Chapter 40 Management of patients with gastric and duodenal disorders

Achlorhydria

lack of hydrochloric acid in the stomach

Zollinger-Ellison Syndrome (ZES):**

- Suspected with resistant peptic ulcers. - Characterized by hypersecretion of gastrin and gastrinomas. - Gastrinomas often found in "gastric triangle." - Symptoms include epigastric pain, pyrosis, diarrhea, and steatorrhea. - Associated with MEN-1 syndrome.

Manifestations of gastritis

- **Acute Gastritis:** - Rapid onset of symptoms: epigastric pain, dyspepsia, anorexia, hiccups, nausea, vomiting. - Lasts hours to a few days. - Erosive gastritis may cause bleeding: blood in vomit, melena (black, tarry stools), or hematochezia (bright red, bloody stools). - **Chronic Gastritis:** - Symptoms include fatigue, heartburn, belching, sour taste, halitosis, early satiety, anorexia, nausea, vomiting. - Some may experience mild epigastric discomfort, intolerance to spicy/fatty foods, or pain relieved by eating. - Vitamin B12 absorption may be impaired, leading to pernicious anemia. - Some patients may have no symptoms.

promting optimal health for gastritis pts

- **Acute Gastritis Nursing Care:** - **Symptom Management:** - Provide physical and emotional support. - Help manage symptoms like nausea, vomiting, and pyrosis. - **Dietary Restrictions:** - Patient refrains from foods and fluids until acute symptoms subside. - If IV therapy is needed, monitor fluid intake, output, and electrolytes. - After symptoms ease, start with ice chips and progress to clear liquids. - **Introduction of Solid Food:** - Introduce solid food as soon as possible for oral nutrition. - Reduces the need for IV therapy and minimizes gastric irritation. - Nurse monitors for any signs of recurring gastritis during food introduction. - **Lifestyle Recommendations:** - Discourage intake of caffeinated beverages to reduce gastric activity. - Discourage alcohol use and cigarette smoking. - Highlight the impact of nicotine on gastric acid secretion and mucosal barrier. - **Behavioral Support:** - Initiate referrals for alcohol counseling and smoking cessation programs when appropriate.

Peptic Ulcer Disease

- **Peptic Ulcer Disease Overview:** - Affects approximately 4.6 million Americans annually. - Peak onset between 30 and 60 years of age. - **Types of Peptic Ulcers:** - Gastric, duodenal, or esophageal ulcers. - Result from erosion of mucosa. - **Prevalence and Risk Factors:** - More common in duodenum than stomach. - NSAID use and H. pylori infections major risk factors. - Smoking and alcohol may contribute. - Familial tendency and blood type O susceptibility. - **Demographic Trends:** - Women have 8-11%, men have 11-14% lifetime risk. - Rates among middle-age men decreased, increased among older adults. - Higher incidence in those 65 years and older. - **NSAIDs and H. pylori Connection:** - Both impair protective gastric mucosa. - Failure to repair mucosa may lead to ulceration. - **Other Associations:** - Chronic obstructive pulmonary disease, cirrhosis, chronic kidney disease, autoimmune disorders. - Associated with Zollinger-Ellison syndrome (ZES).

Pathophysiology of peptic ulcer disease

- **Peptic Ulcers Overview:** - Mainly occur in gastroduodenal mucosa. - Caused by digestive action of gastric acid (HCl) and pepsin. - Erosion due to increased acid-pepsin or decreased mucosal barrier resistance. - **NSAIDs and H. pylori Connection:** - NSAIDs inhibit prostaglandin synthesis, disrupting mucosal barrier. - Damaged barrier increases susceptibility to H. pylori infection. - **Zollinger-Ellison Syndrome (ZES):** - Suspected with resistant peptic ulcers. - Characterized by hypersecretion of gastrin and gastrinomas. - Gastrinomas often found in "gastric triangle." - Symptoms include epigastric pain, pyrosis, diarrhea, and steatorrhea. - Associated with MEN-1 syndrome.

stress ulcers

Acute mucosal ulceration after stressful events (burns, shock, sepsis). Different from peptic ulcers. Common in significant burn injuries, traumatic brain injury, and mechanical ventilation. Result from ischemia and alterations in mucosal barrier

The nurse is assessing an 80-year-old client for signs and symptoms of gastric cancer. The nurse differentiates which as a sign/symptom of gastric cancer in the geriatric client, but not in a client under the age of 75? Hepatomegaly Ascites Agitation Abdominal mass

Agitation Rationale:The nurse understands that agitation, along with confusion and restlessness, may be the only signs/symptoms seen of gastric cancer in the older client. Abdominal mass, hepatomegaly, and ascites may all be signs/symptoms of advanced gastric cancer.

The nurse is evaluating a client's ulcer symptoms to differentiate ulcer as duodenal or gastric. Which symptom should the nurse at attribute to a duodenal ulcer? Vomiting Constipation Hemorrhage Awakening in pain

Awakening in pain Rationale:The client with a duodenal ulcer is more likely to awaken with pain during the night than is the client with a gastric ulcer. Vomiting, constipation, diarrhea, and bleeding are symptoms common to both gastric and duodenal ulcers.

The nurse is assessing a client with advanced gastric cancer. The nurse anticipates that the assessment will reveal which finding? Weight gain Bloating after meals Increased appetite Abdominal pain below the umbilicus

Bloating after meals Symptoms of progressive disease include bloating after meals, weight loss, abdominal pain above the umbilicus, loss or decrease in appetite, and nausea or vomiting

A morbidly obese client asks the nurse if medications are available to assist with weight loss. The nurse knows that the client would not be a candidate for phentermine if the following is part of the client's health history: Coronary artery disease Diabetes Peptic ulcer disease Use of lithium

Coronary artery disease Rationale:Phentermine, which requires a prescription, stimulates central noradrenergic receptors, causing appetite suppression. It may increase blood pressure and should not be taken by people with a history of heart disease, uncontrolled hypertension, hyperthyroidism, or glaucoma.

Specific Types of Stress Ulcers:

Curling Ulcer: Seen after extensive burn injuries. Often involves the antrum of the stomach or duodenum. Cushing Ulcer: Common in traumatic head injury, stroke, brain tumor, or intracranial surgery. Caused by increased intracranial pressure and vagal nerve stimulation. Deep, single ulcerations with an increased risk of perforation.

Which ulcer is associated with extensive burn injury? Curling ulcer Peptic ulcer Duodenal ulcer Cushing ulcer

Curling ulcer Rationale:Curling ulcer is frequently observed about 72 hours after extensive burns and involves the antrum of the stomach or the duodenum.

proximal vagotomy without drainage

Denervates acid secreting parietal cells but preserves vagal innervation to the gastric antrum and pylorus

cause of stress ulcers

Disruption of mucosal barrier and decreased mucosal blood flow (ischemia). Reflux of duodenal contents into the stomach. Increased exposure to gastric acid (HCl) and pepsin.

Assesment and diagnostic findings of peptic ulcer

Endoscopy serologic testing for antibodies against h pylori stool antigen test urea breath

Which medication is classified as a histamine-2 receptor antagonist? Lansoprazole Esomeprazole Famotidine Metronidazole

Famotidine Rationale:Famotidine is a histamine-2 receptor antagonist. Lansoprazole and esomeprazole are proton pump inhibitors (PPIs). Metronidazole is an antibiotic.

Which is a true statement regarding the nursing considerations in administration of metronidazole? Metronidazole decreases the effect of warfarin. It leaves a metallic taste in the mouth. The drug should be given before meals. It may cause weight gain.

It leaves a metallic taste in the mouth. Rationale:Metronidazole leaves a metallic taste in the mouth. It may cause anorexia and should be given with meals to decrease gastrointestinal upset. Metronidazole increases the blood-thinning effects of warfarin.

medical management of gastritis

Management:Refrain from alcohol and food until symptoms subside.Nonirritating diet recommended when oral nourishment is possible.IV fluids may be needed if symptoms persist.Bleeding management similar to upper GI tract hemorrhage procedures. Supportive Therapy: Includes nasogastric intubation, antacids, H2 blockers (e.g., famotidine, cimetidine), proton pump inhibitors (e.g., omeprazole, lansoprazole), and IV fluids. Diagnostic Procedures and Surgery: Fiberoptic endoscopy may be required. Emergency surgery in extreme cases:Removal of gangrenous or perforated tissue.Gastric resection or gastrojejunostomy for pyloric obstruction. Chronic Gastritis Management: Modify diet, promote rest, reduce stress. Avoid alcohol and NSAIDs. Medications may include antacids, H2 blockers, or proton pump inhibitors. H. pylori Treatment: Select drug combinations:Proton pump inhibitor, antibiotics, and sometimes bismuth salts.

The nurse in the ED admits a client with suspected gastric outlet obstruction. The client's symptoms include nausea and vomiting. The nurse anticipates that the physician will issue which order? Pelvic x-ray Nasogastric tube insertion Stool specimen Oral contrast

Nasogastric tube insertion Rationale: The nurse anticipates an order for nasogastric tube insertion to decompress the stomach. Pelvic x-ray, oral contrast, and stool specimens are not indicated at this time.

Truncal vagotomy

Severs the right and left vagus nerves as they enter the stomach at the distal part of the esophagus

Peptic ulcer disease occurs more frequently in people with which blood type? AB A B O

O Rationale:People with blood type O are more susceptible to peptic ulcers than those with blood type A, B, or AB.

Which medication classification represents a proton (gastric acid) pump inhibitor? Sucralfate Famotidine Metronidazole Omeprazole

Omeprazole Rationale:Omeprazole decreases gastric acid by slowing the hydrogen-potassium adenosine triphosphatase pump on the surface of the parietal cells. Sucralfate is a cytoprotective drug. Famotidine is a histamine-2 receptor antagonist. Metronidazole is an antibiotic, specifically an amebicide.

The nurse is conducting a community education class on gastritis. The nurse includes that chronic gastritis caused by Helicobacter pylori is implicated in which disease/condition? Pernicious anemia Colostomy Systemic infection Peptic ulcers

Peptic ulcers

Selective vagotomy

Severs vagal innervation to the stomach but maintains innervation to the rest of the abdominal organs.

Antrectomy Billroth I (gastroduodenostomy)

Removal of the LOWER PORTION of the ANTRUM of the STOMACH (which contains the cells that secrete gastrin) as will as a small portion of the duodenum and pylorus -> the remaining segment is anastomosed to the duodenum -May be performed in conjunction to a truncal vagotomy ADVERSE EFFECTS -Clients may have problems with feeling of fullness, dumping syndrome, and diarrhea

Diet for peptic ulcers

Small frequent meals high-protein high fat Low carb no alcohol or caffine

Which is an accurate statement regarding gastric cancer? The incidence of stomach cancer continues to decrease in the United States. Females have a higher incidence of gastric cancers than males. A diet high in smoked foods and low in fruits and vegetables may decrease the risk of gastric cancer. Most gastric cancer-related deaths occur in people younger than 40 years

The incidence of stomach cancer continues to decrease in the United States. Rationale:While the incidence in the United States continues to decrease, gastric cancer still accounts for 10,700 deaths annually. While gastric cancer deaths occasionally occur in younger people, most occur in people older than 40 years of age. Males have a higher incidence of gastric cancers than females. More accurately, a diet high in smoked foods and low in fruits and vegetables may increase the risk of gastric cancer.

Gastric Outlet Obstruction (GOO)

any condition that mechanically impedes normal gastric emptying; there is obstruction of the channel of the pylorus and duodenum through which the stomach empties

hematochezia

bright red blood in stool

Which statement correctly identifies a difference between duodenal and gastric ulcers? Vomiting is uncommon in clients with duodenal ulcers. A gastric ulcer is caused by hypersecretion of stomach acid. Malignancy is associated with duodenal ulcer. Weight gain may occur with a gastric ulcer.

Vomiting is uncommon in clients with duodenal ulcers. Rationale:Vomiting is uncommon in clients diagnosed with duodenal ulcer. Malignancy is associated with a gastric ulcer. Weight gain may occur with a duodenal ulcer. Duodenal ulcers cause hypersecretion of stomach acid. Clear

Pharmalogic Therapy for peptic ulcers

a combination of antibiotics, proton pup inhibitors, and sometimes bismuth salts.

pathophysiology of gastritis

characterized by a disruption of the mucosal barrier that normally protects the stomach tissue from digestive juices. The impaired mucosal barrier allows corrosive hydrochloric acid, pepsin, and other irritating agents to come in contact with the gastric mucosa, resulting in inflammation. In acute gastritis, this inflammation is usually transient and self-limiting in nature. Inflammation causes the gastric mucosa to become edematous and hyperemic (congested with fluid and blood) and to undergo superficial erosion. Superficial ulceration may occur as a result of erosive disease and may lead to hemorrhage. In chronic gastritis, persistent or repeated insults lead to chronic inflammatory changes, and eventually atrophy of the gastric tissue

The nurse is creating a discharge plan of care for a client with a peptic ulcer. The nurse tells the client to avoid decaffeinated coffee. acetaminophen. octreotide. skim milk.

decaffeinated coffee. Rationale:The nurse should include avoidance of decaffeinated coffee in the client's discharge teaching plan. Decaffeinated coffee is avoided to keep from overstimulating acid secretion.

H2 Reseptor antagosnis (cimetidine, famotidine, nzatidine) action

decreases amount of HCI produced by stomach by blocking action of histamine on histamine receptors of parietal cells in the stomach

first portion of the small intestine

duodenum Rationale:The duodenum is the first portion of the small intestine, between the stomach and the jejunum. The pylorus is the opening between the stomach and duodenum. The peritoneum is the thin membrane that lines the inside the wall of the abdomen and covers all the abdominal organs. The omentum is the fold of the peritoneum that surrounds the stomach and other organs of the abdomen.

duodenum

first portion of the small intestine, between the stomach and the jejunum

The nurse is conducting a community education program on peptic ulcer disease prevention. The nurse includes that the most common cause of peptic ulcers is: alcohol and tobacco. stress and anxiety. gram-negative bacteria. ibuprofen and aspirin

gram-negative bacteria. Rationale:The nurse should include that the most common cause of peptic ulcers is gram-negative bacteria (Helicobacter pylori).

The nurse is assessing a client with an ulcer for signs and symptoms of hemorrhage. The nurse interprets which condition as a sign/symptom of possible hemorrhage? Hypertension Polyuria Bradycardia Hematemesis

hematemisis

dyspepsia

indigestion

The nurse recognizes that the client diagnosed with a duodenal ulcer will likely experience vomiting. pain 2 to 3 hours after a meal. hemorrhage. weight loss.

pain 2 to 3 hours after a meal. Rationale:The client with a duodenal ulcer often awakens between 1 and 2 with pain, and ingestion of food brings relief. Vomiting is uncommon in the client with duodenal ulcer. Hemorrhage is less likely in the client with duodenal ulcer than in the client with gastric ulcer. The client with a duodenal ulcer may experience weight gain.

dumping syndrome

physiologic response to rapid emptying of gastric contents into the jejunum, manifested by nausea, weakness, sweating, palpitations, syncope, and possibly diarrhea; occurs in patients who have had partial gastrectomy and gastrojejunostomy

antrectomy

removal of the pyloric (antrum) portion of the stomach with anastomosis (surgical connection) to the duodenum (gastroduodenostomy or Billroth I) or anastomosis to the jejunum (gastrojejunostomy or Billroth II)

vagotomy

severing of the vagus nerve. Decreases gastric acid by diminishing cholinergic stimulant to the parietal cells, making them less responsive to gastrin.

Billroth II

the removal of the lower stomach, with the remaining portion of the stomach connected to the jejunum

hematemesis

vomiting blood

pyloroplasty

•Longitudinal incision is made into the pylorus and transversely sutured closed to enlarge the outlet and relax the muscle