Gastroenterology Quiz on Gastric Conditions

Management of Peptic Ulcer Disease

• A peptic ulcer is an excavation in the mucosal lining of the esophagus, stomach, pylorus, or duodenum caused by erosion of a circumscribed area of the mucous membrane.
• Types of peptic ulcers include esophageal ulcers, gastric ulcers, and duodenal ulcers. Esophageal ulcers form in the esophagus, gastric ulcers in the stomach, and duodenal ulcers in the duodenum (the upper part of the small intestine).

Pathophysiology of Peptic Ulcer

• Acid secretion is regulated by endocrine, neural, and paracrine factors.
• Mucosal defenses, including mucosa, tunica muscularis, serosa, secrete bicarbonate to maintain pH. Mucus is primarily water (95%) and glycoprotein (5%).
• H. pylori affects the stomach lining by producing urease, influencing neutral gastric acid, and creating toxic effects on mucosal epithelial cells.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) irritate the mucosa and inhibit the production of prostaglandins, which normally protect the mucosa.

Causes and Risk Factors

• Helicobacter pylori infection
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Zollinger-Ellison syndrome (gastrinoma)
• Severe stress (e.g., surgery, trauma, head injury, burns)
• Cigarette smoking
• Excessive alcohol intake
• Aging

Pain

• Pain/discomfort is sharply localized in the midepigastrium.
• Heartburn (substernal burning) may occur.
• Pain may radiate to the back if a duodenal ulcer is involved.
• Pain is usually worse when the stomach is empty, typically 30 minutes to 2 hours after meals. Pain may wake the patient in the early morning hours (12 midnight - 3 AM). Pain is usually less prominent when the patient first awakens as gastric secretions are lowest at that time.
• Pain can occur in cycles (clusters) lasting days to weeks.
• Pain relief is often achieved by food or antacids, within 5-10 minutes if effective.

Nausea and Vomiting

• Reflex vomiting occurs in 10-20% of patients with peptic ulcers; it is often associated with ulcer pain or duodenal obstruction, sometimes occurring just after evening meals.

Belching

• Belching is caused by excessive air swallowing.

Heartburn (Pyrosis)

• Heartburn is a burning sensation in the lower esophagus and just below the sternum.

Duodenal vs. Gastric Ulcer

Diagnostic Tests

• For H. pylori: Urea breath test, stool test, biopsy
• For peptic ulcers: Upper GI series (barium swallow), Upper gastrointestinal X-ray (GI X-ray), Esophago-gastro-duodeno-scopy (EGDS), gastric secretory studies (used to identify Zollinger-Ellison syndrome).

Peptic Ulcer Complications

• Hemorrhage: Bleeding can lead to shock
• Perforation: Ulcer can rupture causing peritonitis
• Pyloric obstruction: Blockage of the pylorus, leading to dehydration
• Intractability: Inability to control illness; can cause incapacitation, needing surgery

Therapeutic Measures

• Antibiotics (e.g., amoxicillin, clarithromycin)
• Proton pump inhibitors (PPIs) to reduce acid secretion
• Histamine antagonists to inhibit histamine action on gastric cells
• Antacids to neutralize stomach acid
• Bland diet (soft food, avoid spicy foods)
• Avoid irritants (e.g., smoking, caffeine, alcohol, trigger foods)

Gastric Cancer

• Gastric cancer is a malignant lesion in the stomach, more common in men than women.
• H. pylori is implicated in gastric cancer development.
• Other factors associated with gastric cancer development include pernicious anemia, exposure to occupational substances like lead.
• A poor prognosis is common due to metastasis often present at diagnosis.

Signs and Symptoms

• Detected late; presenting symptoms are easily confused with peptic ulcers; they include indigestion, anorexia (loss of appetite), pain, weight loss, nausea, vomiting, and anemia. Later stages may lead to involvement of other organs like the liver.

Diagnostic Tests for Gastric Cancer/Disorders

• X-ray studies
• Gastroscopy
• Gastric fluid analysis using a nasogastric tube

Therapeutic Measures for Gastric Cancer/Disorders

• Medical treatment isn't effective; surgery (subtotal or total gastrectomy) is often needed.
• Potential surgical complications include hemorrhage, acute gastric distension, and nutritional issues

Gastric Bleeding

• Bleeding may result from ulcer perforation, tumors, or gastric surgery.
• Causes include blood loss into the stomach and intestines.
• Signs/Symptoms: occult blood in stool, hematemesis (vomiting blood), and melena (black, tarry stool)
• Diagnostics: hypovolemic shock, endoscopy, low hemoglobin/hematocrit
• Treatment: stopping blood loss, treating hypovolemic shock with NPO (nothing by mouth), IV fluids, oxygen therapy, nasogastric tube, removal or ligation of bleeding area, medications to reduce gastric acid.
• Complication: hypovolemic shock

Disorders of the Lower GI Tract

• Includes appendicitis, peritonitis, diverticulitis, Crohn's and ulcerative colitis

Appendicitis

• Inflammation of the appendix, commonly due to infection.
• Often requires surgery.
• Usually occurs in young adults but can happen at any age.
• Appendix is a small, finger-like organ (approx 10 cm/4 inches).
• Obstruction of the appendix (narrow lumen) is common, often caused by fecalith (hardened feces) or foreign body.
• Signs and symptoms include progressively severe abdominal pain (initially periumbilical, then migrating to the right lower quadrant); localized tenderness (McBurney's point), loss of appetite, slight to moderate fever, mild changes in bowel habits (constipation), nausea, and vomiting.

Appendicitis: Diagnosis

• Physical examination (focus on pain location and rebound tenderness).
• Blood tests (elevated white blood cell count).
• Urinalysis.
• Careful history to rule out other causes.

Appendicitis: Complications

• Perforation (severe pain, elevated temperature):     - Abscess formation (collection of pus)     - Peritonitis (inflammation of the abdominal lining)

Appendicitis: Treatment and Management

• Palliative preoperative care:     - Comfortable position to relieve pain and tension (upright position usually).     - Nothing by mouth to decrease peristalsis and allow the stomach to empty before surgery.     - Ice packs applied to the right lower quadrant.     - Monitor vital signs frequently to track infection progression.     - Administer antibiotics when acute appendicitis is diagnosed.
• Operative care (simple appendectomy): If acute appendicitis is confirmed. Increased operative urgency required if perforation is suspected and generalized peritonitis has developed.

Peritonitis

• Inflammation of the abdominal lining (peritoneal cavity).
• Etiology:     - Bacterial infections (e.g., E. coli, Proteus, Pseudomonas)     - Trauma     - Extension of inflammation from other organs (e.g., inflamed kidney)     - Appendicitis     - Perforated ulcers     - Diverticulitis     - Bowel perforation

Types of Peritonitis

• Primary peritonitis: Typically affecting young women, can result from pathogenic bacteria (e.g., streptococci, gonococci) entering the fallopian tubes.
• Secondary peritonitis: Related to appendicitis, peptic ulceration, biliary tract disease, colonic inflammation, or from trauma.

Peritonitis: Common Signs

• Increasing pain with movement
• Rebound tenderness
• Signs of paralytic ileus (abdominal distention and absent bowel sounds/activity)
• Abdominal rigidity and tenderness

Peritonitis: Diagnostic Tests

• Blood studies (elevated WBC count)
• Urine analysis (may show urinary tract problems)
• Peritoneal aspiration to check for blood, pus, bile, bacteria, amylase, etc., in the peritoneal fluid.
• Cultures of peritoneal fluid
• Abdominal X-rays

Peritonitis: Management

• Fluid, colloid, and electrolyte replacement to counteract dehydration and imbalances.
• Nasogastric tube (NGT) intubation and suction to empty stomach contents
• Oxygen therapy
• Antibiotics
• Surgery (directed toward excision - e.g., appendicitis or inflamed bowel; resection with optional anastomosis - for intestines; repair for perforation or drainage for abscesses)

Diverticulosis and Diverticulitis

• Diverticulosis: Multiple outpouchings (diverticula) in the colon; usually asymptomatic
• Diverticulitis: Inflammation and infection of diverticula, common with trapped bacteria

Diverticulosis and Diverticulitis: Signs and Symptoms

• Usually asymptomatic until diverticulitis occurs.
• Symptoms may include:     - Abdominal cramping/pain
• Worsening symptoms associated with:     - Fever, nausea, vomiting     - Weakness; anemia, leading possibly to peritonitis

Diverticulitis: Diagnostic Tests

• Colonoscopy: can show irregular colon narrowing and thickened walls.
• Barium enema: may show irregularities.
• Stool examination: Possible for occult blood.
• Abdominal x-ray to identify perforated diverticula.

Diverticulitis: Treatment

• Prevention (increasing dietary fiber intake)
• In severe instances: intravenous antibiotics, pain control, and nasogastric tube
• May involve NPO (nothing by mouth) until nausea and vomiting subside

Crohn's Disease

• Inflammatory bowel disease (IBD) affecting any part of the GI tract but commonly the terminal ileum or the large intestine.
• Inflammation extends through the intestinal mucosa and causes abscesses, fistulas (abnormal connections), and fissures (unnatural tracts/ulcers).

Ulcerative Colitis

• Inflammatory bowel disease affecting the colon and rectum mucosa. Submucosal inflammation occurs less often.

Ulcerative Colitis: Etiology and Incidence

• Unknown (idiopathic).
• Possible factors:     - Emotional response altering blood supply and causing mucosal ulceration.     - Unidentified organisms causing pathology     - Infection, stress, allergy, autoimmunity.
• Most common in young adulthood and middle age.

Ulcerative Colitis: Clinical Manifestations

• Bloody diarrhea, tenesmus (straining), urgency, and cramping.
• Multiple crypt abscesses often form, which may become necrotic and lead to ulceration.
• May be associated with weight loss, fever, dehydration, hypokalemia, anorexia, nausea, vomiting, and iron-deficiency anemia/cachexia (extreme weight loss).

Ulcerative Colitis: Diagnostic Evaluation

• Stool exam to rule out bacillary or ameobic dysentery.
• Sigmoidoscopy
• Barium enema and x-ray (careful to avoid laxatives in acute cases, as they can exacerbate and cause toxic megacolon).
• Review of patient's history to understand patterns of fatigue, overwork, and other emotional stressors.
• Assessing food habits (e.g. milk intolerance).
• Careful clinical evaluation to rule out diverticulitis, cancer, etc.

Ulcerative Colitis: Complications

• Skin ulcers
• Bowel obstruction
• Malnutrition
• Anemia
• Abscess formation
• Anal fistulas
• Electrolyte imbalance
• Bleeding/hemorrhage
• Malignancy (e.g., colon cancer)
• Peritonitis

Ulcerative Colitis: Medical Management

• High-protein diets with supplements (vitamins and iron) are recommended to meet nutritional needs.
• Correct fluid and electrolyte imbalances (often caused by dehydration) via intravenous therapy
• Avoid foods that worsen diarrhea
• Avoid smoking/cold foods (intestinal motility is increased by both)

Ulcerative Colitis: Surgical Management

• Surgical management may include segmental colectomy with anastomosis, subtotal colectomy with ileorectal anastomosis, and total colectomy.

Nursing Process for Patients with Gastric Disorders

• Assessment:     - Pain history (character, degree, relation to meals, relief by antacids).     - Nausea/Vomiting (color, if blood is present).     - Melena     - Food habits, smoking, stress level     - Weight loss, anorexia     - Family history of gastric disease.     - Vital signs for anemia indicators     - Physical examination (palpating for abdominal tenderness)
• Nursing Diagnoses:     - Pain related to gastric acid effects on damaged tissue.     - Anxiety related to coping with an acute disease.
• Planning and Implementation: Setting goals to address pain and anxiety.
• Interventions: Administer pain medication, encourage relaxation techniques, ensure regular nutrition in a calming environment and address patient concerns and anxiety.
• Evaluation: Patient outcome concerning pain and anxiety resolution