CHAPTER 35. Gastrointestinal Care
Denise O’brien
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. List name and locate the major anatomical components of the gastrointestinal tract and the accessory organs of digestion.
2. Identify the major functions of each of the divisions of the gastrointestinal system and the accessory organs of digestion.
3. Describe the fluid and electrolyte problems most frequently encountered in the patient with a gastrointestinal disorder.
4. Incorporate the care of the other body systems into the postoperative management of the gastrointestinal surgery patient.
5. Describe two specific system complications of the gastrointestinal surgery patient.
6. State the rationale for placement of tubes and drains in the gastrointestinal surgery patient.
7. State the rationale for observations necessary in postanesthesia care of the patient undergoing gastrointestinal surgery.
Acknowledgement: I thank Lisa Colletti, MD, for her assistance in preparing this chapter.
I. ANATOMY AND PHYSIOLOGY
A. Major anatomic components (Figure 35-1)
1. Mouth
a. Begins mechanical breakdown of food
b. Secretion of saliva
c. Tongue
d. Teeth
2. Pharynx
3. Esophagus
a. Carries food to stomach through peristalsis
b. Lower esophageal sphincter
4. Stomach
a. Main site of digestion
b. Produces digestive enzymes
c. Cardiac sphincter
(1) Prevents backflow of food and digestive enzymes
d. Fundus
(1) Begins digestion of proteins
e. Pylorus
(1) Contracts to empty stomach contents into small intestine
f. Pyloric sphincter
(1) Prevents food and digestive enzymes from entering the small intestine before digestion is completed
g. Rugae
(1) Provide the stomach with increased surface area
(2) Expands with food
5. Small intestine
a. Duodenum
(1) Chemical digestion occurs
(a) Neutralizes stomach acids
(b) Breaks down carbohydrates and fats
b. Jejunum
(1) Absorbs most nutrients
c. Ileum
(1) Absorbs water and vitamins
d. Villi
6. Large intestine
a. Absorbs remaining water and vitamins
b. Appendix
c. Colon
d. Rectum
e. Anus
 |
| FIGURE 35-1 ▪ The gastrointestinal system. (From Ignatavicius DD, Bayne MV: Medical-surgical nursing, ed 4, Philadelphia, 2002, WB Saunders.) |
B. Accessory organs of digestion
1. Salivary glands
a. Produce amylase
b. Begins chemical breakdown of starch
c. Provides lubrication
2. Liver
a. Detoxifies
b. Neutralizes stomach acid
c. Produces bile
3. Gallbladder
a. Stores bile
4. Pancreas
a. Produces insulin
b. Produces digestive enzymes that are released into the duodenum
II. PATHOPHYSIOLOGY
A. Neoplasms and growths
1. Malignancies
a. Primary
b. Metastatic
2. Polyps: a benign proliferation of cells lining the gastrointestinal tract
a. Some with potential for malignant transformation
3. See Strictures (II.C.1) and Adhesions below (II.C.2).
B. Calculi
1. Calculi or stones (e.g., cholelithiasis), primarily resulting from supersaturation of bile with cholesterol
C. Strictures or obstructions
1. Stricture: abnormal narrowing of gastrointestinal passage
a. Neoplasms commonly cause strictures; for example:
(1) Colon
(2) Biliary tree
b. Strictures can:
(1) Progress to obstruction (blockage of gastrointestinal passage)
(2) Be caused by adhesions
2. Adhesions: union of two normally separate surfaces or a fibrous band that connects them
a. Occasionally, produce obstruction or malfunction of an organ
b. Result of the formation of scar tissue
c. Abdominal surgery results in the formation of:
(1) Adhesions
(2) Scar tissue
(3) Magnitude of these adhesions or scar tissue varies.
d. Approximately 5% of cases associated with adhesions occur in persons who have had no previous abdominal surgery.
(1) Virtually always the result of some other previous or ongoing pathological process, such as:
(a) Pelvic inflammatory disease
(b) Appendicitis
(c) Diverticulitis
D. Ulceration
1. Ulcer disease
a. Peptic ulcer disease
(1) Helicobacter pylori ( H. pylori)
(2) Medications
(a) Aspirin
(b) Steroids
(c) Nonsteroidal anti-inflammatory agents
b. Stress ulceration, resulting from the following:
(1) Surgical stress
(2) Burns
(3) Cranial trauma
(4) Sepsis associated with multisystem failure
E. Perforations
1. Caused by ulceration
2. Resulting from trauma
3. Can also result from vascular compromise or obstruction
F. Inflammation
1. Regional enteritis (Crohn’s disease)
2. Cholecystitis
3. Pancreatitis
4. Appendicitis
5. Diverticulitis
6. Esophagitis
7. Gastritis
8. Ulcerative colitis
G. Altered innervation
1. Achalasia
H. Congenital defects
1. Hirschsprung’s disease
2. Tracheoesophageal fistula
3. Imperforate anus
4. Pyloric stenosis
5. Arteriovenous malformation
I. Ischemia: arterial or venous infarction
1. Complication after abdominal aortic aneurysmectomy
2. After repair of coarctation of aorta
3. After coronary artery bypass
4. Embolic
5. Related to atherosclerosis of the abdominal vasculature; can result in mesenteric ischemia
6. Low flow states: either related to cardiac disease, especially congestive heart failure, or sepsis
J. Gastroesophageal reflux disease (GERD)
1. Results from the reflux of stomach contents into the esophagus
2. Symptoms may include:
a. Heartburn
b. Gastric regurgitation
c. Dysphagia
d. Pulmonary manifestations
(1) Asthma
(2) Coughing
(3) Wheezing
(4) Laryngeal inflammation
III. DIAGNOSTIC TESTS OR PROCEDURES
A. Tests ordered depend on gastrointestinal area thought to be involved.
B. Laboratory tests
1. Basic hematology and electrolyte studies
2. Serum enzyme levels
a. Amylase
b. Lipase
c. Liver function tests or hepatic function panel
(1) Albumin
(2) Bilirubin (total and direct)
(3) Aspartate aminotransferase (AST)
(4) Alanine aminotransferase (ALT)
(5) Alkaline phosphatase
(6) Total protein
3. Serum markers
a. CA 19-9 for pancreatic cancer
b. Alpha-fetoprotein (AFP) for hepatocellular cancer
c. Carcinoembryonic antigen (CEA) for different types of cancer
(1) Pancreas
(2) Large intestine (colon and rectum)
(3) Breast
(4) Lung
4. Coagulation studies
a. If liver involvement suspected
b. With malabsorption syndromes
(1) Cause malabsorption of vitamins that can compromise metabolism of coagulation factors produced by liver
C. Endoscopic procedures
1. Motility studies (e.g., esophageal manometry)
2. Esophagogastroduodenoscopy (EGD)
3. Endoscopic retrograde cholangiopancreatography (ERCP)
a. With or without stents
b. With or without sphincterotomy
c. Purpose
(1) To remove retained common duct stones before or after biliary tract surgery
(2) As an emergency measure in patients with common bile duct obstruction (single or multiple stones) resulting in cholangitis
(3) May be done preoperatively to explore common bile duct in patients needing:
(a) Laparoscopic cholecystectomy
(b) Temporary or permanent treatment for biliary obstruction and jaundice
(i) Pancreatic malignancies
(ii) Biliary malignancies
d. Description—by use of side-viewing fiberoptic endoscope:
(1) Pancreatic and biliary ducts cannulated through ampulla of Vater
(2) Ducts visualized fluoroscopically after retrograde injection of radiopaque contrast medium
4. Colonoscopy
5. Sigmoidoscopy
6. Twenty-four-hour pH monitoring with probe for reflux
D. Radiological examinations
1. Barium swallow
2. Upper gastrointestinal series—may also include a small bowel follow-through to evaluate:
a. Small intestine
b. Stomach
c. Duodenum
3. Cholangiogram—typically done as part of:
a. ERCP
b. Percutaneous transhepatic cholangiography (PTC)
c. Operatively
4. PTC
5. Barium enema
6. Flat plate of abdomen
7. Visceral angiography
a. Angiography
b. Carbon dioxide (CO 2) digital subtraction angiography
8. Computed tomography (CT) scan
E. Other modalities
1. Endoscopic ultrasonography
a. Endoscopic ultrasonography of:
(1) Esophagus
(2) Stomach
(3) Pancreas
(4) Biliary tree
b. Transanal ultrasonography
2. Radionuclide
a. Gastrointestinal studies
b. Liver and spleen studies
c. Hepatobiliary iminodiacetic acid (HIDA) scan for acute cholecystitis or to detect biliary leak
d. Labeled red blood cells to check site of bleeding
3. Magnetic resonance imaging
4. Magnetic resonance angiography: used to evaluate vasculature
5. Magnetic resonance cholangiopancreatography
F. Tissue biopsies as indicated with cytological or histological studies; typically done with ultrasound or CT guidance
IV. INTRAOPERATIVE CONCERNS
A. Proper positioning
1. Maintain neurovascular integrity.
a. Padding and support of all body parts with particular attention given to vulnerable areas (e.g., elbows, sacrum, heels, occiput)
b. For comfort
c. Proper alignment in presence of arthritis, lumbar disorders, and contractures
d. Preserve integrity of popliteal nerve and/or ulnar and brachial nerve plexus when lithotomy or exaggerated arm abduction is used.
2. Prevent complications.
a. Proper application of electrosurgical grounding pads to prevent cautery burns; avoid contact with metal or hard surfaces.
b. Careful positioning changes of anesthetized patient (to and from Trendelenburg or lithotomy position) to prevent adverse alterations in tidal volume and cardiac output; position of padding and support rechecked after each change
c. Protect skin from shearing while positioning and moving.
B. Cardiovascular stability
1. Factors influencing altered fluid volume, electrolyte, and nutritional status
a. Chronic bleeding
b. Diarrhea
c. Vomiting
d. Increased secretions
e. Fluid loss
(1) Nasogastric suctioning
(2) Fistula drainage
(3) Bowel preparation
(4) Length of operative procedure
2. Problems with preceding factors if not corrected preoperatively
a. Hypotension: caused by deficits in circulating volume
(1) Poorly tolerated in pediatric, elderly, and debilitated patients vulnerable to adverse effects of hypotension because of decreased body reserve necessary to handle crises
(2) Potential rapid fluid (blood) loss because of rich intestinal blood supply and its proximity to aorta and vena cava
(3) Rapid fluid resuscitation with crystalloid or colloid solution can result in overhydration, leading to pulmonary edema and congestive heart failure in compromised patient.
b. Altered electrolyte balance: cardiac dysrhythmias can occur with abnormal potassium or calcium levels.
c. Clotting abnormalities caused by poor nutritional status or hemodilution or in presence of liver disease
(1) Decreased vitamin K, leading to decreased levels of factors V, VII, IX, and X
(2) Prolonged prothrombin times
C. Thermal regulation (see Chapter 24)
1. Hyperthermia
a. Elevated temperature on arrival in the operating room, possibly as a result of:
(1) Infection
(2) Peritonitis
(3) Other inflammatory process
b. Anesthesia care provider must observe for signs and symptoms of possible adverse reaction to anesthetic agents and muscle relaxants, which may lead to malignant hyperthermia, either in operating room or in post anesthesia care unit (PACU).
2. Hypothermia
a. Prolonged exposure of abdominal viscera causes loss of body heat.
(1) Procedures of 3 or more hours
(2) Extensive gastrointestinal resection
b. Large-volume fluid or blood/blood product resuscitation without adequately warming fluids
c. Temperature control methods
(1) Room temperature control
(2) Use of warming mattresses, convective warming devices, and protective coverings
(3) Warming of intravenous (IV) and irrigating fluids
D. Drug interactions and other concerns
1. Nondepolarizing muscle relaxants (see Chapter 22)
a. Antagonized by hypothermia
b. Patients may reparalyze with postoperative warming.
c. May have slowed return of neuromuscular function because of:
(1) Hypothermia
(2) Decreased elimination of some relaxants (those eliminated by Hofmann elimination)
d. Potentiated by broad-spectrum antibiotics (mycins, aminoglycosides)
2. Metabolism and excretion of medications impaired in presence of:
a. Liver dysfunction
b. Renal failure
c. Obesity
3. Avoid use of histamine-releasing agents such as morphine sulfate.
a. Histamine release can cause hypotension in hypovolemic patient.
4. All opioids increase biliary tract pressure, which may cause spasm of sphincter of Oddi, producing severe right upper quadrant or substernal pain in the patient with biliary obstruction or disease.
a. Severity of symptoms (pain, nausea, diaphoresis, hypotension) requires that myocardial infarction be ruled out.
b. Symptoms usually abate with administration of naloxone (Narcan) or glucagon.
5. Rapid sequence induction (“crash” induction): possible indications
a. History of gastroesophageal reflux
b. Stricture of gastroesophageal sphincter
c. History of recent eating before emergency surgery
d. Bowel obstruction
e. History of gastroparesis
6. Spillage of feces or bile into peritoneal cavity is potential cause of chemical or bacterial peritonitis and should be documented.
V. GASTROINTESTINAL OPERATIVE PROCEDURES
A. Esophageal procedures
1. Cervical esophagostomy
a. Purpose—often done as part of first-stage repair in infants for:
(1) Tracheoesophageal fistula
(2) Esophageal atresia
b. Description: surgical formation of opening into esophagus at cervical level
c. Preoperative phase I assessment and concerns
(1) At risk for aspiration; gastrostomy tube placed as soon as atresia or fistula identified
(2) May have multiple anomalies of cardiovascular, gastrointestinal systems
d. Postanesthesia phase I priorities
(1) Maintain normothermia.
(2) Tracheal leak may be present.
(3) Pain management
e. Complications
(1) Pulmonary aspiration
(2) Vocal cord paralysis
2. Esophagectomy with colon or gastric interposition
a. Purpose: used in presence of esophageal atresia or for esophageal damage anywhere, except very proximal cervical esophagus
(1) Commonly performed for:
(a) Esophageal malignancies
(b) End-stage achalasia
b. Description: usually a piece of colon or stomach (more common) is used to establish continuity between esophagus and stomach.
c. Preoperative assessment and concerns
(1) May have recurrent aspiration pneumonia from gastric reflux
(2) Malnutrition related to dysphagia or anorexia
(3) Evaluation of cardiovascular and respiratory status (may be compromised in patients with esophageal malignancies because these patients often are smokers and drink excess alcoholic beverages)
d. Intraoperative concerns
(1) Hypothermia
(2) Positioning to avoid neural injuries or soft tissue damage
e. Postanesthesia phase I priorities
(1) At risk for aspiration and atelectasis; head of bed elevated
(2) Pain management: consider thoracic epidural continuous analgesia.
(3) Assess for hypoventilation, pneumothorax, anastomotic leak.
(4) Patient may be hoarse.
f. Complications
(1) Aspiration
(2) Atelectasis, hypoventilation
(3) Hemorrhage
(4) Pneumothorax
(5) Esophageal anastomotic leak
(6) Recurrent laryngeal nerve injury
3. Esophageal dilation
a. Purpose: to allow free passage of food and fluids into stomach; used to correct:
(1) Achalasia
(2) Esophageal spasms
(3) Strictures
b. Description: dilating instruments (bougies or balloons) passed in increasingly larger sizes or inflated to enlarge lumen of esophagus
c. Preoperative assessment and concerns
(1) Nothing by mouth (NPO) before procedure
d. Intraoperative concerns
(1) Procedure may be done with sedation and analgesia or with general anesthesia.
e. Postanesthesia priorities
(1) Phase I
(a) Minimal postprocedure pain expected
(b) Observe for:
(i) Subcutaneous emphysema
(ii) Pain
(iii) Aspiration
(c) Monitor temperature.
(2) Phase II
(a) Assess gag reflex before giving fluids.
(b) Review appropriate instructions with patient, family, and responsible accompanying adult.
f. Psychosocial concerns
(1) May require frequent dilations
(2) May prefer particular type of sedation or anesthesia for procedure based on past experience
g. Complications
(1) Esophageal perforation
(2) Pain
(3) Hemorrhage
(4) Bacteremia or sepsis
4. Esophagomyotomy (Heller procedure)
a. Purpose: to allow food to pass from esophagus to stomach when a segment of esophagus is narrowed, causing functional obstruction
b. Description: surgical division or anatomical dissection of muscles at distal esophagogastric junction, leaving mucosa intact
5. Herniations (see Chapter 36)
a. Part of stomach protruding through an opening, or hiatus, in diaphragm
b. Surgical repair of hiatal or diaphragmatic hernias accomplished through either an abdominal or a thoracic approach
c. Hiatal hernia is not a true hernia, while diaphragmatic hernia is.
(1) Hiatal hernia occurs when the gastroesophageal junction slides up and down between the chest and abdomen.
(2) Tends to be associated with GERD
(3) No indication to fix hiatal hernia unless patient also has GERD
d. Diaphragmatic hernia is a true hernia and should always be repaired because of risk of incarceration or strangulation of the stomach.
e. Purposes
(1) To restore herniated part below diaphragm for diaphragmatic hernias
(2) For patients with GERD and hiatal hernias
(a) To narrow esophageal hiatus
(b) To recreate esophagogastric angle to enhance lower esophageal sphincter function
(c) To stop reflux of gastric contents
f. Description (these procedures are done for GERD and not specifically for a hiatal hernia)
(1) Collis-Belsey and Collis-Nissen repairs: esophageal lengthening with antireflux wrap of distal esophagus
(2) Hill repair: abdominal approach that narrows esophageal orifice and fixes esophagogastric junction in intra-abdominal position; includes 180 ° wrap of stomach around esophagus
(3) Belsey Mark IV repair: performed through incision in left side of chest
(a) Consists of 240 ° wrap of distal portion of esophagus with fundus of stomach
(b) This partial fundoplication is technically difficult.
(c) Risk of leakage or diverticulum developing in esophagus is higher because sutures are required in esophageal wall.
(d) Newer procedure: modified thoracoscopic Belsey repair
(4) Nissen fundoplication: transabdominal or laparoscopic (similar to open approach and most common procedure for this condition) treatment for sliding esophageal hiatal hernia
(a) Portion of fundus of stomach is mobilized and completely wrapped around (360 °) distal portion of esophagus.
(b) Prevents stomach displacement into posterior portion of mediastinum through diaphragmatic defect
(5) Toupet partial fundoplication: alternative antireflux procedure; fundal wrap reduced to 180 ° to 270 °
g. Preoperative assessment and concerns
(1) Possible recurrent aspiration pneumonia
(2) Antacid and antireflux prophylaxis recommended
h. Intraoperative concerns
(1) Aspiration risk during induction and emergence
(2) Hemorrhage
(3) Visceral injury
(4) Hypothermia
i. Postanesthesia priorities
(1) Phase I
(a) Nausea and vomiting
(b) Shoulder pain (if laparoscopic approach)
(c) Pain management
(d) Hypoventilation
(2) Length of stay usually 2 to 3 days for Nissen fundoplications
j. Complications
(1) Gastric perforation
(2) Bleeding, hemorrhage
(3) Pneumothorax
(4) Aspiration
(5) Hypoventilation
(6) Wrap too tight, with resultant dysphagia and difficulty eating/swallowing
6. Esophageal band ligation
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a. Purpose: to obliterate esophageal varices to reduce risk of bleeding or hemorrhage
b. Description: endoscopic procedure involves placing a band around (ligation) varices in esophagus.
c. Preoperative assessment and concerns
(1) NPO before procedure
d. Intraoperative concerns
(1) Procedure may be done with sedation and analgesia or with general anesthesia.
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