Editing Medical-Surgical Nursing (section)

== Gastrointestinal and Hepatobiliary Disorders ==

=== Gastroesophageal Reflux and Peptic Ulcer Disease ===

Reflux produces heartburn, regurgitation, and sometimes a chronic cough or hoarseness. Teach the patient to avoid large meals, to remain upright for two to three hours after eating, to elevate the head of the bed, to lose weight if indicated, and to limit caffeine, alcohol, chocolate, peppermint, fatty foods, and tobacco.

Peptic ulcer disease is most often caused by ''Helicobacter pylori'' infection or by nonsteroidal anti-inflammatory drug use. Gastric ulcer pain typically worsens with eating, whereas duodenal ulcer pain typically improves with eating and returns two to three hours later or at night. Treatment includes proton pump inhibitors and, for ''H. pylori'', combination antibiotic therapy.

Nursing application: sudden severe diffuse abdominal pain with a rigid board-like abdomen, absent bowel sounds, rebound tenderness, and tachycardia indicates perforation. Keep the patient nothing by mouth, notify the provider immediately, and prepare for surgery. Coffee-ground emesis or melena indicates upper gastrointestinal bleeding.

=== Inflammatory Bowel Disease ===

Ulcerative colitis affects the colon and rectum continuously with mucosal inflammation and produces frequent bloody diarrhea with mucus, tenesmus, and left lower quadrant cramping. Crohn disease can affect any part of the gastrointestinal tract in skip lesions with transmural inflammation and produces right lower quadrant pain, nonbloody diarrhea, fistulas, strictures, and malabsorption with nutritional deficiencies.

Nursing care during exacerbation includes bowel rest, monitoring for dehydration and electrolyte loss, a low-residue and low-fat diet as tolerated, and administration of aminosalicylates, corticosteroids, immunomodulators, or biologics. Toxic megacolon, marked by abdominal distention, fever, tachycardia, and a silent abdomen, is a surgical emergency.

=== Diverticular Disease ===

Diverticulosis is the presence of outpouchings in the colon wall and is prevented and managed with a high-fiber diet and fluids. Diverticulitis is inflammation or infection of those pouches, causing left lower quadrant pain, fever, and leukocytosis. During acute diverticulitis the diet is temporarily restricted to clear liquids or nothing by mouth with a low-fiber progression, and antibiotics are given; high fiber is resumed only after the acute episode resolves. Avoid enemas and laxatives that increase intraluminal pressure during the acute phase.

=== Appendicitis and Bowel Obstruction ===

Appendicitis produces periumbilical pain migrating to the right lower quadrant at McBurney point, rebound tenderness, anorexia, nausea, low-grade fever, and leukocytosis. Do not apply heat, do not give enemas or laxatives, and keep the patient nothing by mouth, because these measures can precipitate rupture. Sudden relief of pain followed by worsening diffuse pain suggests perforation with peritonitis.

Small bowel obstruction presents with colicky pain, profuse vomiting, and early high-pitched then absent bowel sounds; large bowel obstruction presents with marked distention and obstipation. Care includes nothing by mouth, nasogastric decompression, intravenous fluids with electrolyte replacement, and monitoring for strangulation.

=== Liver Disease ===

Cirrhosis is diffuse fibrosis with loss of hepatocyte function and portal hypertension. Findings include jaundice, ascites, splenomegaly, caput medusae, spider angiomas, palmar erythema, easy bruising and prolonged prothrombin time from impaired clotting factor synthesis, hypoalbuminemia with edema, and hepatic encephalopathy with asterixis and altered mentation from accumulated ammonia.

Nursing interventions: monitor abdominal girth and daily weight, restrict sodium, give lactulose titrated to produce two to three soft stools per day to eliminate ammonia, protect fragile skin, monitor for bleeding, avoid hepatotoxic drugs including acetaminophen beyond prescribed limits and alcohol, and assist with paracentesis, checking that the bladder is emptied first and monitoring for hypotension afterward.

Nursing application: esophageal varices are the most dangerous complication. Sudden hematemesis with hypotension and tachycardia is a life-threatening hemorrhage requiring immediate airway protection, large-bore intravenous access, volume resuscitation, and emergent endoscopy. Teach the patient to avoid straining, coughing forcefully, and heavy lifting.

Viral hepatitis A and E spread by the fecal-oral route; hepatitis B, C, and D spread by blood and body fluids. Hepatitis B has a vaccine and is a required occupational health protection for nurses; hepatitis C has no vaccine but has highly effective antiviral treatment.

=== Pancreatitis and Cholecystitis ===

Acute pancreatitis produces severe epigastric pain radiating to the back, often relieved somewhat by leaning forward or by a fetal position, with nausea, vomiting, fever, and abdominal distention. Serum lipase is the more specific marker; amylase also rises. Cullen sign (periumbilical bruising) and Grey Turner sign (flank bruising) indicate hemorrhagic pancreatitis. Hypocalcemia may develop. Care includes nothing by mouth with bowel rest, aggressive intravenous fluids, pain control, and abstinence from alcohol.

Cholecystitis produces right upper quadrant pain radiating to the right shoulder or scapula after a fatty meal, nausea, vomiting, and a positive Murphy sign. Obstruction of the bile duct adds jaundice, clay-colored stools, dark urine, and pruritus. Teach a low-fat diet and monitor after laparoscopic cholecystectomy for referred shoulder pain from residual carbon dioxide, which is relieved by ambulation.

=== Ostomy Care ===

An ileostomy produces liquid to pasty output that is high in enzymes and very irritating to skin, with substantial fluid and electrolyte loss. A colostomy produces progressively more formed stool the more distal it is. A healthy stoma is beefy red and moist; a pale, dusky, purple, or black stoma indicates compromised circulation and is reported immediately. Fit the appliance opening to the stoma with only a small margin to protect surrounding skin.