management of patients with gastric and duodenal disorders

• Learning objectives include comparing the etiology, clinical manifestations, and management of acute gastritis, chronic gastritis, and peptic ulcer, as well as describing the pharmacologic, dietary, and surgical treatment of patients with gastric cancer.

Gastritis

• Gastritis is a common gastrointestinal problem that can be chronic or acute.
• It equally affects women and men and is more common in older adults.
• Nonerosive gastritis is caused by infection with Helicobacter pylori (H. pylori).
• Erosive gastritis is caused by long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, alcohol abuse, and/or recent exposure to radiation therapy.
• Acute gastritis can be caused by dietary indiscretion, overuse of certain medications, excessive alcohol intake, bile reflux, radiation therapy, ingestion of strong acid or alkali, or as a sign of acute systemic infection.
• Chronic gastritis may be caused by benign or malignant ulcers, Helicobacter pylori (nonerosive), autoimmune diseases, or dietary factors.
• The pathophysiology of gastritis includes edema and hyperemia, decreased secretion, superficial erosion, and hemorrhage.
• Acute gastritis symptoms include abdominal discomfort, headache, lassitude, nausea and vomiting, anorexia, hiccuping (few hours to few days), and erosive gastritis (melena or hematochezia).
• Chronic gastritis symptoms include anorexia, heartburn after meals, belching, nausea and vomiting, sour taste plus Vitamin B12 deficiency due to diminished intrinsic factor by the parietal cells
• Assessment and diagnostic findings may include achlorhydria/hypochlorhydria to hyperchlorhydria, endoscopy, upper GI radiographic studies, histologic exam, and diagnostic measures for H. Pylori.
• Medical management of gastritis includes refraining from alcohol or food until symptoms subside, controlling bleeding, diluting/neutralizing the offending agent (if it was ingestion of acid and alkalis), possible emetics and/or lavage, NGT, and gastric resection.
• Diet modification, promoting rest, reducing stress, and pharmacologic therapy are used for chronic gastritis.

Nursing Process and the Patient with Gastritis

• Assessment includes patient history, asking about presenting signs and symptoms, a 72-hour dietary recall, and any methods used to treat the symptoms.
• Nursing diagnoses include anxiety related to treatment, imbalanced nutrition (less than body requirements) related to inadequate intake, risk for imbalanced fluid volume related to insufficient fluid loss due to vomiting, deficient knowledge, and acute pain.
• Planning and goals include reduced anxiety, avoidance of irritating foods, fluid balance, relief of pain, and managing the diet
• Nursing interventions include reducing anxiety, optimal nutrition, promoting fluid balance, and relieving pain.
• Evaluation includes exhibiting less anxiety, avoiding eating irritating foods or drinking carbonated beverages, maintaining fluid balance, adhering to the medical regimen, maintaining appropriate weight, and reporting less pain.

Peptic ulcer disease

• A peptic ulcer is an excavation that forms in the mucosal wall of the stomach, in the pylorus, and duodenum, or in the esophagus.
• Depth of peptic ulcer erosion is variable.
• Occurs mostly in people between 40 and 60 years old.
• Results from infection with H. Pylori and excessive secretion of HCL may also be the cause.

Duodenal vs. Gastric Ulcers

• Duodenal Ulcer: affects people aged 30-60, male to female ratio 2-3:1, represents 80% of ulcers: Hypersecretion of stomach acid (HCI), may have weight gain, pain occurs 2-3 hours after a meal; often awakened between 1-2 AM; ingestion of food relieves pain, vomiting uncommon, Hemorrhage less likely than with gastric ulcer, but if present melena more common than hematemesis, rare chance of malignancy, risk factors: H. pylori, alcohol, smoking, cirrhosis, stress
• Gastric Ulcer: affects people aged 50 and over, male to female ratio 1:1, 15% of peptic ulcers are gastric: Normal-hyposecretion of stomach acid (HCl), weight loss may occur, pain occurs ½ to 1 hour 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, occasional chance of malignancy, risk factors include H. pylori, gastritis, alcohol, smoking, use of NSAIDs, stress

Risk Factors and Pathophysiology of Peptic Ulcer Disease

• Risk factors: Familial tendency, use of NSAIDs, alcohol ingestion, excessive smoking, and Zollinger-Ellison syndrome.
• Pathophysiology: Erosion is either caused by increased activity of pepsin and HCL or decreased resistance of the mucosa, Zollinger-Ellison syndrome (ZES) is suspected in unresponsive peptic ulcer, and stress ulcers can also be the cause due to ischemia, increased acid and pepsin production, or reflux.
• Can be Cushing and Curling types

Clinical Manifestations of Peptic Ulcers

• Can be asymptomatic or include dull, gnawing pain/burning sensation in the midepigastric area or in the back.
• Eating usually relieves pain plus pyrosis and vomiting, constipation, diarrhea or bleeding.
• Assessments and diagnostic findings include physical findings, upper GI barium study, endoscopy, stool analysis, biopsy and histology with culture and/or urea breath test.
• Medical management includes pharmacologic interventions like, antibiotics, protein pump inhibitors, bismuth salts, and H2 receptor antagonists, as well as Octreotide and cytoprotective agents and alongside stress reduction, rest, and dietary modification

Surgical management of PUD

• Vagotomy with or without pyloroplasty, can be Truncal, Selective or Proximal gastric vagotomy
• Billroth I and Billroth II

Nursing Process and Peptic Ulcers

• Assessment: Chief complaint, nature of the pain, 72-hour dietary recall, lifestyle habits plus vital signs and physical exam.
• Nursing Diagnoses: Acute pain is related to the impact of gastric acid secretion on damaged tissue, and imbalanced nutrition is related to changes in diet + potential complications like Hemorrhage, Perforation, Penetration or Gastric Outlet Obstruction
• Goals: Relief of pain, reduced anxiety, nutrition maintenance, and absence of complications
• Nursing interventions include relieving pain (avoiding caffeine and aspirin, plus relaxation techniques), as well as reducing anxiety.
• Monitoring and managing complications:
  • hemorrhage
  • perforation
  • penetration
  • pyloric obstruction

Gastric Cancer

• Incidence: Men>Women
• Japan has a higher incidence of it
• Diet is a significant factor
• Chronic inflammation of the stomach, pernicious anemia, achlorhydria, gastric ulcers, H. Pylori infection and genetics are other factors.
• Early stages of gastric cancer are asymptomatic. Its early symptoms are seldom definitive, with may be pain relieved with antacids
• Progressive symptoms include anorexia, dyspepsia, weight loss, abdominal pain, constipation, anemia, nausea, and vomiting.
• Medical management includes removal of the tumor through gastrectomy (total/subtotal), chemotherapy and/or radiation therapy.

Patients Undergoing Gastric Surgery

• Assessment: Determine patient and family knowledge, patients nutritional status, and palpate the abdomen. Assess bowel sounds and watch for possible complications postop.
• Nursing Diagnoses: Anxiety related to surgical intervention, acute pain related to surgical incision, deficient knowledge about surgical procedures and postoperative course, and imbalanced nutrition (less than body requirements) related to poor nutrition before surgery and altered GI system after surgery.
• Nursing Interventions:
  • Relieve anxiety and pain
  • Resume enteral intake
  • Recognize obstacles to adequate nutrition, such as dysphagia, gastric retention, bile reflux, dumping syndrome, and vitamin/mineral deficiencies.