disease activity is important in the assessment of severity of disease and response to treatment. The most commonly used activity assessment tool is the Crohn's Disease Activity Index (CDAI), which is summarised in Table 6.2. Symptoms and physical and laboratory manifestations of Crohn's disease are recorded and assigned a weight. Disease activity is determined from the overall score derived, as shown in Table 6.3. The Harvey-Bradshaw Index and Dutch Activity Index are also...

As a registered nurse midwife or health visitor you must obtain consent before you give any treatment or care

3.1 All patients and clients have a right to receive information about their condition. You must be sensitive to their needs and respect the wishes of those who refuse or are unable to receive information about their condition. Information should be accurate, truthful and presented in such a way as to make it easily understood. You may need to seek legal or professional advice, or guidance from your employer, in relation to the giving or withholding of consent. 3.2 You must respect patients'...

The Liver

After reading this chapter you should be able to Describe the normal anatomy and physiology of the liver. Understand the normal physiology of the liver with respect to bile formation, metabolism, vitamin storage, coagulation and detoxification. Identify the range of clinical conditions of the liver. Relate the corresponding pathophysiology, diagnosis and treatment of the disorders of the liver to nursing practice. The liver is the largest gland in the body and is described as a gland due to its...

Absorption of electrolytes in the small intestine

Sodium is absorbed along the length of the small bowel but mainly in the jejunum via active transport. Magnesium, phosphate and potassium are absorbed throughout the small intestine. Absorption of most water-soluble vitamins takes place by diffusion. The exception is vitamin B12, which combines with intrinsic factor (produced by the parietal cells in the stomach) for active transport and is mainly absorbed in the terminal ileum. Carbohydrates are broken down by digestive enzymes in the...

Amebiasis

Amebiasis is a form of colitis caused by the protozoan Entamoeba histolytica. It is mainly transmitted by faecal contamination of water or food. Ingested cysts form trophozoites in the small bowel. The amoebae penetrate host tissues causing necrosis without inflammation. Carriers of Entamoeba histolytica are often asymptomatic but may suffer from amoebic diarrhoea. Diagnosis of amebiasis requires demonstration of Entamoeba histolytica trophozoites and cysts in stool samples. Amebiasis is...

Antacids

Antacids are used to reduce gastric acidity and afford relief in gastritis, gastro-oesphageal reflux, dyspepsia and any form of hyperacidity. Antacids usually contain combinations of aluminium, calcium and magnesium salts. Unlike other anti-ulcer agents, they have no direct effect on gastric acid secretion and they do not coat or protect the mucous lining. They work by reducing the total acid load in the gastrointestinal tract by buffering the acid that is being produced, thereby raising the...

Absorption of water in the small intestine

Water transport in the gastrointestinal tract is largely a function of the small intestine. It is an example of passive diffusion across the wall of the small intestine. The stomach is almost impermeable to water but the small intestine is highly permeable therefore the transport of water in the small intestine can occur both from the lumen to the blood, or from the blood to the lumen. Net transport of water is achieved by the osmotic gradient and it will occur in whatever direction the osmotic...

Bacterial overgrowth

The small intestine normally supports a large number of bacterial flora. These are normally kept in check by intestinal peristalsis, the acidity of chyme leaving the stomach, and the secretion of immunoglobulins into the intestinal lumen by mucosal cells. If one or more of these factors is reduced, bacterial overgrowth may result in malabsorption. Diagnosis is by aspiration of the contents of the jejunum, which will reveal increased numbers of both aerobic and anaerobic organisms. If bacterial...

As a registered nurse midwife or health visitor you must cooperate with others in the team

4.1 The team includes the patient or client, the patient's or client's family, informal carers and health and social care professionals in the National Health Service, independent and voluntary sectors. 4.2 You are expected to work co-operatively within teams and to respect the skills, expertise and contributions of your colleagues. You must treat them fairly and without discrimination. 4.3 You must communicate effectively and share your knowledge, skill and expertise with other members of the...

Bacterial and viral infections

Improved sanitation has led to a decreased prevalence of infectious enterocolitis in the developed world. However, infectious enterocolitis accounts for up to 50 of all deaths before the age of five worldwide, and over 12 000 deaths each day in the children of developing countries. The small bowel may become infected by any of the following types of agents. Enterotoxigenic bacteria can produce enterotoxins that stimulate the active secretion of electrolytes into the lumen of the small...

As a registered nurse midwife or health visitor you must protect confidential information

5.1 You must treat information about patients and clients as confidential and use it only for the purposes for which it was given. As it is impractical to obtain consent every time you need to share information with others, you should ensure that patients and clients understand that some information may be made available to other members of the team involved in the delivery of care. You must guard against breaches of confidentiality by protecting information from improper disclosure at all...

Blood supply to the small intestine

The duodenum receives arterial blood from the hepatic artery, whereas the rest of the small intestine blood is derived from the superior mesenteric artery. Numerous arterial branches form an extensive network in the submucosal layer, which supplies the wall of the small intestine. Venous blood from the entire small bowel drains through the superior mesenteric vein. Nerves, hormones and local paracrine factors control the intestinal circulation. Stimulation of sympathetic nerves causes...

Contents

Section 1 Structure, Function and Disorders of the 2 An Overview of the Gastrointestinal Tract 13 Section 2 Essential Aspects of Gastroenterology 135 10 Diagnostic Procedures and Tests in Gastroenterology 137 11 Gastrointestinal Emergencies 151 12 Pharmacology in Gastroenterology 158 Section 3 Living with Gastrointestinal Disorders 165 13 The Role of Psychosocial Factors in Gastroenterology 167 14 Quality of Life in Gastroenterology 179

Colonic polyps

Colonic polyps are elevated areas above the mucosal surface into the lumen of the bowel. Polyps range in appearance from tiny translucent and almost invisible bumps only 1-2 mm in diameter to those having a head 1-3 cm in diameter on a vascular stalk. They may be single or may occur together in small numbers, or in hundreds. Diagnosis is achieved by colonoscopy or proctosigmoidoscopy. Most polyps are asymptomatic, but some patients experience intermittent bleeding which can cause mild anaemia....

Chronic gastritis

Chronic gastritis is common in adults and may be associated with a number of conditions including gastric ulcers and Helicobacter pylori (HP). It usually involves the gastric body and antrum of the stomach. Most patients are asymptomatic and do not require any treatment. At present there is no indication for widespread use of HP eradication therapy in patients with chronic gastritis but without evidence of peptic ulcer disease. Chronic gastritis can be classified as Type B (bacterial infection)...

Clinical nurse specialists in IBD

Clinical nurse specialists in IBD are valuable and cost-effective members of gastroenterology teams. IBD nurse specialists have well-defined roles in delivering clinical care, such as specialised care, medication monitoring, patient education and psychological support. Research undertaken to date on IBD clinical nurse specialists has been very general in its nature and there is limited evidence to highlight the specific benefits that an IBD nurse specialist may have upon specific sub-groups of...

Choledocholithiasis

The presence of stones in the common bile duct or hepatic duct is called choledocholithiasis. This condition arises when stones passed out of the gall bladder become lodged in the common bile duct or hepatic duct and prevent the flow of bile into the duodenum. Patients may be asymptomatic or can present with biliary colic, right upper quadrant abdominal pain, obstructive jaundice, acute gallstone pancreatitis and cholangitis. Therapeutic ERCP is the preferred method of medical treatment.

Clinical features of oesophageal cancer

Most patients have a history of progressive, painless dysphagia for solid foods. Others present acutely because of food bolus obstruction. In late stages weight loss is often extreme chest pain or hoarseness suggest mediastinal invasion. Fistulation between the oesophagus and the trachea or bronchial tree leads to coughing after swallowing, pneumonia and pleural effusion. Physical signs may be absent but even at initial presentation cachexia, cervical lymphadeno-pathy or other evidence of...

Chronic pancreatitis

Chronic pancreatitis is related to acute pancreatitis, usually caused by excessive long-standing alcohol abuse. In chronic pancreatitis the destruction of the pancreas is a slow and progressive disorder (Toskes 2000). It is seen most commonly in male patients aged between 40 and 60 who normally present with prolonged ill-health (abdominal pain, vomiting and nausea) weight loss and malabsorption steatorrhea (a condition where faeces have a high fat content) diabetes mellitus (as a result of...

Composition of gastric juice

The adult human secretes approximately two litres of gastric juice per day. Eating food stimulates the stomach to secrete gastric juice. Gastric juice is isotonic with blood plasma but the concentrations of its various constituents vary with the rate of flow the higher the rate the more acid the juice. Following ingestion of a meal the chyme becomes more acidic the acidity can reach pH 2.0. Maximum acid secretion can be induced by an injection of histamine this procedure is used clinically to...

Complications of Crohns disease

Aphthous ulceration is the most common oral complication of Crohn's disease. Ulcers can be extensive and painful enough to impair nutrition. They often occur in association with intestinal disease and respond to treatment directed at the bowel. In Crohn's disease small bowel obstruction results from strictures due to fibrosis, with superimposed spasm, inflammation or intestinal adhesions. Patients with Crohn's disease present most commonly with partial small bowel obstructions, which usually...

Duodenal ulcers

Peptic ulcers can develop in the oesophagus, stomach or duodenum. Around 80 of all peptic ulcers are duodenal ulcers (Misiewicz and Punder 2000). Duodenal ulcers are most common in men aged between 20 and 50 years and in individuals who have type O blood. It is now well recognised that Helicobacter pylori, a spiral Gram-negative bacteria, is present in the stomach of over 80 of individuals who present with gastric or duodenal ulcers. The presence of Helicobacter pylori leads to impairment of...

Diagnostic Tests And Procedures In Gastroenterology

The remainder of this chapter examines a number of tests and procedures that nurses will encounter in gastrointestinal medicine. These tests and procedures are available to confirm or disprove diagnoses. Endoscopic procedures have been covered earlier in this chapter. Radiological studies and tests involving the analysis of blood, urine and faeces are reviewed in this section. It is vital for the nurse to understand the role of tests and investigations that are undertaken in gastroenterology as...

Blood supply to the large intestine

The right-hand side of the large intestine receives its blood from the branches of the superior mesenteric artery, and the left-hand side and lower portions receive blood from the inferior mesenteric artery. Venous blood from the large bowel is drained mainly through the superior and inferior mesenteric veins. The rectum and anal canal receive arterial blood from the haemorrhoidal artery, which branches from the inferior mesenteric artery. The rectum also receives arterial blood from branches...

Complications of ulcerative colitis

Toxic dilatation is defined as dilatation (> 6 cm) of the colon associated with severe, fulminant disease. It is a feature of pan-colitis and most commonly Table 6.1 Disease severity in ulcerative colitis (Truelove and Witts 1955). Table 6.1 Disease severity in ulcerative colitis (Truelove and Witts 1955). occurs at the first presentation of the disease. Features include severe bloody diarrhoea, abdominal pain, pyrexia and tachycardia. Without prompt treatment, toxic dilatation may lead to...

Code of Professional Conduct

As a registered nurse, midwife or health visitor, you are personally accountable for your practice. In caring for patients and clients, you must respect the patient or client as an individual obtain consent before you give any treatment or care protect confidential information co-operate with others in the team maintain your professional knowledge and competence act to identify and minimise risk to patients and clients. These are the shared values of all the United Kingdom healthcare regulatory...

The Pancreas

After reading this chapter you should be able to Describe the normal anatomy and physiology of the pancreas. Understand the normal physiological functions of the pancreas, including both endocrine and exocrine secretions. Identify the range of clinical conditions specific to the exocrine function of the pancreas. Relate the corresponding pathophysiology, diagnosis and treatment of disorders of the pancreas to nursing practice.

Conclusion

The biliary system is intimately related in terms of structure and function to the liver and shares a common entrance to the gastrointestinal tract at the duodenum. The biliary system merely concentrates and stores a liver product bile. While important in fat breakdown, bile is not essential for life. On the other hand, disorders of the biliary system can cause considerable suffering and also disfigurement in the form of jaundice, if the outflow of bile from the gall bladder is blocked. The...

Conclusion And Acknowledgements

We are responding to a demand for a book such as this and take full responsibility for any deficiencies. The book would not have been written without the support of Dr Kelvin Palmer, Dr Helen J. Dallal, Miss Tonks Fawcett and Ms Rosemary Patterson, or without the patience and support of Beth Knight at Blackwell Publishing. Anonymous reviewers also played a significant role in shaping the book. Special thanks to Linda S. Smith for indexing and to Gillian Kidd for her artwork. We hope this book...

Computed tomography CT scan

CT scanners have been used since the 1970s and produce computerised images of the body in a series of cross-sectional views. CT scanning is a non-invasive, radiological scanning technique that involves the measurement of differences in tissue density to reflect tissue configuration. CT scanning Table 10.1 Approximate reference ranges. Males 4.5-6.5 x 1012 l Females 3.9-5.6 x 1012 l Males 13.5-17.5 g dl Females 11.5-15.5 g dl Males 40-52 Mean cell haemoglobin concentration (MCHC) 20-35 g dl...

Complications of cirrhosis

Complications of liver cirrhosis include hepatic encephalopathy Portal hypertension When liver blockage leads to increased portal vein resistance and back-flow, portal vein pressure increases. Symptoms of portal hypertension include splenomegaly (enlargement of the spleen), oesophageal varices and haemorrhoids. Although varices may present in other regions of the digestive tract, they develop most commonly in the submucosal veins of the distal oesophagus and in the stomach. Oesophageal varices...

Cryptosporidiosis

Cryptosporidiosis is caused by the sporozoa Cryptosporidium. The colon and the small intestine are the most common sites for infection, but Cryptosporidium has been found in all areas of the digestive and respiratory tracts. Transmission is usually by the faecal-oral route. The severity of the infection ranges from diarrhoeal episodes, which last for up to four weeks in immunocompetent hosts, to death in individuals who are immunocompromised. Before the 1980s very few cases of cryptosporidiosis...

Endoscopic ultrasound

Advances in technology have led to the combination of endoscopes with ultrasonography to enhance visualisation of the gastrointestinal tract. This technique is called endoscopic ultrasound (EUS) and allows for better quality resolution, which enhances evaluation of structures. The walls of the oesophagus, stomach, duodenum and colon can be visualised, as well as the structure of several adjacent organs. The general indications for EUS include Staging tumours of the gastrointestinal tract,...

Control of gastric secretion

There are three phases of stimulation the cephalic, gastric and intestinal phases. Cephalic phase During the cephalic phase, gastric acid and pepsinogen secretion is activated by the thought, sight, smell and taste of food. It is mediated entirely by the vagus nerve if vagal innervation of the stomach is ligated, the cephalic phase is abolished. This response to the sight or smell of food is a conditioned reflex, a learned response based on previous experiences of food. The gastric phase, as...

Diagnostic Procedures and Tests in Gastroenterology

The material in this chapter is presented in two sections the first considers endoscopy and the second considers a range of tests used in gastroenterology. After reading this chapter you should be able to Describe the main diagnostic procedures and equipment used in gastro-enterology. Understand the rationale behind diagnostic procedures. Identify the role of appropriate investigations for the range of gastrointestinal disorders. Relate diagnostic procedures to clinical nursing practice.

Further Information

This Code of professional conduct is available on the Nursing and Midwifery Council's website at www.nmc-uk.org. Printed copies can be obtained by writing to the Publications Department, Nursing and Midwifery Council, 23 Portland Place, London W1B 1PZ, by fax on 020 7436 2924 or by e-mail at publications nmc-uk.org. A wide range of NMC standards and guidance publications expand upon and develop many of the professional issues and themes identified in the Code of professional conduct. All are...

Endoscopy

Gastrointestinal endoscopy involves the direct visual examination of the lumen of the gastrointestinal tract. It is a relatively safe and effective way of evaluating the appearance and integrity of the gastrointestinal mucosa for the purpose of diagnosis and provides access for therapeutic procedures. The techniques for endoscopic investigations of the upper and lower gastrointestinal tract include gastroscopy (oesophogastroduodenoscopy), ERCP (endoscopic retrograde cholangiopancreatography),...

Gastric carcinoma

Gastric cancer is exceptional, in that its incidence has been declining for the past 20 years whilst other gastrointestinal tumours have increased in frequency. Despite this, it remains a common cause of death in the Western world and is extremely common in China, Japan and parts of South America. Variations in populations are believed to be due to local environmental, mainly dietary, factors. Gastric cancer is more common in men and the incidence rises sharply after 50 years of age....

Control of intestinal secretions

Secretion in the small intestine can be controlled by hormones, paracrine factors and nervous activity. Hormones and paracrine factors such as gastrin, serotonin and prostaglandins stimulate the epithelial cells directly. The cells are innervated by secretomotor neurones, mainly the ganglia in the submucosal plexus, but also via ganglia in the myenteric plexus. The submucosal neurones release acetylcholine, vasoactive inhibitory peptide and serotonin, to stimulate secretion. Parasympathetic...

Endoscopic retrograde cholangiopancreatography ERCP

ERCP uses a combination of endoscopic and radiological techniques to visualise the biliary and pancreatic ducts. It involves the injection of a contrast material into the biliary and pancreatic systems followed by radiological screening. Two different contrasts are used low iodine for the common bile duct and higher iodine contrast for the pancreatic duct. ERCP is indicated for the following Signs and symptoms of pancreatic malignancy. Evaluation of acute, recurrent pancreatitis. Removal of...

Diagnosis of coeliac disease

Diagnosis is usually made by small bowel biopsy showing evidence of villous atrophy. Elevated blood levels of antigliadin and antiendomysium antibodies are detectable in most untreated cases. These antibodies are a valuable 'screening' test in patients with diarrhoea but they are not a substitute for small bowel biopsy and become negative with successful treatment. Other investigations are usually unnecessary. Barium follow-through X-rays show dilated loops of bowel, coarse or diminished folds...

Duodenitis

mucosal tear in patients with strictures Mallory-Weiss (cardio-oesophageal) tear In an acute upper gastrointestinal bleed, upper endoscopy may reveal stigmata of recent haemorrhage, such as a visible vessel, fresh blood clot or active bleeding. If no signs of recent haemorrhage are visible, medical therapy may be sufficient. In patients with continued bleeding or stigmata of recent haemorrhage, therapeutic endoscopy may be indicated. Resuscitation of upper gastrointestinal bleeding The main...

Digestion and absorption

Digestion and absorption are the ultimate functions of the gastrointestinal tract. Digestion is the chemical breakdown of ingested foods into absorbable molecules. The digestive enzymes are secreted in salivary, gastric, and pancreatic juices as well as the mucosa of the small intestine. Absorption is the movement of nutrients, water and electrolytes from the lumen of the intestine into the blood system. There are two distinct paths for absorption, a cellular path and a paracellular path. In...

Diagnosis of IBS

The symptoms of IBS may be chronic or recurrent and can vary between patients in nature and severity. Diagnosis must be based on the presence of key symptoms and IBS is diagnosed positively on the basis of symptom criteria and the exclusion of organic GI illnesses. Symptom-based diagnostic criteria have been used to define IBS for some time, initially the Manning criteria in the 1970s followed by Rome I criteria in 1992. The most recent criteria are the Rome II guidelines, which are summarised...

Essential aspects of gastroenterology

After an overview of the gastrointestinal tract, each chapter takes one region of the tract and covers the anatomy and physiology, the range of disorders with causes and then describes the management of the disorder including medical, surgical and nursing care. The chapters on the regions of the tract should all enable the reader to Describe the region of the tract in anatomical terms Understand the physiological function of the region Identify the main disorders, and Relate the anatomy,...

Faeces

In the human adult approximately 150 g of faecal material is eliminated each day. Of this, two-thirds are water and one-third solid. The solid components of faeces comprise undigested cellulose, intestinal bacteria, cell debris, bile pigments and some salts. There is a high content of potassium ions in faeces owing to the secretion of the ions from the colonic walls. The brown colour of faeces is due to the presence of the bile pigment stercobilinogen. The odour is caused by products of protein...

Gastrointestinal nursing what this text adds

This introduction will help you to understand the purpose of this book and how to get the best out of it. It is written for a wide range of nurses at one end of the spectrum for nurses who may have an interest in entering gastroentero-logy as a speciality, and at the other end for nurses working in the speciality who may wish to develop further into one of many roles such as nurse endoscopist, nurse practitioner or nurse consultant. These roles are developing in the UK at the time of writing...

Introduction

1.1 The purpose of the Code of professional conduct is to inform the professions of the standard of professional conduct required of them in the exercise of their professional accountability and practice inform the public, other professions and employers of the standard of professional conduct that they can expect of a registered practitioner. 1.2 As a registered nurse, midwife or health visitor, you must protect and support the health of individual patients and clients protect and support the...

Gastrointestinal Nursing

2005 by Blackwell Science Ltd, a Blackwell Publishing company Blackwell Science Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK Tel +44 (0) 1865 776868 Blackwell Publishing Inc., 350 Main Street, Malden, MA 02148-5020, USA Tel +1 781 388 8250 Blackwell Science Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia Tel +61 (0)3 8359 1011 The right of the Author to be identified as the Author of this Work has been asserted in accordance with the Copyright, Designs and Patents Act...

Control of swallowing deglutition

Swallowing can be divided into three phases The tongue moves food backwards and upwards into the back of the mouth. This is initiated voluntarily but once it has been initiated it cannot be stopped voluntarily, it is a classical 'all or none' reflex. As the food moves into the pharynx, it activates pressure receptors in the pharynx. These receptors send impulses via the trigeminal and glossopharyn- geal nerves to the brain stem swallowing centre. Each impulse serves as a trigger for the...

Exocrine tissue

Pyramidal acinar cells are exocrine cells that compose the bulk of pancreatic tissue. Groups of acinar cells form an acinus, and groups of acini form grapelike lobules. The acini secrete the digestive enzymes of the pancreatic juice. The nucleus of the acinar cell is situated at the base of the cell. The cytoplasm in the basal region can be stained with a dye to show the presence of rough endoplasmic reticulum, the site of digestive enzyme production. Small mito- Figure 9.1 Structure of the...

Education and research in gastrointestinal nursing

Gastrointestinal nurses have a responsibility as educators. This educational role covers nursing students, trained and untrained nursing staff. The development of advanced nurse practitioners and specialists in gastrointestinal nursing has led to nurses being involved in medical education and the teaching of other professionals who are allied to medicine. Nurse specialists in inflammatory bowel disease who disseminate both their academic and clinical knowledge in presentations, papers and...

Drug therapy

Drugs used in the treatment of Crohn's disease can be broadly grouped into anti-inflammatory compounds, drugs that may act by affecting immune responses, anti-bacterial drugs and symptomatic treatments. Sulphasalazine has been widely used in the medical therapy of Crohn's disease. Unfortunately, sulphasalazine is less than ideal as many patients suffer side-effects (abdominal discomfort, nausea, vomiting and headache). Today there are newer aminosalicylates, particularly Pentasa , which are...

Educational preparation

It is important that nurses wishing to work within gastroenterology are familiar with the established educational prerequisite to work within this practice setting. Although these requirements vary throughout the UK, in general, nurses wishing to work in this speciality are required to possess an understanding of the following normal anatomy and physiology of the gastrointestinal tract pathophysiology related to common gastrointestinal conditions pharmacology in gastrointestinal medicine...

Investigations for GORD

Investigation is advisable if patients present in middle or late age, if symptoms are atypical or if a complication is suspected. Endoscopy is the investigation of choice. This is done to exclude other upper gastrointestinal diseases that can mimic gastro-oesophageal reflux, and to identify complications. A normal endoscopy in a patient with compatible symptoms should not preclude treatment for gastro-oesophageal reflux disease. When, despite endoscopy, the diagnosis is unclear or if surgical...

Food intolerance

This is adverse reactions to food that are not immune-mediated and result from a wide range of mechanisms. Contaminants in food, preservatives and lactase deficiency may all be involved. Lactose intolerence may be as a result of lactase deficiency secondary to a disease process, such as coeliac disease or Crohn's disease. It may also result from decreased time of exposure to the intestinal mucosa, such as in short bowel syndrome or dumping syndrome. Human milk contains around 200mmol l of...

Gastrointestinal oncology

Malignancies of the digestive system constitute more than one-fifth of all newly diagnosed cancers. Oesophageal, gastric and colorectal cancer are three of the most common gastrointestinal malignancies, which often do not respond to traditional medical or surgical therapy, necessitating palliative management. Therefore measurement of HRQoL may be the best outcome measure to assess the success or failure of these treatments and nursing interventions. The European Organisation for Research and...

Informed

3.4 You should presume that every patient and client is legally competent unless otherwise assessed by a suitably qualified practitioner. A patient or client who is legally competent can understand and retain treatment information and can use it to make an informed choice. 3.5 Those who are legally competent may give consent in writing, orally or by co-operation. They may also refuse consent. You must ensure that all your discussions and associated decisions relating to obtaining consent are...

Motility in the small intestine

The smooth muscle lining the small intestine performs two functions. First, it is responsible for a thorough mixing of digestive juices arriving from the pancreas and liver via the common bile duct with the chyme received from the stomach. Second, it is responsible for moving the contents, usually slowly but occasionally rapidly, along the 6 m from the stomach to the ileo-caecal valve. This movement enables one meal to make way for the next. It is vitally important that food is retained in each...

Generic instruments

Generic instruments are also called 'general health status measures'. Generic instruments are multi-item problem lists that are meant to be independent of sex, age and disease. Items are frequently clustered in subscores, such as 'physical' or 'emotional function', 'somatic sensation' or 'mental health', which all appear relevant in IBD. In some instruments these sub-scales may be summarised into one single score. Garratt et al. (1993) illustrated the controversy as to whether or not generic...

Management of colorectal cancer

Treatment of colorectal cancer depends on the stage of the disease. Most patients with colonic cancer require either curative or palliative surgery, such as bowel resection or stoma formation. Surgery will involve the resection of the tumour and associated blood and lymph vessels. In intestinal cancer, patients may require the formation of permanent or temporary colostomy. Formation of a colostomy involves making an outside opening, or stoma, on the abdomen using a section of the colon. The...

Glossary

Responsible for something or to someone. To provide help or comfort. Possessing the skills and abilities required for lawful, safe and effective professional practice without direct supervision. Any individual or group using a health service. The case of Bolam v. Friern Hospital Management Committee (1957) produced the following definition of what is reasonable. 'The test is the standard of the ordinary skilled man exercising and professing to have that special skill. A man need not possess the...

Motility

The movements of the stomach serve two basic functions mixing and grinding of food, which takes place in the distal areas, and the controlled emptying of the gastric contents into the small intestine. When a meal is ingested, weak peristaltic waves begin in the body of the stomach, pushing food into the antrum. Gradually these contractions become more intense, especially in the antral region. This contractile activity is responsible for the churning of food material and mixing with gastric...

Neural control of the oesophagus

The oesophagus receives both sympathetic and parasympathetic innervation. The swallowing centre in the medulla oblongata initiates peristaltic contractions via the vagus (Xth crainial) nerve, which innervates the skeletal muscles in the upper oesophagus. The smooth muscle is innervated indirectly by neurons in the vagus nerve, which synapse with neurons in the myenteric plexus. The lower part of the oesophagus is believed to receive both sympathetic and parasympathetic innervation.

Intestinal resection

The long-term effects of small bowel resection depend on the site and amount of intestine resected and vary from trivial to life-threatening. Following ileal resection, vitamin B12 and bile salt malabsorption usually develops. Unabsorbed bile salts pass into the colon, stimulating water and electrolyte secretion and resulting in diarrhoea. If hepatic synthesis of new bile salts cannot keep pace with faecal losses, then fat malabsorption occurs. Another consequence is the formation of lithogenic...

Intestinal bacteria

Most of the microbial cells that colonise the body reside in the large intestine. A large number of bacteria are excreted in human faeces and more than 99 of these bacteria are non-sporing, anerobes. Apart from these anerobic bacteria, lactobacilli and coliforms also reside in the large bowel. These bacteria syn-thesise vitamins which are required by the body vitamins of the B complex (thiamine, riboflavin and vitamin B12) and vitamin K. The production of vitamin K is of particular importance...

Measurement of psychological wellbeing in gastrointestinal medicine

The measurement of psychological morbidity is based on assessment of signs and symptoms of 'dysfunction'. There are numerous scales of psychological well-being, as summarised in Box 13.1. These scales have been used to measure psychological and psychiatric morbidity in both inflammatory bowel disease and irritable bowel syndrome. The HDS is inappropriate for use in this patient population due to its emphasis on physical symptoms and the high number of items that concern somatic problems. The...

Healthrelated quality of life an overview

The theoretical framework of health-related quality of life (HRQoL) is largely based on a multi-dimensional perspective of health based upon a combination of physical, psychological and social well-being. The physical dimension is concerned with the effects of illness on a person's ability to carry out normal activities of daily living. The psychosocial dimensions deal with the effects of illness upon emotion and social interaction with friends, family, work colleagues and the community. Often...

Nurse endoscopists

The British Society of Gastroenterology (BSG) Working Party (1994) gave support to the establishment of nurse endoscopists. Their report highlighted the potential role for nurses to perform gastrointestinal endoscopy as long as adequate training for all procedures is available (BSG 1994). The BSG proposed the role of the nurse endoscopist to complement and increase the capacity of existing medical endoscopy teams. The NMC document The Scope of Professional Practice (NMC 2002) supports nurses in...

Liver tumours

Benign and malignant tumours may arise in the liver from the hepatocytes, bile duct epithelium or supporting hepatic tissue. With the exception of hepatocellular carcinoma, primary malignant tumours of the liver are rare, but the liver is frequently the site of metastatic tumours from other areas in the body (lungs, breast and bronchus). Predisposing factors for primary cancerous liver tumours include a history of cirrhosis, hepatitis B, hepatitis C, alcohol abuse and exposure to hepatotoxic...

Global assessment

The global assessment, usually a graded summary such as 'good', 'fair' or 'poor' or a 10 cm visual analogue scale, may help to predict a relationship between simple parameters such as disease severity and function, but it is often inadequate for more sophisticated hypothesis testing. To outline this, global questions such as, 'How do you rate your quality of life today ' are of limited value. They categorise patients but do not explain why a patient is placed in a particular category. Global...

Pancreatic cancer

Tumours, wherever they present, are classified as benign or malignant. In the pancreas most tumours are malignant and most commonly affect the exocrine portion of the pancreas. Over 90 of malignant tumours are adenocarcinomas. Pancreatic cancer most often develops in persons aged between 60 and 80. Potential risk factors for the development of a pancreatic tumour include chronic pancreatitis, smoking and a high fat diet. Of pancreatic carcinomas, over 60 occur in the head of the pancreas, 15-25...

Giardiasis

Giardiasis is caused by the protozoa Giardia lamblia and is often associated with ingestion of contaminated food or water. The parasite can present in two forms cysts and trophozoites. After a cyst has been ingested orally or nasally it matures, and once in the stomach it releases trophozoites. These adhere to the mucosal lining of the proximal small intestine and initiate an inflammatory response. Most adults with giardiasis are asymptomatic, although non-bloody diarrhoea, headaches, nausea...

Management of GORD

The first-line nursing of patients with GORD should relate to behaviour modification and nurses should encourage the following recommendations avoidance of tight-fitting garments avoidance of dietary items which the patient finds worsens symptoms elevation of the bed-head in those who experience nocturnal symptoms Antacids, which are said to produce a protective mucosal 'raft' over the oeso-phageal mucosa, are taken with considerable symptomatic benefit by most patients. H2 receptor antagonist...

Nursing responsibilities during ERCP

The main responsibilities of the nurse during ERCP are Assess, monitor, and document oxygen saturation and vital signs. Observe the patient for signs of abdominal distension. Maintain the patient's airway until the gag reflex returns. Observe for signs of pancreatitis, low-grade fever, pain, vomiting and tachycardia. Administer antibiotics as prescribed. ERCP may introduce infection leading to cholangitis, therefore prophylactic antibiotics are given to patients with biliary or pancreatic...

Motility movement in the gastrointestinal tract

Motility refers to contraction and relaxation of the walls and sphincters of the gastrointestinal tract. Motility involves the grinding and mixing of ingested food in preparation for digestion and absorption it then propels the food along the gastrointestinal tract. Smooth muscle in the gastrointestinal tract enables Contractile tone to be maintained even in the absence of food. Activity to be increased and decreased as necessary. The tract to distend to accommodate different volumes. The...

Oesophageal perforation

If the perforation is in the upper third of the oesophagus the patient will have dysphagia, stiffness of the neck and tenderness in the region affected. Perforation in the thoracic oesophagus can result in sub-sternal or epigastric pain that is increased with respirations and movement. In the distal region of the oesophagus a perforation may result in shoulder pain, dyspnea, severe back and abdominal pain, tachycardia, cyanosis and hypotension. Sudden chest pain after vomiting is the cardinal...

Parasympathetic innervation

Parasympathetic nervous innervation is supplied by both the vagus nerve and the pelvic nerve. The pattern of parasympathetic innervation is consistent with its function. The vagus nerve innervates the upper portions of the gastrointestinal tract (upper third of oesophagus, wall of stomach, small intestine and ascending colon), whilst the pelvic nerve innervates the lower portions of the system (striated muscle of external anal canal and walls of the transverse, descending and sigmoid colons)....