1.

Diagnostic testing
 Blood test: CBC, complete metabolic panel, prothrombin/partial thromboplastin time, Triglycerides, Liver function
test, Amylase and lipase
 Stool tests
 Breath tests
 Ultrasound
2. Stool test
 Inspection of stool specimen for consistency, color, occult blood.
 Look for fecal urobilinogen, leukocytes, parasites, pathogens, C. Diff, food residues, must be sent to lab promptly
after specimen collection
 Occult stool test  look for H. pylori (cause PUD)
o Contraindication: hemorrhage bleeding
o Assess diet and medication regimen before test cos patient need to hold PPIs, oral bismuth subsalicylate,
antibiotic. They need to avoid red meats, fish, turnips, horseradish, NSAIDs 72hrs prior test (prevent false
positive) while avoid vitamin C to prevent false negative result.
3. Breath test  test to detect H. pylori
 Procedure: Two breaths before and after carbon-labeled urea administration are collected. Patient is instructed to
take carbon-labeled urea by mouth that will absorb in the gastric mucosa  sample obtained 10-20min later by
measuring amount of exhaled CO2. Presence of Pylori as urea convert to CO2, delivered to the lung and exhaled.
 Tool to measure exhaled CO2: a mass spectrometer or gas chromatography
 Assess medication regimen cos patient needs to avoid prior testing:
o H2-receptor antagonist (cimetidine, famotidine, ranitidine)  24hrs
o Omeprazole (PPI)s  1 week
o Antibiotics and loperamide  1 month
4. Abdominal Ultrasonography  noninvasive, use high frequency sound waves
 Useful detect abnormality of solid organs in the abdominal cavity (enlarged organs, gall stones,
appendicitis)
 Procedure:
o NPO 9-12hrs to decrease amount of bowel gas
o Contraindication with barium study  complete ultrasound first as it interferes with
soundwaves
o Patient is instructed to lie down, may be asked to change position to examine different areas
and hold their breath for short period of time during examination
5. X-ray studies  Upper GI tract and lower GI tract study

Upper GI study Lower GI study

 Barium swallow  outline the entire GI tract  barium enema inserted rectally  detect present
after introduction of a contrast agent (barium of polyps, tumors, diverticulitis
sulfate)  Pre-procedure includes emptying and cleansing
 Assess size, contour, peristaltic motility, organ the lower bowel to ensure adequate bowel
structure of upper GI  detect foreign body, evacuation.
pyloric stenosis, hiatal hernia o Eat low-residue diet 1-2 days before test.
 Procedure: o Have clear liquid and laxative the evening
o NPO after midnight the day before before.
the test o NPO after midnight
o Assess patient ability to swallow o Cleansing enemas until returns are clear
before test. patient is instructed to  Barium enemas are scheduled before barium
swallow barium contrast and change swallow
positions to adequate visualize  Contraindication: megacolon, diverticulitis, acute
esophagus. ulcerative colitis, signs of perforation or
o Follow-up care to ensure patient has obstruction  water-soluble contrast study may
already eliminate ingested barium. be performed for these conditions.
Educate patient to drink plenty of  Post-procedure: tell patient to drink plenty of fluid
fluid. and may be given a laxative to expel barium.
Inform them stool may be white/light color for 2-3
days postop
6. CT scan  provide cross-sectional image of abdominal organs and structure
 With or without contrast. Better image with contrast agent but need to assess for any allergies to contrast
agent (iodine or shellfish)
 Patients need to hold metformin on the day of CT scan and 48hrs after test. Patient creatinine level and
human chorionic gonadotropin (pregnancy status) must be determined before CT contrast study. Patients
stay still and hold their breath during test.
7. MRI  useful in evaluating the cause of abdominal pain, soft tissues, blood vessels, gallstone, source of
bleeding
 NPO 6-8hours before test
 Patient is instructed to remove any ferromagnetic or metal objects including jewelry, dental implant, pen,
keys, oxygen tucks, IV poles, transdermal patch
 Contraindication: internal mental devices like pacemaker, artificial heart valves, implanted insulin pumps,
…
 Tell patient the procedure takes 60minutes or longer and they have to take deep breaths at some point.
May feel claustrophobia and hear loud noise but they can have earplugs, headphones, or wear blindfold.
8. Endoscope procedures

Esophago-gastro-duodeno-scopy (upper GI Endoscopic retrograde cholangio-pancreato-graphy

fibroscopy/EGD) (ERCP)
 Visualization of upper GI tract to detect  To view ductal structures of biliary tract
esophageal, gastric duodenal abnormalities,  Helpful in detecting and treating bile duct
bleeding, tumors stones, strictures.
 Collect and evaluate secretion and tissue
specimens
 Remove foreign bodies
 Procedure:
o NPO 6-8hours
o local analgesic gargle or spray use to
relieve anxiety and paralyze gag reflex
o patient is placed on the left lateral
position with neck tilted forward to
facilitate clearance of pulmonary
secretions and provide smooth entry of
the scope
 Post-op: assess LOC, V/S, SaO2, pain level
and monitor for sign of perforation (pain,
bleeding, unusual difficulty swallowing, high
temperature). Don’t advance diet until gag
reflex returns. When gag reflex has returns,
lozenge, saline gargle and oral analgesic
may be offered to relieve minor throat
discomfort. Tell them they may experience
belching, bloating, and excess flatus
secondary to insufflation.

9. Fiberoptic colonoscopy
 Direct visualization of the large intestine, aid in diagnosis and screening, to obtain tissue biopsy,
remove polyps, and evaluate patient with changes in bowel habits, bleeding, anemia
 Colonoscopy  the flexible scope is pass through the rectum and sigmoid colon into the descending,
traverse, ascending colon.
 Preparation: ensure adequate colon cleansing, laxative 2 night before test, a fleet’s or saline enema
until the return is clear the morning of the test. Patient maintain clear liquid diet starting at noon the
day before test.
 Pre-op: patient ingests the lavage solution PO at interval over 3-4hrs, use NG feeding tube if difficultly
swallowing.
 Side effect of lavage electrolyte solution: nausea, bloating, cramping or abdominal fullness, fluid and
electrolyte imbalance.
10. Anoscopy, proctoscopy, sigmoidoscopy:
 Endoscopic eval of anus, rectum, sigmoid, and descending colon
 Patient may receive enema until return is clear
 During procedure, nurse monitor V/S, skin color and temperature, pain tolerance, vegal response
 Post-procedure: monitor rectal bleeding and sign of perforation (fever, rectal drainage, abdominal
distention and pain). Resume regular activity and diet after examination.
11. Gastric analysis, gastric acid stimulation test, pH monitoring  analysis of gastric juice, pH, presence of mucos,
blood abnormal cells, aid in diagnosis of PUD, cancers, Zollinger-Ellison syndrome.
 NPO after evening meal of the night before and no drinking water 1hr before the test
 Some meds may be held 72hrs before test
 No tobacco and chewing gum 12hr before test (cos it increase gastric secretion)
12. Small bowel enteroscopy  capsule/wireless endoscopy visualize entire small bowel, used to eval the source of
GI bleeding, lesions, inflammation
13. Liver function tests include blood tests, liver biopsy, and paracentesis
 Blood test: serum liver enzyme test, serum concentration of protein (albumin and globulins), bilirubin,
ammonia, clotting factors, lipids.
o Patient with high ammonia, put them on NG tube and give lactulose to bring it down
 Liver biopsy: required consent, to diagnose liver disease by obtaining a small liver tissue through
needle aspiration. After liver biopsy, turn patient to right side to provide pressure on puncture side to
prevent bleeding.
 Paracentesis: removal of large amount of fluid (ascites) from peritoneal cavity. Monitor BP, and fluid
loss, and protein level.
14. PICC line and CVAD long-term therapy required for total parenteral nutrition (formula: TPN 2-3L of solution)
 Confirm placement with chest x-ray
 PN is the delivery of nutrients directly into the bloodstream bypassing the gastrointestinal (GI) tract.
 PN solution includes proteins, carbohydrates, electrolytes, vitamin
 Nursing management:
o Use aseptic technique at all times
o Do NOT use PN line for other meds or blood draws
o Monitor:
 Vital signs (especially temp for infection)
 Labs: electrolytes, liver function, triglycerides
 Blood glucose q4–6hr → risk of hyperglycemia
 Risk for infection (due to high glucose content
o Start TPN slowly: e.g., 50 mL/hr., then titrate per order
 If PN is not available, give D10W (dextrose 10% in water) to prevent hypoglycemia.
15. Gastritis – inflammation of the gastric mucosa – N/V, abdominal discomfort, anorexia
 Acute (few hours to several day)  caused by dietary indiscretion like irritating/highly seasoned foods,
microorganism, aspirin overuse and excessive alcohol intake
 Chronic (repeat exposure to irritating agents or recurring episodes of acute gastritis)  caused by
benign or malignant gastric ulcer or bacteria H. pylori
 Medication treatment: antibiotic, histamine2 receptor antagonist, PPIs, prostaglandin E analog
 Surgical treatment: gastric resection or gastrojejunostomy for gangrenous or perforated tissue
 client education for acute gastritis:
o Avoid alcohol and irritating food until symptoms subside
o follow non-irritating diet (BRAT): banana, rice, applesauce, toast
o take antacids to neutralize strong acids from offending agents
o take diluted lemon juice or vinegar to neutralize alkalis from offending agent
 Client education for chronic gastritis:
o Modify diet, avoid alcohol, NSAIDs,
o Promote rest and stress reduction
o Take medication as follows including drug for H. pylori
16. Peptic ulcer disease – excavation in the stomach mucosa – dull, gnawing pain or burning sensation in the mid-
epigastrium or in the back, pyrosis (heartburn), vomiting, constipation or diarrhea, and bleeding
 This lesion may occur in stomach, duodenum, or esophagus
 caused by concentration HCL or activity of acid-pepsin. Infection from H. pylori bacteria and stress-
related mucosal disease (SRMD) can also contribute to mucosal damage
 Gastric ulcers cause weight loss, occur 30-1hr after meal, rarely occur at night and may be relieved by
vomiting. Indigestion of food does not help but increase more pain. More likely to see hemorrhage
(melena then hematemesis)
 Duodenal ulcers cause weight gain, hypersecretion of HCL in the stomach, pain occur 2-3hr after meal
or at night. Pain is relieved with food. Less likely to have hemorrhage (hematemesis than melena)
 Medical and nursing management:
o Drug treatment: Antibiotic, PPI, histamine2 receptor antagonists, bismuth salts
o Lifestyle changes: no smoke, no stress, no NSAIDs or alcohol, change diet.
o Monitor for complication: hemorrhage (hematemesis, melena), bright red/dark coffee grounds
perforation, pyloric obstruction
o Monitor for faintness, dizziness, monitor V/S, hgb, hct, occult blood test, IV fluid
o Surgical management: vagotomy, pyloroplasty, antrectomy, selective embolization (for high-
risk bleeding patients in interventional radiology)
17. Gastric surgery  perform on patient with PUD who have life-threatening hemorrhage, obstruction, perforation,
penetration, or whose condition does not respond to medication
 Pre-op assessment: prioritize nutrition and recent weight change
  Post-op assessment: prioritize complications such as hemorrhage, infection, abdominal distention,
atelectasis, or impaired nutritional status
 Nursing intervention: reduce anxiety, relieve pain, provide teaching, resume enteral intake, recognize
obstacles to nutrition which include difficult swallowing, gastric retention, bile reflux, dumping
syndrome, dietary deficiencies.
 Dumping syndrome: patient has a feeling of fullness, nausea and diarrhea. This causes dehydration,
hypotension, tachycardia
18. Dietary Guidelines after Gastric Surgery to help prevent dumping syndrome and promote healing:
 Lie down after meals: 20–30 minutes to delay stomach emptying.
 Take antispasmodics as prescribed (slows gastric emptying).
 Avoid drinking fluids with meals. But patient can drink fluids 1 hour before or after eating (not
during).
 Choose dry over liquid meals.
 Eat smaller, more frequent meals throughout the day.
 For Nutrients, fat is OK if tolerated. But avoid or limit carbs—especially simple sugars (e.g., soda,
pastries). And Increase fiber (or use fiber supplements).
 Take these vitamin supplements:
o Medium-chain triglycerides (MCTs)
o Vitamin B₁₂ and iron injections as prescribed (to prevent vitamin B12 deficiency)
19. Hepatitic dysfunction manifestation:
 Jaundice caused by impaired liver metabolism and excretion of bilirubin
o Types of jaundice: hepatocellular, obstructive, hemolytic
 Portal hypertension caused by increased resistance to blood flow through liver and increased blood flow
due to vasodilation
o Major complication: ascites and gastroesophageal varices
 Vitamin deficiency
20. Viral hepatitis – a systemic viral infection involving necrosis and inflammation of liver cells
 Types include A, B, C, D, E, and G  Can result in either acute or chronic liver dysfunction and disease
 Hepatitis A:
o Transmission occurs through fecal–oral route
o Can present either asymptomatically or with acute symptoms such as fever, malaise, anorexia,
nausea, diarrhea, vomiting, abdominal pain, and jaundice
o Vaccination is encouraged and travelers to hepatitis A-endemic countries should be advised to eat
only properly cooked food, avoid uncooked vegetable and shellfish, consume only purified water
and rice
o IV fluids to prevent dehydration
o Liver failure-referral for transplant
 Hepatitis B virus
o Transmitted primarily by perinatal, percutaneous, sexual exposure, and close person-to-person
contact
o HBV has a long incubation period
o Clinical Manifestations- anorexia, fever, dyspepsia, malaise, pain in the right upper quadrant
o Medical and nursing management: vaccination (most effective).
o The goals of treatment are to prevent replication of active hepatitis B virus (viral suppression) and
reduce the effects of chronic liver inflammation
o Antiviral treatment. Symptomatic management of malaise, nausea, vomiting, fever. Adequate
nutrition. Fluid intake, avoidance of lifestyle factors that may exacerbate liver disease
 Hepatitis C virus
o The leading cause of liver disease and is the primary indication for liver transplantation
o Occurs primarily through injection of drugs and through transfusion of blood products prior to
1992
o Most patients with acute or chronic hepatitis C are asymptomatic
o Antiviral therapy is available
o Patient education-avoid sharing razors, toothbrushes, nail clippers, safe sex practices
 Hepatitis D (delta agent)- individuals with hep B are at risk. Symptoms similar to hep B. Treatment is
Interferon for 12 months
 Hepatitis E- transmitted by fecal-oral route, contaminated water, poor sanitation. Prevention-
improvement of sanitation, clean water supplies
Simple nursing notes:
 Type A: Fecal-Oral
 Type B: Blood, body fluids, sexual transmission
 Type C: Blood, body fluids, sexual transmission
 Type D: Co infection with Type B
 Type E: Fecal-oral
Symptoms of hepatitis:
 Flu- like symptoms (headache, fever, malaise, N/V)
 Elevated ALT and AST, and bilirubin
 Jaundice
 Itching
 Clay-colored stools
 Dark urine
Diagnosis:
 Liver biopsy
 Lay on right side (to prevent bleeding)
21. Gallbladder disorders: cholelithiasis (gallstones) and Cholecystitis (inflammation of the gallbladder)
 Cholelithiasis (gallstones)calculi in the gall bladder
o May be made up of pigment or cholesterol
o Risk factors-females, over 40
o Clinical Manifestations-abdominal pain radiating to the back or right shoulder, nausea, vomiting
o Murphy sign (pain under the ribcage when ask to take deep breath to expand chest during
palpitation of the right upper quadrant)
 Cholecystitis (acute inflammation of the gallbladder).
o Caused by obstruction of the cystic duct by gallstones
o Symptoms include upper right abdominal pain, nausea, and vomiting
o Treatments include medication, cholecystectomy, and laparoscopic cholecystectomy

22. Cholecystectomy
 NPO, IV fluids, pain management, antibiotics
 Ursodeoxycholic acid to dissolve gallstones
 Laparoscopic/open cholecystectomy
 Inform patient may feel pain in the right shoulder due to CO2 gas  intervene with ambulation and
reassurance.