Endocrine/​Hematology/​Gastrointestinal/​Renal/​Integumentary Study Guide for the CCRN

Gastrointestinal

The gastrointestinal system is responsible for numerous bodily functions, including digestion, metabolism, and nutrient absorption. Disruption of this system can cause severe organ dysfunction and a range of complications due to the physical damage done. Review these common gastrointestinal conditions and understand the critical elements for treatment and nursing care.

Abdominal Compartment Syndrome

Patients with abdominal trauma complicated by shock are at risk for compartment syndrome. Compartment syndrome occurs when the pressures in the abdomen become so great that the organs inside are compressed, causing decreased perfusion and ischemia. Trauma to the abdomen may involve the bowels, external burns, hemorrhage, and excessive edema or ascites. Intra-abdominal pressure greater than 20 \(cmH_2O\) is diagnostic for compartment syndrome. Pressures may be measured by Foley catheter or NG tube with a pressure transducer. Other indicators include an increased CVP, increased ICP, decreased CO and decreased GFR.

Patientswith compartment syndrome should be treated carefully. Decompression must occur slowly to prevent reperfusion syndrome and cardiac arrest. In many cases, patients will have an “open belly” to prevent recurrence of compartment syndrome. This allows the wound to close slowly and reduce intra-abdominal pressures while healing.

Acute Abdominal Trauma

Patients with acute abdominal trauma must be monitored closely for a variety of concerns. Numerous organs are housed in the abdomen. Acute abdominal trauma may be due to blunt force or penetrating event. In particular, nurses should monitor for signs of injury in the spleen, liver, kidneys, and bowel.

Splenic Injuries

Splenic injuries most often occur in blunt trauma to the abdomen. The spleen is an extremely vascular organ and is not protected by the ribs, making it vulnerable in the abdomen. Two signs, the Kehr sign and Cullen sign, are indicators of the type of splenic trauma that has occurred. The Kehr sign is noted when the patient has radiating pain in the left shoulder. This pain could indicate internal, intra-abdominal bleeding. The Cullen sign is signified by bruising around the umbilicus and occurs due splenic rupture. Other symptoms include generalized abdominal pain, left upper abdominal pain, and hypotension.

Grades of Injury

Splenic injuries are identified by grades of injury. There are four grades. Grade 1 injury indicates a tear in the splenic capsule or a hematoma around the spleen. Grades 2 and 3 involve lacerations of the spleen itself, with Grade 2 being a tear smaller than 3 cm and Grade 3 being a tear greater than 3 cm. Grade 4, the highest grade of injury, is reserved for patients with multiple lacerations or a burst-type injury of the spleen.

Treatment

Treatment of splenic injuries is usually supportive. Surgery is rarely indicated and is delayed as long as possible, as removal of the spleen places the patient at risk for severe, life-threatening infections and thrombus formation. Patients, instead, will be placed on strict bed rest, possibly receive blood transfusions, and have restricted activity orders for several weeks.

Hepatic Injuries

The liver, while slightly more protected than the spleen, is also prone to injury when abdominal trauma occurs. Complications from hepatic injury can cause death and are the primary cause of death in those with abdominal trauma. Initial injury may not always be identified, especially if the injury results in a hematoma. Hepatic hematomas may not rupture until six weeks after injury.

Diagnosis

To determine if a patient has a liver injury, liver transaminase values should be monitored. Elevated liver transaminase levels are concerning for injury. Chest x-ray may also show an elevation of the right hemidiaphragm, indicating liver trauma. Liver injuries are then graded from grade 1 to grade 6, based on the severity of injury. Grade 1 injuries involve just tears in the capsule and a liver hematoma. Grade 2 and 3 injuries involve lacerations of the parenchyma, Grade 2 being less than 3 cm and Grade 3 being equal to or greater than 3 cm. Grades 4 and 5 injuries involve destruction of the liver lobes due to burst injury. Grade 4 injuries involve 25-75% destruction whereas grade 5 involves greater than 75% destruction. The final grade and most severe injury, Grade 6, is indicated by complete avulsion of the liver from the surrounding structures.

Treatment

Treatment of liver injury depends on patient status and severity of the injury. Being a highly vascular organ, hemorrhage is a common complication and some blood vessels may require litigation to stop the bleeding. Patients should be adequately hydrated and fluid deficits should be treated with IV fluids and blood products as indicated. If patients are unstable or actively bleeding, surgical repair of the lacerations may be indicated.

Kidney and bowel injuries will be discussed later in this guide.

Acute GI Hemorrhage

Gastric ulcers are the primary cause of acute GI hemorrhage. Hemorrhages, though, may occur in both the upper and lower GI tracts. Symptoms of hemorrhage include abdominal pain, abdominal distension, melena, black/tarry stools, coffee-ground emesis, tachycardia, and hypotension.

Treatment

Treatment focuses on stopping the source of the bleeding. Upper and lower endoscopies may be performed to identify sources of bleeding. During these procedures, cauterization may be performed if active lesions are found. Patients should have supportive fluid and blood replacement as needed and be assessed for the need for medications such as antibiotics, antacids, and proton pump inhibitors (pantoprazole). Long-term therapy should focus on prevention of future GI bleeds.

Bowel Infarction/Obstruction/Perforation

Bowel infarction occurs when blood flow is restricted to the bowel due to damaged or blocked arteries. A common type of bowel infarction is known as mesenteric ischemia, which primarily affects the small intestine. Mesenteric ischemia can be acute due to blood clot or chronic due to progressive build up and compression of the internal artery. Acute mesenteric ischemia requires immediate surgery to remove the blood clot and any damaged tissues whereas chronic ischemia requires the use of angioplasty or open surgery to address the damaged tissues. Bowel infarction can quickly lead to sepsis and shock. If not treated, it may result in death.

Bowel obstruction occurs when material, usually stool, becomes lodged somewhere along the intestine and is unable to pass. This may be due to paralytic ileus, constipation, or bowel constriction. Adhesions may cause bowel obstruction as narrowed areas of bowel can cause increased difficulty in passing stool. Adhesions can occur following abdominal trauma, surgery, or previous bowel exploration. Bowel obstruction becomes an emergency if the bowel then perforates due to infarction and ischemia. Treatment of bowel obstruction includes gastric decompression, time allotted for stool to pass, therapeutic enema, and bowel resection if necessary.

Treatment

Treatment for bowel obstruction involves NPO status, abdominal decompression, IV fluids, and monitoring for passing of the obstruction. In the event of a bowel infarct, surgical resection is required to remove the affected bowel. In critically ill patients, bowel obstruction may occur due to decreased peristalsis and medication administration. Prevention of obstruction is key, and patients should be on a variety of bowel prep therapies to prevent this from occurring.

Gastroesophageal Reflux

Gastroesophageal reflux (GERD) is not often considered a critical care condition. However, complications of GERD can become very critical to the patient. A lower esophageal sphincter issue, GERD occurs when the sphincter opens and allows stomach contents to regurgitate. Chronic damage to the esophagus may cause Barrett’s esophagus, making patients more prone to esophageal adenocarcinoma.

Diagnosis

Patients with GERD often complain of heartburn, dysphagia, belching, sore throat, chest pain, and hoarseness. Ambulatory esophageal reflux monitoring and/or endoscopy may be used to diagnose this condition. Proton pump inhibitors are used to reduce gastric acid secretion that may cause reflux. Patients should be educated on common triggers of GERD, including caffeine, alcohol, chocolate, and acidic foods. Scheduling food intake should also be taken into consideration, making sure that last snacks and meals are approximately two to three hours prior to lying down to sleep.

GI Surgeries

Several procedures may be performed to and surrounding the GI system. The most common of the GI surgeries in critical care are outlined below.

Whipple Procedure

A Whipple procedure is a surgical procedure performed to remove the head of the pancreas, the duodenum, the gallbladder, and the bile duct. It is also known as a pancreaticoduodenectomy. It is most commonly recommended in the event of pancreatic cancer. It can also be performed to treat tumors located in the duodenum or bile duct, chronic persistent pancreatitis (may additionally require complete pancreatectomy), and address trauma to the associated organs.

The Whipple procedure can be performed via open abdominal, laparoscopic, or robotic surgery. It is a prolonged surgery lasting a minimum of four hours and up to 12 hours. Complications of the procedure include bleeding, infection, poor stomach emptying, pancreatic fistula, bowel obstruction, enzyme leakage, sepsis, and diabetes.

Esophagectomy

Esophagectomy and esophago-gastrectomy are procedures indicated in the event of esophageal or gastric cancer. In the esophagectomy procedure, part or all of the esophagus is removed. The distal portion of the stomach is then reconstructed to replace this portion of the esophagus. In the esophago-gastrectomy procedure, lymph nodes and upper stomach have to be removed in addition to the esophagus.

Abdominal Organ Resection

Abdominal organ resections are surgical procedures where removal of part or all of an abdominal organ is required due to some medical pathology. The organs that can be involved in an abdominal organ resection include the intestines, stomach, esophagus, liver, pancreas, spleen, and adrenal glands/kidneys (note kidneys may be part of either abdominal or genitourinary resection).

Abdominal organ resection may be required due to organ injury/death, tumor growth, or infection. Resections can be performed either laparoscopically or via open abdominal incision. Nurses should monitor patients closely for complications from the procedure including bleeding, compartment syndrome, electrolyte imbalance, and infection.

Bariatric Surgery

Bariatric surgery is another GI surgery that is becoming more common. This procedure is reserved for patients who are morbidly obese looking for assistance in losing weight. The procedure may be completed both with open incisions and laparoscopic techniques. There are several styles of bariatric surgery, including banding, sleeve gastrectomy, Roux-en Y (staples and band), and gastric ballooning.

When caring for patients post bariatric surgery, careful monitoring and precautions must be taken to prevent stomach rupture. Nurses must ensure that patients maintain strict NPO status and avoid checking placement or irrigating NG/PEG tubes placed surgically. Respiratory complication is one of the most common effects of this surgery and patients must be monitored closely for respiratory distress.

Hepatic Failure/Coma

The liver is an important organ that is housed in the abdomen. Several hepatic complications can cause serious illness in patients.

Portal Hypertension

Portal hypertension is a condition that occurs when blood flow is restricted through the portal veins, increasing hepatic blood pressure and preventing the liver from functioning appropriately. When the liver cannot filter the blood appropriately, new blood vessels are developed to assist in the return of blood into circulation. Since the liver is prevented from filtering the blood, aldosterone levels rise and, in turn, increase sodium levels and fluid retention. This may result in ascites and esophageal varices. Portal hypertension is often presented by liver disease, cirrhosis, or inherited blood diseases.

Diagnosis and Treatment

Diagnosis of portal hypertension is made after a variety of lab tests, abdominal ultrasound, CT, or hemodynamic measurement of the hepatic venous pressure gradient. Treatment involves correcting electrolytes, managing sodium levels, and providing diuretics as needed. Obstruction may be corrected with surgical intervention. In severe cases, a liver transplant may be indicated. Nurses should monitor patients closely for status changes, especially with known esophageal varices, as rupture of these becomes immediately life-threatening and can result in death.

Cirrhosis

Cirrhosis is caused by chronic liver disease and injury. It is classified by fibrotic changes in tissue that reduce liver function and filtration. There are two types of cirrhosis, compensated and decompensated. In compensated cirrhosis, the patient’s symptoms are often non-specific and can include abdominal pain, fever, edema, epistaxis, and palmar erythema. In decompensated cirrhosis, hepatomegaly, palmar erythema, spider nevi, epistaxis, jaundice, and ascites may occur. Three types of decompensated cirrhosis include alcoholic, post-necrotic, and biliary.

Diagnosis

Patients with cirrhosis may present with thrombocytopenia. Lab values may indicate decreased albumin levels, vitamin A, vitamin C, and vitamin K levels. Patients may also have increased ammonia levels, bilirubin, and AST/ALT. Radiologic imaging may show enlarging and hardening of the liver.

Treatment

Treatment of cirrhosis involves correcting electrolyte imbalances and restricting sodium and fluids. Potassium-sparing diuretics may be used to reduce ascites and edema. Fibrotic changes may be reduced with colchicine. Ultimately, though, for curative outcomes, liver transplant is required.

Esophageal Varices

Esophageal varices occur due to liver disease, liver cirrhosis, and portal vein hypertension. They are classified by tortuous, dilated veins located at the base of the esophagus. These are delicate structures and can rupture easily. Rupture of the esophageal varices result in instantaneous hemorrhage and death.

Diagnosis

Diagnosis of esophageal varices can be obtained via upper endoscopy, CT, or MRI. The condition is usually asymptomatic until the varices rupture. When rupture occurs, bright red blood, vomiting, and dark stools will occur. Patients will quickly develop hemovomic shock and even if promptly treated, mortality is high.

Treatment

Treatment of esophageal varices focuses on prevention of formation. If the varices rupture, emergency blood and fluid replacement, IV vasopressin, somatostatin, and octreotide should be implemented. Patients may have endoscopic intervention with band ligation and sclerosing of the bleeding lesions. Some patients may need esophagogastric balloon tamponade. This can be performed using Stengstaken-Blakemore and Minnesota tubes. This therapy should not be used for more than 24 hours to reduce the incidence of pressure ulcers from these devices. Transjugular intrahepatic portosystemic shunting (TIPS) may also be conducted to reduce portal hypertension and stress on the esophagus.

Fulminant Hepatitis

Fulminant hepatitis can occur spontaneously in previously healthy patients without liver disease or cirrhosis. This condition causes severe liver injury that then causes inflammation of the brain and changes in coagulation patterns. Some causes of fulminant hepatitis include exposure to toxins, illicit drug/mushroom exposure, viral hepatitis, acetaminophen, cytomegalovirus, and herpes simplex virus. Patients may have underlying conditions, such as Wilson’s disease, that may also contribute to this condition.

Patients with fulminant hepatitis should be monitored for changes in level of consciousness, respiratory distress, renal failure, and liver failure. Patients may present to the emergency department with jaundice, headache, agitation, disorientation, drowsiness, confusion, tremors, and seizures. Changes in coagulopathy and hypoglycemia may also occur. Cerebral edema is a common complication resulting from hepatic encephalitis. Patients will require liver transplants to cure this condition. For those whom liver transplant is not performed, mortality exceeds 80%.

Biliary Atresia

Biliary atresia is a rare infantile disease without cause. It is defined as the inflammation of bile ducts which in turn causes damage and blockage of bile from the liver to the gallbladder. Infants with this condition will have liver failure if not treated. Two treatment choices are available. A Kasai procedure may be performed to move a piece of intestine to replace the damaged bile duct passage. This is a fairly successful procedure in children less than three months of age. Patients who are not candidates for the Kasai procedure or in whom the Kasai procedure fails will need a liver transplant for cure.

Drug-Induced

Many drugs are metabolized by the liver. Chronic use, misuse, or poor reaction to these medications can cause significant liver damage. Some prescription medications that can cause hepatic failure include broad-spectrum antibiotics, antifungal medications, anticonvulsants, and chemotherapy agents. Over-the-counter medications that most commonly cause hepatic damage include acetaminophen (overdose) and herbal supplements.

Symptoms of drug-induced liver damage include fatigue, weakness, abdominal pain, jaundice, and mental status changes (encephalitis). Symptoms can develop rapidly or over time. Patients may experience elevated hepatic enzyme levels (ALT and AST) and electrolyte imbalance. Diagnosis can be supported with liver biopsy and radiographic imaging as well.

The primary treatment for drug-induced hepatic failure starts by stopping the offending medication/drug. Supportive measures should be used to treat the patient’s other symptoms. These can include fluid resuscitation, medication antidotes or reversal agents, and frequent neurologic checks. If damage is severe and the recovery margin is slim, a liver transplant may be required. Patients should understand that treatment and resolution of injury may take several months or may become a chronic issue depending on the level of damage and potential for recovery.

Liver Lab Values

Liver function tests play an important role in the interpretation of diseases/conditions involving the liver. Remember to review normal values and important indications regarding elevated or decreased levels of the following:

• Bilirubin— direct, total, and urine
• Total protein— albumin, globulin, and albumin/globulin (A/G) ratio
• Alkaline phosphatase— may indicate biliary tract obstruction
• AST(SGOT)/ALT(SGPT)— increase in liver damage
• Serum ammonia— increase in liver failure
• Lipids
• Cholesterol
• Clotting factors

Malnutrition and Malabsorption

Malabsorption is often a precursor for malnutrition. Malabsorption occurs when the gastrointestinal tract is unable to process and absorb the nutrients needed. This may occur in the event of intestinal trauma, infection, anesthesia, radiation, or multiorgan failure. Patients at increased risk for malabsorption include ICU patients who are intubated with prolonged NPO times or those on vasopressor medications that restrict blood flow to the intestines. Patients with malabsorption and malnutrition are at increased risk for infection, respiratory failure, heart concerns, and delayed healing.

Symptoms and Treatment

Signs of malabsorption and malnutrition include bloating, abdominal cramping, diarrhea, muscle wasting, weight loss, fatigue, amenorrhea, steatorrhea, vitamin deficiencies, and electrolyte imbalances. Common labs drawn in the event of suspected malabsorption include complete blood count, electrolytes, ferritin, vitamin B12, albumin, and protein. Treatment involves replacement of the nutrients. TPN (total parenteral nutrition) may need to be implemented depending on the severity of nutrient imbalances. Patients in the ICU with NPO status should have their diets advanced as quickly as safely possible to prevent malabsorption and malnutrition.

Pancreatitis

Pancreatitis may be acute or chronic. Chronic pancreatitis is often a genetic condition and can have acute flares. Acute pancreatitis often occurs due to chronic alcoholism or cholelithiasis. In occasional cases, pancreatitis has no determinate cause. Tetracycline, thiazides, acetaminophen, and oral contraceptives have also been known to cause acute pancreatitis at times.

Symptoms and Diagnosis

Symptoms of acute pancreatitis include acute midepigastric to left upper quadrant abdominal pain, nausea, vomiting, and abdominal distension. Acute shock, respiratory distress syndrome, and multiorgan distress may develop. Patients with acute pancreatitis will have serum lipase levels greater than two times the normal level and an elevated amylase. CT, abdominal MRI, and abdominal ultrasounds may be used to assist in diagnosis.

Treatment

Treatment of pancreatitis is supportive. IV fluids, antiemetics, and antibiotics may be used to treat fluid deficits, nausea/vomiting, and any concern for infection or secondary necrosis. Strict NPO status with supplemental TPN may provide the patient nutrients. Surgical removal of the gallbladder and biliary duct may be indicated if pancreatitis is recurrent due to concerns with these structures. Prevention of pancreatitis is recommended. Patients should be instructed on smoking cessation and decreased alcohol consumption. Limiting fat intake and increasing fresh fruits and vegetables may also help reduce a patient’s chance of developing this condition.

Gastrointestinal Drains

Drains are commonly used to help alleviate drainage when invasive procedures are performed to and within the abdomen. Review the common types of drains and the reasons for their placement. Monitor for changes to the drainage output, site erythema, edema, and surgical incisions or wounds.

• Simple drains— latex or vinyl, placed in stab wounds
• Penrose drains— flat rubber or latex strips, designed to drain with gravity and capillary action
• Sump drains— double or triple lumen devices, work by allowing venting of air in one lumen while the drainage is forced out of the larger lumen
• Percutaneous drainage catheter— continuous drainage catheter, may need to be irrigated
• Closed drainage systems— low-pressure suction for continuous drainage and drainage collection, Jackson-Pratt® or Hemovac®