NLE Gastrointestinal Nursing — Lower GI & Bowel DisordersCheat Sheet

Section Title

GI Assessment & Examination Technique

Important Facts

• INSPECTION → AUSCULTATION → PERCUSSION → PALPATION (correct abdominal exam order; auscultate BEFORE palpating to avoid altering sounds).
• Normal bowel sounds: 5–35 per minute in all four quadrants.
• Hyperactive/borborygmi: early obstruction, diarrhea, or gastroenteritis.
• Hypoactive/absent sounds: ileus, peritonitis, late obstruction—listen ≥5 minutes before declaring them absent.
• Tympany on percussion = gas-filled bowel; dullness = organs/masses/fluid.
• Palpation: check for tenderness, guarding (voluntary muscle tension), rigidity (involuntary), rebound tenderness (peritoneal irritation), and masses.
• Key history: pain timing vs meals, weight loss, dysphagia, hematemesis, melena, NSAID/alcohol use, smoking.

Key Definitions

Diagrams To Know

• Four quadrants of abdomen and landmarks (RUQ, LUQ, RLQ, LLQ; epigastric, umbilical, hypogastric regions).
• Sites of referred pain (e.g., liver/RUQ, stomach/epigastrium, appendix/RLQ).

Section Title

GERD (Gastroesophageal Reflux Disease)

Important Facts

• Manifestations: pyrosis, regurgitation, sour/bitter taste, dysphagia, chronic cough, hoarseness, nocturnal symptoms.
• GERD may mimic cardiac chest pain—ALWAYS rule out MI first in acute presentation.
• Gold standard diagnostic test: 24-hour ambulatory pH monitoring; EGD visualizes mucosal damage.
• Trigger foods/substances that LOWER LES tone: fatty/fried foods, chocolate, caffeine, alcohol, peppermint, citrus, tomatoes, carbonated drinks.
• Smoking and excess weight worsen GERD; tight abdominal clothing exacerbates symptoms.

Key Definitions

Diagrams To Know

• LES anatomy and mechanism of reflux when incompetent.
• Progression from reflux esophagitis to Barrett's esophagus to adenocarcinoma.

Section Title

GERD Management & Nursing Interventions

Important Facts

• ELEVATE HEAD OF BED 15–20 cm (6–8 inches) and stay UPRIGHT for 2–3 hours after eating.
• Small, frequent meals; NO eating within 3 hours of bedtime.
• Avoid identified trigger foods and beverages.
• STOP SMOKING and lose weight if overweight.
• Avoid tight clothing/binders around abdomen.
• Sleep on left side (if possible) to reduce reflux; avoid right-sided sleeping.
• Pharmacological management: PPIs (first-line) or H2 blockers; antacids for acute symptom relief.
• Patient teaching: report persistent dysphagia, progressive symptoms, or alarm features (weight loss, anemia, persistent vomiting) to physician—may indicate Barrett's or malignancy.

Diagrams To Know

• Safe sleeping position and HOB elevation setup.
• Algorithm for GERD symptom control (lifestyle → antacid → H2 blocker → PPI).

Section Title

Hiatal Hernia

Important Facts

• Sliding type: management mirrors GERD (positioning, small meals, acid suppression, weight loss, smoking cessation).
• Rolling type: often ASYMPTOMATIC until complications occur; HIGH surgical indication due to strangulation risk.
• Symptoms may include dysphagia, regurgitation, chest pain, dyspnea (if large hernia compresses lung).
• Teach patients to AVOID heavy lifting, straining, and prolonged bending—increases intra-abdominal pressure.
• Severe cases: Nissen fundoplication (surgical wrapping of stomach around esophagus to restore LES).
• CXR may show gastric air-fluid level in thorax; EGD or barium swallow confirms diagnosis.

Key Definitions

Diagrams To Know

• Sliding vs rolling hiatal hernia anatomy and mechanisms.

Section Title

Peptic Ulcer Disease (PUD) — Pathophysiology & Manifestations

Important Facts

• Two dominant causes: Helicobacter pylori infection and NSAID use (including aspirin).
• Contributing factors: smoking, alcohol, corticosteroids, physiologic stress.
• Gastric ulcer classic presentation: pain 30–60 min after eating; food WORSENS pain; weight loss; higher malignancy risk—ALWAYS biopsy to rule out cancer.
• Duodenal ulcer classic presentation: pain 2–3 h after eating or nocturnal; food RELIEVES pain; weight often stable or gain (patient eats to relieve pain); malignancy rare.
• Manifestations: gnawing/burning epigastric pain, dyspepsia, early satiety.
• COMPLICATIONS (dramatic presentations): hemorrhage (hematemesis/melena), perforation (sudden rigid abdomen = surgical emergency), gastric outlet obstruction (vomiting/distension).

Key Definitions

Diagrams To Know

• Gastric vs duodenal ulcer comparison: pain timing, food relationship, weight change, malignancy risk.

Section Title

PUD Diagnostics & H. pylori Testing

Important Facts

• EGD (upper endoscopy) with biopsy: DEFINITIVE diagnostic test; visualizes ulcer, rules out malignancy, and allows biopsy for H. pylori (urease test, culture, histology).
• H. pylori testing methods: urea breath test, stool antigen test, serology (antibodies—confirms past/present exposure but NOT active infection), biopsy urease test.
• CRITICAL: STOP PPIs ≥2 weeks and antibiotics/bismuth ≥4 weeks BEFORE breath/stool testing—they cause FALSE NEGATIVES.
• Serology alone does NOT confirm active H. pylori infection (only exposure); use breath test or stool antigen for active status.
• If EGD shows gastric ulcer: ALWAYS biopsy to exclude malignancy (duodenal ulcers rarely malignant).

Key Definitions

Diagrams To Know

• H. pylori testing algorithm: when to use which test, interpretation, and pre-test drug cessation requirements.

Common Values

Section Title

PUD Pharmacology — PPIs (Proton Pump Inhibitors)

Important Facts

• Common PPIs: omeprazole 20–40 mg daily, pantoprazole 40 mg daily, esomeprazole 20–40 mg daily, lansoprazole 30 mg daily.
• TIMING CRITICAL: Take 30–60 minutes BEFORE the first meal of the day (or first meal if taking BID) because they block the activated (acid-secreting) proton pump.
• Once-daily dosing typical for maintenance; BID for acute ulcer or severe reflux.
• Long-term PPI use side effects: hypomagnesemia (monitor Mg, risk of arrhythmias), low vitamin B12 (impaired absorption), increased fracture risk (reduced Ca absorption), increased Clostridium difficile risk.
• PPIs effective for GERD, PUD, gastritis, and stress ulcer prophylaxis in ICU.
• Monitor for diarrhea (C. difficile risk) and hypomagnesemia symptoms (weakness, tetany).

Key Definitions

Diagrams To Know

• PPI mechanism: blocking H+/K+-ATPase pump and timeline of acid suppression.

Common Values

Section Title

PUD Pharmacology — H2 Blockers, Antacids, Mucosal Protectants

Important Facts

• H2 blockers: famotidine 20–40 mg (ranitidine withdrawn due to NDMA contamination). Give at bedtime for nocturnal protection; less effective than PPIs.
• Antacids: aluminum hydroxide (constipating), magnesium hydroxide (diarrheal)—often combined. Give 1–3 hours AFTER meals and at bedtime.
• CRITICAL antacid interaction: SEPARATE antacids from other drugs by 1–2 hours—they impair absorption of many medications (iron, digoxin, levothyroxine, fluoroquinolones, azoles, etc.).
• Sucralfate 1 g four times daily (QID) on EMPTY stomach; give 1 hour before meals and at bedtime; coats ulcer protectively.
• Sucralfate ALSO separates from other drugs by 1–2 hours; do NOT mix with antacids (impairs efficacy).
• Bismuth compounds darken stool and tongue (black/grayish)—reassure patient this is harmless and reversible.

Key Definitions

Diagrams To Know

• Timeline and mechanism of action: antacid (immediate, short-lived) vs H2 blocker (slower onset, 12 h) vs PPI (slow onset, >24 h effect).

Common Values

Section Title

H. pylori Eradication Therapy — Triple & Quadruple Regimens

Important Facts

• TRIPLE THERAPY (standard first-line): PPI BID (any PPI) + clarithromycin 500 mg BID + amoxicillin 1 g BID for 14 days.
• If penicillin ALLERGY: substitute metronidazole 500 mg BID for amoxicillin.
• QUADRUPLE (bismuth) therapy: reserved for clarithromycin resistance or treatment failure; includes PPI + bismuth + tetracycline + metronidazole × 10–14 days.
• SUCCESS RATE: ~90% eradication with proper adherence; resistance increasing globally.
• CRITICAL TEACHING: Complete the FULL course (14 days triple, 10–14 days quadruple) to prevent resistance and relapse; do NOT stop early even if symptoms resolve.
• Metronidazole + alcohol = DISULFIRAM-LIKE REACTION (flushing, vomiting, hypotension, tachycardia, chest pain)—ABSOLUTELY NO ALCOHOL during therapy and 48 hours after last dose.
• Metronidazole side effects: metallic taste, nausea, dark urine, peripheral neuropathy (rare, long-term use).
• Bismuth: blackens stool and tongue (grayish-black)—harmless and reversible; reassure patient.
• Tetracycline: DO NOT give with antacids, H2 blockers, or dairy (chelation reduces absorption); avoid sun exposure (photosensitivity).
• Clarithromycin: macrolide antibiotic; can prolong QT interval—avoid in patients with cardiac arrhythmias; drug interactions with many medications.

Key Definitions

Diagrams To Know

• H. pylori eradication regimen decision tree (penicillin allergy vs. allergy-free; treatment-naïve vs. treatment-failure).
• Timeline of therapy and when to re-test (≥4 weeks after end of therapy for confirmation).

Common Values

Section Title

Gastritis — Acute & Chronic

Important Facts

• Acute gastritis causes: NSAIDs (most common), alcohol, spicy foods, H. pylori, acute stress (Curling's ulcer after severe burns; Cushing's ulcer after head injury/raised ICP).
• Manifestations: epigastric pain, dyspepsia, nausea, vomiting, anorexia; may have hematemesis (erosive gastritis).
• Chronic H. pylori gastritis (Type B): most common globally; progresses over decades: inflammation → atrophy → intestinal metaplasia → dysplasia → gastric cancer.
• Chronic autoimmune gastritis (Type A): antibodies to parietal cells and intrinsic factor; causes loss of parietal cells; risk of carcinoid tumors and gastric cancer.
• PERNICIOUS ANEMIA CONSEQUENCE: Loss of intrinsic factor → B12 malabsorption → megaloblastic anemia, neurologic symptoms (paresthesias, ataxia, dementia).
• Management: remove offending agent (NSAIDs, alcohol); H. pylori eradication if present; acid suppression (PPI/H2 blocker); treat pernicious anemia with LIFELONG vitamin B12 injections (IM 1000 mcg monthly or weekly initially, then maintenance).
• Pernicious anemia diagnosis: low serum B12, elevated methylmalonic acid, elevated homocysteine, positive anti-intrinsic factor antibodies, positive anti-parietal cell antibodies.

Key Definitions

Diagrams To Know

• Progression of chronic H. pylori gastritis to gastric cancer (Correa cascade).
• Autoimmune gastritis pathophysiology and B12 malabsorption mechanism.

Common Values

Section Title

Stress-Related Mucosal Disease & Stress Ulcers

Important Facts

• Stress-related mucosal disease (SRMD): acute erosions/ulcers in critically ill patients (ICU); pathophysiology involves mucosal ischemia from shock, reperfusion injury, and continued acid exposure.
• High-risk patients: severe burns, head/CNS injury, mechanical ventilation, coagulopathy, multiorgan failure, hypotension, sepsis.
• Curling's ulcer: classic in severe burn patients (>20% TBSA); starts within 24–72 hours of injury.
• Cushing's ulcer: associated with head trauma, neurosurgery, or raised ICP; gastric acid secretion paradoxically INCREASED (vagal stimulation).
• PREVENTION is KEY: stress ulcer prophylaxis with PPI (omeprazole 20–40 mg daily) or H2 blocker (famotidine 40 mg BID) for all high-risk ICU patients.
• Additional supportive measures: treat underlying shock/hypoperfusion aggressively (fluids, vasopressors), early enteral feeding when tolerated (protects mucosa), avoid gastric distension.
• Manifestations: hematemesis (often coffee-ground), melena, abdominal pain (if not already sedated); may be asymptomatic until bleeding occurs.
• Management: prophylaxis (PPI/H2 blocker), treat shock, maintain gastric pH >4, early feeding, endoscopy if bleeding occurs.

Key Definitions

Diagrams To Know

• Pathophysiology of stress ulcer: shock → mucosal ischemia + acid exposure → erosion/ulceration.

Common Values

Section Title

Upper GI Bleeding — Causes, Assessment, Priority Interventions

Important Facts

• Leading causes of upper GI bleeding: peptic ulcer disease (most common ~40%), esophageal/gastric varices (portal hypertension ~15%), erosive gastritis/esophagitis, Mallory-Weiss tears (~5%), others (angiodysplasia, dieulafoy lesion).
• ASSESSMENT for UGI bleeding: hematemesis (bright red = fresh; coffee-ground = old), melena, orthostatic vital signs, signs of shock (tachycardia, hypotension, cool skin, altered mentation), falling Hgb/Hct.
• MASSIVE BLEEDING: >5–6 units PRBC or ongoing >2 units in 24 hours; requires transfusion protocol, surgical standby, ICU monitoring.
• ABC PRIORITY: Airway (prevent aspiration), Breathing (O2 high-flow), Circulation (two large-bore IVs, isotonic fluids, type & crossmatch, transfuse as ordered).
• Specific nursing interventions: NPO (nothing by mouth), place NGT as ordered (for decompression and assessing bleeding volume), continuous vitals monitoring, insert Foley catheter to monitor urine output, position upright to prevent aspiration, prepare for emergency endoscopy.
• NGT placement: NEVER place blindly if esophageal varix suspected (risk of rupture); wait for physician assessment in such cases.
• Prepare for endoscopy (diagnostic AND therapeutic: hemoclip, cautery, sclerotherapy, banding for varices).
• Administer IV PPI high-dose: pantoprazole 80 mg IV bolus then 8 mg/hr infusion for PUD, or famotidine 20 mg IV BID if allergy.
• Monitor for complications: continued bleeding, aspiration pneumonia, acute kidney injury (from hypoperfusion), electrolyte imbalance (from fluid shifts/transfusions).

Key Definitions

Diagrams To Know

• ABC priority sequence for UGI bleed management.
• Hemodynamic parameters in hypovolemic shock (BP, HR, urine output, mental status correlation).

Common Values

Section Title

Nasogastric Tube (NGT) Management & Placement Verification

Important Facts

• NGT indications: gastric decompression (obstruction, post-op ileus), assessment of bleeding volume, gastric lavage, medication administration, enteral feeding.
• MOST RELIABLE bedside verification: aspirate gastric contents and test pH—gastric aspirate is acidic (pH ≤5.5); respiratory/esophageal aspirate is neutral-alkaline (pH >6).
• Gold standard verification: chest X-ray showing tube tip in stomach.
• OUTDATED/UNRELIABLE method: air-auscultation ('whoosh' sound)—can give false positives (air in lung or esophagus sounds similar); NO LONGER RECOMMENDED as sole method.
• Pre-insertion measurement: NEX (Nose-Earlobe-Xiphoid) mark on tube; typically 50–60 cm for adults.
• Insertion technique: position patient head flexed FORWARD; lubricate tube; insert through nostril; ask patient to swallow water/ice chips as tube passes oropharynx (aids passage); stop if patient coughs, chokes, or cannot speak—tube may be in airway.
• CRITICAL SAFETY: If coughing, choking, or inability to speak during insertion → STOP and WITHDRAW tube immediately (possible tracheal placement).
• Check residual volume for feeding tubes: if >200 mL (or facility protocol), hold feeding, recheck in 1 hour; high residuals suggest delayed gastric emptying or obstruction.
• Maintain head of bed ELEVATED 30–45° during and after feeding to prevent aspiration.
• For decompression (obstruction, ileus): connect to low intermittent suction as ordered; monitor drainage volume, color (should be yellow-green for gastric; dark/bloody suggests bleeding).
• Assess for complications: nasal erosion/necrosis, sinusitis, tube obstruction, aspiration, tracheal/esophageal placement.
• Daily care: irrigate tube with 30 mL warm water (q4h or after feeding) to maintain patency; secure tube at nose with tape to prevent migration.
• Before ANY feeding/medication use: re-verify placement by aspirate pH and auscultation (verify against baseline residual).

Key Definitions

Diagrams To Know

• NGT insertion steps: patient positioning, tube advancement, verification sequence.
• Algorithm for placement verification: aspirate → pH test → X-ray confirmation → safe use.

Common Values

Section Title

PUD & Upper GI Complications

Important Facts

• PERFORATION (surgical emergency): sudden, severe 'board-like' rigid abdomen with rebound tenderness; acute peritonitis; patient appears acutely ill.
• Perforation management: STAT NPO, IV fluids, broad-spectrum antibiotics, emergency surgical consultation—usually Graham patch (omentum patching) or gastrectomy for large perforations.
• HEMORRHAGE (most common complication): present as hematemesis/melena, hypovolemic shock; manage per UGI bleed protocol.
• GASTRIC OUTLET OBSTRUCTION: from scarring of healed ulcer or acute edema from current ulcer; presents with vomiting (non-bilious if pre-pyloric), early satiety, weight loss, dehydration, hypokalemic hypochloremic metabolic alkalosis (from loss of HCl in vomitus).
• Outlet obstruction management: NPO, NGT decompression, IV fluids (normal saline to correct hypokalemia/hypochloremia), acid suppression, H. pylori eradication; surgery if refractory to medical management.
• DUMPING SYNDROME (post-gastrectomy): occurs in up to 50% of gastrectomy patients; early dumping (30 min post-meal): cramping, diarrhea, flushing, palpitations, weakness; late dumping (2–3 h post-meal): hypoglycemic symptoms (tremor, diaphoresis, anxiety, confusion).
• Dumping management: small frequent meals (6 per day), low-carbohydrate diet (complex carbs >refined sugars), avoid lactose/sucrose, HIGH protein/fat, drink fluids BETWEEN meals (not with meals), eat slowly, lie down 30 min post-meal.
• Medications for dumping: octreotide (somatostatin analog) for severe cases.
• ASPIRATION PNEUMONIA: risk in GERD with nocturnal reflux or post-stroke/neurologic impairment; prevent with HOB elevation, smaller meals, avoiding food before bed.
• IRON-DEFICIENCY ANEMIA: from chronic occult GI bleeding (gastritis, ulcers); presents with fatigue, dyspnea, tachycardia, low ferritin; manage with oral iron (ferrous sulfate 325 mg daily) or IV iron if malabsorption.

Key Definitions

Diagrams To Know

• Complications cascade: untreated PUD → scarring → outlet obstruction OR perforation → acute emergency.
• Dumping syndrome timeline: early (30 min) vs late (2–3 h) symptoms and mechanisms.

Rows

Columns

• Feature
• Gastric Ulcer
• Duodenal Ulcer

Table Title

Gastric Ulcer vs Duodenal Ulcer — Critical Distinctions for NLE

Rows

Columns

• Intervention Level
• Actions
• Timeline to Effect

Table Title

GERD Management — Lifestyle vs Pharmacological Progression

Rows

Columns

• Test
• Method
• Timing (pre-test cessation)
• Active infection?
• Best for

Table Title

H. pylori Testing — When to Use & Interpretation

Rows

Columns

• Method
• Procedure
• Reliability
• Recommendation

Table Title

NGT Placement Verification — Methods, Reliability, & Evidence

Rows

Columns

• Cause
• Frequency (%)
• Pathophysiology
• Key Nursing Consideration

Table Title

Upper GI Bleed — Causes Ranked by Frequency & Nursing Priorities