Adult Health- Chapter 23

Decreased iron

Fatigue, anemia, lethargy, pallor, and loss of hair

Gastritis (inflammation of the gastric or stomach mucosa) is a common GI problem.

Gastritis may be acute, lasting several hours to a few days, or chronic, resulting from repeated exposure to irritating agents or recurring episodes of acute gastritis.

duodenal ulcer risk factors

H.pylori, alcohol, smoking, cirrhosis, stress

gastric ulcer risk factors

H.pylori, gastritis, alcohol, smoking, use of nonsteroidal anti-inflammatory drugs (NSAIDs), stress

Because chemical peritonitis develops within a few hours after perforation and is followed by bacterial peritonitis, the perforation must be closed as quickly as possible and the abdominal cavity lavaged of stomach or intestinal contents.

In select patients, it may be safe and advisable to perform surgery to treat the ulcer disease in addition to suturing the perforation.

Gastric surgery may be performed on patients with peptic ulcers who have life-threatening hemorrhage, obstruction, perforation, or penetration, or whose condition does not respond to medication.

It also may be indicated for patients with gastric cancer or trauma. Surgical procedures include a vagotomy and pyloroplasty (transecting nerves that stimulate acid secretion and opening the pylorus), a partial gastrectomy, or a total gastrectomy (

The Roux-en-Y gastric bypass is recommended for long-term weight loss.

It is a combined restrictive and malabsorptive procedure. Biliopancreatic diversion with duodenal switch combines gastric restriction with intestinal malabsorption

Although vomiting is rare in uncomplicated duodenal ulcer, it may be a symptom of a complication of an ulcer.

It results from obstruction of the pyloric orifice caused by either muscular spasm of the pylorus or mechanical obstruction from scarring or acute swelling of the inflamed mucous membrane adjacent to the ulcer.

In gastritis, the gastric mucous membrane becomes edematous and hyperemic (congested with fluid and blood) and undergoes superficial erosion

It secretes a scanty amount of gastric juice, containing very little acid but much mucus. Superficial ulceration may occur and can lead to hemorrhage.

duodenal ulcer symptoms

- hyper-secretion of stomach acid - weight gain - pain occurs 2 to 3 hrs after a meal; often awakened around 1 or 2 AM; ingestion of food relieves pain - vomiting uncommon - hemorrhage less likely than with gastric ulcer but if present melena more common than hematemesis - more likely to perforate

gastric ulcer symptoms

- normal to hypo-secretion of stomach acid - weight loss may occur - pain occurs 1/2 to 1 hr after a meal; rarely occurs at night; may be relieved by vomiting; ingestion of food does not help; sometimes increases pain - vomiting common - hemorrhage more likely to occur than with duodenal ulcer; hematemesis more common than melena

gastric ulcer incidence

- usually 50 years of age or older - 15 % of peptic ulcers are gastric

Duodenal ulcer incidence

-30 to 60 years of age - 80% of peptic ulcers are duodenal

Perforation signs and symptoms:

-Sudden, severe upper abdominal pain (persisting and increasing in intensity); pain may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm -Vomiting -Collapse (fainting) -Extremely tender and rigid (boardlike) abdomen -Hypotension and tachycardia, indicating shock

Amoxicillin (Amoxil)

A bactericidal antibiotic that assists with eradicating H. pylori bacteria in the gastric mucosa

The traditional approach to duodenal tumor diagnosis is an upper GI x-ray series with small bowel follow-through using oral water-insoluble contrast with frequent and detailed x-rays to follow the contrast through the small bowel.

A more sensitive examination is an enteroclysis, in which an NG tube is advanced into the small bowel to a position above the area in question; then the area is studied by single-contrast and double-contrast techniques.

A radical subtotal gastrectomy is

performed for a resectable tumor in the middle and distal portions of the stomach. A Billroth I or Billroth II operation is performed.

A person who has a peptic ulcer has peptic ulcer disease.

A peptic ulcer is an excavation (hollowed-out area) that forms in the mucosal wall of the stomach, in the pylorus (the opening between the stomach and duodenum), in the duodenum (the first part of small intestine), or in the esophagus.

Metronidazole (Flagyl)

A synthetic antibacterial and antiprotozoal agent that assists with eradicating H. pylori bacteria in the gastric mucosa when administered with other antibiotics and proton pump inhibitors

A proximal subtotal gastrectomy may be performed for a resectable tumor located in the proximal portion of the stomach or cardia.

A total gastrectomy or an esophagogastrectomy is usually performed in place of this procedure to achieve a more extensive resection. A palliative surgical procedure may be required for patients with gastric cancer to achieve a better quality of life (QOL).

Bariatric surgery, or surgery for morbid obesity, is

performed only after other nonsurgical attempts at weight control have failed.

Scarring can occur, resulting in

pyloric stenosis or obstruction.

The gastric mucosa is capable of repairing itself after a bout of gastritis.

As a rule, the patient recovers in about 1 day, although the appetite may be diminished for an additional 2 or 3 days.

Peptic ulcers are more likely to be in the duodenum than in the stomach.

As a rule, they occur alone, but they may occur in multiples. Chronic gastric ulcers tend to occur in the lesser curvature of the stomach, near the pylorus.

Many times, the bleeding from a peptic ulcer stops spontaneously; however, the incidence of recurrent bleeding is high.

Because bleeding can be fatal, the cause and severity of the hemorrhage must be identified quickly and the blood loss treated to prevent hemorrhagic shock. If bleeding cannot be managed by medical therapies (IV infusion of crystalloids and colloids, gastric lavage, and pharmacologic agents), other treatment modalities may be used.

Other ulcer symptoms include

pyrosis (heartburn), vomiting, constipation or diarrhea, and bleeding.

Sucralfate (Carafate)

Creates a viscous substance in the presence of gastric acid that forms a protective barrier, binding to the surface of the ulcer, and prevents digestion by pepsin

Clarithromycin (Biaxin)

Exerts bactericidal effects to eradicate H. pylori bacteria in the gastric mucosa

Tetracycline

Exerts bacteriostatic effects to eradicate H. pylori bacteria in the gastric mucosa

Patients with duodenal ulcer disease secrete more acid than normal, whereas patients with gastric ulcer tend to secrete normal or decreased levels of acid.

Damage to the gastroduodenal mucosa allows for decreased resistance to bacteria, and, thus, infection from H. pylori bacteria may occur.

Cimetidine (Tagamet)

Decreases amount of HCl produced by stomach by blocking action of histamine on histamine receptors of parietal cells in the stomach

Lansoprazole (Prevacid)

Decreases gastric acid secretion by slowing the H+, K+-ATPase pump on the surface of the parietal cells

Omeprazole (Prilosec)

Decreases gastric acid secretion by slowing the H+, K+-ATPase pump on the surface of the parietal cells

Pantoprazole (Protonix)

Decreases gastric acid secretion by slowing the H+, K+-ATPase pump on the surface of the parietal cells

Rabeprazole (AcipHex)

Decreases gastric acid secretion by slowing the H+, K+-ATPase pump on the surface of the parietal cells

Esomeprazole (Nexium)

Decreases gastric acid secretion by slowing the hydrogen-potassium adenosine triphosphatase (H+, K+-ATPase) pump on the surface of the parieta

Decreased zinc

Delayed wound healing, altered immune function, mental lethargy, perhaps association with alopecia

Proximal (Parietal Cell) Gastric Vagotomy without Drainage

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

Gastric restrictive procedures, such as adjustable gastric banding (AGB), vertical banded gastroplasty and sleeve gastrectomy (SG), cause early satiety during meals by decreasing the volume of the stomach.

Laparoscopic adjustable gastric banding has replaced the vertical gastric banding (VGB) as the favored restrictive procedure

Pyloroplasty

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

Gastric MALT (mucosa-associated lymphoid tissue) lymphoma is the most common entity with H. pylori as the decisive pathogenic factor

MALT is acquired as a secondary process against H. pylori. The bacterium is the cause of chronic gastritis and leads to the formation of intramucosal lymph follicles

Decreased vitamin B12

Macrocytic anemia, pernicious anemia, leukopenia, thrombocytopenia, paresthesia, neuropathy, muscular pains, weakness, fatigue, dizziness, and brittle nails

When the hemorrhage is small, much or all of the blood is passed in the stools, which appear tarry black because of the digested hemoglobin.

Management depends on the amount of blood lost and the rate of bleeding.

Decreased magnesium

Muscle cramps, muscle pain, constipation, headaches, insomnia, anxiety, hyperactivity

Histamine-2 (H2) receptor antagonists (H2 blockers) and PPIs are used to treat

NSAID-induced ulcers and other ulcers not associated with H. pylori infection

Decreased calcium

Osteopenia, bone fractures

The nurse assesses the patient for faintness or dizziness and nausea, which may precede or accompany bleeding. It is important to monitor vital signs frequently and to evaluate the patient for tachycardia, hypotension, and tachypnea.

Other nursing interventions include monitoring the hemoglobin and hematocrit, testing the stool for gross or occult blood, and recording hourly urinary output to detect anuria or oliguria (absence of or decreased urine production).

In the past, stress and anxiety were thought to be causes of ulcers, but research has documented that peptic ulcers result from infection with the gram-negative bacteria H. pylori, which may be acquired through ingestion of food and water.

Person-to-person transmission of the bacteria also occurs through close contact and exposure to emesis. Although H. pylori infection is common in the United States, most infected people do not develop ulcers.

Decreased β-carotene

Reducing the fat-soluble antioxidant capacity, neuropathy

Billroth Ii (Gastrojejunostomy)

Removal of lower portion (antrum) of stomach with anastomosis to jejunum. Dotted lines show portion removed (antrectomy). A duodenal stump remains and is oversewn.

Billroth I (Gastroduodenostomy)

Removal of the lower portion of the antrum of the stomach (which contains the cells that secrete gastrin) as well as a small portion of the duodenum and pylorus. The remaining segment is anastomosed to the duodenum.

Vagotomy

Severing of the vagus nerve. Decreases gastric acid by diminishing cholinergic stimulation to the parietal cells, making them less responsive to gastrin. May be performed via open surgical approach, laparoscopy, or thoracoscopy.

Truncal Vagotomy

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

Selective Vagotomy

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

Ulcer Pain is usually relieved by eating because food neutralizes the acid or by taking alkali; however, once the stomach has emptied or the alkali's effect has decreased, the pain returns.

Sharply localized tenderness can be elicited by applying gentle pressure to the epigastrium at or slightly to the right of the midline.

Orlistat, available by prescription and over the counter as Alli, reduces caloric intake by binding to gastric and pancreatic lipase to prevent digestion of fats.

Side effects of orlistat may include increased frequency of bowel movements, increased gas with oily discharge, decreased food absorption, decreased bile flow, and decreased absorption of some vitamins

Palpable nodules around the umbilicus, called

Sister Mary Joseph's nodules, are a sign of a GI malignancy, usually a gastric cancer. Patients appear cachectic.

The patient with chronic gastritis may complain of anorexia, heartburn after eating, belching, a sour taste in the mouth, or nausea and vomiting.

Some patients may have only mild epigastric discomfort or report intolerance to spicy or fatty foods or slight pain that is relieved by eating.

Bismuth subsalicylate (Pepto-Bismol)

Suppresses H. pylori bacteria in the gastric mucosa and assists with healing of mucosal ulcers

Decreased vitamin D3

Symptoms may include osteopenia, muscle pain, bone fractures

Symptoms of early disease, such as pain relieved by antacids, resemble those of benign ulcers and are seldom definitive because most gastric tumors begin on the lesser curvature of the stomach, where they cause little disturbance of gastric function.

Symptoms of progressive disease include dyspepsia (indigestion), early satiety, weight loss, abdominal pain just above the umbilicus, loss or decrease in appetite, bloating after meals, nausea and vomiting, and sympto

Misoprostol (Cytotec)

Synthetic prostaglandin; protects the gastric mucosa from agents that cause ulcers; also increases mucus production and bicarbonate levels

The Billroth I involves a limited resection and offers a lower cure rate than the Billroth II.

The Billroth II procedure is a wider resection that involves removing approximately 75% of the stomach and decreases the possibility of lymph node spread or metastatic recurrence.

A total gastrectomy may be performed for a resectable cancer in the midportion or body of the stomach.

The entire stomach is removed, along with duodenum, the section of esophagus attached to the stomach, supporting mesentery, and lymph nodes

Peptic ulcers occur mainly in the gastroduodenal mucosa because this tissue cannot withstand the digestive action of gastric acid (HCl) and pepsin.

The erosion is caused by the increased concentration or activity of acid-pepsin or by decreased resistance of the mucosa. A damaged mucosa cannot secrete enough mucus to act as a barrier against HCl.

In addition, excessive secretion of HCl in the stomach may contribute to the formation of peptic ulcers, and stress may be associated with its increased secretion.

The ingestion of milk and caffeinated beverages, smoking, and alcohol also may increase HCl secretion. Stress and eating spicy foods may make peptic ulcers worse.

The patient may have coexisting parathyroid adenomas (benign tumor of glandular origin) or hyperplasia and, therefore, may exhibit signs of hypercalcemia.

The most common symptom is epigastric pain. H. pylori is not a risk factor for ZES

When the patient is symptomatic, benign tumors often present with intermittent pain.

The next most common presentation is occult bleeding. Malignant tumors often result in symptoms that lead to their diagnosis, although these symptoms may reflect advanced disease.

During surgery and postoperatively, the stomach contents are drained by means of an NG tube.

The nurse monitors fluid and electrolyte balance and assesses the patient for localized infection or peritonitis (increased temperature, abdominal pain, paralytic ileus, increased or absent bowel sounds, abdominal distention). Antibiotic therapy is administered parenterally as prescribed.

Hemorrhage, the most common complication, occurs in 28% to 59% of patients with peptic ulcers. Bleeding may be manifested by hematemesis (vomiting blood) or melena

The vomited blood can be bright red, or it can have a dark "coffee grounds" appearance from the oxidation of hemoglobin to methemoglobin.

People with blood type O are more susceptible to peptic ulcers than are those with blood type A, B, or AB; this is another genetic link.

There also is an association between peptic ulcers and chronic pulmonary disease or chronic kidney disease. Other predisposing factors associated with peptic ulcer include chronic use of NSAIDs, alcohol ingestion, and excessive smoking.

Roux-en-Y gastric bypass, gastric banding, vertical banded gastroplasty, laparoscopic sleeve gastrectomy, and biliopancreatic diversion with duodenal switch are the current obesity procedures of choice.

These procedures may be performed by laparoscopy or by an open surgical technique.

The most common primary malignant tumor of the duodenum is adenocarcinoma; the second and third portions of the duodenum are most often involved.

These tumors may present with bleeding or duodenal obstruction . If the tumor is located at the ampulla of Vater, obstructive jaundice is likely. Other rare malignant tumors of the duodenum include carcinoid tumors, lymphoma, and GI stromal tumors. Specialized abdominal surgery may be required to remove these rare tumors. Chemotherapy and radiation therapy may also be part of the treatment regimen.

The first surgical procedure used to treat morbid obesity was jejunoileal bypass.

This procedure, which resulted in significant complications, has been largely replaced by gastric restriction procedures.

If gastritis is caused by ingestion of strong acids or alkalis, emergency treatment consists of diluting and neutralizing the offending agent.

To neutralize acids, common antacids (e.g., aluminum hydroxide) are used; to neutralize an alkali, diluted lemon juice or diluted vinegar is used. If corrosion is extensive or severe, emetics and lavage are avoided because of the danger of perforation and damage to the esophagus.

In treating the patient with pyloric obstruction, the first consideration is to insert an NG tube to decompress the stomach.

Usually, an upper GI study or endoscopy is performed to confirm pyloric obstruction. Decompression of the stomach and management of extracellular fluid volume and electrolyte balances may improve the patient's condition and avert the need for surgical intervention. A balloon dilation of the pylorus via endoscopy may be beneficial.

Acute gastritis is also managed by instructing the patient to refrain from alcohol and food until symptoms subside.

When the patient can take nourishment by mouth, a nonirritating diet is recommended. If the symptoms persist, IV fluids may need to be administered. If bleeding is present, management is similar to the procedures used to control upper GI tract hemorrhage, discussed later in this chapter.

Zollinger-Ellison syndrome (ZES) is suspected when a patient has several peptic ulcers or an ulcer that is resistant to standard medical therapy

ZES is identified by the hypersecretion of gastric juice, duodenal ulcers, and gastrinomas (islet cell tumors) in the pancreas.

Stress-related mucosal disease (SRMD) is

a term used to describe the phenomenon of injury to the lining of the stomach and the duodenum during conditions of physiologic stress. Other terms commonly used include stress erosion, stress ulcer, stress gastritis, erosive gastritis, and hemorrhagic gastritis. These terms also have been given to the acute mucosal ulceration of the duodenal or gastric area that occurs after physiologically stressful events, such as burns, shock, severe sepsis, and multiple organ traumas

The patient with acute gastritis may have a rapid onset of symptoms, such as

abdominal discomfort, headache, lassitude, nausea, anorexia, vomiting, and hiccupping, which can last from a few hours to a few days.

Gastritis is sometimes associated with

achlorhydria or hypochlorhydria (absence or low levels of hydrochloric acid [HCl]) or with hyperchlorhydria (high levels of HCl).

Acute gastritis also may develop in

acute illnesses, especially when the patient has had major traumatic injuries; burns; severe infection; liver, kidney, or respiratory failure; or major surgery. Gastritis may be the first sign of an acute systemic infection.

Most gastric cancers are

adenocarcinomas; they can occur anywhere in the stomach. The tumor infiltrates the surrounding mucosa, penetrating the wall of the stomach and adjacent organs and structures.

Benign tumors of the duodenum include

adenomas, lipomas, hemangiomas, and hamartomas (a focal malformation that resembles a neoplasm but, unlike a neoplasm, does not result in compression of adjacent tissue).

Reconstruction of the GI tract is performed by anastomosing the end of the jejunum to the end of the esophagus, a procedure called

an esophagojejunostomy.

Decreased ferritin

anemia

Decreased hemoglobin

anemia

Currently, the most commonly used therapy for peptic ulcers is a combination of

antibiotics, proton pump inhibitors (PPIs), and bismuth salts that suppress or eradicate H. pylori

Women of childbearing age who have bariatric surgery are advised to use contraceptives for

approximately 2 years after surgery to avoid pregnancy until their weight stabilizes.

Patients with morbid obesity are

at higher risk for health complications, such as diabetes, heart disease, stroke, hypertension, gallbladder disease, osteoarthritis, sleep apnea and other breathing problems, and some forms of cancer (uterine, breast, colorectal, kidney, and gallbladder).

Symptoms of penetration include

back and epigastric pain not relieved by medications that had been effective in the past. Like perforation, penetration usually requires surgical intervention.

When the hemorrhage is large (2,000 to 3,000 mL), most of the blood is vomited.

because large quantities of blood may be lost quickly, immediate correction of blood loss may be required to prevent hemorrhagic shock.

Chronic gastritis and prolonged inflammation of the stomach may be caused either by

benign or malignant ulcers of the stomach or by the bacteria Helicobacter pylori (H. pylori)

Bariatric surgical procedures have their own unique complications in addition to those associated with any major abdominal surgery. The most common complications are

bleeding, blood clots, bowel obstruction, incisional or ventral hernias, and infection from a leak at the anastomosis.

Pyrosis is a

burning sensation in the esophagus and stomach that moves up to the mouth. Often heartburn is accompanied by sour eructation, or burping, which is common when the patient's stomach is empty.

Malabsorptive procedures, such as biliopancreatic diversion with or without duodenal switch (BPD/DS), rely on

bypassing various lengths of the small intestine, reducing nutrient absorption. Mixed procedures such as the Roux-en-Y gastric bypass (RYGB) combine gastric restriction with bypass of a short segment of the small intestine.

Bariatric surgical procedures work by

restricting a patient's ability to eat (restrictive procedure), interfering with ingested nutrient absorption (malabsorptive procedures), or both.

Medication for zollinger ellison syndrome

clomididine

Acute gastritis is often caused by

dietary indiscretion—the person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. Other causes of acute gastritis include overuse of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux, and radiation therapy.

As a rule, the patient with an ulcer complains of

dull, gnawing pain or a burning sensation in the midepigastrium or in the back. It is believed that the pain occurs when the increased acid content of the stomach and duodenum erodes the lesion and stimulates the exposed nerve endings.

what cancer can you only see in an autopsy?

duodenal tumor

Ninety percent of tumors are found in the "gastric triangle," which

encompasses the cystic and common bile ducts, the second and third portions of the duodenum, and the junction of the head and body of the pancreas.

What test do u perform for a peptic ulcer?

endoscopy

Penetration is

erosion of the ulcer through the gastric serosa into adjacent structures such as the pancreas, biliary tract, or gastrohepatic omentum.

Curling ulcer is

frequently observed about 72 hours after extensive burns and involves the antrum of the stomach or the duodenum.

A peptic ulcer may be referred to as a

gastric, duodenal, or esophageal ulcer, depending on its location.

Ascites, hepatomegaly (enlarged liver), and jaundice may be apparent if

he cancer cells have metastasized to the liver.

Cushing ulcers are common in patients with

head injury and brain trauma. They may occur in the esophagus, stomach, or duodenum and usually are deeper and more penetrating than stress ulcers.

Patients with chronic gastritis from vitamin deficiency usually have evidence of

malabsorption of vitamin B12 caused by the production of antibodies that interfere with the binding of vitamin B12 to intrinsic factor.

Morbid obesity is a term applied to

people who are more than two times their ideal body weight or whose body mass index (BMI) exceeds 30 kg/m2.

Misoprostol (a mucosal protective drug) has

similar effects as H2 blockers in preventing ulcers when given in full doses, but its usefulness is limited due to gastrointestinal side effects. It is not given to pregnant women because it can cause abortion, premature birth, or birth defects.

Pyloric obstruction, also called gastric outlet obstruction (GOO), occurs when

the area distal to the pyloric sphincter becomes scarred and stenosed from spasm or edema or from scar tissue that forms when an ulcer alternately heals and breaks down.

Perforation is

the erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning. It is an abdominal catastrophe and requires immediate surgery

A more severe form of acute gastritis is caused by

the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate.

What vitamin do you hav to take for life after gastric surgery?

vitamin B12