GERD and Peptic Ulcer (PDF)

Gastro Esophageal Reflux Diseases (GERD) Dr/ Huda Rady Sobh Lecturer of medical surgical nursing Faculty of nursing, Mansoura university  Learning objectives Define the gastro esophageal reflux (GERD) & Peptic ulcer. Discuss etiology and pathophysi...

Gastro Esophageal Reflux Diseases (GERD) Dr/ Huda Rady Sobh Lecturer of medical surgical nursing Faculty of nursing, Mansoura university  Learning objectives Define the gastro esophageal reflux (GERD) & Peptic ulcer. Discuss etiology and pathophysiology of GERD & Peptic ulcer.. Describe the symptoms of GERD & Peptic ulcer.. Recognize the diagnostic studies of GERD & Peptic ulcer.. Discuss the collaborative management of GERD & Peptic ulcer. Discuss the nursing management of GERD & Peptic ulcer. Identify the complications of GERD & Peptic ulcer.  Introduction Gastro esophageal reflux disease and peptic ulcer are the most common diseases that affect GIT tract. Unhealthy food, analgesia and bad lifestyle are risk factors. GERD common, affecting 15 – 20% of adults  Definition Gastroesophageal reflux is the backward flow of gastric content into the esophagus  Pathophysiology Gastroesophageal reflux results from transient relaxation or incompetence of lower esophageal sphincter, or increased pressure within stomach  Factors contributing to gastroesophageal reflux disease:  Increased gastric volume (post meals)  Position pushing gastric contents close to gastroesophageal junction (such as bending or lying down)  Increased gastric pressure (obesity or tight clothing)  Hiatal hernia  Symptoms of GERD Typical symptoms: o Heartburn (Pyrosis):  Most common  Felt as a retrosternal sensation of burning or discomfort  Occurs usually after eating or when lying down or bending over.  Often relieved with milk or water  o Regurgitation:  Effortless return of gastric and/or esophageal contents into the pharynx.  It can induce respiratory complications if gastric contents spill into the trachea bronchial tree. Atypical symptoms o Cough, dyspnea, hoarseness, and chest pain  Diagnosis of GERD - Exclude other potential causes for the heartburn: o Cardiac o Peptic ulcer o Esophagitis - Esophageal Endoscopy: o The gold standard as a definitive diagnosis - Barium swallow o Not as definitive in mild cases Collaborative management of GERD – Dietary and Lifestyle Management – Drug Therapy – Surgical therapy Dietary and Lifestyle Management o Weight reduction (Maintain ideal body weight) o Elevate head of bed on 6 – 8 blocks (20-30 cm) to decrease reflux o Elimination of acid foods (tomatoes, spicy, citrus foods, coffee) o Avoiding food which relax esophageal sphincter or delay gastric emptying (fatty foods, chocolate, peppermint, alcohol) o Eat small meals and stay upright 2 hours post eating; no eating 3 hours prior to going to bed o No smoking o Avoiding bending and wear loose fitting clothing  Drug Therapy Antacids: for mild to moderate symptoms, e.g. Maalox, Gaviscon H2-receptor blockers: decrease acid production e.g. cimetidine, ranitidine (zantac), famotidine. Proton-pump inhibitors: reduce gastric secretions, promote healing of esophageal erosion and relieve symptoms, e.g. omeprazole. Surgical therapy – Indicated for persons not improved by diet and life style changes – Laparoscopic procedures to tighten lower esophageal sphincter (Nissen fundoplication) Nursing management of GERD Avoid factors that cause reflux – Stop smoking – Small, frequent meals. – Avoid acid or acid producing foods Elevate head of bead ~30° Do not lie down 2 to 3 hours after eating Drug therapy – Evaluate effectiveness – Observe for side effects Complications of GERD o Esophageal strictures, which can progress to dysphagia o Barrett’s esophagus: changes in cells lining esophagus with increased risk for esophageal cancer  Peptic Ulcer Definition Peptic ulcer is a hole or open sore in the lining of the stomach, duodenum ( beginning of the small intestinal) or esophagus.  Pathophysiology: Defensive Aggressive  Bicarbonate  Helicbacter pylori  Mucus layer  NSAIDs  Prostaglandins  Bile acids  Mucosal blood flow  Smoking and alcohol  Epithelial renewal  Pathophysiology: Under normal conditions, a physiologic balance exists between gastric acid secretion and gastro-duodenal mucosal defense Mucosal injury and, thus, peptic ulcer occur when the balance between the aggressive factors and the defensive mechanisms is disrupted. Aggressive factors, such as NSAIDs, H pylori infection, alcohol, bile salts, acid, and pepsin, can alter the mucosal defense by allowing back diffusion of hydrogen ions and subsequent epithelial cell injury.  Etiology/ Risk Factors 1- Lifestyle  Smoking, Alcohol  Acidic drinks  Medications (NSAID) 2- H. Pylori infection – 90% have this bacterium: Passed from person to person (fecal-oral route or oral-oral route) 3- Age (Duodenal 30-40 – Gastric over 50) 4- Gender ( common in male) 5- Genetic factors 6- Other factors: stress Types of peptic ulcer Gastric Peptic Ulcer Duodenal Peptic Ulcer Stress  Clinical Presentation  (epigastric pain) dull, gnawing pain or a burning  Pain is usually relieved by eating (duodenal)  Tenderness  Pyrosis (heartburn),  Vomiting, constipation or diarrhea, and bleeding  burping  bleeding  tarry stool Comparing duodenal and gastric ulcers Duodenal Gastric Incidence : Usually 50 and over Age 30-40 Male: female=1:1 Male: female=2-3:1 15% of peptic ulcers are gastric 80% of peptic ulcers are duodenal Signs, symptoms, and clinical findings May have weight gain Weight loss may occur Pain occurs 2-3 hours after a meal Pain occurs 1/2 to 1 hour after a meal Ingestion of food relieves pain May be relieved by vomiting Vomiting not common Vomiting common More likely to hemorrhage manifests Less likely to hemorrhage, but if occurs, as melena likely to manifests as hematemsis Risk factors H.pylori, gastritis, alcohol, smoking, H.pylori, alcohol, smoking, cirrhosis, use of NSAIDs, stress stress  Investigation/ Diagnostic Test Investigation  Stool examination for fecal occult blood.  Complete blood count (CBC) for decrease in blood cells.  Diagnostic tests of peptic ulcers Esophagogastroduodenoscopy (EGD)  Fiberoptic endoscope. Endoscopic procedure Visualizes ulcer crater Ability to take tissue biopsy to rule out cancer and diagnose H. pylori Barium study: o A patient ingests barium, a thick, white, milkshake-like liquid, and then multiple X-rays. Can detect structural disorders o After the exam, provide plenty of liquids for 24 to 48 hours. o The barium may make the stool white for several days. o If constipation occurs, the doctor may recommend a mild laxative Urea Breath Testing  Used to detect H.pylori  Client drinks a carbon-enriched urea solution  Exhaled carbon dioxide is then measured N.B: In all patients with “Alarming symptoms” endoscopy is required.  Dysphagia.  Weight loss.  Vomiting.  Anorexia.  Hematemesis or Melena  Hemorrhage Complications Perforation of peptic ulcers Pyloric obstruction 1) Hemorrhage  Blood vessels damaged as ulcer erodes into the muscles of stomach or duodenal wall Manifested by: o Coffee ground vomitus or occult blood in tarry stools o Orthostatic hypotension,  BP, HR, cool, clammy skin. o Hematemesis (bloody vomit) – bright red or coffee ground. o Melena (bloody or tarry [black] stool) – more likely with duodenal ulcer o Hgb, Hct  Management during hemorrhage includes o Monitor S/S o Determine rate amount of blood loss (Hgb /Hct), o NGT o Replace blood, fluid and electrolyte loss Saline lavage via NGT to Prevents distension o Assess amount/rate of bleeding, o Medications, oxygen, possible surgery 2- Perforation  An ulcer can erode through the entire wall  Bacteria and partially digested food spill into peritoneum=peritonitis o Manifested by: Sudden, sharp sever epigastric pain which spread to all abdomen Rigid, tender, board-like abdomen Patient assumes the fetal position to reduce tension on muscles o Can lead to shock o It is a surgical emergency  Management during perforation includes  NGT to prevent additional spillage of GI contents in peritoneum  Replace blood, fluid, electrolytes  Antibiotics  I & O, NPO  SURGERY: Urgent  3- Narrowing and obstruction (pyloric)  Swelling and scarring can cause obstruction of food leaving stomach=repeated vomiting  Stomach cannot empty abdominal bloating, N&V  Persistent vomiting Hypokalemia and metabolic alkalosis  Management of ulcers 1. Conservative therapy 2. Pharmaceutical 3. Surgical  1- Conservative therapy: Rest: Both physical and emotional Dietary modifications Life style modification:  Discontinue NSAIDs  Smoking cessation  Alcohol cessation  Stress reduction Long term follow up care  2- Pharmaceutical: o Antibiotics  To eradicate H. Pylori infections  Recurrence of ulcer is 75-90% as high with infection o Antiacids  Initial drugs of choice o H2 receptor antagonists  Histamine is the final intracellular activator of HCL secretion o Anticholinergic:  Stop the cholinergic stimulation of HCL secretion and slow gastric motility  4- Surgical treatment Indication:  Failure of medical treatment  Development of complications  High level of gartric secreation  Combined duodenal and gastric ulcer  Type of surgical procedure: 1. Gastroenterostomy:  Creates a passage between the body of stomach to small intestines.  Allows regurgitation of alkaline duodenal contents into the stomach.  Keeps acid away from Gastroenterostomy ulcerated area  2-Vagotomy  Cuts vagus nerve and eliminates acid secretion stimulus Vagotomy  3-Pyloroplasty  Widens the pylorus to guarantee stomach emptying even without vagus nerve stimulation  Dumping syndrome  A complication of gastric surgery  Dumping syndrome occurs when food, especially sugar, moves from your stomach into your small bowel too quickly.  In dumping syndrome, food and gastric juices from your stomach move to your small intestine in an uncontrolled, abnormally fast manner. This is most often related to changes in your stomach associated with surgery.  Signs and symptoms of early dumping syndrome generally occur after eating, especially after a meal rich in table sugar (sucrose) or fruit sugar (fructose). Signs and symptoms might include: (15-30 minute) Nausea Vomiting Abdominal cramps Diarrhea Flushing Dizziness, lightheadedness Rapid heart rate  Late dumping signs and symptoms which occur one to three hours after eating, are due to your body releasing large amounts of insulin to absorb the large amount of sugars entering your small intestine after you eat a high-sugar meal. The result is low blood sugar. Signs and symptoms of late dumping can include: Sweating Hunger Fatigue Dizziness, lightheadedness Weakness Rapid heart rate  Generally, you can help prevent dumping syndrome by changing your diet after surgery. Changes might include eating smaller meals, increase fiber diet, limit water intake during meal and limiting high-sugar foods. In more- serious cases of dumping syndrome, you may need medications or surgery.  Nursing management of peptic ulcer  Nursing Assessment:  assessment pain, (type timing, duration)  use of antacids  vomitus  smoking  use of alcohol  use of NSAID  Is the patient experiencing occupational stress o Is there a family history of ulcer disease?  eating habbits , blood in stool  physical examination  Nursing Diagnosis  Acute pain related to increased gastric secretions ,decreased mucosal protection ,and ingestion of gastric irritants as evidenced by burning cramp like pain in epigastrium and abdomen  Imbalanced nutrition (nausea) related to acute exacerbation of disease process as evidenced by episodes of nausea and vomiting  Anxiety related to fear from unknown prognosis  Ineffective therapeutic regimen management related to lack of knowledge of long term management of peptic ulcer disease and consequence of not following treatment plan and unwillingness to modify lifestyle as evidenced by frequent questions about home care incorrect response to questions about peptic ulcer disease  Nursing Interventions 1. Relieving pain 2. Maintaining optimal nutritional status 3. Promote fluid intake 4. Reducing anxiety 5. Teaching patients self-care Teach patient self care  Questions  A patient complains of epigastric pain that relieved by food intake, in addition, awaking him in the mid night with a gnawing pain in the stomach. What is this type of peptic ulcer? A. Duodenal B. Gastric C. Esophageal D. Refractory  Which of the following best describes the method of action of medications, such as ranitidine (Zantac), which are used in the treatment of peptic ulcer disease? A. Neutralize acid B. Reduce acid secretions C. Stimulate gastrin release D. Protect the mucosal barrier Select from the following a forbidden habit for patients with gastroesophageal reflux? A. No alcohol B. No smoking C. There is no time limit for eating hours prior to going to bed. D. Avoid bending and wear loose-fitting clothing