Chapter 57

Chronic gastritis Type B

(Most common)affects glands of antrum, but may involve entire stomach, caused by H. pylori infection, chronic local irritation (alcohol, radiation, smoking, some surgical procedures)

Aerophagia

(awir swallowing0 Teach them to relax consciously before and after meals, to eat and drink slowly, and to chew all food thoroughly. +Frequent position changes and ambulation are often effective interventions for eliminating air from the GI tract. If gas pain is still present, patients are taught to take simethicone, 80 mg four times daily as needed. Be sure to remind the patient to crus and dissolve the medication in water before taking.

Chronic gastritis Type A

(nonerosive) refers to an inflammation of the glands, as well as the fundus and body of the stomach. -Been associated with the presence of antibodies to parietal cells and intrinsic factor. -A genetic link to this disease, with an autosomal dominant pattern of inheritance, has been found in the relatives of patients with pernicious anemia.

Stress Ulcers

+Acute gastric mucosa lesions occurring after an acute medical crisis or trauma +Associated with head injury, major surgery, burns, respiratory failure, shock, and sepsis +Principal manifestation—bleeding caused by gastric erosion

Teaching patient when they sleep

+Elevate head by 6 to 12 inches for sleep to prevent night time reflux. +Teach the patient to sleep in the right side-lying position to decrease the effects of nighttime episodes of reflux

Clinical Manifestations

+Epigastric tenderness usually located at the midline between the umbilicus and the xiphoid process +Dyspepsia (indigestion)-Described as sharp, burning, or gnawing. +Typically described as sharp, burning, or gnawing pain +Sensation of abdominal pressure or of fullness or hunger

Postoperative Care

+Monitor the nasogastric tube. -Make sure tube is secure -Monitor for amount of blood, abdominal distension +Monitor for postoperative complications: -Dumping syndrome (constellation of vasomotor symptoms after eating)- vertigo, tachycardia, syncope, sweating, pallor, palpitations. Managed by nutrition changes. -Reflux gastropathy- occurs when pylorus is bypassed or removed. Regurgitated bile in the stomach and mucosal hyperemia- early satiety, abdominal discomfort, vomiting. -Delayed Gastric Emptying- edema at anastomosis or adhesions obstructing distal loop. Resolved with NG suction, proper nutrition, fluid and electrolyte balance

Potential for Gastrointestinal Bleeding: Interventions include:

+Monitoring and early recognition of complications (critical to the successful management of PUD) +Preventing and/or managing bleeding, perforation, and gastric outlet obstruction +Possible surgical treatment

Diagnostic Assessment for GERD

+Most accurate method of diagnosis GERD is 24-hour ambulatory esophageal pH monitoring. -Involves placing a small catheter through the nose into the distal esophagus. Pt is asked to keep a diary of activities and symptoms, and the pH is continuously monitored and recorded.

Complications of Ulcers

+Most common complications of PUD are hemorrhage, perforation, pyloric obstruction, and intractable disease. Hemmorrhage is the most serious complication.

Pain and Drug Therapy

+One of the primary purposes for employing drug therapy is to eliminate or reduce pain. +Analgesics are not the mainstay of pain relief for PUD.

Key features in Acute gastritis

+Rapid onset of epigastric pain or discomfort +Nausea and vomiting +Hematemesis (vomiting blood) +Gastric hemorrhage +Dyspepsia (Heartburn) +Anorexia

Esophageal Diverticula

+Sacs resulting from the herniation of esophageal mucosa and submucosa into surrounding tissue +Zenker's diverticulum most common=Caused by the incomplete or late opening of swallowing muscles can cause high pressure in the hypopharynx. pt report dysphagia, regurgitation, nocturnal cough, and halitosis, risk for perforation. +Diet therapy and positioning major interventions for controlling symptoms -Semisoft foods and smaller meals are often best tolerated and may reduce or relieve the symptoms of pressure and reflux +Surgical management +Removal of diverticula

Postoperative instructions for patients having laparoscopic Nissen fundoplication (LNF)

+Stay on soft diet about a week, avoid carbonated beverages, tough foods, and raw vegetables that are difficult to swallow +Remain on antireflux meds for at least a month +Walk every day, but do not do any heavy lifting +Wash incisions with soap and water, rinse well, and pat dry, report any redness or drainage from the incisions to your surgeon +report fever above 101, nausea, vomiting, or uncontrollable bloating or pain.

Nonsurgical management of GERD

+Teach the patients to limit or eliminate foods that decrease LES pressure, such as chocolate, alcohol, fatty foods (especially fried), caffeine, and carbonated beverages. The patient should also restrict spicy and acidic foods (orange juice, tomatoes) until esophageal healing can occur, because these foods irritate the inflamed tissue and cause heartburn. +Peppermint may also aggravate symptoms.

Complementary and Alternative Therapies

+Therapies that reduce stress --Yoga, hypnosis, imagery, meditation +Certain herbs are thought to heal inflamed tissue and increase blood flow to the gastric mucosa. +Other substances include zinc, vitamin C, essential fatty acids, acidophilus, vitamins E and A, and glutamine

Key features of chronic gastritis

+Vague report of epigastric pain that is relieved by food +Anorexia +Nausea or vomiting +Intolerance of fatty and spicy foods +Pernicious anemia

Sliding hernias

+most common type -Esophagogastric junction and a portion of the fundus of the stomach slide upward though the esophageal hiatus into the chest, usually as result of weakening of the diaphragm. The hernia generally moves freely and slides into and out of the chest during changes in position or intra-abdominal pressure. +Major concern for a sliding hernia is the development of GERD

Key features of upper GI bleeding

1. Bright red or coffee-ground vomitus 2. Tarry stools or frank (bright red) blood in stools 3. Melena (occult blood)(especially in older adults) 4. Decreased blood pressure 5. Increased weak and thready pulse 6. Decreased hemoglobin and hematocrit 7. Vertigo 8. Acute confusion (in older adults) 9. Dizziness 10. Syncope

Nutrition Therapy

1. Controversial- no evidence that dietary restriction reduces gastric acid secretion and promoting healing 2. Nutrition therapy may be directed toward neutralizing acid and reducing hypermotility. 3. A bland, nonirritating diet is recommended during the acute symptomatic phase. 4. Avoid bedtime snacks. 5. Avoid alcohol and tobacco, caffeine containing beverages, coffee.

Key features of GERD 14

1. Dyspepsia 2. Regurgitation 3. Coughing, hoarseness, or wheezing at night 4. Water brash (hypersalvitation) 5. Dysphagia 6. Odynophagia (painful swallowing) 7. Epigastric pain 8. Belching 9. Flatulence 10. Nausea 11. Pyrosis 12. Globus (feeling of something in back of throat 13. Pharyngitis 14. Dental caries (severe cases)

Clinical Manifestations 5

1. Dyspepsia 2. Regurgitation, eructation, flatulence 3. Hypersalivation 4. Dysphagia and odynophagia 5. Others manifestations—chronic cough, asthma, atypical chest pain, bloating, nausea and vomiting (rare)

Factors that contribute to decreased lower esophageal sphincter pressure 13

1. Fatty foods 2. Caffeinated beverages, such as coffee, tea, and cola 3. Chocolate 4. Citrus fruits 5. Tomatoes and tomato products 6. Smoking and use of other tobacco products 7. Calcium channel blockers 8. Nitrates 9. Peppermint, spearmint 10. Alcohol 11. Anticholinergic drugs 12. High levels of estrogen and progesterone 13. Nasogastric tube placement

Key features of paraesophageal hernias 5

1. Feeling of fullness after eating 2. Breathlessness after eating 3. Feeling of suffocation 4. Chest pain that mimics angina 5. Worsening of manifestations in a recumbent position

Key features of sliding hiatal hernias 5

1. Heartburn-reflux (therefore assess lung sounds) 2. Regurgitation 3. Chest pain 4. Dysphagia 5. Belching

Hyposecretory Drugs- reduce gastric acid

1. Proton Pump Inhibitors- drug class of choice 2. H2 Receptor Antagonists (Pepcid, Axid) - block histamine stimulated gastric secretions 3. Prostaglandin Analogues- used for duodenal ulcers, reduce gastric acid secretion and enhance gastric mucosal resistance to injury 4. Antacids- buffer gastric acid and prevent formation of pepsin 5. Mucosal Barrier Fortifiers- forms complexes with proteins at the base of a peptic ulcer, preventing further digestive action of acid and pepsin

Rolling hernia

AKA paraesophageal hernias, the gastroesophageal junction remains in its normal intrabdominal location but the fundus rolls through the esophageal hiatus and into the chest beside the esophagus. +Reflux is not usually present because the LES remains anchored below the diaphragm. However, the risks for volvulus (twisting), obstruction (blockage), and strangulation (structure) are high. The development of iron deficiency anemia is common because slow bleeding from venous obstruction causes the gastric mucosa to become engorged and ooze.

Clinical Manifestations of acute gastritis

Abdominal tenderness Bloating Hematemesis Melena Intravascular depletion and shock

Acid suppression

Aggressive acid suppression is used to prevent rebleeding. Acid-suppressive agents are used to stabilize the clot by raising the pH level of gastric contents.

Dyspepsia or heartburn

And regurgitation are the main symptoms of GERD. The pain is described as a sub sternal burning sensation that tends to move up and down the chest in a wavelike fashion.

Drug therapy

Antacids-May be effective for occasional episodes of heartburn. Antacids act by elevating the pH level of the gastric contents, thereby deactivating pepsin. They are not helpful in controlling frequent symptoms because their length of action is too short and their nighttime effectiveness is minimal. +These drugs also increase LES pressure and therefore are not given for long-term use. +Teach the pt to take the antacid 1 hour before and 2 to 3 hours after each meal. +They can also increase LES, so there not supposed to be taken for long periods of time (Maalox, Mylanta) and Gaviscon

Assessment

Assess airway, chest pain, dysphagia, vomiting, bleeding Can use x-ray, endoscopy, or chest CT for further evaluation

What to assess for in aspiration

Assess for crackles in lungs, can be a sign of aspiration. Long-term regurgitation may lead to bronchitis

Regurgitation

Backward flow into the throat. Pt feels warm fluid traveling up the throat without nausea. May taste sour.

Drug and Diet Therapy

Calcium channel blockers, Nitrates- used to decrease LES pressure Direct injection of Botox into the lower esophageal muscle Semisoft, warm foods and liquids Smaller meals more frequently Arching the back while swallowing- changes pressure to aid in food passage Avoiding restrictive clothing- increases esophageal pressure Drug therapy is used for symptom relief Botox relaxes muscle- suppresses releases of acetylcholine release- long term treatment required for management, but long term affects are unknown.

Acute gastritis

Can heal after several months -Causes: Long-term NSAIDs, alcohol, caffeine, corticosteroids, radiation therapy, ingestion of corrosive agents, emotional stress

Causes of gastric and duodenal ulcers

Caused by H. pylori infection, which is transmitted via the fecal-oral route and throught to be acuired in childhood.

Interventions with chronic gastritis

Chronic: eliminating the causative agents, treatments of underlying disease, avoidance of toxic substances

Post-Op Care for endoscopic therapies

Clear liquids for 24 hrs Advance to soft diet Avoid NSAIDS/ASA for 10 days PPIs Utilize liquid form of meds, if possible No NG tubes for 1 month Contact MD immediately for the following: chest/abdominal pain, bleeding, dysphagia, SOB, nausea, vomiting

Gas bload syndrome

Common complication of this surgery in which patients are unable to voluntarily eructate (belch) +Teach patients to avoid drinking carbonated beverages and ato avoid eating gas-producing foods, especially high fat foods, chewing gum, and drinking with a straw.

Histamine receptor antagonists

Commonly called histamine blockers, such as famotidine (Pepcid), rantidine (Zantac). +They are long acting, allowing less-frequent dosing. They also appear to produce fewer side effects and may be safe for long-term use. +Although these drugs do not affect the occurrence of reflux directly, they do reduce gastric acid secretion, improve symptoms, and promote healing of inflamed esophageal tissue.

Esophagogastroduodenoscopy (EGD)

Diagnose esophageal diverticula.

Manigment of obstruction

Directed toward restoring fluid and electrolyte balance and decompressing the dilated stomach. +Interventions are directed at correcting metabolic alkalosis and dehydration. The NGT is clamped after about 72 hours. Check the patient for retention of gastric contents. If the amount retained is not more than 50 ml in 30 minutes, the health care provider may allow oral fluids.

Barretts epithelium

During the process of healing, the body may substitute barretts epithelium (columnar epithelium) for the normal squamous cell epithelium of the lower esophagus. Although this new tissue is more resistant to acid and therefore supports esophageal healing, it is considered premalignant. It is associated with an increased risk for cancer in patients with prolonged GERD. The fibrosis and scarring that accompany the healing process can produce esophageal stricture.

The most common cause of GERD is

Excessive relaxation of the LES, which allows the reflux of gastric contents into the esophagus and exposure of the esophageal mucosa to acidic gastric contents.

Features of gastric ulcer: General nourishment, stomach acid production, occurrence, pain, hemmorrhage

General nourishment: May be malnourished Stomach acid production: Normal secretion or hyposecretion Occurrence: Mucosa exposed to acid-pepsin secretion Pain: occurs 30-60 min after a meal; at night: rarely, worsened by ingestion of food Hemmorrhage: Hematemesis more common than melena

Features of duodenal ulcer: General nourishment, stomach acid production, occurrence, pain, hemmorrhage

General nourishment: Usually well nourished stomach acid production: Hypersecretion occurrence: Mucosa exposed to acid-pepsin secretion pain: Occurs 1.5-3 hr after a meal; at night: often awakens patient between 1 and 2 AM hemmorrhage: Melena more common than hematemesis

Nonsurgical Management (drug therapy)

H2-receptor antagonists-Such as famotidine (Pepcid) and nizatidine (Axid), are used to block gastric secretions. Mucosal barrier fortifier (Sucralfate)-A mucosal barrier fortifier. Antacids-Buffering agentsw include aluminum hydroxide combined with magnesium hydroxide (Maalox) and mylanta Antisecretory agents-(proton pump inhibitors) such as omeprazole to suppress gastric acid secretion Vitamin B12-chronc gastritis, for prevention or treatment of pernicious anemia. Treatment for Helicobacter pylori infection

NURSING Safety priority for caring for hiatal hernia

Health teaching. Encourage the patient to avoid eating in th elate evening and to avoid foods associated with reflux. Teach the patient and family that the patient should follow a restricted diet and exercise to reduce body weight if overweight. +teach about positioning

Hemorrhage

Hemorrhage is most serious complication. Most common in people with gastric ulcers and older adults. Patients will have a 2nd episode of bleeding if H. pylori infection is not treated or no H2 antagonist. Hematemesis usually indicates bleeding at or above the duodenojejunal junction (upper GI bleed)

Hiatal Hernia

Hiatal hernias aka diaphragmatic hernias, involve the protrusion of the stomach through the esophageal hiatus of the diaphragm into the chest.

Clinical manifestations if perforation happened

If perforation into the peritoneal cavity is present, the patient has a rigid, boardlike abdomen accompanied by rebound tenderness and pain. Initially, auscultation of the abdomen may reveal hyperactive bowel sounds, but these may diminish with progression of the disorder.

Second episode of bleeding

If underlying infection with H. pylori remains untreated or if therapy does not include an H2 antagonist. With massive bleeding, the patient vomits bright red or coffee-ground blood (hematemesis). Hematemesis usually indicates bleeding at or above the duodenojejunal junction.

Managemt of perforation

Immediately replacing fluid, blood, and electroylytes, administering antibiotics, and keeping the patient NPO. Maintain nasogastric suction to drain gastric secretions and thus preventing further peritoneal spillage. Monitor the patient for clinical manifestations of septic shock, such as fever, pain, tachycardia, lethargy, or anxiety.

Overweight and obese patients and GERD

Increased risk for the disease. Increased weight increases intra-abdominal pressure, which contributes to reflux of stomach contents into the esophagus.

Operative procedures

Involve reinforcement of the lower esopghageal sphincter (LES) by fundoplication. Surgeon wraps a portion of the stomach fundus around the distal esophagus to anchor it and reinforce the LES.

Pyloric obstruction

Is caused by edema, spasm, or scar tissue. Symptoms of obstruction related to difficulty in emptying the stomach iinclude feeling of fullness, distention, or nausea after eating, as well as vomiting undigested food.

Gastric emptying in gastric ulcers

Is often delayed in patients with gastric ulceration. This causes regurgitation of duodenal contents, which worsens the gastric mucosal injury.

Gastritis

Is the inflammation of gastric mucosa (stomach lining). Gastritis can be scattered or localized. Can be erosive or nonerosive. Break in the protective layer of the stomach, injury occurs. Worsened by release of histamine and vagus nerve stimulation, hydrochloric acid can diffuse back into the mucosa and injure small vessels. This causes edema, hemorrhage, erosion of the lining. Helicobacter pylori, Escherichia coli can cause both acute and chronic gastritis . Less common- staphylococci, streptococci, salmonella

Gastroesophageal reflux disease (GERD)

Is the most common upper GI disorder in the US. IT occurs most often in middle-aged and older adults but can affect people of any age. -It occurs as a result of reflux (backward flow) of GI contents into the esophagus. -Reflux produces symptoms by exposing the esophageal mucosa to the irritating effects of gastric or duodenal contents, resulting in inflammation. -A person with acute symptoms of inflammation is often described as having reflux esophagitis.

Barium swallow study with fluoroscopy

Is the most specific diagnostic test for identifying hiatal hernia.

Esophagogastroduodenoscopy (EGD)

Is useful in diagnosing or evaluating reflux esophagitis or in monitoring complications such as Barretts esophagus. This test requires the use of moderate sedatin during the procedure, the patients must have someone accompany them home after recovery. During the procedure, tissue samples can be obtained for biopsy and stricture can be dilated..

Laparoscopic Nissen fundoplication (LNF

LNF: gold standard for surgical management of GERD. Wraps a portion of the stomach fundus around the distal esophagus to anchor it and reinforce the LES

What does the stricture lead to?

Leads to progressive difficulty in swallowing. Uncontrolled esophageal reflux also creates a risk for other serious complications, such as hemorrhage and aspiration pneumonia.

Diet therapy:

Limit intake of foods and spices that cause distress (tea, coffee, cola, chocolate, mustard, paprika, cloves, pepper, and hot spices), as well as tobacco and alcohol

Esophageal manometry or motility testing

May be performed when the diagnosis is uncertain. Water-filled catheters are inserted in the patients nose or mouth and slowly withdrawn while measurements of LES pressure and peristalsis are recorded.

What GERD may cause

May cause of adult-onset asthma, laryngitis, and dental decay. It has also been associated with cardiac disease.

Duodenal ulcers

Most occur in the upper portion of the duodenum. They are deep, sharply demarcated lesions that penetrate through the mucosa and submucosa into the mucularis propria. +The main feature of a duodenal ulcer is high gastric acid secretion, although a wide range of secretory levels is found. In patients with duodenal ulcers, pH levels are low in the duodenum for long periods. -Protein-rich meals, calcium, and vagus nerve excitation stimulate acid secretion. -Many patients with duodenal ulcer disease have confirmed H. pylori infection.

Surgical Repair post op care

NG tube for several days Oral intake started gradually Soft diet for 1 week Encourage CDB, spirometry Continue anti-reflux meds at least 1 month Walk daily, no heavy lifting Remove gauze 2 days post-op and steri-strips 10 days post-op Wash incisions with soap and water, rinse well, pat dry; report any redness or drainage from the incisions to your MD. Report fevers about 101° F, nausea, vomiting, uncontrolled bloating/pain

Teaching patients

Nocturnal reflux associated with diverticula is managed by patients sleeping with HOB elevated and to avoid the supine position for at least 2 hours after eating. +Avoid restrictive clothing and frequent stooping or bending.

Minimal bleeding from ulcers is manifested by

Occult blood in a tarry stool (melena). May occur in patients with gastric ulcers but is more common in those with duodenal ulcers.

Perforation

Occurs when the ulcer becomes so deep that the entire thickness of the stomach or duodenum is owrn away. The stomach or duodenal contents can then leak into the peritoneal cavity. Sudden, sharp pain begins in the mid-epigastric region and spreads over the entire abdomen. The abdomen is tender, rigid, and boardlike (peritonitis). +Peptic ulcer perforation is a surgical emergency and can be life threatening.!!

clopidogrel (Plavid) and omeprazol

Omeprazole reduce the effect of clopidogrel (Plavix), an antiplatelet drug.

Esophageal Dilation

Passage of progressively larger sizes of esophageal dilators using polyurethane balloons on a catheter Metal stents used to keep the esophagus open for longer durations Complications—bleeding, signs of perforation, chest and shoulder pain, elevated temperature, subcutaneous emphysema, hemoptysis

Peptic ulcer and Peptic ulcer disease (PUD)

Peptic ulcer-Is a mucosal lesion of the stomach or duodenum PUD-Results when mucosal defenses become impaired and no longer protect the epithelium from the effects of acid and pepsin

Post op care

Post-op pt is NPO for several days, provide pain relief, monitor for complications NG tube is placed during surgery and should not be manipulated, irrigated or repositioned unless specified by the surgeon

Drug therapy: Helicobacter pylori treatment

Powerpoid-(PPIs, Metronidazole, tetracycline, Clarithromycin, amoxicillin ) Triple-PPIs therapy, which includes a proton pump inhibitor (PPI) such as lansoprazole (Prevacid) plus two antibiotics such as metronidazole (Flagyl) and tetracycline (Ala-Tet, Panmycin) or clarithromycin (Biazin) and amoxicillin (Amoxil) for 7 to 14 days.

management of Hiatal hernias, preoperative care, operative procedures, postop care

Preoperative care Non-urgent: weight loss, quit smoking Operative procedures Laparoscopic Nissen Fundoplication Postoperative care: Respiratory care Nasogastric tube management (p. 1260) Nutritional care for complications of surgery including gas bloat syndrome and aerophagia (air swallowing), (p. 1258

Surgical Management

Preoperative care—insertion of a nasogastric tube. Operative procedure: A simple gastroenterostomy permits neutralization of gastric acid. Vagotomy (vagus nerve cutting) eliminates the acid-secreting stimulus to gastric cells and decreases the response of parietal cells. Pyloroplasty (opening the pylorus) facilitates emptying of stomach contents. (Used for patients who do not respond to medical treatment, surgical emergency Minimally invasive surgery- laparoscopy (partial gastrectomy, total gastrectomy) )

NURSING Safety priority after conventional surgery for a hiatal hernia repair

Prevention of respiratory complications. Elevate the head of the patients bed at least 30 degrees to lower the diaphragm and promote lung expansion. Assist the patient out of bed and begin ambulation as soon as possible. Be sure to support the incision during coughing to reduce pain and to prevent excessive strain on the suture line, especially with obese patients.

Four primary goals for drug therapy:

Provide pain relief Eradicate Helicobacter pylori infection Heal ulcerations Prevent recurrence

Achalasia

Rare esophageal motility disorder that results from loss of nerve impulses to the smooth muscle of the esophagus characterized by chronic and progressive dysphagia Primary symptoms—dysphagia and regurgitation of solids, liquids, or both Cause is unknown Epigastric pain, sensation of food sticking in the lower esophagus, regurgitation of ingested food may occur. Complications include esophageal candidiasis (yeast), lower esophageal diverticula, airway obstruction, aspiration pneumonia Diagnostics: barium swallow, chest x-ray, endoscopy

Gastric Lavage

Requires the insertion of a large-bore NGT with instillation of a room-temperature solution in volumes of 200 to 300 mL. The solution and blood are repeatedly withdrawn manually until returns are clear or light pink and without clots. Instruc the patient to lie on the left side during this procedure to limit the flow of the lavage solution out of the stomach.

NG tube care and drainage

Should be dark brown with old blood but should become normal yellowish green within the first 8 hours after surgery. +Provide frequent oral hygiene to increase comfort. Assess the patients hydration status regularly, including accurate measures of intake and output. Adequate fluid replacement helps thin respiratory secretions. +Carefully supervise the first oral feedings because temporary dysphagia is common. Continuous dysphagia usually indicates that the fundoplication is too tight, and dilation may be required.

Non-surgical magement

Similar to GERD and include drug therapy, nutrition therapy, and lifestyle changes.

Surgical Management

Surgical intervention is rare, for patients with major bleeding caused by severe erosion Partial gastrectomy Pyloroplasty Vagotomy Total gastrectomy

Esophagomyotomy

Surgical procedure for achalasia is done to facilitate the passage of food. Laparoscopic approach is most common. For long-term refractory achalasia, the surgeon may attempt excising the affected portion of the esophagus with or without replacement of a segment of colon or jejunum.

Eating meals

Teach patient to eat four to six small meals each day rather than three larger ones. Encourage patients to eat no foods for at least 3 hours before going to bed. Encourage patients to eat no food for at least 3 hours before going to bed. -Advise patients to eat slowly and chew thoroughly to facilitate digestion and prevent eructation.

NURSING SAFETY PRIORITY for antacids

Teach the patient that to achieve a therapeutic effect, sufficient antacid must be ingested to neutralize the hourly production of acid. For optimal effect, take antacids about 2 hours after meals to reduce the hydrogen ion load in the duodenum. Antacids may be effective from 30 minutes to 3 hours after ingestion. If taken on an empty stomach, they are quickly evacuated. Thus the neutralizing effect is reduced.

NURSING SAFETY PRIORITY

Teach the patient to monitor for symptom relief and side effects of drugs to treat gastritis and to notify the health care provider of any adverse effects or worsening of gastric distress. Remind patients not to take additional over-the-counter drugs such as Pepcid AC if they are taking similar prescribed drugs.

Nighttime reflux

Tends to cause prolonged exposure of the esophagus to acid because the supine position decreases peristalsis and the benefit of gravity. Helicobacter pylori may contribute to reflux as well.

Tests to detect H. pylori

Tests to detect H. pylori: blood test for IgG or IgM anti-H. pylori antibodies. IgG antibodies are elevated 2 months after infection and remain elevated 1+ years after treatment. IgM levels become elevated 3-4 weeks after infection and disappear 3 months after treatment. EGD with biopsy (gold standard)

NURSING SAFETY PRIORITY for Emergency upper gi bleeding

The first priority for care of the patient with upper GI bleeding is to maintain ABC's. Provide oxygen and other ventilatory support as needed. Start two large-bore IV lines for replacing fluids and blood. Monitor vital signs, hematocrit, and oxygen saturation.

What happens when a person has continued reflux

The inflamed esophagus cannot eliminate the refluxed material as quickly as a healthy one, and therefore the length of exposure increases with each reflux episode. Hyperemia (increase blood flow) and erosion (ulceration) occur in the esophagus in response to the chronic inflammation. Gastric acid and pepsin injure tissue.

If the heartburn is severe

The pain may radiate to the neck or jaw or may be referred to the back. The pain typically worsens when the patient bends over, strains, or lies down.

Other Treatments: Stretta procedure

The physician applies radiofrequency energy through the endoscope using needles placed near the gastroesophageal junction. The RF energy decreases vagus nerve activity, thus reducing discomfort for the patient. This nonsurgical procedure has also been approved for patients with Barretts esophagus.

Gastroplication procedure

The physician tightens the LES though the endoscope using sutures near the sphincter.

Esophageal Trauma

Trauma to the esophagus can result from blunt injuries, chemical burns, surgery or endoscopy, or stress of protracted vomiting. Assessment is focused on the nature of the injury Nothing is administered by mouth; broad-spectrum antibiotics are given. Surgical management requires resection of part of the esophagus with a gastric pull-through and repositioning or replacement by a bowel segment.

Interventions with acute gastritis

Treated symptomatically and supportively because the healing process is spontaneous, usually occurring within a few days. When the cause is removed, pain and discomfort usually subside. If bleeding is severe, a blood transfusion may be necessary.

Gastric ulcers

Usually develop in the antrum of the stomach near acid-secreting mucosa. WHen a break in the mucosal barrier occurs (such as that caused by H. pylori infection), hydrochloric acid injures the epithelium. Gastric ulcers may then result from back-diffusion of acid or dysfunction of the pyloric sphincter, bile refluxes into the stomach.

Clinical Manifestations of Chronic gastritis

Vague report of epigastric pain that is relieved by food Anorexia Nausea or vomiting Intolerance of fatty and spicy foods Pernicious anemia

Hypovolemia Management

Volume replacement should be started immediately with isotonic solutions (.9% NS, LR). Goal is to expand intravascular fluid in a patient who is volume depleted. Blood products may be ordered to expand volume and correct abnormalities in the CBC.(Packed RBCs) +For patients with active bleeding, fresh frozen plasma may be given if the prothrombin time is 1.5 times higher than the midrange control value.

Atrophic gastritis-

affects all layers of the stomach, total loss of fundal glands, minimal inflammation, thinning of mucosa, intestinal metaplasia. These changes can lead to PUD and gastric cancer, most common in older adults, caused by exposure to toxic substances, H. pylori infection, autoimmune factors

Endoscopic therapy

can assist in achieving hemostasis- EGD to cauterize vessels

Intractable disease

disease—the patient no longer responds to conservative management, or recurrences of symptoms interfere with ADLs

PPIs

main treatment for GERD. Provide affective, long-acting inhibition of gastric acid secretion by affecting the proton pump of the gastric parietal cell. Reduce gastric secretion and can be given once daily. Can be increased to 2x per day if failing 1/day. Also promote rapid tissue healing, but recurrence can occur if treatment is stopped. omeprazole (Prilosec), lansoprazole (prevacid), rabeprazole (aciphex), pantoprazole (protonix), esomeprazole (nexium)

Pyloric obstruction

manifested by vomiting caused by stasis and gastric dilation +Obstruction occurs at the pylorus and is caused by scarring, edema, inflammation, or a combination of these factors. +Symptoms include abdominal bloating, nausea, and vomiting.

NURSING SAFETY PRIORITY, after esophagogastroduodensoscopy (EGD)

monitor vital signs, heart rhythm, and oxygen saturation frequently until they return to baseline. Assess the patients ability to swallow saliva. After the procedure , do not allow the patient to have food or liquids until the gag reflex is intact.