1. health and fitness
2. disease

Preparing patients for their procedure(s) in the GI/ Endoscopy Units
What is a Gastroscopy?
A gastroscopy is a test in which a gastroscope (a long flexible tube) is passed through the mouth and down the back of the throat into the upper digestive tract. It allows the physician to examine the lining of the esophagus, stomach and duodenum (the first portion of the small intestine). It has its own lens and light source and the image is projected onto a video monitor.
IT IS VERY IMPORTANT TO ENSURE YOUR PATIENT IS PROPERLY PREPARED FOR THE TEST THAT IS ORDERED
What to tell your patients to expect FOR GASTROSCOPY
•Ensure patient is NPO
•Ensure any bloodwork that is ordered is completed
•Document prep (NPO) and any pre meds given as ordered
•Notify GI unit of any changes in patient’s
patient s condition or if patient
has not been NPO
•Leave dentures on unit in marked container
•Notify GI unit if patient is on ISOLATION and type
•Ensure a patent IV/SL is in place. If your patient has a PICC or
Central line only, please ensure that they have a saline solution
infusing that may be used for medications.
Why is it done? This test allows the gastroenterologist to diagnose a condition and prescribe
or recommend a treatment. It can evaluate and treat problems such as:
•Ulcers or growths in the esophagus, stomach or intestine
•Narrowing in the esophagus or other areas of the upper digestive system
•Abdominal pain, heartburn or persistent nausea and/or vomiting
•Enlarged
E l
d bl
blood
d vessels
l iin the
h esophagus
h
or stomach
h
•Celiac disease (can’t digest gluten and wheat products)
•Difficulty swallowing
Gastroscopy can also be used to:
•Remove small objects such as coins, bones, and food from the esophagus
and stomach
•Obtain samples to look at under the microscope
•Treat bleeding in the esophagus, stomach, or small intestine
•They will be asked to lie on their left side.
•A mouth guard will be placed between their teeth.(This prevents damage to
the patients teeth and the endoscope).
• They will receive sedation through the IV line. Their throat may or may not
be sprayed with a topical anaesthetic to numb itit.(This
(This is physician
dependent)
•A flexible tube, called a gastroscope, will be inserted into their mouth. This
tube will not interfere with their breathing. The tube will pass over the back
of their tongue and is then passed down the esophagus (“food pipe”) down
to the stomach.
•Air is used to inflate the areas to allow the doctor to see the area better.
They may have some bloating, feel pressure in their abdomen or feel a
need to burp.
The procedure takes from 5-20 minutes.
Did you know?
• 70 % of ulcers are found in the duodenum. Why is that?
Answer: NSAIDS are one of the leading causes of ulcers and typically
those ulcers develop in the duodenum.
The stomach defends itself from hydrochloric acid and pepsin by
creating a mucus coating.
• What is the name of the primary bacterium that causes ulcers?
Answer: Helicobacter pylori (H. pylori). H. pylori is a spiral-shaped
bacterium found in the stomach. Unlike other bacterium, H. pylori is able
to twist through the layer of mucous that protects the stomach cavity.
1
What is a Colonoscopy?
What are the possible risks? What you should watch for when patients return to the unit.
A Gastroscopy is a safe procedure, however it carries a very small risk of
complications, including:
•Bleeding – watch for S&S of GI bleeding – vomiting blood, tachycardia, cool extremities,
syncope (change in postural BP), unexplained confusion
A colonoscopy is a procedure that allows the doctor to see and
examine the lining of the lower gastrointestinal tract. This includes
the rectum and the large colon (also known as the large intestine
or large bowel) using a flexible tube called a colonoscope.
•Perforation – watch for severe epigastric/chest pain with movement, nausea and
vomiting, or fever and/or chills
vomiting
chills. Observe upper chest area for signs of subcutaneous
emphysema. It is easily palpable if present…..snap, crackle, pop feel.
•Aspiration-from fluid or foods getting into their lungs – watch for coughing, SOB,
increased chest wheeziness
•Possible complications from the sedation received -watch for decreased LOC
over a prolonged time, decreased respirations, decreased pulse, decreased BP, inability to
rouse after approximately 1 hour – IF your patient received a reversal agent, watch out for
re-sedation.
Important
You should check your patients’ vital signs and LOC upon return to the
unit and within an hour post and as indicated. Be aware of any significant
changes in vital signs or patient condition either from pre procedure state
or upon return to unit post procedure.
IT IS VERY IMPORTANT TO ENSURE YOUR PATIENT IS PROPERLY PREPARED FOR THE TEST THAT IS ORDERED
FOR COLONOSCOPY
•Ensure patient receives all of the ordered prep (ie: Colyte) and is on clear fluids only the
day before the test.
•Ensure the physician/GI unit is notified if the patient is not tolerating the prep so further
orders can be given.
•Patient should be passing clear/colorless liquid or clear yellow liquid if prep was effective-a
small amount of sediment is fine as long as you can see the bottom of the toilet---if prep is
ineffective notify GI unit well in advance of sending the patient for the test
ineffective,
test.
•Document the prep given and results from the prep.
•Ensure any bloodwork that is ordered is completed. ie INR
•Notify GI unit of any changes in patient’s condition.
•Ensure a patent IV/SL is in place. If your patient has a PICC or Central line only, please
ensure that they have a saline solution infusing that may be used for medications.
The most important thing that you can do to ensure the success of your patients colonoscopy is to
make sure they are properly prepared for the test. The colon must be cleaned out to allow for clear
examination of the bowel wall and detection of any abnormalities. Excellent bowel preparation
results in a clean colon that allows the test to be done quickly and easily. A poor bowel preparation
increases the risk of missing significant lesions, such as cancers or polyps, and may result in the
test needing to be repeated.
What to tell your patients to expect •They will lie on their left side for the procedure but may be repositioned
during the test.
•They will be given sedation through their intravenous to help them relax.
• Many patients will fall asleep during the procedure and may not remember
many of the details of what happened during the test.
test
•A flexible tube, called a colonoscope, will be lubricated and inserted into the
rectum.
•Air is used to inflate the colon to allow the doctor to see the area better. This
may cause them some abdominal cramping and/or the urge to have a bowel
movement.
The procedure takes about 15-45 minutes to complete.
Why is it done?
Crohn’s disease versus Ulcerative Colitis
This test allows the gastroenterologist to diagnose a condition and prescribe or
recommend a treatment. Biopsies can be obtained to look at under the
microscope if deemed necessary from symptoms or visualization of
abnormalities. It can evaluate and treat problems such as:
Crohn’s disease
Ulcerative Colitis
Usual lesion site
Primarily the ileum, but can affect any portion of the GI tract from mouth to anus. Affects the large intestine only
•change
change of bowel pattern such as diarrhea or constipation
constipation, pencil thin stool
stool,etc
etc
Type of lesions
Intermittent granulomatous skip
l i
lesions with healthy tissue in i hh l h i
i
between(cobblestone appearance). Continuous ulcerative and exudating l i
lesions
•abdominal pain
Tissue involvement
• screening for polyps or cancer (polyps can be removed and/or biopsies taken
if found)
May involve all layers of the Intestinal wall
Mucosal layer only, unless disease is very severe
Rectal bleeding
Unusual unless colon is involved
Commonly seen
•bleeding or determine cause of unexplained anemia
Fistulas and abscesses
Common
Rare
•Crohn’s disease or Ulcerative colitis(Inflammatory Bowel Disease)
Cancer development
Uncommon
Fairly common with long‐
standing disease. (Surveillance Colonoscopies with biopsies are required to monitor)
•Narrowing in the colon
2
What are the possible risks? What you should watch for when patients return to the unit.
A colonoscopy is a safe procedure but potential risks or complications are
involved:
Bleeding – watch out for S&S of GI bleeding – passing blood rectally, tachycardia,
cool extremities, syncope (change in postural BP), unexplained confusion
Perforation – watch for severe abdominal pain with movement, nausea and
vomiting or fever and/or chills
Infection – watch for fever and/or chills
Possible complications from the sedation received – watch for decreased
LOC over a prolonged time, decreased respirations, decreased pulse, decreased
BP, inability to rouse after approximately 1 hour – IF your patient received a
reversal agent, watch out for re-sedation.
What is an ERCP?
An ERCP is a procedure which allows the doctor to examine the gallbladder,
pancreas and the ducts that carry bile and pancreatic juices to the duodenum (first
part of the small bowel)
During an ERCP(endoscopic retrograde
cholangiopancreatography) a catheter is advanced
through the endoscope and inserted into the pancreatic
or biliary ducts. A contrast agent is injected into these
ducts and X
X-rays
rays are taken to evaluate their caliber,
length and course. Narrowing, stones, and tumors in
the ducts can be identified in the X-rays.
Important
You should check your patients’ vital signs and LOC upon return to the unit and
within an hour post or as indicated. Be aware of any significant changes in vital
signs or patient condition either from pre procedure or from initial assessment
upon return post test.
•Encourage patients to pass air after the test to relieve any abdominal distension
and/or cramping.
IT IS VERY IMPORTANT TO ENSURE YOUR PATIENT IS PROPERLY PREPARED FOR THE TEST THAT IS ORDERED
FOR ERCPs
•Ensure patient is NPO
•Ensure any bloodwork that is ordered is completed– usually an INR is
needed – call GI unit if result is abnormal.
•Document prep (NPO) and any premeds given as ordered
•Notify GI unit of any changes in patient’s condition or if patient has not been
NPO
•Leave dentures on unit in marked container
•Ensure a patent IV/SL is in place. If your patient has a PICC or Central line
only, please ensure that they have a saline solution infusing that may be
used for medications.
What to tell your patients to expect
•They will lie on an X-ray table on their abdomen unless otherwise instructed.
•They will be given medication through the intravenous to help them relax. Most
patients fall asleep during the procedure and don’t remember details of what
happened.
•A flexible tube, called a duodenoscope will be passed through their mouth, into
their stomach, and down into their duodenum. This tube does not interfere with
breathing.
•Air
Air is used to inflate the stomach and duodenum to allow the doctor to see the
area better. You may feel bloating and/or pressure in your abdomen or feel a need
to burp.
•If there is anything that appears abnormal, the doctor can take biopsies or
brushings or do therapeutic interventions through the scope.
•They may have a slight sore throat for 1-2 days after. Warm, salt water rinses or
throat lozenges may be used to lessen the discomfort.
•They may have bloating, abdominal cramping, and soft bowel movements
because of the air and the dye that was injected. It is strongly recommended that
they expel the air to relieve discomfort.
•They may feel light-headed or drowsy due to the effects of the medication.
The procedure can take from about 15-60 minutes to complete.
Why is it done?
This test allows the doctor to diagnose a patient’s condition and prescribe a
treatment. An ERCP may be done to evaluate problems such as:
•jaundice (yellow – tinged skin and/or eyes)
•abdominal pain/recurrent pancreatitis
•abnormal liver function tests
•stones, tumors, or narrowings
And can also be done to:
•remove gallstones from the bile duct (tube that drains the liver)
•relieve blockage at the bottom end of the bile duct
•remove stones from the pancreas
•place stents – plastic tubes – temporary or metal tubes – permanent
•obtain biopsies or brushings for microscopic examination
•dilate (stretch) strictures (narrowings) of the ducts
•treat leaks in the duct that were caused from trauma or surgery
What are the possible risks of having an ERCP & what you should watch for when your patients return to the unit
Bleeding – watch out for S&S of GI bleeding – vomiting blood, tachycardia, cool
extremities, syncope (change in postural BP), unexplained confusion
Perforation – (hole or tear) – watch out for severe chest or epigastric pain with
movement, nausea and vomiting, or fever and/or chills
Pancreatitis – epigastric pain, nausea and vomiting and abnormal liver enzymes
Allergic reaction to X-ray dye or the medication used to relax the
duodenum – watch out for rash, hives, sign of anaphylaxis
Infection – new
ne onset of increased temperat
temperature,
re rigors and/or chills
Allergic reaction or breathing problems caused by the medication used for
sedation – watch out for decreased LOC over a prolonged time, decreased
respirations, decreased pulse, decreased BP, inability to rouse after
approximately 1 hour –IF your patient received a reversal agent, watch out for resedation.
Important
•You should check your patients vital signs and LOC upon return to the unit and within an
hour post or as indicated. Be aware of any significant changes in vital signs or patient
condition either from pre procedure or from initial assessment upon return post test.
•Encourage patients to burp, pass gas, or change position to aide in relieving bloating and
/or cramping. Once awake enough, ambulation also helps with passing air.
3
COMMON MEDICATIONS YOU SEE ORDERED ON THE UNIT FOR PATIENTS WITH GI ISSUES
Medications continued……
COLYTE/GOLYTELY
is used for bowel evacuation before a GI examination. 4 Litres must be consumed as ordered – maintain
hydration by oral fluids (if patient isn’t NPO) or with IV therapy as ordered. Cramping, nausea and
vomiting and bloating are not unusual – treat as needed
OCTREOTIDE
is often ordered to treat variceal bleeding. It causes vasoconstriction in the blood vessels thereby
reducing portal vessel pressures in bleeding varices. It is usually ordered as a bolus then continuous
infusion.
PANTOLOC
is a proton pump inhibitor – is used for treatment of ulcers and decreasing acid reflux – IV form is often
used to treat acute upper GI bleeds. It is usually ordered as a bolus then continuous infusion.
SOLUMEDROL
is a corticosteroid used for treatment of ulcerative colitis or Crohns disease. It is
usually given IV and dose is dependent on severity of pt’s condition. More common adverse effects
include acne, fluid and electrolyte imbalance, blood sugar variations, increased appetite and weight gain.
Antibiotics may be ordered pre GI procedure for certain pre existing patient
conditions or new conditions.
•ERCP patients who are jaundiced almost always have IV antibiotics pre
procedure.
procedure
•Erythromycin may be ordered 1-2 hours pre procedure as it is known to
help clean out the stomach of blood allowing better visualization during the
test.
PREDNISONE
is a corticosteroid used for treatment of ulcerative colitis or Crohns disease. It can be ordered either
orally or intravenously. Dose and route is dependent on severity of pt’s condition. Dosage must be
tapered to discontinue. More common adverse effects include acne, fluid and electrolyte imbalance, blood
sugar variations, increased appetite and weight gain.
DRUGS COMMONLY GIVEN IN THE GI UNIT
FENTANYL– used for procedural sedation/analgesic for endoscopic procedures
to decrease procedural discomfort. Watch out for respiratory depression, apnea,
chest wall rigidity, and bradycardia.
VERSED– is a short acting benzodiazepine sedative/hypnotic used for
endoscopic procedures to decrease anxiety and recall of procedure. Watch out
for respiratory depression and arrest.(Drug Half-life 1-4 hours)
DIAZEMULS - is a long acting benzodiazepine sedative/hypnotic used for
endoscopic procedures to decrease anxiety and recall of procedure. Watch out
for respiratory depression and arrest.(Drug Half-life 21-37 hours)
GLUCAGON – may be used to decrease motility of the stomach, duodenum,
small bowel and colon during GI exams (used most often in ERCPs). Watch for
blood sugar changes mainly hyperglycemia.
NARCAN – is a reversal agent for narcotic depression. Watch for re-sedation.
ANEXATE – is a reversal agent for benzodiazepines. Watch for re-sedation.
Watch for seizures in patients who frequently take benzodiazepines.
Gastrointestinal bleeding
Gastrointestinal (GI) bleeding is responsible for 1% to 2% of all hospital
admissions.
•Bleeding can be either acute or chronic.
•The source can be upper or lower, overt or occult.
•The patient can be either hemodynamically stable or unstable on presentation.
UPPER GI BLEED
• can be in esophagus due to varices, esophagitis, cancer or Mallory Weiss tear
• can be in stomach due to ulcer, gastritis or cancer
• can be in duodenum due to ulcer or Aortoenteric fistula
• can be due to coagulopathy
Signs and Symptoms:
In general, patient presents with melena and/or coffee ground emesis. They may
have chest pain, anemia, fatigue, decreased O2 sat, abdominal distention, and
have a change in vital signs (increased pulse, decreased BP, and postural
changes).
GI Bleeding continued
Your Nursing Assessment questions should include:
•Is there a prior history of GI bleeding (60% rebleed from the same site)?
• Does the patient have any co morbidity diseases (peptic ulcer disease, pancreatitis, cirrhosis, cancer)?
• Is the patient taking any medications (especially nonsteroidal anti‐inflammatory Is the patient taking any medications (especially nonsteroidal anti inflammatory
agents)? •Does the patient use recreational drugs, cigarettes, or alcohol? •What is the character of the pain? Peptic ulcer pain is epigastric, gnawing, rhythmic, and dull. GI cancers are associated with vague epigastric pain, dysphagia, or weight loss. •Was there an history of excessive retching (Mallory–Weiss tear)?
LOWER GI BLEED
• can be in small bowel due to diverticulum, Crohns, Aorto enteric fistula,
vascular problems, or neoplasm
• can be in colon due to diverticulum, angiodysplasia, inflammatory bowel
disease, ischemic gut, infection, or neoplasm
• can be perianal d
due
e to hemorrhoids
hemorrhoids, fist
fistula
la or a fiss
fissure
re
• can be due to coagulopathy
Signs and Symptoms:
In general, presents with fresh blood per rectum. They may have chest pain,
anemia, fatigue, decreased O2 sat, abdominal distention, and have a change in
vital signs (increased pulse, decreased BP, and postural changes).
4
Your Nursing Assessment questions should include:
•How old is the patient? Age is an important feature in discriminating the source of lower GI bleeding. A/ Patients aged less than 50 years usually bleed from infectious causes, anorectal disease, or inflammatory bowel disease. B/For patients aged more than 50 years, diverticulosis, angiodysplasia, cancer, and ischemia are most common
and ischemia are most common . •Are there any associated symptoms? A/Diverticular disease presents as painless, high volume bleeding. B/Angiodysplasia and cancer present with symptoms of chronic blood loss (fatigue, dyspnea on exertion, positive fecal occult blood). C/Inflammatory bowel disease presents with bloody diarrhea, cramping, weight loss, and fever. A prior history of inflammatory bowel disease, cancer, or radiation to the abdomen is also important. Important to Note
MANAGEMENT OF GI BLEEDS
CONTACT ADMITTING PHYSICIAN
For non-variceal UGI Bleed – PPIs (oral
vs IV depending on pt stability) to reduce
AS ORDERED:
the bleeding and risk of rebleeding.
• O2 therapy to maintain O2 sats
For variceal UGI Bleed – Octreotide
• large bore IVs
• administer IV fluids/boluses
(reduces blood flow and portal pressure) or
• crossmatch
vasopressin (potent vasoconstrictor that
• keep NPO
• GI consult – then prep for procedure as decreases blood flow and portal pressure)
–if not actively bleeding, may be treated
ordered
• correct coagulopathy
with beta blockers
• bloodwork – CBC,e’lytes,Creatinine,
For both Upper and Lower GI bleeds
BUN, PTT,INR,LFTs
treatment may include blood
•Administer blood products/FFPs
products/FFPs (to correct coagulopathy).
•Administer medications
A THERAPEUTIC ENDOSCOPY MAY BE
NECESSARY
The End!
•Both upper and lower GI BLEEDS should be managed with maintaining
ABCs and volume resusutation.
•BE PREPARED – A STABLE GI BLEED MAY SUDDENLY BECOME
UNSTABLE Keep a close eye on their condition and monitor the trend of
UNSTABLE.
their vitals.
•DO ACCURATE AND TIMELY DOCUMENTATION
If you wish to view a procedure to familiarize yourself with GI tests, please contact
your clinical nurse educator to have this arranged .
5