Upper GI Problems PDF

Nausea and Vomiting: Nausea: ○ Feeling of discomfort in epigastric area Vomiting: ○ Action of “throwing up” or emesis; Forceful ejection of food and secretions Manifestation ○ Anorexia ○ Weight Loss ○ Fluid and electrolyte imbalances...

Nausea and Vomiting: Nausea: ○ Feeling of discomfort in epigastric area Vomiting: ○ Action of “throwing up” or emesis; Forceful ejection of food and secretions Manifestation ○ Anorexia ○ Weight Loss ○ Fluid and electrolyte imbalances ○ acidosis/alkalosis ○ Decreased blood volume ○ Circulatory failure Treatment/Nursing considerations: ○ Identify and treat cause ○ SYMPTOM RELIEF Anticholinergic: Scopolamine patches Antihistamines: Hydroxyzine Serotonin Antagonists: Ondansetron (Zofran) Phenothiazines: Chlorpromazine, promethazine, metoclopramide, Reglan (CNS side effects) Antiemetic drugs - can CNS side effects: confusion, falls During hospital visit; patient is having issues with keeping food down; ○ NPO ○ IV Fluids ○ NGT ○ Monitor I/O, assess for dehydration ○ Aspiration precautions ○ Dietary consult Oral Cancer: Types ○ Oral cavity: earlier stages of oropharyngeal; starts in the mouth and progresses to the oropharynx behind the mouth ○ Oropharyngeal cancer ○ Head and neck squamous cell carcinoma: Majority are SCC Predisposing factors ○ Tobacco ○ Alcohol ○ Sun exposure ○ HPV, STD Clinical Manifestations ○ Chronic sore throat ○ Voice changes ○ Ulcers ○ Dysphasia ○ Slurred speech ○ Toothache ○ Leukoplakia: precancerous lesion due to smoking  ○ Erythroplakia-progresses to squamous cell CA Diagnostics ○ Biopsy ○ Oral cytology: microscopic exam ○ Toluidine blue test: cancer cells turn blue; does not automatically rule out malignancy condition ○ CT, MRI, PET scan for staging Treatment: ○ Surgery Minimally invasive robotic Radical Partial mandibulectomy: removal of mandible Hemiglossectomy: removal of ½ of tongue Glossectomy: removal of entire tongue Radical neck dissection: removal of deep cervical lymph nodes, channels, and lesions ○ May need to remove accessory organs close to tumor: thyroid, parathyroid etc. ○ Non surgical Radiation Chemo Palliative Nutritional PEG Tube, enteral feedings Goals ○ Patent airway ○ Communication ○ Nutrition Nursing Implementation and Evaluation ○ Good oral hygiene ○ Smoking cessation ○ Early detection Pts w an ulcer that doesn't heal in 2-3 weeks; reports that are abnormal(prolonged bleeding, soreness, dysphagia swollen lymph nodes) Gastroesophageal Reflux Disease(GERD): Chronic mucosal damage d/t reflux of stomach acid into the esophagus Patho: ○ Gastric contents are acidic, overwhelm the esophagus defenses, and causes irritation and inflammation ○ Primary factor: incompetent lower esophageal sphincter (LES) Caused by food, drugs, obesity, hiatal hernia Clinical Manifestations ○ Heartburn (pyrosis) Most common Burning, tight sensation under lower sternum spread into throat or jaw May mimic angina but relieved with antacids ○ Dyspepsia Pain/discomfort in upper abdomen  ○ Regurgitation Hot, bitter, or sour, liquid in mouth or throat ○ Respiratory disturbances: Wheezing, coughing, dyspnea, nighttime disturbances, hoarseness, sore throat, lump on throat, choking, increased saliva Complications ○ Esophagitis: ulcerations lead to scar tissue, stricture and dysphagia ○ Barrett’s Esophagus: replacement of esophageal cells; increases risk for cancer ○ Respiratory: cough, bronchospasm, laryngospasm, aspiration into respiratory systems, chronic bronchitis, pneumonia ○ Dental erosion of posterior teeth Diagnostic studies ○ Upper GI endoscopy**hallmark dx for ANY upper GI issue** ○ esophagram (barium swallow) ○ PH monitoring Treatment/Nursing Considerations: ○ Nutritional implementations: Low-fat diet Avoid alcohol Avoid caffeine Upright position for 2-3 hours after eating Avoid eating for 3 hrs before bedtime Weight management Drug Therapy ○ PPIs: “prazole” Decrease HCI secretion and irritation Decreased incidence of strictures; take before 1st meal Adverse s/e with with prolonged use: decreased bone density, kidney disease, vitamin B12 deficiency, risk of dementia ○ H2 receptor blockers: “tidines” Decrease HCL secretion and irritation Onset 1 hour duration up to 12 hours ○ Prokinetics: metoclopramide (Reglan) Extrapyramidal effects (tremor and dyskinesia) ○ Antacids (tums, AlkA-Seltzer) Neutralize acid Provides quick relief for mild, intermittent symptoms Short duration: 1-3 hours after meals and at bedtime Cautious use with older adults, cirrhosis, HTN, and renal pts, due to increased Na+ Nursing and Interprofessional Management ○ Surgical therapy: Nissen Fundoplications: Hiatal Hernia: Part of stomach through an opening in diaphragm Two types: ○ Sliding: part of the stomach slides thru the opening in the diaphragm ○ Rolling: fundus rolls up and creates a fixed pocket; MEDICAL EMERGENCY!! Why? Can cut circulation and cause tissue damage d/t ischemia  Increased intraabdominal pressure causes weakened muscle in diaphragm and esophagogastric opening Clinical Manifestations: similar to GERD ○ Heartburn (pyrosis) ○ Dyspepsia ○ Regurgitation ○ Chest pain Complications ○ GERD ○ Esophagitis ○ Ulcers ○ Stenosis ○ Strangulation ○ Aspiration Diagnostic studies: same as GERD Nursing and Interprofessional Management ○ Conservative Reduce intra abdominal pressure ○ Surgical Reduce hernia Herniotomy Fundoplication-top part of stomach is folded and sewn to LES ESOPHAGEAL DIVERTICULA ○ Sac-like outpouchings of one or more layers Three main areas ○ Above upper esophageal sphincter ○ Near esophageal midpoint ○ Above LES  Symptoms ○ Dysphagia ○ regurgitation ○ Chronic cough ○ Food trapped in pouches ○ Sour taste and smell ○ Perforation of esophagus Treatment ○ Dietary modifications ○ Surgery or endoscopic procedures Esophageal Strictures: Narrowing of the esophagus from GERD Manifestations: all the same HAHA ○ Dysphagia ○ Regurgitation ○ Weight loss Treatment ○ Dilation with bougies or balloons using endoscopy or fluoroscopy ○ Surgical excision Peptic Ulcer Disease: PUD Erosion that results in an inflammatory response d/t the increased secretion of HCL and pepsin(digestive enzymes) ○ Can occur in any portion of the GI tract that comes in contact with gastric secretions Subtypes: ○ Acute: Superficial erosion and minimal inflammation ○ Chronic: Erosion of muscular wall with formation of fibrous tissue, Classified by locations, gastric or duodenal Risk Factors: ○ H. PYLORI ○ fecal/oral transmission ○ NSAIDS ○ Smoking ○ Drinking excessive alcohol or caffeine Gastric: ○ Prevalent in females >50 years ○ Increased obstruction ○ High recurrence ○ s/s: Burning or gaseous pain Pain at 1-2 hours after meal**different from duodenal Food worsens the pain Perforation: the first symptoms in some patients; causes peritonitis Duodenal: ○ Prevalent for ages 35-45 ○ High HCL secretions ○ High risk factors: COPD  Cirrhosis Pancreatitis Zollinger-Ellison syndrome: digestive disorder that results in too much gastric acid ○ Constant phases of appearances and disappearances ○ s/s: Burning across the mid-epigastric line or back; under the xiphoid process Pain at 2-5 hrs after eating; why? Duodenum is further down the GI tract Pain relief w/ antacids Diagnostic Studies ○ Endoscopy gives direct visualization ○ Barium contrast ○ Labs: CBC, Liver enzymes, serum amylase ○ Stool sample: guaiac test Test for blood Interprofessional Management ○ Treatment goals is to decrease acid in stomach(PPI)and enhance the mucosal defenses ○ NO NSAIDS ○ NO ASPIRIN ○ Medications: PPIs(proton pump inhibitors)**first like for peptic ulcer disease More effective than H2 receptor blockers Used with ABX to treat H. Pylori Sucralfate Protects esophagus, stomach, and duodenum Give 1 to 2 hours before or after antacids ○ Nutritional Therapy AVOID CAFFEINE AND ALCOHOL ○ Complications Duodenal hemorrhage is the most common Perforation GI Contents spill into peritoneal cavity Sudden, severe abdominal pain that radiates to the back and shoulders. Abdomen is rigid and boardlike w/ absent bowel sounds Gastric Surgery: can also be used to treat stomach cancer Partial gastrectomy ○ Gastroduodenostomy- Billroth I Removal of the distal ⅔ of stomach with anastomosis(fusing of stomach to duodenum) ○ Gastrojejunostomy-Billroth II Removal of the distal ⅔ of stomach with anastomosis(fusing of stomach to jejunum) ○ Gastrectomy: Total remove stomach (anastomosis of esophagus to jejunum) ○ Vagotomy: total or selective; sever vagus nerve; decreases gastric acid secretion  ○ Pyloroplasty Enlargement of pyloric sphincter Gastric Surgery Complications: Hemorrhage Dumping Syndrome: ○ Rapid transit of food contents causing decreased plasma volume and distension ○ s/s: Weakness Sweating Palpitations Dizziness Cramping Increased bowel sounds(borborygmi) Defecation urge ○ Lasts about 1 hour ○ Treatment: Reduced with rest after eating: tell patient to lay down for at least 30 min after eating; slows down digestion Post op complications: ○ Postprandial hypoglycemia: low BG after eating.. Uncontrolled high carbohydrate bolus enters small intestine causing excess insulin and resulting hypoglycemia 2 hours after eating ○ Bile reflux gastritis Bile reflux causes damage to gastric mucosa, chronic gastritis, and PUD Administer CHOLESTYRAMINE Binds to bile salts thus decreasing amount of reflux Nursing Management: Gastric Surgery ○ Prevent infection ○ Monitor for complications Respiratory comp.(dyspnea, chest pain, cyanosis) ANASTOMOSIS LEAK Tachycardia Fever Abdominal pain REQUIRES IMMEDIATE TREATMENT TO PREVENT SEPSIS  ○ Hemorrhage: VS, NG aspirate contents(check for blood) Nursing Management: Nutrition Therapy ○ Small, frequent meals(6 meals) ○ No fluids with meals(takes up space for food) ○ Chew thoroughly ○ Avoid simple sugars and extreme food temps GASTRITIS Inflammation of gastric mucosa ○ Acute or chronic diffuse localized Patho: ○ Breakdown in gastric mucosal barrier allowing HCL acid and pepsin to diffuse back into mucosa resulting in edema and possible hemorrhage Causes ○ Drug related; NSAIDS ○ Spicy foods ○ H. Pylori Clinical Manifestations ○ Acute Anorexia Nausea and vomiting Epigastric tenderness Hemorrhage ○ Chronic Pernicious anemia: gastric mucosa is damaged so it does not secrete intrinsic factor Nursing Management ○ Acute Gastritis Eliminate causes Supportive care; NPO, IV FLUIDS, ANTIEMETICS, MONITOR FOR DEHYDRATION Severe; NGT to monitor for bleeding, empty stomach Risk for hemorrhage Monitor VS, heme test for vomiting Drugs; PPIs or H2 receptor blockers ○ Chronic gastritis ABX FOR H. Pylori Cobalamin for pernicious anemia Upper GI bleeding: Hematemesis: bloody vomitus ○ Bright Red: arterial blood loss ○ Coffee ground: digested blood Melena: ○ Black Tarry stools from upper GI source Occult: ○ Guaiac test blood in gastric secretions, vomitus or stool Causes:  ○ Stomach and duodenal H.pylori and NSAIDS Corticosteroids Cancer Gastritis polyps ○ Esophageal origin Chronic esophagitis, Mallory Weiss tear or esophageal varices Varices: swollen veins in esophageal tract (medical 911!!) Diagnostics ○ ENDOSCOPY IS GOLD STANDARD ○ CBC ○ BUN ○ Vomitus and stool occult Nursing Management ○ Acute Care EMERGENCY MANAGEMENT ABCS Interprofessional Management ○ Massive GI Bleed >1500 ml blood loss ○ ASSESS FOR SHOCK ○ Monitor urine output hourly: monitoring kidney function ○ Hemodynamic monitoring ○ Oxygen ○ Assess FOR PERFORATION AND PERITONITIS Rigid abdomen ○ Blood transfusions EMERGENCY ASSESSMENT AND MANAGEMENT Endoscopy Therapy- FIRST LINE MGMT within 24 hours to determine treatment or surgery ○ clips/bands ○ Cauterization ○ Balloon tamponade Surgical Therapy ○ Site identified ○ Requires more than 2000 ml blood or shock Drug therapy: ○ PPIs ○ Antacids