Ch 57 Gastritis, Peptic Ulcer, GI Bleeds
GMB Destroyers
Helicobacter pylori: Produces enzyme urease, inflammation, making mucosa more vulnerable -Aspirin and NSAIDS: Inhibit synthesis of prostaglandins, cause abnormal permeability -Corticosteroids: Decrease the rate of mucosal cell renewal, ↓ Protective effects -Lifestyle factors: Alcohol, coffee, smoking, psychologic stress
PUD Diet
-Avoid food and beverages irritating to patient -Bland diet -Six small meals/day during symptomatic phase -Avoid foods that commonly cause gastric irritation: hot spicy foods; pepper; carbonated beverages
PUD Medical Regimen
-Adequate rest -Drug therapy -Elimination of smoking and alcohol -Dietary modification -Long-term follow-up care -Stress management -Complete healing 3-9 weeks
Acute Gastritis Symptoms
-Anorexia -Nausea and vomiting -Epigastric tenderness -Hemorrhage is commonly associated with alcohol abuse and may be the only symptom -Self-limiting, lasting from a few hours to a few days, with complete healing of mucosa expected
Drugs to Avoid w GI Bleed
-Antacids -Cyto-protective drugs such as Carafate obscure the visualization during endoscopy -Surgery is considered if bleeding continues to be uncontrolled and blood pressure cannot be maintained
GI Bleed Drugs
-Acid suppression: histamine blockers and/or proton pump inhibitors. -Octreotide (Sandostatin): reduce upper GI bleeding, inhibit the release of GI hormones -gastrin, decreasing hydrochloric acid (HCL) secretion
PUD Diagnoses
-Acute pain r/t increased gastric secretions -Ineffective self-health management r/t lack of knowledge of long-term management of PUD -Nausea r/t acute exacerbation of disease process
Gastritis Care
-Clear liquids resumed when acute symptoms have subsided, with gradual reintroduction of solid, bland food -GI Bleed strategies -Reducing irritation with Histamine (H2)-receptor blockers and Proton Pump Inhibitors -Treatment of chronic gastritis focuses on eliminating the cause -H-pylori: antibiotics -Pernicious anemia: lifelong administration of cobalamin is needed
Gastric Outlet Obstruction Treatment
-Constant NGT aspiration of stomach contents may relieve symptoms; irrigate NG tube frequently -Repositioning from side to side -IV hydration -Accurate I/O -Surgical intervention if conservative treatment is not successful
GI Bleed Diagnosis
-Decreased cardiac output -Deficient fluid volume -Ineffective peripheral tissue perfusion -Anxiety
PUD Patient Teaching
-Disease Process: Basic etiology/pathophysiology -Drugs: actions, side effects, danger of taking any medication without health care provider approval -Necessary lifestyle changes: changes in diet, smoking cessation, negative effects of alcohol -Need for regular follow-up care -Encourage compliance with plan of care -Importance of immediate reporting of N/V, epigastric pain, bloody emesis, or tarry stools
Gastritis Diagnostics
-Endoscopic examination with biopsy necessary for definitive diagnosis (EGD) -Samples of breath, urine, serum, stool, and gastric tissue to detect presence of H. pylori -Stools are tested for occult blood -CBC may demonstrate anemia from blood loss or lack of intrinsic factor
PUD Diagnostics
-Endoscopy with biopsy to test for H. Pylori -H Pylori breath test - 13C urea + spectrometer -Barium contrast studies -Gastric analysis: Analysis of gastric contents for acidity and volume -Labs: CBC or Urinalysis
GI Bleed Nursing Interventions
-Endoscopy: determine location of bleed -Cautery, variceal ligation, or embolization of bleeding vessel may be used -Gastric lavage may be used: 'iced saline' -Stools will remain guiaic positive for a week or more following a resolved bleeding episode -Melena (tarry stools) result frmo the breakdown of hemoglobin and release of iron and is indicative of a slow bleed
Peptic ulcer disease (PUD)
-Erosion of GI mucosa resulting from digestive action of hydrochloric acid and pepsin -Ulcer development can occur in: Lower esophagus, Stomach, Duodenum, Margin of gastro-jejunal anastomosis after surgical procedures
Lab Vules for GI Bleed
-Hematocrit will not change for 8-10hrs -Normal Hematocrit: 45% men, 40% women -Increased platelet counts due to instant coagulation process -BUN and creatinine will elevate
PUD Medications
-Histamine (H2)-Receptor Blockers (famotidine: Pepcid) -Proton Pump Inhibitors (omeprazole: Prilosec) -Antibiotics to treat H. pylori -Antacids (calcium carbonate: Tums) -Cyto-protective therapy (sucralfate: Carafate)
PUD Implementation
-Identify patients at risk -Provide early detection and treatment -Encourage patients to take ulcerogenic drugs (aspirin, NSAIDS) with food or milk -Teach patient to report to health care provider symptoms related to gastric irritation
PUD Acute Phase
-Keep NPO, possibly NG tube (if obstruction) -IV hydration -Explain treatment measures to patient/family -Provide regular mouth care -Cleanse and lubricate nares if NG tube is in place -Frequent vital signs, I/O, rest -Sedatives can mask symptoms of shock
Gastric Ulcers
-Less common than duodenal ulcers -Prevalent in women, older adults -Peak incidence >50 years of age -Risk factors: H. pylori, Medications, Smoking, Bile reflux
GI Bleed Endoscopic Therapies
-Mallory-Weiss tears: endoscopic ligation or cauterization -Bleeding esophageal varices: treated by use of 'banding' the vessel -Balloon tamponade: temporary measure where a multi-lumen tube such as the Sengstaken-Blakemore is inserted nasally or orally. Complications include: aspiration or asphyxiation
Hemorrhage Monitoring
-Monitor changes in vital signs, or an increase in amount and redness of aspirate (may signal massive upper GI bleeding) -Monitor for increase in the amount of blood in gastric contents -Monitor for a decrease in pain because blood neutralizes acidic gastric contents
Chronic PUD
-Muscular wall erosion with formation of fibrous tissue -Long duration: present continuously for many months
Gastritis Treatment - Vomiting
-NPO, IV fluids - Dehydration can occur rapidly -Rest -Anti-emetics
Gastritis Treatment - NG Tube
-Observe for bleeding -Lavage to flush precipitating agent from stomach -Keep stomach empty and free of noxious stimuli
Duodenal Ulcers
-Occur at any age and in anyone -Increased incidence between 35-45 years -Account for 80% of all peptic ulcers -Familial tendency -Person with blood group O: ↑ risk -Associated with increased hydrochloric acid secretion: Alcohol and smoking -H. pylori is found in 90% to 95% of patients -Increased risk of duodenal ulcers noted in patients' with: COPD, Cirrhosis of liver, Chronic pancreatitis, Hyperparathyroidism
Pain with a Gastric Ulcer
-Occurrence: 1-2 hours after meals -Location: "Burning" or "gaseous" pressure in high left epigastrium and upper abdomen -Food aggravates pain as ulcer has eroded through gastric mucosa -Recurrence rate is high -Complications include hemorrhage, perforation, obstruction
Pain with Duodenal Ulcer
-Occurrence: 2-4 hours after meals -Location: Mid-epigastric region beneath xiphoid process -Back pain—if ulcer is located in posterior aspect -"Burning" or "cramp-like" -Tendency to occur, then disappear, then occur again -Recurrence rate is high -Complications include hemorrhage, perforation, obstruction
Dumping syndrome
-PUD surgery complication -Direct result of surgical removal of a large portion of stomach and pyloric sphincter -↓ Ability of stomach to control amount of gastric chyme entering small intestine -Large bolus of hypertonic fluid enters intestine -↑ Fluid drawn into bowel lumen -Occurs at end of meal or 15-30 minutes after eating -Symptoms: weakness, sweating, palpitations, dizziness, abdominal cramps, borborygmi, urge to defecate -Last less than an hour
PUD Assessments
-Past health history -Medication usage -Heartburn -Weight loss -Black, tarry stools -Epigastric tenderness
Post Hernia Care
-Pt may have difficulty voiding -Measure I and O and to observe for distended bladder. -A scrotal support with application of ice may help relieve edema -Encourage deep breathing, but not coughing after surgery. -Teach patient to splint the incision and to cough and sneeze with the mouth open.
Gastritis Risk Factors
-Repeated alcohol abuse results in chronic gastritis -Eating large quantities of spicy, irritating foods -Metabolic conditions such as renal failure can cause acute gastritis -Helicobacter pylori (H. pylori) causes chronic gastritis. This is a gram (-) bacteria.
Chronic Gastritis Symptoms
-Similar to those of acute gastritis -Loss of intrinsic factor can occur when acid-secreting cells are lost or nonfunctioning -Essential for absorption of cobalamin (vitamin B12) -Pernicious anemia and neurologic complications can result
Perforation Signs/Treatment
-Sudden, severe abdominal pain unrelated in intensity and location to pain that brought patient to hospital -Indicated by a rigid, board-like abdomen -Stop the spillage of gastric contents by nasogastric tube or surgery -Blood volume is replaced with IV fluids and packed red blood cells (RBC's) if necessary
Acute PUD
-Superficial erosion -Minimal inflammation
GI Bleed Complications
-Tissue ischemia from blood loss may result in angina, myocardial infarction, acute tubular necrosis, and/or bowel infarction -Monitor cardiac, renal, and GI function
GI Bleed Teaching
-Treat anemia (red meats, green leafy vegetables, iron supplements) -prevent recurrence of bleeding: compliance with ulcer treatment regimen, abstain from alcohol, avoid activity that increases intra-abdominal pressure, use of NSAIDS
H-Pylori Infection
-Triple-Drug Therapy 7-14 days: PPI, amoxicillin, clarithromycin (Biaxin) -Quadruple Therapy 10-14 days: PPI, bismuth, tetracycline, metronidazole (Flagyl)
PUD indications for surgery
-Unresponsive to medical management -Concern about gastric cancer -Perforation uncommon today: anti-secretory agents
Postprandial Hypoglycemia
-Variant of dumping syndrome -Result of uncontrolled gastric emptying of a bolus of fluid high in carbohydrate into small intestine -↑ Blood glucose -Release of excessive amounts of insulin into circulation
Gastric Mucosal Barrier Impairment
-back diffusion can occur -Cellular destruction and inflammation occur -Release of histamine: Vasodilation, Increased capillary permeability, Secretion of acid and pepsin
Gastrointestinal Bleeding
-blood volume is 7% of weight -4.7-5.5 liters in body -can lose up to 20% of blood volume without signs of hypovolemic shock
Complications of PUD
-hemorrhage -perforation -gastric outlet destruction
Hernia Repair
-hernioplasty: reinforcement of the weakened area with wire, fascia, or mesh -Strangulated hernias: treated immediately with resection of the involved area
Gastritis
-inflammation of the gastric mucosa -can be acute or chronic -diffuse or localized -results in tissue edema, disruption of capillary walls with plasma lost into the gastric lumen, and possible hemorrhage
Gastritis NSAIDS Risk Factors
-inhibit the synthesis of prostaglandins that are protective to the gastric mucosa, making the mucosa more susceptible to injury -Being female -Being over age 60 -Having a history of ulcer disease -Taking anticoagulants -Having a chronic debilitating disorder such as cardiovascular disease
Gastric outlet obstruction
-obstruction in the distal stomach and duodenum -edema, inflammation, or pylorospasm, fibrous scar tissue formation -Pt reports discomfort or pain that is worse toward the end of the day
Stress-Related Mucosal Disease (SRMD)
-physiologic stress ulcer -Acute ulcers that develop after major physiologic insult -Trauma or surgery -Patients are put on prophylactic proton pump inhibitors after surgery to prevent this
Hypovolemic Shock
-signs of "altered or inadequate tissue perfusion" -Cyanosis -Tachycardia -Decreased urine output, cold clammy skin -Confusion -Poor skin turgor, thirst
GI Bleed Medical Interventions
1. Stop the bleed 2. Maintain circulating blood volume and electrolytes The majority of bleeds stop spontaneously, but treatment is aggressively initiated
PUD Surgical Procedures
Billroth I: gastroduodenostomy -Partial gastrectomy with removal of distal two thirds of stomach and anastomosis of gastric stump to duodenum Billroth II: gastrojejunostomy -Partial gastrectomy with removal of distal two thirds of stomach and anastomosis of gastric stump to jejunum
Etiology of GI Bleeds
Esophageal tears (Mallory-Weiss tear) -strong correlation with ETOH and aspirin abuse Esophageal varices due to increased pressure in esophageal veins from portal hypertension - liver destruction Erosive lesions Ulcer disease
Lower GI bleed
causes include hemorrhoids, NSAIDS, ulcerative colitis, cancer
Ventral Hernia (Incisional Hernia)
due to weakness of the abdominal wall at the site of a previous incision
Hemorrhage
most common complication of PUD
Umbilical Hernia
occurs when the rectus muscle is weak (as with obesity) or the umbilical opening fails to close after birth
Perforation
ulcer penetrates the serosal surface with spillage of gastric or duodenal contents into the peritoneal cavity