Gastrointestinal Disorders

GERD (Gastroesophageal Reflux Disease)

Stomach acid backs up into the esophagus — one of the most common GI complaints.

GERD occurs when the lower esophageal sphincter (LES) weakens or relaxes inappropriately, allowing stomach acid to reflux into the esophagus. Chronic GERD can lead to Barrett's esophagus (precancerous changes) and esophageal strictures.

Signs & Symptoms

• Heartburn (pyrosis) — burning sensation in the chest, worse after eating and when lying down
• Regurgitation of acidic material
• Dysphagia (difficulty swallowing)
• Chronic cough, hoarseness, sore throat (atypical symptoms)
• Worsened by: large meals, lying down after eating, fatty/spicy foods, caffeine, alcohol, chocolate, peppermint

Nursing Interventions & Teaching

• Elevate HOB 30–45 degrees (prevents reflux when lying down)
• Small, frequent meals — avoid eating 2–3 hours before bedtime
• Avoid trigger foods: caffeine, alcohol, spicy/fatty foods, chocolate, citrus, peppermint
• Avoid NSAIDs (irritate gastric mucosa)
• Weight loss if overweight
• Stop smoking (nicotine relaxes the LES)
• Do not lie flat after meals — remain upright for at least 30 minutes

Peptic Ulcer Disease (PUD)

Gastric vs duodenal — know which one hurts with food and which one is relieved by food.

Gastric Ulcer

Pain DURING or right after eating. Food makes it WORSE. Weight loss (patient avoids food). Lesser curvature of the stomach. Less common.

Duodenal Ulcer

Pain 2–3 hours AFTER eating, often at night. Food RELIEVES pain temporarily. Weight gain (patient eats to relieve pain). First part of the duodenum. More common.

Causes

• H. pylori infection — #1 cause. Gram-negative bacterium that burrows into gastric mucosa.
• NSAID use — inhibits prostaglandin production, reducing mucosal protection
• Stress, smoking, excessive alcohol

Diagnosis

• EGD (esophagogastroduodenoscopy) — gold standard for visualization and biopsy
• H. pylori testing: stool antigen test, urea breath test, or biopsy during EGD

Treatment — Triple Therapy for H. pylori

PPI + 2 antibiotics for 10–14 days (e.g., omeprazole + clarithromycin + amoxicillin)

Dumping Syndrome

A post-gastrectomy complication — food "dumps" too fast into the small intestine.

Early Dumping15–30 min after eating

Cause: Rapid gastric emptying pulls fluid into intestine (hypertonic bolus). Symptoms: Nausea, cramping, diarrhea, dizziness, tachycardia, diaphoresis.

Late Dumping2–3 hrs after eating

Cause: Rebound insulin surge → hypoglycemia. Symptoms: Shakiness, confusion, diaphoresis, weakness (hypoglycemia symptoms).

Key Nursing Interventions

• Lie down for 30 minutes after eating — slows gastric emptying
• Small, frequent meals (6 per day)
• High-protein, high-fat, LOW-carb diet
• Avoid simple sugars (draws fluid into intestine)
• Avoid fluids WITH meals — drink 30–60 minutes before or after

Crohn's Disease vs Ulcerative Colitis

The IBD comparison that shows up on almost every nursing exam.

Crohn's Disease

Location: ANY part of GI tract (mouth to anus); most common: terminal ileum. Pattern: Skip lesions (patchy). Depth: Transmural (full thickness). Cobblestone appearance. Key symptoms: RLQ pain, diarrhea (non-bloody), weight loss, malnutrition. Complications: Fistulas, strictures, abscesses, bowel obstruction, malabsorption. Surgery NOT curative — recurs. Smoking WORSENS (#1 modifiable risk).

Ulcerative Colitis (UC)

Location: Colon and rectum ONLY. Pattern: Continuous (starts at rectum, moves upward). Depth: Mucosal only (superficial). Friable mucosa with pseudopolyps. Key symptoms: Bloody diarrhea (hallmark), LLQ pain, urgency, tenesmus. Complications: Toxic megacolon, colorectal cancer risk (high), severe hemorrhage. Surgery IS curative — total colectomy removes the disease.

Nursing Interventions for IBD

• Monitor strict I&O, daily weights, nutrition status
• Low-residue, high-calorie, high-protein diet during flares
• TPN if severe malnutrition or bowel rest needed
• Monitor for dehydration and electrolyte imbalances (from chronic diarrhea)
• Perianal skin care (frequent diarrhea causes skin breakdown)
• Administer medications: aminosalicylates (mesalamine), corticosteroids, immunomodulators, biologics (infliximab)
• Emotional support — chronic illness with unpredictable flares

Appendicitis

Know the location, the one thing you should NEVER do, and when it becomes an emergency.

• Pain begins periumbilical → localizes to RLQ at McBurney's point
• Rebound tenderness (pain worse when pressure is released)
• Low-grade fever, nausea, vomiting, anorexia
• Elevated WBC

• Keep patient NPO (surgery is the definitive treatment — appendectomy)
• Position: right side-lying or semi-Fowler's for comfort
• Ice pack to RLQ (NOT heat)
• Monitor for signs of perforation/peritonitis

Bowel Obstruction

Mechanical vs functional — know the signs and the NG tube management.

A bowel obstruction occurs when the normal flow of intestinal contents is partially or completely blocked. Mechanical causes include adhesions (#1 cause post-surgery), hernias, tumors, and volvulus. Functional (paralytic ileus) occurs when peristalsis stops without a physical blockage — common after abdominal surgery, with opioid use, or electrolyte imbalances.

Signs & Symptoms

• Crampy, colicky abdominal pain (comes in waves)
• Abdominal distension
• Nausea and vomiting (may become fecal-smelling in late/complete obstruction)
• Absent bowel sounds (paralytic ileus) OR hyperactive, high-pitched "tinkling" bowel sounds (mechanical early obstruction)
• No passage of flatus or stool
• Constipation (partial) or obstipation (complete)

Nursing Interventions

• NPO — nothing by mouth until obstruction resolves
• NG tube to low intermittent suction — decompresses the stomach, removes gas and fluid
• IV fluids for hydration and electrolyte replacement
• Monitor I&O strictly
• Assess bowel sounds every 4 hours
• Monitor for signs of strangulation: increasing pain, fever, tachycardia, bloody stool (surgical emergency)
• Post-op: listen for return of bowel sounds and passage of flatus before advancing diet

Cirrhosis & Hepatic Encephalopathy

End-stage liver disease — know the complications and lactulose.

Cirrhosis is irreversible scarring (fibrosis) of the liver. The most common causes are chronic alcoholism and hepatitis C. As the liver scars, blood flow through the liver is obstructed, leading to portal hypertension and a cascade of complications.

Complications of Cirrhosis

• Portal hypertension → esophageal varices (dilated veins in the esophagus that can rupture and hemorrhage — LIFE-THREATENING)
• Ascites — fluid accumulation in the peritoneal cavity. Measure abdominal girth daily. Low-sodium diet, fluid restriction, diuretics (spironolactone). Paracentesis for relief.
• Hepatic encephalopathy — ammonia buildup in blood causes confusion, asterixis (flapping hand tremor), personality changes, and can progress to coma
• Coagulopathy — liver makes clotting factors; damaged liver = bleeding risk
• Jaundice — liver can't conjugate bilirubin → yellowing of skin and sclera
• Spider angiomas, palmar erythema — from estrogen excess (liver can't metabolize)

Hepatic Encephalopathy Management

• Lactulose — the key drug. Traps ammonia in the colon for excretion in stool. Goal: 2–3 soft stools per day. Side effect: diarrhea (therapeutic!).
• Rifaximin — antibiotic that kills ammonia-producing bacteria in the gut
• Low-protein diet during acute episodes (protein breakdown produces ammonia)
• Monitor ammonia levels and neurological status

Hepatitis

Know the transmission routes — this is heavily tested.

Hepatitis A (HAV)fecal-oral

Fecal-oral transmission (contaminated food/water). Self-limiting, no chronic state. Vaccine available. Think: travel, shellfish, poor sanitation.

Hepatitis B (HBV)blood/body fluids

Blood and body fluids (sexual, needlestick, perinatal). Can become chronic → cirrhosis, liver cancer. Vaccine available. Healthcare worker risk.

Hepatitis C (HCV)blood-to-blood

Blood-to-blood (needlestick, IV drug use, transfusions before 1992). Most common cause of chronic hepatitis → cirrhosis. No vaccine. Now curable with antivirals.

General Hepatitis Signs & Symptoms

• Jaundice (yellowing of skin and sclera)
• Dark (tea-colored) urine, clay-colored stools
• Fatigue, malaise, anorexia
• RUQ tenderness (hepatomegaly)
• Elevated liver enzymes (AST, ALT)
• Nausea, vomiting

Pancreatitis

Know the pain pattern, the labs, and why the patient is NPO.

Pancreatitis is inflammation of the pancreas caused by premature activation of pancreatic enzymes, which begin to digest the pancreas itself. The two most common causes are gallstones and chronic alcohol use.

Signs & Symptoms

• Severe epigastric pain radiating to the back — hallmark symptom
• Pain worsens after eating (especially fatty foods) and when lying flat
• Pain relieved by leaning forward or fetal position
• Nausea, vomiting
• Abdominal distension and tenderness
• Cullen sign (bruising around umbilicus) and Turner sign (bruising on flanks) — indicate hemorrhagic pancreatitis

Key Labs

• Amylase: elevated (↑) — rises within hours
• Lipase: elevated (↑) — more specific for pancreatitis
• WBC elevated, blood glucose elevated (pancreas produces insulin)

Nursing Interventions

• NPO — resting the pancreas is priority #1 (eating stimulates enzyme production)
• NG tube if vomiting is severe
• IV fluids, electrolyte replacement
• Pain management (meperidine historically used, but morphine is now acceptable)
• Position: side-lying with knees flexed or sitting/leaning forward (reduces pain)
• Monitor blood glucose (pancreatitis can cause hyperglycemia)
• When diet resumes: low-fat, bland, small frequent meals. No alcohol — ever.

Ostomies & NG Tubes

Ileostomy vs colostomy, and NG tube management.

Ileostomysmall intestine

Liquid to semi-liquid stool. I&O monitoring critical (high fluid/electrolyte losses). HIGH dehydration risk (colon bypassed — no water reabsorption). HIGH skin breakdown risk (liquid output contains digestive enzymes).

Colostomylarge intestine

Semi-formed to formed stool (depends on location). I&O less critical. Lower dehydration and skin breakdown risk.

Stoma Assessment (All Ostomies)

• Normal stoma: red, moist, and beefy (like the inside of your cheek)
• Abnormal: pale/dusky/black (ischemia — report immediately), dry, retracted, prolapsed
• Change appliance when output is lowest (usually before meals)
• Cut the wafer to fit 1/8 inch larger than the stoma
• Protect peristomal skin with skin barrier

NG Tube Management

• Verify placement: X-ray (gold standard before first feeding), pH of aspirate (<5.5 = gastric), auscultation is least reliable
• Low intermittent suction for decompression
• Monitor for electrolyte imbalances (NG suction removes acid → metabolic alkalosis)
• Oral and nasal care every 2 hours (mouth breathing, dry mucous membranes)
• Keep HOB elevated ≥30 degrees to prevent aspiration
• Monitor I&O — document NG output as output

Key GI Medications

Medications you'll see on every GI question.

Omeprazole (Prilosec)PPI

First-line for GERD/ulcers. Blocks acid production. Take 30 min before breakfast. Long-term use: ↑ fracture risk, ↓ Mg²⁺, C. diff risk.

Famotidine (Pepcid)H2 blocker

Reduces acid. Used for milder GERD. Fewer side effects than PPIs.

Sucralfate (Carafate)mucosal protectant

Forms a protective coating over the ulcer. Take on empty stomach 1 hr before meals. Do not take with antacids.

Metoclopramide (Reglan)prokinetic / antiemetic

Increases gastric motility. Used for GERD, gastroparesis. Side effect: EPS (extrapyramidal symptoms — tardive dyskinesia).

Ondansetron (Zofran)antiemetic

Blocks serotonin receptors. First-line for nausea/vomiting (especially chemo-induced). Can cause constipation, headache, QT prolongation.

Lactuloseosmotic laxative

Traps ammonia in colon for excretion. Used for hepatic encephalopathy. Goal: 2–3 soft stools/day. Diarrhea = expected.

Mesalamine (Asacol)aminosalicylate

Anti-inflammatory for IBD (especially UC). Oral or rectal. Monitor kidney function.

Infliximab (Remicade)biologic (anti-TNF)

Used for moderate-severe Crohn's/UC. Screen for TB before starting. Immunosuppressive — infection risk.

Pancrelipase (Creon)pancreatic enzyme

Enzyme replacement for chronic pancreatitis. Take WITH meals. Do not crush enteric-coated capsules.

Docusate (Colace)stool softener

Prevents straining. First-line for opioid-induced constipation prevention. Increase fluid intake.

Frequently Asked Questions

Common student questions on this topic.

Quick-Reference Cheatsheet

Every key point from this guide on a single printable page.