Management of Patient with Digestive Disorders PDF

Management of patient with digestive disorders By Dr. Manal Sayed Dr. Soad Mohammed Dr.Walaa Elithy Peptic ulcer Gastric surgery Hernia Peptic and duodenal ulcer Definition of peptic and duodenal ulcer. Explain types of ulcer. Etiology and Pathophysiology of ulcer....

Management of patient with digestive disorders By Dr. Manal Sayed Dr. Soad Mohammed Dr.Walaa Elithy Peptic ulcer Gastric surgery Hernia Peptic and duodenal ulcer Definition of peptic and duodenal ulcer. Explain types of ulcer. Etiology and Pathophysiology of ulcer. Clinical manifestation of ulcer. Diagnostic test of ulcer. types of ulcer. Management of patient with ulcer. Nursing process as a framework for care of patients with gastritis and peptic ulcer. Education of patient with peptic ulcer. Definition: A Peptic ulcer disease (PUD) is a condition characterized by erosion of the GI mucosa resulting from the digestive action of HCl acid and pepsin.  Peptic and duodenal ulcer The ulcer forms in the mucosal wall of the stomach, in the: - Pylorus (opening between stomach and duodenum), - Duodenum (first part of small intestine), or esophagus. - A peptic ulcer is referred either on its location as: gastric, duodenal, and esophageal ulcer. Ulcer: a breach in the mucosa of the alimentary tract extending through muscularis mucosa into submucosa or deeper Types of ulcer: 1- Depending on the degree and duration of mucosal involvement;Peptic ulcers can be classified as acute or chronic: A- acute ulcer is associated with superficial erosion and minimal inflammation. It is of short duration and resolves quickly when the cause is identified and removed. B- chronic ulcer is one of long duration, eroding through the muscular wall with the formation of fibrous tissue. It is present continuously for many months or intermittently throughout the person’s lifetime. 2- According to the location. Gastric or duodenal,  3- Stress-Related Mucosal Disease (SRMD), - Stress ulcer: Term given to the acute mucosal ulceration of the duodenal or gastric area that occurs after physiologically stressful events Burns, shock, severe sepsis, multiple organ traumas, ventilator- dependent patients, Trauma, surgery, 24 hours after injury: shallow erosions of the stomach wall, 72 hours: multiple gastric erosions are observed. When the patient recovers, the lesions are reversed.  Pathophysiology The pathogenesis of peptic ulcer involves a disturbance in the balance between the secretion of acid and pepsin by the stomach and the mucosal barrier (a thick layer of mucus). The normal stomach mucosa is adapted to contain the acid produced by the parietal cells. Where the mucosal defence is nonexistent, the acid causes mucosal ulceration. Ulcers also occur where acid attacks mucosa not specialized to deal with it.  Pathophysiology Imbalance Aggressive Factors Defensive Factors H. pylori Mucus Drugs (NSAIDs) bicarbonate Acid Defensive Aggressive Blood flow, pepsin Factors Factors Bile salts cell renewal Prostaglandins Phospholipid Etiology : 1. Helicobacter pylori infection. 2. NSAID, Aspirin is the most ulcerogenic NSAID. inhibit the production of protective prostaglandins in the mucosa 3. Hyper secretion of acid: Overactive vagus nerve, which stimulates the release of gastrin. Methylxanthines (tea, coffee, cola, and chocolate) and smoking. Zollinger-Ellison syndrome tumors of the pancreas which increases gastrin secretion. 4. Genetic predisposition and stress. 5. Gastric tumors. Overactive vagus nerve, Items Gastric ulcers Duodenal ulcers Incidence Usually 50 and over Age 35–45 Greater in women Male: Female 2:1 Represent 20 % of Represent 80% of peptic ulcers peptic ulcers Lesion Superficial; smooth Penetrating margins; round, oval or cone shaped. Location of Antrum, also in body First 1-2 cm of lesion and fundus of the duodenum. stomach.  Gastric Duodenal - Weight loss - Weight gain Weight Pain occurs 1-2 hours - Pain occurs 2–4 hours after Pain after a meal, ingestion of a meal; ingestion of food food doesn’t relieve pain relieves pain. - Pain occurring in the - Pain located to the right of high left epigastric area the midline epigastric region radiating to the back & radiating to the back upper abdomen - Described as dull, - Describes as burning, aching, and gnawing, cramping, pressure like pain across midepigastrium & upper abdomen Items Gastric ulcers Duodenal ulcers Vomiting Common Uncommon Hemorrhage Hemorrhage Hemorrhage less likely more likely Hematemesis Hematemesis Melena more common more common Malignancy Occasionally Rare Possibility Potential complications of peptic ulcer: 1. GI hemorrhage. 2. Ulcer perforation. 3. Pyloric obstruction (Gastric outlet obstruction). Diagnostic evaluation: 1. Endoscopy is the preferred diagnostic procedure because it allows direct visualization of duodenal mucosa; inflammatory changes, ulcers, lesions, bleeding sites, and malignancy. 2. Cytological brushings and biopsies may be performed to obtained samples. 3. Serial stool specimens to detect occult blood 4. Gastric secretory studies (gastric acid secretion test and the serum gastric level test). 5. Serum test for H. pylori antibodies may be positive. Management: 1. Specific pharmacotherapy: H2 receptor antagonists, such as cimetidine (Tagamet), ranitidine (Zantac), inhibit action of histamine on the H2 receptors of the parietal cells, thus reducing gastric acid. Anti-secretory or proton pump inhibitor drug inhibits the production of HCL Cytoprotective drug protects the ulcer by forming a protective barrier against acid, bile, pepsin. Acid-neutralizing agents (antacids) provide additional relief of symptoms. Antibiotics such as tetracycline and Flagyl used with bismuth as “triple therapy” to eradicate H. pylori. For NSAID ulcers discontinue NSAID and treat as mentioned above  Principles of medical treatment The main principles of treatment are to eradicate H. pylori and to reduce and neutralize (using alkalis and milk) acid secretion. Failure to eradicate H. pylori by giving antacid therapy alone results in high relapse rates. H. pylori eradication. A 2-week course of antimicrobial therapy + acid reduction therapy will eradicate H. pylori. Acid reduction is usually afforded by a proton pump inhibitor (e.g. omeprazole, lanzoprazole) and the antimicrobial therapy is based on either clarithromycin or amoxicillin, together with metronidazole. The combination of two antibiotics is recommended because of the high incidence of antibiotic resistance. Such protocols will eradicate H. pylori in over 90% of patients. 2. Dietary measures Well-balanced diet, high fiber content, meals at regular intervals (6 meals a day). Avoid caffeine, colas, and alcohol. Avoid smoking )decreases healing rate and increases recurrence(. 3. Gastric surgery Indications: Patients with peptic ulcers who have life-threatening ,haemorrhage, Obstruction, Perforation, or penetration. Condition does not respond to medication. Gastric cancer or trauma. Surgical procedures include: Vagotomy. Pyloroplasty. Partial gastrectomy (Billroth I and Billroth II). Total gastrectomy: Removal of the stomach (esophagojejunal anastomosis). 1- Vagotomy: (cutting of vagus nerve) to eliminate the stimulus that triggers gastric acid secretion by the gastric cells; can choose to cut all or portions. Vagotomy 2-Pyloroplasty: A surgical procedure in which a longitudinal incision is made into the pylorus and transversely sutured closed to enlarge the outlet and relax the muscle. 3- Billroth I Procedure (Gastroduodenostomy): Removal of the lower portion of the antrum of the stomach (which contains the cells that secrete gastrin) as well as a small portion of the duodenum and pylorus. Gastric stump is anastomosed with the duodenum  Billroth II Procedure (Gastrojejunostomy): Removal of distal third of stomach; Removes gastrin-producing cells in the antrum and part of the parietal cells. Gastric stump is anastomosed with the jejunum. Total gastrectomy: esophagus is anastomosed to jejunum. Nursing interventions: Relieving pain: - Analgesics may be administered as prescribed. -- Positioning the patient in a Fowler’s position promotes comfort and allows emptying of the stomach after a partial gastrectomy. - The nurse maintains functioning of the NG tube to prevent distension and resultant pain and damage to the suture line. Normally, the amount of NG drainage after total gastrectomy is small.  Post-operative complications 1. Dumping syndrome: A group of unpleasant vasomotor and gastrointestinal symptoms due to decrease the reservoir capacity of the stomach. The stomach no longer has control over the amount of food entering the small intestine. A large bolus of a hypertonic fluid enters the intestine and result in fluid being drawn into the bowel lumen. This creates a decrease in plasma volume. Distension of the bowel lumen which stimulate intestinal motility and the urge to  The onset of symptoms occurs at the end of the meal or within 15-30 min after eating, lasts for no longer than an hour after meals. The patient usually describes: Feeling of generalized weakness, sweating, palpitation, tachycardia, and dizziness. (These symptoms attributed to the sudden decreases in plasma volume), abdominal cramp, and the urge to defecate. 2. Postprandial hypoglycemia Fluid high in carbohydrate get into the small intestine results in hyperglycemia and the release of excessive amounts of insulin. A secondary hypoglycemia occurs 2 hours after meals. The immediate ingestion of sugared fluid or candy relieves the hypoglycemic symptoms To avoid similar occurrence: limit amount of sugar with each meal, and to eat small frequent meals with moderate amounts of proteins and fat. Nursing process for patient with ulcer: Nursing assessment: - Determine location, character, and radiation of pain, factors aggravating or relieving pain, how long it lasts, when it occurs. - Ask about eating patterns, regularity, types of food, eating circumstances. - Take a social history of alcohol consumption and smoking. - Ask about medications (especially aspirin, anti-inflammatory drugs, or steroids). - Determine if GI bleeding has been experienced. - Take vital signs, including lying, standing, and sitting blood pressures and pulses, to determine if orthostasis is present due to bleeding. Nursing diagnoses: Fluid volume deficit related to hemorrhage Pain related to epigastric distress secondary to hypersecretion of acid, mucosal erosion, or perforation. Diarrhea related to GI bleeding or antacid therapy. Altered Nutrition, Less Than Body Requirements, related to the disease process. Knowledge Deficit related to physical, dietary, and pharmacologic treatment of disease. A. Avoiding fluid volume deficit - Monitor intake and output continuously to determine fluid volume status. - Observe stools for occult blood. - Monitor hemoglobin and hematocrit and electrolytes. - Administer prescribed IV fluids and blood replacement, as prescribed. - Insert an NG tube as prescribed and monitor the tube drainage for signs of visible and occult blood. - Administer medications through the NG tube to neutralize acidity, as prescribed. - Prepare patient for saline lavage, as ordered. - Observe the patient for an increase in pulse and a decrease in blood pressure (signs of shock). B. Achieving pain relief: - Encourage bed rest to reduce physical activity and to separate patient from usual environment if pain continues. - Provide small, frequent meals to prevent gastric distention if not NPO. - Teach the patient that caffeine, alcoholic beverages, and nicotine may increase gastric acidity and promote erosion of the gastric mucosa. - Advise the patient about the irritating effects on the gastric mucosa of certain drugs, such as aspirin, NSAIDs, and certain antibiotics. - Administer prescribed medication. C. Decreasing diarrhea: - Monitor patient’s elimination patterns to determine effects of medications. - Monitor vital signs and watch for signs of hypovolemia. Persistent diarrhea may be a sign of bleeding. - Restrict foods and fluids that promote diarrhea: raw vegetables, fruits, whole grain cereals, carbonated drinks. - Administer antidiarrheal medication as prescribed. - Watch for signs of impaired skin integrity (erythema, soreness) around anus to promote comfort and decrease risk of infection. D. Achieving adequate nutrition: - Eliminate foods that cause pain or distress; otherwise, the diet is usually not restricted. - Provide small, frequent feedings on time. This will decrease distention and the release of gastrin. - Advise the patient to avoid coffee and other caffeinated beverages as well as carbonated drinks; these may increase acid. - Advise the patient to avoid extremely hot or cold food or fluids, to chew thoroughly, and to eat in a leisurely fashion for better digestion. - Administer parenteral nutrition if bleeding is prolonged and patient is emaciated, as ordered. Patient education: Modify lifestyle to include health practices that will prevent recurrences of ulcer pain and bleeding. Plan for rest periods and avoid or learn to cope with stressful situations; avoid fatigue. Dietary modification: avoiding extremes of temperature and overstimulation from consumption of meat extracts, alcohol, coffee and other caffeinated beverages, and diets rich in milk and cream (which stimulate acid secretion). Take antacids 1 hour after meals, at bedtime, and when needed. Warn the patient that antacids may cause changes in bowel habits. Abdominal hernia At the end of this lecture, the student will be able to: Define abdominal hernia Describe Pathophysiology of hernia Identify etiology of hernia Identify types of hernia Describe clinical manifestations Identify diagnostic evaluation Management of patient with hernia Definition: Hernia is an abnormal protrusion of an organ or structure through a weakness or tear in the abdominal wall. Etiology: Hernias are caused by a weakness in the abdominal wall along with increased intra-abdominal pressure, such as the pressure from 1. Coughing 2. straining 3. heavy lifting. 4. Obesity, pregnancy, and poor wound healing Indirect hernias are caused by a defect of structural closure. Direct hernias are acquired and arise from a weakness in the abdominal wall, usually at old incisional sites. Types of hernias: The most common types are: ❑ 1- Inguinal hernias: An inguinal hernia or groin hernia is a hernia of abdominal cavity contents through the inguinal canal. This common hernia is an example of an indirect hernia and is usually seen in males. ❑ 2- Umbilical hernias ❑ An umbilical hernia is a defect in the ventral abdominal fascia at or near the umbilicus ❑ are seen most often in obese women and in children. They are caused by a failure of the umbilical orifice to close. 3. Ventral (incisional) hernias: Usually result from a weakness in the abdominal wall following abdominal surgery, especially in the obese patient, if a drainage system was used, the patient experienced poor wound healing, or the patient received inadequate nutrition. 4- Epigastric hernia: lumps or bulges that show up in the upper part of the belly between the breastbone and the belly button Signs and symptoms: - An abnormal bulging can be seen in the affected area of the abdomen, especially when straining or coughing. - The patient may have some discomfort due to tension on tissues around the hernia, feeling of fullness - The herniation may disappear when the patient lies down. If the intestinal mass easily returns to the abdominal cavity or can be manually placed back in the abdominal cavity, it is called a reducible hernia. - When adhesions or edema occur between the sac and its contents, the hernia becomes irreducible or incarcerated hernia. Complications: 1.Strangulation if the blood and intestinal flow are completely cut off in the trapped loop of bowel. 2.Intestinal obstruction and possibly gangrene and bowel perforation, symptoms are pain at the site of the strangulation, nausea and vomiting and colicky abdominal pain. Management: Therapeutic measures: - Treatment include, observing the hernia, using short-term support devices, or surgery to cure hernia. A supportive truss or brief applies pressure to keep the reduced hernia in place. - Emergency surgery is needed for strangulation or the threat of bowel obstruction. Surgical procedures include herniorrhaphy or hernioplasty (open or laparoscopically). - Herniorrhaphy involves making an incision in the abdominal wall, replacing the contents of the hernial sac, sewing the weakened tissue, and closing the opening. - Hernioplasty involves replacing the hernia into the abdomen and reinforcing the weakened muscle wall with wire, fascia, or mesh. Bowel resection or a temporary colostomy may be necessary if the hernia is strangulated. A supportive truss or brief Nursing care: The patient is instructed to avoid activities that increase intra-abdominal pressure, such as lifting heavy objects. The patient is taught to recognize signs of strangulation and the importance of notifying the physician immediately. If a support truss or brief has been ordered, the patient is taught to apply it before arising from bed each morning while the hernia is not protruding. Special attention should be paid to maintenance of skin integrity beneath the truss. Postoperative care: - Care following inguinal hernia repair is generally similar to any abdominal postoperative care. - Patients can perform deep breathing to keep lungs clear postoperatively but should avoid coughing. Coughing increases abdominal pressure and could affect the hernia repair. - Because most patients are discharged the same day of surgery, they are taught to change the dressing and report difficulty urinating, bleeding, and signs and symptoms of infection. - The patient is also instructed to avoid lifting, driving, or sexual activities for 2 to 6 weeks. Prevention: - Congenital defects cannot be prevented. - Reducing strain on abdominal muscles is helpful. - Those who do heavy lifting, or pushing should wear a support binder or avoid the lifting. - A healthy lifestyle of maintaining normal weight, not smoking, and eating high- fiber foods is recommended. Questions 1. Definition - Peptic ulcer - Hernia 2. List - Diagnostic tests for peptic ulcer. - Prevention of abdominal hernia. - Types of hernias. 3. Differentiate between gastric and duodenal ulcers as regard clinical manifestations. Situation (problem solving) Mr (A) a 50-year-old male is admitted to the hospital with a diagnosis of peptic ulcer. He is about to begin a therapeutic regimen that includes diet modification, antacids, and ranitidine (Zantac). According to this situation answer the following questions: 1. Before Mr (A) discharged from hospital, what are the most important instructions the nurse should provide? - - - - 2. Identify common causes of peptic ulcer? - - - - 3. Which specific data should the nurse obtain from Mr (A)? a. History of side effects experienced from all medications. b. Use of non-steroidal anti-inflammatory drugs (NSAIDs). c. Any known allergies to drugs and environmental factors. d. Medical histories of at least 3 generations. B 4. Which test confirms the diagnosis of Mr (A)? a. Esophagogastroduodenoscopy. b. Magnetic resonance imaging. c. Occult blood test. d. Gastric acid stimulation. A 5. Which expected outcome should the nurse include for Mr (A)? a. The patient's pain is controlled with the use of NSAIDs. b. The patient maintains lifestyle modifications. c. The patient has no symptoms of hemoptysis. d. The patient takes antacids with each meal. B 6. Mr (A) should be instructed to increase intake of Methylxanthines. a. True b. false B 8. Chronic peptic ulcer is of short duration & resolves quickly when the cause is and removed. a. True b. false B MCQ 1. The nurse is caring for a patient following a Billroth I procedure. On review of the post-operative orders, which of the following, if prescribed, would the nurse question and verify? a. Early ambulation. b. Irrigating the nasogastric tube. c. Leg exercises. d. Coughing and deep breathing exercises. B 2. Which of the following is most accurate description of Bilroth II procedure? a. The procedure will result in enlargement of the pyloric sphincter. b. The procedure will result in anastomosis of gastric stump to jejunum. c. The procedure will result in repositioning of the vagus nerve. d. The procedure will result in removal of the duodenum. B 3. Which of the following types of hernia is an example of an indirect hernia and is usually seen in males? a. Inguinal b. Abdominal c. Epigastric d. Umbilical A 4. Which of the following types of hernia is seen most often in obese women and in children? a. Inguinal b. Femoral c. Epigastric d. Umbilical D 5. What type of hernia in which the intestinal mass easily returns to the abdominal cavity or can be manually placed back in the abdominal cavity? a. Irreducible b. Incarcerated c. Reducible d. Strangulated C 6. Which of the following occurs in a strangulated hernia? a. Continuous enlargement of hernia size. B. Patient complains of abdominal pain. c. Decreased blood supply to the protruding part. d. Protruding tissue or organ that can’t be pushed back into place. C 7. What is the most serious complication of strangulated hernia? a. Hemorrhage. b. Shock. c. Pulmonary edema. d. Intestinal obstruction. D