Chapter 40 Gastric & Duodenal Disorders Flashcards
Gastritis
Inflammation of the gastric & stomach mucosa
- Can be acute (lasting several hours- few days) or chronic (repeated exposure to irritating agents or recurring gastritis)
Prevalence of Gastritis
Common GI problem accounts for 2 Million visits to outpatient clinics annually in the United States
What are the 2 types of acute gastritis?
Erosive & Non-erosive Gastritis
Erosive Gastritis
Caused by long-term use of nonsteroidal anti-inflammatory drugs
(NSAIDS, ex: ibuprofen, alcohol abuse, and recent exposure to radiation therapy)
Non-Erosive Gastritis
Often caused by spiral-shaped, gram (-) Heliobacter pylori (H.pylori)
Prevalence of H. pylori Infections
~50% of individuals globally
Stress-Related Gastritis
May develop in acute illnesses when the patient has had major traumatic injuries, burns, severe infection, lack of perfusion to stomach lining, or major surgery
Severe Acute Gastritis
Caused by ingestion of strong acids or alkali-> mucosa may either become gangrenous or perforation
- Scarring causes pyloric stenosis or obstruction
Pathophysiology of Gastritis
Gastritis is a disruption of the mucosal barrier that protects the stomach tissue from digestive juices.
In gastritis, the gastric mucous membrane becomes edematous and hyperemic (congested with fluid and blood) and undergoes superficial erosion.
Superficial ulcerations may occur as a result of erosive disease and leads to ->hemorrhage
Clinical Manifestations of Acute Gastritis
Anorexia
Epigastric pain (rapid onset)
Hematemesis: Vomiting blood
Hiccups
Melena or hematochezia
Nausea and vomiting
Clinical Manifestations of Chronic Gastritis
Belching
Early satiety
Intolerance of spicy/fatty foods
Nausea and vomiting
Pyrosis (heartburn)
Sour taste in the mouth, halitosis
Vague epigastric discomfort relieved by eating and inability to absorb vitamin B12
Possible signs of shock
Anemia
Fatigue
Dyspepsia
Indigestion
Upper abdominal discomfort associated w/eating
Hematochezia
Bloody stool
Pyrosis
Heartburn
Burning sensation in the stomach & esophagus that moves up to the mouth
How is a patient dx w/ gastritis?
The definitive dx is determine by an endoscopy and histologic exam of a tissue specimen obtained by biopsy
Medical Management of Gastritis
NGT, IV Fluids, Fiberoptic endoscopy, antacids, H2 blockers (ex. famotidine, ranitidine), proton pump inhibitors (ex. omeprazole, lansoprazole)
In extreme cases surgery is required to remove gangrenous or perforated tissue
Ex: Gastric resection or a Gastrojejunostomy (anastomosis of jejunum to stomach to detour around
the pylorus), this is necessary to treat pyloric obstruction
Chronic gastritis is managed by modifying the pt’s diet, promoting rest, reducing stress, recommending avoidance of alcohol and NSAIDS, and initiating medications that may include antacids, H2 blockers, or proton pump inhibitors
Nursing Management of Gastritis: Managing Anxiety
The nurse offers supportive therapy
& uses a calm approach to assess
the pt and answer all questions
Nursing Management of Gastritis: Promoting Optimal Nutrition
Pt should refrain from alcohol and food until symptoms subside
A nonirritating diet is introduced when pt is able to take nourishment by mouth
- IV Fluids are needed if symptoms persist
- Fluid I & O w/electrolytes are closely monitored
As food is introduced, nurse evaluates & reports any symptoms that suggest a repeat episode of gastritis
NO caffeinated beverages & NO smoking!! Caffeine is a stimulant that increases gastric activity & pepsin secretions. Nicotine will increase gastric acid secretions & interfere w/ GI mucosal barrier
Nursing Management of Gastritis: Promoting Fluid balance
Daily I’s & O’s to detect early signs of dehydration
- Minimal fluid intake 1.5L/day
- Urine output: < 1mL/kg/hr
If NPO:
- IV fluids 3L/day usually are prescribed
- Record of 1 L of 5% dextrose in water= 170 cal of carbs need to be maintained
Electrolyte values (Na+, K+, & Cl -) are assessed every 24 hrs to detect any imbalances
Be alert of any signs of hemorrhagic gastritis
- Hematemesis
- Tachycardia
- Hypotension
All stools should be examined for the presence of frank or occult
Nursing Management of Gastritis: Relieving Pain
Instruct patients to avoid foods & beverages that may irritate the gastric mucosa as well as correct use of meds to relieve chronic gastritis
Nurse must regularly assess the patient’s level of pain & extent of comfort achieved through use of meds & avoidance of irritating substances
Gastric Outlet Obstruction
Any condition that medically impedes normal gastric emptying
Pyloric Obstruction
Obstruction of the channel of the pylorus & duodenum through which the stomach empties
Peptic Ulcer
An excavation (hollowed-out area) that forms in the
mucosal wall of the stomach, in the pylorus, duodenum, or esophagus
- Can be referred to as gastric, duodenal, esophageal, or pyloric ulcer
Pylorus
Opening between the stomach & duodenum
Duodenum
1st part of small intestine between stomach & jejunum
Causes of Peptic Ulcer Disease
Erosion of a circumscribed area of mucous membrane is the cause
Most peptic ulcers results from H. pylori bacteria
Where are peptic ulcers more likely to occur?
They are more likely to occur in the duodenum
-Gastric ulcers occur in the lesser curvature of the stomach, near the pylorus
-> Esophageal ulcers occur as a result of backflow of HCl from the stomach to the into the esophagus (GERD
Risk Factors for Peptic Ulcer Disease
NSAIDS and ASA is a major risk factor for peptic ulcers
Increased secretion of HCL in the stomach & stress
Smoking and alcohol may be risk factors, but evidence is
inconclusive
-There is no evidence that milk, caffeinated drinks, and spicy foods are associated with peptic ulcers
Familial tendency may also be a significant risk factor
Pathophysiology of Peptic Ulcer Disease
The erosion of tissue is caused by the ↑’ed
activity of acid-pepsin or by the ↓’ed resistance of the mucosa
A damaged mucosa cannot secrete enough mucus to act as a barrier against HCL
Damage to the gastroduodenal mucosa results in ↓ resistance to bacteria → H. pylori infection occurring
Clinical Manifestations of Peptic Ulcer Disease
May last for a few days, weeks, or months
- May disappear only to reappear w/out an identifiable cause
Dull, gnawing pain or burning in the midepigastrium or the back
Symptoms shared by both: pyrosis (heartburn), vomiting, constipation or diarrhea, and bleeding
- May be accompanied w/ burping when, patient’s stomach is empty
- Vomiting is rare but could be a sign of an ulcer complication
-> Gastric outlet obstruction (caused by either muscular spasm or the pylorus or mechanical obstruction from scarring)
-> May also be due to acute swelling of the inflamed mucous membranes adjacent to the liver
Emesis may contain undigested food eaten may hours earlier
Clinical Manifestations of Gastric Ulcers
Pain occurs 30-60 min. after eating
30-40% of pts awake with pain during the night
Clinical Manifestations of Duodenal Ulcers
Pain occurs 2-3 hrs after meals
50-80% of pts awake with pain during the night
- More likely to express pain relief after eating or taking an antacid than those with gastric ulcers
Clinical Manifestations of Bleeding Ulcers
May present w/ symptoms of GI bleed
- Hematemesis
- Passage of melena
~20% of pts w/ bleeding ulcers do not experience abdominal pain at time of dx
Signs & Symptoms of Ulcer Perforation
May be sudden in onset
Severe, sharp upper abdominal pain (may be referred to the shoulder)
Extreme abdominal tenderness
N/V may also occur
WATCH OUT FOR SIGNS OF SHOCK!!
- Hypotension
- Tachycardia
Nursing Therapy for Peptic Ulcer Disease
Relieve Pain
- Eat meals @ regularly paced intervals
Nursing Management of Complications Associtaed
Hemorrhage
* Bleeding is manifested by hematemesis or melena
* The vomited blood can be bright red or dark coffee ground
* When hemorrhage is large (2000-3000 mL) most of the blood is vomited and immediate correction of blood loss is needed to prevent hemorrhagic shock
from happening
The nurse assess for dizziness and nausea, evaluate for tachycardia, hypotension, tachypnea, monitor H/H, and assess stool occult blood
Patients with symptoms of GI bleed should have an endoscopy within 24 hours to confirm diagnosis
Endoscopic interventions include injecting the bleeding site with epinephrine, cauterizing the site, or clipping the ulcer to stop the bleeding
Treatment Measures
- Insert at least an 18 G IV
- Fluid replacement therapy
- Packed RBCs, frozen plasma cells
- NG tube insertion to decompress the stomach
Dyspepsia
Indigestion
Upper abdominal discomfort associated w/eating
Pyrosis
Heartburn
Burning sensation in the stomach & esophagus that moves up to the mouth
Purpose of Pharmacological Therapy in Peptic Ulcer Disease & Gastritis
Used to eradicate H. pylori & manage gastric acidity
Recommended therapy is for 10-14 days
4 Antibiotics Used to Treat Peptic Ulcer Disease & Gastritis
Amoxicillin, clarithomycin, metronidazole, & tetracycline
Major Action & Key Nursing Considerations of Amoxicillin in Peptic Ulcer Disease & Gastritis
Bacterial antibiotic that aids in eradicating H.pylori bacteria in the gastric mucosa
Key Nursing Considerations:
- May cause abdominal pain & diarrhea
- Should NOT be used in patients w/ allergies to penicillin
Major Action & Key Nursing Considerations of Clarithomycin in Peptic Ulcer Disease & Gastritis
Exerts bactericidal effects to eradicate H. pylori bacteria in the gastric mucosa
Key Nursing Considerations:
- May cause GI upset, headache, altered state
- Many drug-drug interactions
Ex) Colchicine, lovastatin, warfarin
- Interacts w/ grapefruit juice
Major Action & Key Nursing Considerations of Metronidazole in Peptic Ulcer Disease & Gastritis
Synthetic antibacterial & antiprotozoal agent that assists w/ eradicating H. pylori in the gastric mucosa when given w/ other antibiotics & proton pump inhibitors
Key Nursing Considerations:
- Should be given w/ meals to prevent GI upset
- May cause anorexia & metallic taste
- Patient should AVOID alcohol
- Increases blood-thinning effects of warfarin
Major Action & Key Nursing Considerations of Tetracycline in Peptic Ulcer Disease & Gastritis
Exerts bacteriostatic effects to eradicate H. pylori bacteria in the gastric mucosa
Key Nursing Considerations:
- May cause photosensitivity reaction
-> Advise patients to use sunscreen
- May cause GI upset
- Must be used in CAUTION w/ renal or hepatic impairment
- Milk or dairy products may decrease the effectiveness
Anti-Diarrheal Agent Used in Peptic Ulcer Disease & Gastritis Treatment
Bismuth subsalicylate
Major Action & Key Nursing Considerations of Bismuth subsalicylate in Peptic Ulcer Disease & Gastritis
Suppresses H. pylori bacteria in the gastric mucosa & assists w/ healing of mucosal ulcers
Key Nursing Considerations:
- Given concurrently w/ antibiotics to treat H.pylori infection
- Should be taken on empty stomach
- May darken BMs
Proton Pump Inhibitors of Gastric Acid
Esomeprazole
Lansoprazole
Omeprazole (May cause diarrhea, N/V, constipation, abdominal pain, headache, or dizziness)
Pantoprazole (May cause diarrhea & hyperglycemia, headache, abdominal pain, & abnormal LFTs)
Rabeprazole (May cause abdominal pain, nausea, diarrhea, & headache)
- May be taken w/out regard to meals
-> In duodenal ulcers, give after meals
-> In H. pylori treatment, give w/ food
- Drug-drug interactions w/ digoxin, iron, & warfarin
Major Action & Key Nursing Considerations of Proton Pump Inhibitors in Peptic Ulcer Disease & Gastritis
Decreases gastric acid secretion by slowing the H+, K+-ATPase pump on the surface of the parietal cells of the stomach
Key Nursing Considerations:
- Used mainly for the treatment of duodenal ulcer disease & H. pylori infection
- A delayed-release capsule that is to be swallowed whole & taken before meals
Major Action & Key Nursing Considerations of Misoprostal in Peptic Ulcer Disease & Gastritis
Protects the gastric mucosa from agents that cause ulcers & increases mucus production & bicarb levels
Key Nursing Considerations:
- Used to prevent ulceration in pts using NSAIDs
- Used mainly for the treatment of duodenal ulcers
- Administer w/ food
- May cause diarrhea & cramping (includes uterine cramping)
- DO NOT USE IN PREGNANT WOMEN!!!!! (Category X)
Major Action & Key Nursing Considerations of Sucralfate in Peptic Ulcer Disease & Gastritis
Creates a viscous substance in the presence of gastric acid that forms a protective barrier, binding to the surface of the ulcer, & prevents digestion by pepsin
Key Nursing Considerations:
- Should be taken w/out food but, taken w/ H2O 1hr before meals
- Other meds should be taken 2 hrs before/after this med
- Many drug-drug interactions (digoxin, phenytoin, warfarin)
- May cause constipation or nausea
Triple Therapy
2 antibiotics and 1 proton pump inhibitor
* Antibiotics: Metronidazole, Amoxicillin, Clarithromycin
- Proton Pump Inhibitor: Omeprazole, Lansoprazole, Rabeprazole
Quadruple Therapy
2 antibiotics, 1 proton pump inhibitor, and 1 bismuth salt
* Antibiotics: Metronidazole and Tetracycline
- Proton Pump Inhibitor: Omeprazole, Lansoprazole, Rabeprazole
- Bismuth Salt: Pepto Bismol
Key Difference between the Triple & Quadruple Therapy (Peptic Ulcer Disease)
Tetracycline
- Do NOT add to triple therapy
What effect does smoking have on patients w/ peptic ulcer disease?
Decreases the secretion of bicarbonate from the pancreas, into the duodenum -> Increased acidity of the duodenum
Continued smoking is associated w/ delayed healing of peptic ulcers
Goal of Dietary Modification in Management of Peptic Ulcer Disease
Avoid oversecretion of acid & hypermotility of in the GI tract
Nursing Management of Peptic Ulcer Disease: Dietary Modification
Avoid consuming food/beverages w/extreme temperatures
Minimize alcohol, & caffeinated beverages ( includes de-caff coffee)
Eat 3 regular meals a day to neutralize acid
- Small, frequent feedings are NOT necessary as long as an antacid or an H2 blocker is taken
Diet compatibility becomes an individual matter: Pt eats foods that are tolerated & avoids those that produce pain
Maintain optimal nutrition: Assess for malnutrition & weight loss
Nursing Management of Peptic Ulcer Disease: Pain Relief
Eat meals at regularly paced intervals in a relaxed
setting
Utilize medications prescribed to treat the ulcer
Teach relaxation techniques to help manage stress/pain
Nursing Management of Peptic Ulcer Disease: Reduce Anxiety
Explain diagnostic tests & meds
Help the pt identify stressors and explain coping techniques
Encourage the family to participate in care and provide support
Nursing Management of Peptic Ulcer Disease: Manage Potential Complications (Bleeding)
Bleeding is manifested by hematemesis or melena
* The vomited blood can be bright red or dark coffee ground
When hemorrhage is large (2000-3000 mL) most of the blood is vomited and immediate correction of blood loss is needed to prevent hemorrhagic shock
from happening
The nurse assess for dizziness and nausea, evaluate for tachycardia, hypotension, tachypnea, monitor H/H, and assess stool occult blood
Patients with symptoms of GI bleed should have an endoscopy within 12 hrs to confirm diagnosis
* Endoscopic interventions include injecting the bleeding site with epinephrine, cauterizing the site, or clipping the ulcer to stop the bleeding
Perforation
Erosion of the ulcer through the gastric serosa into the peritoneal cavity w/out warning
THIS IS AN EMERGENCY and requires immediate surgery
Chemical peritonitis develops w/in a few hours after perforation & is treated w/ immediate closure &
abdominal lavage stomach contents
Clinical Manifestations of Peptic Ulcer Perforation
Sudden, severe upper abdominal pain
- Pain may be referred to the shoulders
Vomiting
Fainting
Extremely tender/rigid (board-like) abdomen
Hypotension and tachycardia, indicating shock
Penetration
Erosion of the ulcer through the gastric serosa into adjacent structures such as the pancreas, biliary
tract, or gastrohepaticomentum
- Requires surgical intervention
Clinical Manifestations of Peptic Ulcer Disease Penetration
Back & epigastric pain not relieved by medications
that were effective in the past
