Chapter 46 Flashcards
What are the common upper gastrointestinal (GI) problems reviewed in this chapter?
- Nausea and vomiting
- Oral and gastric cancers
- Gastroesophageal reflux
- Ulcerative disease
- Inflammatory and infectious bowel disorders
- GI bleeding
- Structural problems
These problems can lead to various complications in patients undergoing upper GI surgery.
What nutritional issues may patients with impaired GI function face?
Malnutrition from decreased intake
Impaired GI function can lead to insufficient nutrient absorption and overall nutritional deficits.
What risks are associated with patients who have impaired GI function?
- Altered fluid balance
- Altered electrolyte balance
- Altered acid-base balance
These imbalances can complicate the clinical management of patients with GI issues.
How can problems with eating, drinking, or talking affect patients?
They may impair the ability to communicate
Communication difficulties can arise from both physical and psychological factors related to GI problems.
What is the relationship between pain and aspiration risk?
Pain increases the risk for aspiration
Pain can lead to changes in swallowing patterns, increasing the likelihood of aspiration.
What are the most common manifestations of GI disease?
Nausea and vomiting
These symptoms can occur in various GI disorders and significantly impact patient quality of life.
What effect does swallowing difficulty have on patients?
Increases the risk for aspiration
Difficulty swallowing can lead to food entering the airway, which poses serious health risks.
What is the primary function of the vomiting center?
Coordinates the multiple signals that trigger the vomiting reflex.
What does the chemoreceptor trigger zone (CTZ) respond to?
Chemical stimuli from drugs, toxins, and labyrinthine stimulation.
What are the clinical manifestations associated with nausea?
Subjective experience that usually accompanies anorexia.
What can prolonged vomiting lead to?
Dehydration, severe electrolyte imbalances, fluid volume loss, and circulatory failure.
What metabolic condition can result from loss of gastric hydrochloric acid due to vomiting?
Metabolic alkalosis.
What is the goal of interprofessional care in managing nausea and vomiting?
Determine and treat the underlying cause, correct complications, and provide symptomatic relief.
What type of drugs are used to treat nausea and vomiting?
Antiemetic drugs that act in the CNS via the CTZ.
What are the risks of using promethazine via parenteral routes?
Severe tissue injury.
What are 5-HT3 receptor antagonists effective for?
Reducing chemotherapy-induced vomiting (CINV), postoperative nausea and vomiting (PONV), and nausea related to migraine and anxiety.
What is the risk associated with chronic use of metoclopramide?
Tardive dyskinesia.
What is tardive dyskinesia characterized by?
Involuntary and repetitive movements of the body.
What is a potential outcome of severe vomiting related to weight?
Weight loss due to fluid loss.
What can metabolic acidosis occur with in the context of vomiting?
Vomiting of small intestine contents.
What is the role of dexamethasone in antiemetic therapy?
Given with other antiemetics to manage acute and delayed CINV.
What is the function of the autonomic nervous system during vomiting?
Results in both parasympathetic and sympathetic stimulation.
What does sympathetic activation during vomiting cause?
Tachycardia, tachypnea, and diaphoresis.
What happens to the lower esophageal sphincter (LES) during parasympathetic stimulation?
It relaxes.
What is the mechanism of action of scopolamine?
Block cholinergic pathways to vomiting center
Used as an anticholinergic drug for nausea and vomiting.
Name two antihistamines used for nausea and vomiting.
- dimenhydrinate (Dramamine)
- diphenhydramine
- hydraxyzine
- meclizine (Antivert)
Antihistamines block histamine receptors that trigger nausea and vomiting.
What are common side effects of cannabinoids like dronabinol?
Dry mouth, somnolence
Cannabinoids inhibit the vomiting control mechanism in the medulla oblongata.
What is the primary action of corticosteroids in managing nausea?
Not well understood how it prevents nausea and vomiting
Dexamethasone is a commonly used corticosteroid.
What do dopamine D2/D3 receptor antagonists do?
Block dopaminergic receptors in the CTZ
Amisulpride (Barhemsys) is an example of this class of drugs.
What is the action of 5-HT3 (serotonin) antagonists?
Block action of serotonin
Examples include granisetron, ondansetron (Zofran), and palonosetron (Aloxi).
What are the side effects of phenothiazines?
Hyperglycemia, insomnia, euphoria, chills, hypokalemia, hypotension, abdominal distention
These drugs act on the CNS level of the CTZ.
What is the role of prokinetic agents like metoclopramide?
Inhibit action of dopamine, enhance gastric motility and emptying
CNS side effects can include anxiety and hallucinations.
What do substance P/neurokinin-1 receptor antagonists block?
Interaction of substance P at NK-1 receptor
Examples include aprepitant (Emend), netupitant, and rolapitant (Varubi).
What does the presence of bile in emesis suggest?
Obstruction below the ampulla of Vater
This is significant in assessing the cause of vomiting.
What does bright red blood in vomitus indicate?
Active bleeding
Possible causes include Mallory-Weiss tear or esophageal varices.
What does ‘coffee-grounds’ appearance of vomitus indicate?
Gastric bleeding
Blood changes to dark brown due to interaction with HCl acid.
What is the difference between vomiting and regurgitation?
Vomiting is forceful expulsion of stomach contents; regurgitation is effortless
Retching or vomiting rarely occurs before regurgitation.
What is projectile vomiting?
Forceful expulsion of stomach contents without nausea
Often occurs with brain and spinal cord tumors.
What are important health information factors to assess in patients with nausea and vomiting?
• Recent illness
• Travel history
• Medication use (including alcohol and antibiotics)
• Surgical history
• Pregnancy
• Cancer
• Cardiovascular disease (CVD)
• Renal disease
• Eating disorders
What are common symptoms associated with nausea and vomiting?
• Anorexia
• Weight loss
• Weakness
• Fatigue
• Dry mouth
What objective data should be collected in patients experiencing nausea and vomiting?
• Lethargy
• Sunken eyeballs
• Frequency and character of vomitus
• Content of vomitus (undigested food, bile, feces)
• Color of vomitus (red, coffee-grounds, green, yellow)
• Pallor
• Dry mucous membranes
• Poor skin turgor
What is the initial management for patients with persistent vomiting?
• NPO status
• IV fluids
• Possible nasogastric (NG) tube for decompression
What are the risks associated with prolonged vomiting?
• Dehydration
• Acid-base imbalance
• Electrolyte imbalances
How should a patient be positioned to prevent aspiration during vomiting?
• Semi-Fowler’s position
• Side-lying position
What is the initial fluid of choice for oral rehydration after vomiting?
Water
What dietary recommendations should be given to a patient recovering from severe vomiting?
• Clear liquids initially
• Bland foods (e.g., baked potato, rice, cooked chicken, cereal)
• High carbohydrates and low fat diet
What clinical problems can arise from nausea and vomiting?
• Fluid imbalance
• Electrolyte imbalance
• Nutritional compromise
• Impaired gastrointestinal function
What are the overall goals for a patient with nausea and vomiting?
- Minimal or no nausea and vomiting
- Normal electrolyte levels and hydration status
- Return to normal fluid and nutrient intake
What teaching should be provided to patients and caregivers regarding nausea management?
• How to manage nausea
• Ways to prevent nausea and vomiting
• Maintaining fluid and nutrition intake
• Keeping the environment quiet and well-ventilated
• Avoiding sudden position changes and unnecessary activity
When should a dietitian be consulted for a patient with nausea and vomiting?
When determining nutritious foods that the patient can tolerate
What is aphthous stomatitis commonly known as?
Canker sore
It is a recurrent and chronic form of infection related to various causes.
What are the causes of gingivitis?
Neglected oral hygiene, malocclusion, missing or irregular teeth, faulty dentistry
Gingivitis presents with inflamed gingivae and interdental papillae.
What is the treatment for aphthous stomatitis?
Tetracycline oral suspension, tetracycline (topical or systemic)
Prevention includes health teaching and dental care.
What virus is responsible for herpes simplex infections?
Herpes simplex virus (type 1 or 2)
Risk factors include upper respiratory tract infections and excessive exposure to sunlight.
What are the manifestations of oral candidiasis?
Pearly, bluish white ‘milk-curd’ membranous lesions, sore mouth, yeasty halitosis
It is caused by Candida albicans.
What is parotitis and its common causes?
Inflammation of the parotid gland caused by Staphylococcus or Streptococcus species
Associated with debilitation and dehydration.
What are the symptoms of stomatitis?
Halitosis, sore mouth, trauma from pathogens or irritants
Can be a side effect of chemotherapy and radiation.
What are the risk factors for Vincent’s infection?
Stress, excessive fatigue, poor oral hygiene, nutrition deficiencies (B and C vitamins)
It presents with ulcers that bleed and a fetid mouth odor.
What is the primary concern for older adults experiencing nausea and vomiting?
Fluid loss and rehydration therapy
They have a higher risk for life-threatening fluid and electrolyte imbalances.
What is the recommended action if an older adult suspects a medication is causing nausea?
Notify the healthcare provider (HCP) immediately
Stopping medication without consultation may have adverse effects.
What are expected outcomes for older adults with nausea and vomiting?
- Be comfortable, with minimal or no nausea and vomiting
- Have normal electrolyte levels
- Able to maintain adequate intake of fluids and nutrients
Careful assessment and monitoring are crucial.
What methods may help reduce postoperative nausea and vomiting (PONV) in some patients?
Acupressure, acupuncture, herbs (ginger, peppermint oil), changes in body position, exercise
These methods can be beneficial for certain individuals.
What are the CNS side effects of antiemetic drugs in older adults?
Confusion and increased fall risk
Doses should be reduced and efficacy closely evaluated.
What are the common risk factors associated with oral cancer?
About 75% to 90% report a history of either tobacco or frequent alcohol use, prolonged exposure to sunlight, irritation from pipe smoking, and HPV infection
HPV contributes to 25% of oral cancer cases, especially with multiple oral sex partners.
What is leukoplakia and its significance in oral cancer?
Leukoplakia, called ‘smoker’s patch’, is a white patch on the mouth mucosa or tongue that is a pre-cancerous lesion, with 15% transforming into cancer
It results from chronic irritation, especially from smoking.
What is erythroplasia and its risk in developing cancer?
Erythroplasia (erythroplakia) is a red velvety patch on the mouth or tongue, with more than 50% of cases progressing to squamous cell cancer.
What are common clinical manifestations of oral cancer?
Chronic sore throat, sore mouth, voice changes, leukoplakia, erythroplasia, asymptomatic neck mass, and oral lesions
Lip cancer typically appears as an indurated, painless ulcer.
What are the diagnostic studies used for oral cancer detection?
Oral exfoliative cytologic study and the toluidine blue test
The toluidine blue test is a screening test for oral cancer.
What is the average age for oral cancer diagnosis?
Oral cancer is not common after age 35, with the average age at diagnosis being around 62.
What is the relationship between oral cancer and HPV?
HPV contributes to 25% of oral cancer cases and is associated with multiple sexual partners.
What are the treatment options for oral cancer?
Surgery, radiation
Specific surgical procedures include mandibulectomy, radical neck dissection, and glossectomy.
Which demographic has the highest incidence of oral cancer?
Incidence and mortality rates are highest in Black men.
What is the prognosis for lip cancer compared to other types of oral cancer?
Lip cancer has the most favorable prognosis due to earlier diagnosis from visibility.
What later symptoms may indicate advanced oral cancer?
Increased saliva, slurred speech, dysphagia, toothache, earache.
What are the four processes of ingestion related to oral cancer?
Ingestion, Digestion, Absorption, Elimination
What is the purpose of chemotherapy in cancer treatment?
Chemotherapy is applied to treat cancer.
What does a negative cytologic smear indicate regarding cancer diagnosis?
A negative cytologic smear or negative toluidine blue test does not necessarily rule out cancer.
What imaging techniques are used for staging cancer after diagnosis?
CT scan, MRI, and positron emission tomography (PET)
What are the main management strategies for oral cancer?
Surgery, radiation, chemotherapy, or a combination of these
What is the most effective treatment for early-stage oral cancer?
Surgery
What factors determine the surgical procedure for oral cancer?
Location and extent of the tumor
What types of surgeries may be performed for oral cancer?
Partial mandibulectomy, hemiglossectomy, glossectomy, resections of the buccal mucosa and floor of the mouth, radical neck dissection
What does radical neck dissection involve?
Wide excision of the primary lesion with removal of regional lymph nodes, deep cervical lymph nodes, and lymphatic channels
What structures may be removed during a radical neck dissection?
Sternocleidomastoid muscle, internal jugular vein, mandible, submaxillary gland, thyroid and parathyroid glands, spinal accessory nerve
What is the typical postoperative care for patients after radical neck surgery?
Tracheostomy, drainage tubes for fluid and blood removal
What nutritional therapy is recommended for patients before surgery?
Placement of a percutaneous endoscopic gastrostomy (PEG) tube for enteral nutrition (EN)
What is the initial nutritional support provided after radical neck surgery?
Parenteral nutrition for the first 24 to 48 hours
What are the options for enteral nutrition after the initial postoperative period?
NG tube, gastrostomy tube, jejunostomy tube
What should be assessed for feeding tolerance in patients?
Adjust the amount, time, and formula if nausea, vomiting, diarrhea, or distention occur
What is the role of radiation therapy in the treatment of oral cancer?
Used alone to treat small cancers or when lesions cannot be removed
Why is radiation therapy typically avoided before surgery?
Radiated tissue becomes fibrotic and heals slower, making it hard to remove
What diagnostic assessments are used for oral cancer?
History and physical assessment, biopsy, oral exfoliative cytology, toluidine blue test, CT, MRI, PET scans
What are common clinical problems faced by patients with oral cancer?
Nutritionally compromised, pain, difficulty coping
What are the overall goals for a patient with oral cavity cancer?
Patent airway, able to communicate, adequate intake to maintain nutrition, relief of pain and discomfort
What key role do healthcare providers play in the management of oral cancer?
Early detection and treatment, identifying patients at risk
What are the subjective data important for nursing assessment of oral cancer?
• Recurrent oral herpetic lesions
• HPV infection or vaccination
• Exposure to sunlight
• Immunosuppressants
• Removal of prior tumors or lesions
• Alcohol and tobacco use
• Poor oral hygiene
• Difficulty speaking, dysphagia
What are some objective data findings for oral cancer?
• Slurred speech
• Foul breath odor
• Painless ulcer on lip
• Painless neck mass
What are the expected outcomes for a patient with oral cancer?
• Have no respiratory complications
• Be able to communicate
What is Gastroesophageal reflux disease (GERD)?
A symptom of mucosal damage caused by reflux of stomach acid into the lower esophagus
What is the most common upper GI problem?
Gastroesophageal reflux disease (GERD)
What are the primary factors causing GERD?
• Incompetent lower esophageal sphincter (LES)
• Increased intraabdominal pressure
• Certain foods and drugs
• Obesity
• Smoking
What does the reflux of acidic gastric contents into the esophagus cause?
Esophageal irritation and inflammation (esophagitis)
What are some risk factors for GERD?
• Obesity
• Hiatal hernia
• Cigarette and cigar smoking
What can cause medication-induced esophagitis?
Certain drugs, such as nonsteroidal antiinflammatory drugs (NSAIDs) and potassium
How can good oral hygiene impact health?
• Improves quality of life
• Lowers risk for teeth loss
• Reduces pain and disability
• Aids in early detection of oral and craniofacial cancers
• Decreases cost of care needed from dental professionals
• Decreases risk for periodontal disease, gingivitis, and dental caries
What should patients be taught regarding early detection of oral cancer?
To report unexplained pain or soreness of the mouth, unusual bleeding, dysphagia, sore throat, voice changes, or swelling or lump in the neck
What factors decrease lower esophageal sphincter pressure?
- Alcohol
- Chocolate (theobromine)
- Opiates
- Anticholinergics
- B-Adrenergic blockers
- Calcium channel blockers
- Diazepam (Valium)
- Morphine sulfate
- Nitrates
- Progesterone
- Theophylline
- Fatty foods
- Nicotine
- Peppermint, spearmint
- Tea, coffee (caffeine)
What factors increase lower esophageal sphincter pressure?
- Bethanechol (Urecholine)
- Metoclopramide (Reglan)
What is the most common symptom of GERD?
Heartburn (pyrosis)
Describe heartburn.
A burning, tight sensation felt beneath the lower sternum and spreading upward to the throat or jaw.
What should be evaluated in cases of heartburn?
Heartburn that occurs more than twice a week, is severe, is associated with dysphagia, or occurs at night.
What is GERD-related chest pain commonly mistaken for?
Angina
How does GERD-related chest pain differ from angina?
Antacids relieve GERD-related chest pain.
What is dyspepsia?
Pain or discomfort centered in the upper abdomen.
What is regurgitation?
Hot, bitter, or sour liquid coming into the throat or mouth.
What respiratory symptoms may a person with GERD report?
- Wheezing
- Coughing
- Dyspnea
What are some otolaryngologic symptoms of GERD?
- Hoarseness
- Sore throat
- Globus sensation
- Hypersalivation
- Choking
What is Barrett’s esophagus?
A precancerous lesion characterized by metaplasia in the distal esophagus.
What are some risk factors for Barrett’s esophagus?
- Being male
- Chronic GERD
- Age over 50
- Central obesity
- Ethnicity (white)
What complications can arise from GERD?
- Esophagitis
- Ulcers
- Strictures
- Dysphagia
- Respiratory complications (cough, bronchospasm, laryngospasm)
- Dental erosion
What diagnostic studies are used for GERD?
- Endoscopy
- Biopsy and cytologic specimens
- Manometric studies
- Ambulatory esophageal pH monitoring
- Radionuclide tests
What is esophagitis?
Inflammation of the esophagus.
What lifestyle modifications can help manage GERD?
Lifestyle modifications, drug therapy, and nutrition therapy.
What is GERD?
Gastroesophageal reflux disease, a chronic digestive condition
What is a hiatal hernia?
A condition where part of the stomach pushes through the diaphragm into the chest
What is the purpose of a barium swallow?
To assess swallowing and identify abnormalities in the esophagus
What is Nissen fundoplication?
A surgical procedure to treat GERD by wrapping the top of the stomach around the lower esophagus
What lifestyle modification should be made to manage GERD?
Follow a low-fat diet
What should patients do after eating to help manage GERD?
Avoid lying down for 2-3 hours
What position should the head of the bed be for GERD management?
Elevated 30 degrees
What types of medications are commonly used to treat GERD?
- Proton pump inhibitors (PPIs)
- H2 receptor blockers
- Antacids
- Prokinetics
What dietary items should be avoided by GERD patients?
- Acidic beverages (colas, red wine, orange juice)
- Alcohol
- Fatty foods
- Chocolate
- Peppermint
What is the goal of drug therapy for GERD?
To decrease reflux volume and acidity, improve LES function, and protect esophageal mucosa
How do proton pump inhibitors (PPIs) work?
They suppress gastric acid production
What are potential side effects of long-term PPI use?
- Decreased bone density
- Kidney disease
- Vitamin B12 deficiency
- Magnesium deficiency
What is the onset of action for H2 receptor blockers?
1 hour
What are common antacids used for heartburn relief?
- Magnesium hydroxide
- Aluminum hydroxide
When are antacids most effective?
1 to 3 hours after meals and at bedtime
What is the effect duration of antacids taken on an empty stomach?
20 to 30 minutes
What is a key recommendation for patients who smoke?
Encourage quitting smoking
What is the effect of stopping smoking on LES pressure?
Causes an immediate, marked decrease
What is the primary purpose of adjunctive treatments in GERD?
To provide quick relief of heartburn symptoms
What is the mechanism of action for Proton Pump Inhibitors (PPIs)?
Inhibit the proton pump (H+-K+-ATPase) responsible for the secretion of H+
Examples of PPIs include dexlansoprazole, esomeprazole, lansoprazole, omeprazole, and pantoprazole.
List the common side effects of Proton Pump Inhibitors (PPIs).
- Headache
- Abdominal pain
- Nausea
- Diarrhea
- Vomiting
- Flatulence
These side effects can vary in intensity among individuals.
What is the mechanism of action of Histamine (H2) Receptor Blockers?
Block the action of histamine on the H2 receptors to decrease HCl acid secretion
Examples include cimetidine, famotidine, and nizatidine.
List the common side effects of Histamine (H2) Receptor Blockers.
- Headache
- Abdominal pain
- Constipation
- Diarrhea
These side effects can vary in severity.
What is the primary function of antacids?
Neutralize HCl acid
Antacids are often taken 1-3 hours after meals and at bedtime.
What are some examples of single substance antacids?
- Aluminum hydroxide (Amphojel)
- Calcium carbonate (Tums)
- Sodium bicarbonate (Alka-Seltzer)
These substances vary in their side effects and should be chosen based on patient needs.
What are the side effects associated with aluminum hydroxide?
- Constipation
- Phosphorus depletion with chronic use
Caution is advised in patients with chronic use.
What side effects can calcium carbonate cause?
- Constipation or diarrhea
- Hypercalcemia
- Milk-alkali syndrome
- Renal calculi
These side effects may require monitoring.
What are some potential side effects of magnesium preparations?
- Diarrhea
- Hypermagnesemia
Use magnesium preparations with caution in patients with renal issues.
What is the mechanism of action of cytoprotective agents like sucralfate?
Form a protective layer and serve as a barrier against acid, bile salts, and enzymes in the stomach
Sucralfate can lead to constipation.
What is the primary action of prokinetic agents like metoclopramide?
Increase gastric motility and emptying
Metoclopramide can have CNS side effects ranging from anxiety to hallucinations.
What is the function of prostaglandin (synthetic) agents like misoprostol?
Increase production of gastric mucus and mucosal secretion of bicarbonate
Misoprostol also has antisecretory effects.
What are the risks associated with the use of antacids in patients with renal failure?
Risk for magnesium toxicity
Patients with renal issues should avoid magnesium preparations.
How can antacids interact with other medications?
Enhance the effects of some drugs and decrease absorption rates of others
Timing adjustments may be necessary when administering other medications.
What is a common agent used to promote gastric emptying?
Cisapride
What is the purpose of laparoscopic antireflux surgeries?
To reinforce the lower esophageal sphincter and reduce reflux symptoms
List some complications of laparoscopic antireflux surgery.
- Gastric or esophageal injury
- Splenic injury
- Pneumothorax
- Perforation
- Bleeding
- Infection
- Pneumonia
What is the LINX Reflux Management System?
A ring of small, flexible magnets that strengthens the weak lower esophageal sphincter
What are the potential problems associated with the LINX system?
- Nausea
- Swallowing problems
- Pain when swallowing food
Can patients with a LINX system undergo MRI scans?
No, it could cause serious harm
What is a hiatal hernia?
Herniation of part of the stomach into the esophagus through an opening in the diaphragm
What are the two types of hiatal hernias?
- Sliding hiatal hernia
- Paraesophageal (rolling) hernia
What occurs during a sliding hiatal hernia?
The junction of the stomach and esophagus slides above the diaphragm when the patient is supine
What characterizes a paraesophageal hernia?
The fundus and greater curvature of the stomach roll up through the diaphragm, forming a pocket alongside the esophagus
What factors contribute to the development of a hiatal hernia?
- Weakening of diaphragm muscles
- Obesity
- Pregnancy
- Ascites
- Tumors
- Intense physical exertion
- Heavy lifting
What are some clinical manifestations of hiatal hernia?
Similar to those of GERD, and some individuals may be asymptomatic
What complications can arise from a hiatal hernia?
- GERD
- Esophagitis
- Bleeding from erosion
- Stenosis
- Ulcerations
- Strangulation
- Regurgitation with tracheal aspiration
What diagnostic study may show protrusion of gastric mucosa through the esophageal hiatus?
Esophagram (barium swallow)
What are alternatives to surgery for treating hiatal hernia?
- Endoscopic mucosal resection (EMR)
- Radiofrequency ablation
What is the surgical procedure for hiatal hernia that involves wrapping the fundus of the stomach around the distal esophagus?
Nissen fundoplication
The fundus is then sutured to itself.
What are the conservative therapies for managing hiatal hernia?
Similar to those described for GERD: reducing intraabdominal pressure by eliminating constricting garments and avoiding lifting and straining.
What surgical treatments are included for hiatal hernia?
- Reducing the herniated stomach into the abdomen
- Herniotomy (excision of the hernia sac)
- Herniorrhaphy (closure of the hiatal defect)
- Fundoplication
- Gastropexy (attachment of the stomach below the diaphragm to prevent re-herniation)
What are the goals of surgery for hiatal hernia?
- Reduce the hernia
- Provide an acceptable LES pressure
- Prevent movement of the gastroesophageal junction
What techniques are commonly used for laparoscopic surgery to repair hiatal hernia?
Nissen or Toupet techniques.
What factors increase the incidence of hiatal hernia and GERD in older adults?
- Weakening of the diaphragm
- Obesity
- Kyphosis
- Other factors that increase intraabdominal pressure
What medications may decrease LES pressure in older adults, increasing their risk for hiatal hernia and GERD?
- Nitrates
- Calcium channel blockers
- Antidepressants
What is the overall 5-year survival rate for esophageal cancer in the United States?
20%.
What are the most common types of esophageal cancer?
- Adenocarcinomas
- Squamous cell tumors
What are key risk factors for developing esophageal cancer?
- Barrett’s esophagus (BE)
- Smoking
- Excess alcohol use
- Obesity
What condition associated with delayed emptying of the lower esophagus is linked to squamous cell cancer?
Achalasia.
Where do most esophageal tumors occur?
In the middle and lower portions of the esophagus.
What is the most common symptom of esophageal cancer?
Progressive dysphagia.
How does dysphagia progress in patients with esophageal cancer?
- First with meat
- Then with soft foods
- Eventually with liquids
What is a common site of metastasis for esophageal cancer?
- Liver
- Lung
What is esophagectomy?
Removal of part or all of the esophagus
Esophagectomy may involve the use of a Dacron graft to replace the resected part.
What are the types of surgical procedures for esophageal cancer?
- Esophagectomy
- Esophagoenterostomy
- Esophagogastrostomy
These procedures involve removing or resecting parts of the esophagus and connecting it to other parts of the digestive tract.
What is endoscopic mucosal resection (EMR)?
A procedure that involves removing cancer tissue using an endoscope
EMR is an option for small, very early-stage cancers.
What is photodynamic therapy?
A treatment that uses a photosensitizer, porfimer sodium, activated by light to destroy cancer cells
Patients must avoid direct sunlight for up to 6 weeks after treatment.
What is radiofrequency ablation?
A technique that uses electric currents to kill cancer cells
This method is often used when other treatments are not effective.
What are the benefits of minimally invasive esophagectomy?
Decreased ICU and hospital stays with fewer pulmonary complications
This approach often uses laparoscopic techniques.
List some diagnostic assessments for esophageal cancer.
- History and physical assessment
- Endoscopy of esophagus with biopsy
- Esophagram (barium swallow)
- Bronchoscopy
- CT, MRI, PET scans
These assessments help determine the type and stage of cancer.
What is the role of chemotherapy in treating esophageal cancer?
Chemotherapy can be used with or without radiation therapy to treat esophageal cancer
Regimens may include various combinations of chemotherapy drugs.
Fill in the blank: The surgical approach may be open or _______.
laparoscopic
Laparoscopic surgery involves smaller incisions and is often associated with quicker recovery times.
True or False: Stents can help relieve obstruction in the esophagus.
True
Stents allow food and liquid to pass through stenotic areas.
What is the purpose of dilation in esophageal cancer treatment?
To increase the lumen of the esophagus and relieve dysphagia
Dilation can help improve nutrition by allowing better passage of food.
What are some chemotherapy regimens used for esophageal cancer?
- Carboplatin and paclitaxel
- Cisplatin and irinotecan
- Oxaliplatin with fluorouracil or capecitabine
DCF (docetaxel, cisplatin, fluorouracil) is an option for metastatic disease.
What is targeted therapy in the context of esophageal cancer?
Therapy that targets cancers with excessive HER-2 protein to inhibit cancer cell growth
Trastuzumab is a common targeted therapy used.
What is the function of Herceptin?
Targets the HER-2 protein and kills cancer cells.
What type of drug is Ramucirumab (Cyramza)?
An angiogenesis inhibitor.
How does Ramucirumab work?
Binds to the receptor for vascular endothelial growth factor (VEGF) and prevents VEGF from signaling to make more blood vessels.
What types of cancers does Ramucirumab treat?
Advanced cancers that start at the gastroesophageal junction.
What is a common postoperative care intervention following esophageal surgery?
The patient receives IV fluids.
What may be placed depending on the type of esophageal surgery?
A feeding tube.
What is essential for postoperative care after esophageal surgery?
Meticulous oral care.
What should be given when starting oral fluids post-surgery?
Water (30 to 60 ml) hourly.
How long should the patient remain in an upright position after eating?
At least 2 hours.
What symptoms may indicate leakage of feeding into the mediastinum?
Pain, fever.
What is a common complication to assess for in postoperative patients?
Dysphagia and odynophagia.
What should be assessed in the patient with esophageal cancer?
History of GERD, hiatal hernia, achalasia, BE, and tobacco and alcohol use.
What is the typical duration for an NG tube post-esophageal surgery?
5 to 7 days.
What color does the NG tube drainage change to after 8 to 12 hours?
Greenish yellow.
What is an important nursing action regarding the NG tube?
Do not irrigate, reposition, or reinsert without consulting the HCP.
What should be monitored in chest tube drainage?
Amount and type of drainage.
What are the overall goals for a patient with esophageal cancer?
- Relief of symptoms
- Optimal nutrition intake
- Quality of life appropriate to stage of disease and prognosis.
What should be implemented to prevent respiratory complications?
Have the patient turn, cough, and deep breathe, and use an incentive spirometer every 2 hours.
What is a key health promotion strategy for patients with GERD?
Regular follow-up evaluation.
What dietary habits should be encouraged for patients post-esophageal surgery?
Intake of fresh fruits and vegetables.
What may be necessary for long-term nutritional support after surgery?
A permanent feeding gastrostomy.
What is the expected outcome for a patient with esophageal cancer regarding airway management?
Maintain a patent airway
What is the expected outcome for a patient with esophageal cancer regarding pain management?
Have relief of pain
What is the expected outcome for a patient with esophageal cancer regarding swallowing ability?
Be able to swallow comparably and consume adequate intake
What is the expected outcome for a patient with esophageal cancer regarding quality of life?
Have a quality of life appropriate to stage of disease and prognosis
What is Zenker’s diverticulum?
A pharyngoesophageal diverticulum located just above the upper esophageal sphincter
What are the three main areas where esophageal diverticula occur?
- Above the upper esophageal sphincter (Zenker’s)
- Near the esophageal midpoint (traction)
- Above the LES (epiphrenic)
What is Eosinophilic Esophagitis?
A condition characterized by infiltration of eosinophils in the esophagus, often associated with allergic diseases
What are common environmental allergens that may be involved in Eosinophilic Esophagitis?
- Pollens
- Molds
- Cat allergens
- Dog allergens
- Dust mite allergens
What are the typical symptoms of Eosinophilic Esophagitis?
- Severe heartburn
- Vomiting
- Dysphagia
- Food impaction
What is the primary treatment approach for Eosinophilic Esophagitis?
Avoiding foods that trigger allergic reactions
What is the most common cause of esophageal strictures?
Chronic GERD
What are potential causes of esophageal strictures?
- Ingesting strong acids or alkalis
- External beam radiation
- Surgical anastomosis
- Trauma (e.g., throat lacerations, gunshot wounds)
What are common symptoms of esophageal strictures?
- Dysphagia
- Regurgitation
- Weight loss
What are the methods to dilate strictures in the esophagus?
- Mechanical bougies
- Balloons
- Endoscopy or fluoroscopy
What is Achalasia?
A chronic disorder characterized by the absence of peristalsis in the lower two thirds of the esophagus
What are the typical symptoms of Achalasia?
- Dysphagia
- Regurgitation
- Chronic cough
- Aspiration
- Weight loss
What occurs in the lower esophagus during Achalasia?
Food and fluid accumulate, leading to dilation of the esophagus above the affected segment
How is the diagnosis of Achalasia typically established?
Through endoscopy or barium studies
What is a serious surgical complication associated with esophageal diverticula treatment?
Esophageal perforation
What medications are commonly used to treat Eosinophilic Esophagitis when avoiding allergens does not relieve symptoms?
- PPIs
- Corticosteroids
How can corticosteroids be administered for esophageal conditions?
- Orally (e.g., prednisone)
- Topically (e.g., inhaled fluticasone)
What is a common side effect of using inhaled corticosteroids for esophageal conditions?
Esophageal candidiasis (yeast infection of the throat)
What sensation may patients report during or right after a meal?
Globus sensation and/or substernal chest pain
What percentage of patients experience nighttime regurgitation?
About a third
What is halitosis?
Foul-smelling breath
What symptoms may indicate gastroesophageal reflux disease (GERD)?
Regurgitation of sour-tasting food and liquids, especially when lying down
What common symptom is associated with this condition?
Weight loss
What diagnostic methods are used for this condition?
Esophagram (barium swallow), manometric evaluation, and/or endoscopic evaluation
What are the treatment goals for patients with this condition?
Relieve dysphagia and regurgitation, improve esophageal emptying, and prevent megaesophagus
What is endoscopic pneumatic dilation?
A procedure that dilates the LES muscle using balloons of progressively larger diameter
What happens if endoscopic pneumatic dilation is ineffective?
A Heller myotomy may be performed laparoscopically
What does a Heller myotomy involve?
Cutting through the muscles of the LES to allow food to pass
What common complication may arise after treatment?
GERD with esophagitis and stricture
What is the role of nitrates in treatment?
They are used for symptom management, taken sublingually before meals
What are the side effects of using nitrates?
Drug tolerance and short duration of action
What dietary recommendations are given for symptomatic treatment?
Eating a soft diet, eating slowly, drinking fluids with meals, and keeping the head elevated
What are esophageal varices?
Dilated, tortuous veins occurring in the lower part of the esophagus
What causes esophageal varices?
Portal hypertension
What environment is necessary for the development of peptic ulcers?
An acid environment is necessary for the development of peptic ulcers.
Is an excess of HCl acid necessary for ulcer development?
No, an excess of HCl acid is not necessary for ulcer development.
What changes pepsinogen to pepsin?
HCl acid and a pH of 2 to 3 change pepsinogen to pepsin.
What happens to pepsin activity at a pH of 3.5 or more?
Pepsin has little or no proteolytic activity.
What results from the back diffusion of HCl acid into the gastric mucosa?
Cellular destruction and inflammation result from the back diffusion of HCl acid.
What is released from the damaged mucosa during ulcer development?
Histamine is released from the damaged mucosa.
What are the effects of histamine release in the context of ulcers?
Vasodilation, increased capillary permeability, and further secretion of acid and pepsin occur.
What is the major risk factor for peptic ulcer disease (PUD)?
Infection with Helicobacter pylori is the major risk factor for PUD.
What percentage of gastric ulcers are related to H. pylori infection?
80% of gastric ulcers are related to H. pylori infection.
What is the infection rate of H. pylori in the United States for persons younger than 30 years?
20% of persons younger than 30 years are affected by H. pylori.
What is the infection rate of H. pylori in the United States for persons older than 60 years?
50% of persons older than 60 years are affected by H. pylori.
How is H. pylori likely transmitted to children?
H. pylori is likely transmitted during childhood from family members through fecal-oral or oral-oral routes.
What distinguishes chronic ulcers from acute ulcers?
Chronic ulcers are more common and can erode through the muscular wall.
What are the common sites for gastric and duodenal ulcers?
Common sites include the stomach and small intestine.
What strains of H. pylori are more likely to cause PUD?
CagA-positive strains of H. pylori are more likely to cause PUD.
What are the characteristics of duodenal ulcers?
Superficial, smooth margins; penetrating with deformity of duodenal bulb from healing of recurrent ulcers
Duodenal ulcers are typically found in the first 1-2 cm of the duodenum.
Where are gastric ulcers primarily located?
Predominantly in the antrum; also in the body and fundus of the stomach
Gastric ulcers can occur in any part of the stomach but are most commonly found in the antrum.
What is the typical gastric secretion level in duodenal ulcers?
Normal to decreased
This contrasts with gastric ulcers, which may have different secretion levels.
What is the peak age for duodenal ulcers?
50-60 years
The incidence of duodenal ulcers is higher in men but increasing in women, especially postmenopausal.
What is the incidence of H. pylori infection in duodenal ulcers?
80%
H. pylori infection is a significant risk factor for duodenal ulcers.
What are common clinical manifestations of duodenal ulcers?
Burning or gaseous pressure in midepigastrium and upper abdomen; back pain with posterior ulcers
Pain typically occurs 1-2 hours after meals.
What is the recurrence rate of gastric ulcers compared to duodenal ulcers?
Higher for gastric ulcers
Recurrence rates can vary significantly between the two types of ulcers.
What is the role of NSAIDs in peptic ulcer disease (PUD)?
Responsible for most non-H. pylori peptic ulcers; they inhibit prostaglandin synthesis and increase gastric acid secretion
NSAID use in the presence of H. pylori further increases the risk for PUD.
What lifestyle factors can contribute to the development of ulcers?
High alcohol intake, smoking, stress, and depression
These factors can stimulate acid secretion and delay healing of ulcers.
What is the effect of corticosteroids on the gastric mucosa?
Affects mucosal cell renewal and decreases its protective effects
Patients taking corticosteroids with NSAIDs have a higher risk for PUD.
What is a significant consequence of H. pylori infection?
Increased gastric secretion and tissue damage, leading to PUD
H. pylori produces urease, which metabolizes urea into ammonium chloride and other damaging chemicals.
What are the characteristics of gastric ulcers?
Round, oval, or cone shaped lesions; can occur in any part of the stomach, most often in the antrum
Gastric ulcers are less common than duodenal ulcers.
What is the peak incidence age for gastric ulcers?
35-45 years
Gastric ulcers are more prevalent in women and those over 50 years of age.
What is the incidence of H. pylori infection in gastric ulcers?
90%
This high incidence indicates a strong link between H. pylori and gastric ulcers.
What symptoms are associated with gastric ulcers?
Burning, cramping, pressure-like pain across the epigastrium; pain can occur 2-5 hours after meals
Pain may also occur midmorning, midafternoon, and during the night.
What happens to gastric mucosal blood flow in the presence of ulcers?
Inadequate blood flow leads to tissue anoxia and acidosis
This can result in severe injury to the gastric mucosa.
What are the main risk factors for duodenal ulcers?
High gastric acidity and pulmonary disease
Other risk factors may include chronic use of NSAIDs and smoking.
Where is the discomfort generally located in gastric ulcers?
High in the epigastric region
How soon after meals do gastric ulcer symptoms typically occur?
1 to 2 hours
What is the description of pain in gastric ulcers?
Burning or gaseous
What symptoms occur in duodenal ulcers when gastric acid comes in contact with the ulcers?
Burning or cramplike pain
When do symptoms of duodenal ulcers typically occur after meals?
2 to 5 hours
What region is the pain most often located in duodenal ulcers?
Midepigastric region beneath the xiphoid process
What additional symptoms can duodenal ulcers cause?
Bloating, nausea, vomiting, early feelings of fullness
What are silent peptic ulcers more likely to occur in?
Older adults and those taking NSAIDs
What is the most accurate procedure to determine the presence and location of an ulcer?
Endoscopy
What does endoscopy allow for in relation to ulcers?
Direct viewing of the gastric and duodenal mucosa
What is the gold standard for diagnosing H. pylori infection?
Biopsy of the antral mucosa with testing for urease
What noninvasive tests are available to confirm H. pylori infection?
Serology, stool, and breath testing
Which test is more accurate for identifying active H. pylori infection?
Urea breath test
What laboratory tests may be done to assess complications from ulcers?
CBC, liver enzyme studies, serum amylase, and stool examination
What is the aim of treatment for duodenal ulcers?
Decrease gastric acidity and enhance mucosal defense mechanisms
What is the typical duration for ulcer healing?
3 to 9 weeks
How long after diagnosis and treatment is the usual follow-up endoscopic evaluation?
3 to 6 months
What should be stopped for 4 to 6 weeks in ulcer treatment?
Aspirin and nonselective NSAIDs
What may be prescribed when aspirin must be continued during ulcer treatment?
PPI, H2 receptor blocker, or misoprostol
What are the diagnostic assessments for Peptic Ulcer Disease?
- History and physical assessment
- Upper GI endoscopy with biopsy
- Endoscopic ultrasound
- H. pylori testing of breath, urine, blood, tissue
- Complete blood cell count
- Liver enzymes
- Serum amylase
- Stool testing for blood
These assessments help in confirming the diagnosis and understanding the severity of the condition.
What are the components of conservative therapy for Peptic Ulcer Disease?
- Adequate rest
- Smoking and alcohol cessation
- Stress management
Conservative therapy aims to promote healing and prevent complications.
What types of drug therapy are used for H. pylori infection?
- Antibiotics
- Proton pump inhibitors (PPIs)
- H2 receptor blockers
- Cytoprotective drugs
- Antacids
These medications work synergistically to eradicate H. pylori and promote ulcer healing.
What is the management approach during an acute exacerbation without complications?
- NPO (nothing by mouth)
- NG suction
- Adequate rest
- IV fluid replacement
These measures help stabilize the patient’s condition and prevent further complications.
What additional management is required during an acute exacerbation with complications?
- NPO
- NG suction
- IV proton pump inhibitors (PPIs)
- Bed rest
- IV fluid replacement
- Blood transfusions
- Stomach lavage (possible)
Complications may include bleeding, perforation, or obstruction, necessitating more intensive management.
What surgical therapies may be indicated for Peptic Ulcer Disease?
- Pyloroplasty and vagotomy for gastric outlet obstruction
- Simple closure with omentum graft for perforation
- Ulcer removal or reduction
- Billroth I and II procedures
- Vagotomy and pyloroplasty
Surgical interventions are considered when medical management fails or complications arise.
What role do proton pump inhibitors (PPIs) play in the treatment of ulcers?
PPIs are more effective than H2 receptor blockers in reducing gastric acid secretion and promoting ulcer healing.
They are often used in combination with antibiotics to treat ulcers caused by H. pylori.
What is the function of sucralfate in ulcer treatment?
Sucralfate provides mucosal protection for the esophagus, stomach, and duodenum but does not have acid-neutralizing capabilities.
It is most effective at a low pH and should be administered at least 60 minutes before or after an antacid.
What are the potential side effects of misoprostol?
- Diarrhea
- Abdominal pain
- Teratogenic effects
Misoprostol is used to prevent gastric ulcers caused by NSAIDs but must be used cautiously in women of childbearing age.
What are adjunct drugs used in the management of Peptic Ulcer Disease?
- H2 receptor blockers
- Antacids
These adjunct therapies promote ulcer healing by increasing gastric pH and reducing acid content.
Which antibiotics may be included in a regimen for H. pylori treatment?
- Amoxicillin
- Rifabutin
- Metronidazole
These antibiotics can be part of a combination therapy to effectively eradicate H. pylori.
What is the impact of smoking on ulcer treatment?
Smoking irritates the mucosa and delays mucosal healing.
Patients are advised to stop smoking to enhance treatment outcomes.
What is the first-line drug therapy for H. pylori infection?
PPI, Amoxicillin, Clarithromycin
PPI: Proton Pump Inhibitor
What are the components of Triple Therapy for H. pylori infection?
PPI, Amoxicillin, Clarithromycin
Typically involves 20-40 mg of PPI, 1 g of Amoxicillin, and 500 mg of Clarithromycin.
What is included in Bismuth Quadruple Therapy?
PPI, Bismuth compound, Metronidazole, Tetracycline
Dosages include 20-40 mg PPI, 2 tablets of Bismuth, 500 mg of Metronidazole, and 500 mg of Tetracycline.
What are the major complications of chronic Peptic Ulcer Disease (PUD)?
GI bleeding, Perforation, Gastric outlet obstruction
These complications can be emergency situations requiring surgical intervention.
What is the most common complication of PUD?
GI bleeding
Duodenal ulcers cause more bleeding episodes than gastric ulcers.
What is the most lethal complication of PUD?
Perforation
The risk of perforation is highest with large penetrating duodenal ulcers.
What happens during perforation of an ulcer?
Ulcer penetrates the serosal surface, spilling contents into the peritoneal cavity
Contents may include air, saliva, food particles, HCl, pepsin, bacteria, bile, and pancreatic fluid.
What are the initial symptoms of perforation?
Sudden severe upper abdominal pain, rigid abdomen, absent bowel sounds
Pain may radiate to the back and shoulders, and food or antacids do not relieve it.
What is the immediate focus of managing a patient with a perforation?
Stop spillage of gastric or duodenal contents and restore blood volume
An NG tube can provide continuous aspiration and gastric decompression.
What fluids are used to replace circulating blood volume in perforation management?
Lactated Ringer’s and albumin solutions
These substitute for fluids lost as peritonitis develops.
What is the role of broad-spectrum antibiotics in perforation management?
To treat bacterial peritonitis
Initiated immediately after perforation is diagnosed.
What may happen with small perforations without treatment?
They may spontaneously seal themselves
Symptoms cease due to fibrin formation.
What is the recommended therapy for patients with a history of heart disease during perforation management?
ECG monitoring or pulmonary artery catheter for left ventricular function assessment
Important for monitoring cardiovascular status.
What is Peptic Ulcer Disease (PUD)?
A condition characterized by open sores on the lining of the stomach or the first part of the small intestine.
What are the common medications associated with PUD?
- Aspirin
- Corticosteroids
- NSAIDs
What immediate action is required for larger perforations in PUD?
Immediate surgical closure.
What is the purpose of suctioning gastric contents during surgery for PUD?
To remove excess gastric contents from the peritoneal cavity.
Identify some subjective data to assess in a patient with PUD.
- Chronic pain
- Anorexia
- Nausea
- Vomiting
What are some signs of gastric outlet obstruction caused by PUD?
- Discomfort or pain worse toward the end of the day
- Belching
- Projectile vomiting
What symptoms might indicate a patient is experiencing gastric outlet obstruction?
- Constipation from dehydration
- Visible swelling in the upper abdomen
- Anemia
What is the aim of therapy for gastric outlet obstruction?
- Decompress the stomach
- Correct fluid and electrolyte imbalances
- Improve general health
What diagnostic findings can suggest PUD?
- H. pylori presence
- Abnormal upper GI endoscopic studies
- Barium studies
What nursing management strategies are essential for patients with PUD?
- Identify at-risk patients
- Early detection and treatment
- Encourage taking ulcerogenic drugs with food
What are the overall goals for a patient with PUD during treatment?
- Adhere to therapeutic regimen
- Achieve pain relief
- Be free from complications
- Complete healing of the ulcer
- Make lifestyle changes to prevent recurrence
What might analysis of gastric contents include?
- pH testing
- Analysis for blood
- Analysis for bile or other substances
What should patients be taught regarding symptoms related to gastric irritation?
To report symptoms, including epigastric pain, to their healthcare provider.
What is the initial treatment for a patient with acute upper gastrointestinal problems?
IV fluids with electrolyte replacement to keep the patient hydrated
This treatment is essential until edema and inflammation resolve.
What should patients with Peptic Ulcer Disease (PUD) be taught to prevent recurrence?
Teaching should cover aspects of the disease process, drugs, lifestyle changes, and dietary modifications
Important lifestyle changes include reducing alcohol use and quitting smoking.
What medications should patients with PUD avoid unless approved by their healthcare provider?
Over-the-counter drugs such as NSAIDs and aspirin
These medications can exacerbate ulcer symptoms.
What is a common complication of PUD that requires immediate intervention?
Gastric outlet obstruction
This is most likely to occur when the ulcer is close to the pylorus.
What are the key lifestyle changes recommended for patients with PUD?
- Avoid acidic foods
- Avoid cigarettes
- Reduce or stop alcohol use
Smoking delays ulcer healing and promotes ulcer development.
What should be monitored to check for ongoing obstruction in a patient with PUD?
Gastric residual volume measured by clamping the NG tube intermittently
Clamping the tube helps assess the patient’s comfort level and the amount of aspirate obtained.
What should patients do if they experience increased nausea or vomiting while managing PUD?
Report any increased nausea or vomiting to the healthcare provider
This could indicate complications that need immediate attention.
What should be emphasized to patients regarding prescribed drug therapy for PUD?
Follow prescribed drug therapy to prevent a relapse, including antisecretory and antibiotic drugs
Adherence to medication is crucial for managing PUD effectively.
What is the recommended action if symptoms of obstruction return after resuming oral feedings?
Promptly inform the healthcare provider
Quick communication is essential for timely intervention.
What is a common method for assessing gastric residual volume in patients with PUD?
Clamp the NG tube overnight and measure the residual volume in the morning
A residual volume below 200 mL indicates that the patient can begin oral intake of clear liquids.
What should patients with PUD learn about stress management?
Learn and use stress management strategies
Stress can be related to the exacerbation of PUD symptoms.
What is the main type of cancer associated with the stomach?
Adenocarcinoma
Stomach cancer is primarily classified as adenocarcinoma.
What are the demographics with the highest rates of stomach cancer?
Asian Americans, Pacific Islanders, Blacks, and Hispanics
These groups have the highest incidence rates of stomach cancer.
What is the average age at diagnosis for stomach cancer?
68.5 years
This statistic reflects the typical age at which patients are diagnosed with stomach cancer.
What percentage of stomach cancer patients have disease confined to the stomach at diagnosis?
10% to 20%
This indicates that a majority of patients present with more advanced disease.
What is the overall 5-year survival rate for stomach cancer?
About 32%
This survival rate reflects the prognosis for all diagnosed individuals.
What are common clinical manifestations of stomach cancer?
- Unexplained weight loss
- Indigestion
- Abdominal discomfort or pain
- Anemia
- Early satiety
- Fatigue
These symptoms may indicate the presence of stomach cancer.
What is the best diagnostic tool for stomach cancer?
Upper GI endoscopy
This procedure allows for direct visualization and biopsy of the gastric mucosa.
What does endoscopic ultrasound help with in the context of stomach cancer?
Staging the disease
This imaging technique is useful for assessing the extent of cancer spread.
What is the primary treatment option for stomach cancer?
Surgical removal of the tumor
Surgery aims to excise the tumor along with a margin of healthy tissue.
What are some risk factors for stomach cancer?
- Atrophic gastritis
- Pernicious anemia
- Adenomatous polyps
- Hyperplastic polyps
- Smoking
These factors can increase the likelihood of developing stomach cancer.
What is a poor prognostic sign in stomach cancer patients?
Presence of ascites
Ascites indicates advanced disease and is associated with a worse prognosis.
What is the relationship between first-degree relatives of stomach cancer patients and their risk?
Increased risk of stomach cancer
Family history can be a significant risk factor for developing stomach cancer.
What is the significance of tumor markers in stomach cancer diagnosis?
They can help diagnose cancer
Tumor markers are substances that can indicate the presence of cancer in the body.
What is the role of blood studies in diagnosing stomach cancer?
- Detect anemia
- Determine severity
Blood tests can reveal complications related to stomach cancer.
What common symptom might not be the first to present in older adults with PUD?
Pain
Older patients may experience different symptoms, such as gastric bleeding, as initial indicators.
What lifestyle factors can influence the development of stomach cancer?
- Tobacco use
- Obesity
- Diet high in smoked foods
These lifestyle choices can contribute to the risk of stomach cancer.
What is subtotal gastrectomy?
A surgical procedure where a portion of the stomach is removed, either as Billroth I or Billroth II procedure.
What are the primary types of surgical therapy for stomach cancer?
- Subtotal gastrectomy (Billroth I or II)
- Total gastrectomy with esophagojejunostomy
What are the common biomarkers used in the diagnosis of duodenal cancer?
- Carbohydrate antigen (CA) 19-9
- CA-125
- CA 72-4
- Carcinoembryonic antigen (CEA)
What is vagotomy?
A surgical procedure that involves cutting the vagus nerve to reduce acid secretion in the stomach.
What is the purpose of preoperative management in stomach cancer?
To correct nutritional status and treat anemia, often through packed RBCs transfusions.
What may be necessary if gastric outlet obstruction occurs?
Gastric decompression may be needed before surgery.
What are the main chemotherapy agents used in stomach cancer treatment?
- Docetaxel
- Epirubicin
- Irinotecan
- Oxaliplatin
- Paclitaxel
What is the significance of a nutrition assessment in stomach cancer patients?
To evaluate appetite changes, weight loss, and overall nutrition status, as malnourished patients respond poorly to treatment.
What are the two targeted therapies mentioned for stomach cancer?
- Trastuzumab (Herceptin)
- Ramucirumab (Cyramza)
How does Trastuzumab work in treating stomach cancer?
It targets the HER-2 protein on cancer cells and kills them.
What role does ramucirumab play in cancer treatment?
It binds to the VEGF receptor, preventing VEGF from binding and thus inhibiting cancer growth.
What symptoms might a patient with stomach cancer experience?
- Vague abdominal symptoms
- Dyspepsia
- Intestinal gas discomfort or pain
What is cachexia in the context of stomach cancer?
A condition characterized by severe weight loss and muscle wasting due to prolonged oral intake reduction.
What is the potential benefit of combining radiation therapy with chemotherapy?
It can reduce recurrence or provide palliative measures to decrease tumor mass and relieve obstruction.
What is the primary focus of acute care for patients with stomach cancer?
Assessing the patient’s expectations about surgery and their response to previous surgical procedures.
List some clinical problems for patients with stomach cancer.
- Nutritionally compromised
- Pain
- Impaired GI function
- Difficulty coping
What are the overall goals for a patient with stomach cancer?
- Have minimal discomfort
- Achieve optimal nutrition status
- Maintain a degree of spiritual and psychologic well-being appropriate to the disease stage
What is the role of health promotion in early detection of stomach cancer?
Identifying patients at risk due to problems like H. pylori infection, pernicious anemia, and achlorhydria.
What symptoms should patients with a positive family history of stomach cancer monitor?
- Anemia
- PUD
- Vague epigastric distress
What is an important consideration for patients treated for PUD?
Recognizing the possibility of stomach cancer if relief was not achieved.
What are the expected outcomes for a patient with stomach cancer?
- Have minimal discomfort, pain, or nausea
- Achieve optimal nutrition status
- Maintain a degree of psychologic well-being appropriate to the disease stage
What are gastrointestinal stromal tumors (GISTs)?
A rare cancer that originates in cells in the wall of the GI tract.
What should be provided to patients undergoing chemotherapy or radiation treatment?
A referral to home health care for support during recovery.
Why is regular follow-up important for cancer patients?
Recurrence of cancer is common, requiring regular examinations and imaging assessments.
What is dumping syndrome?
A condition that occurs after surgical removal of a large part of the stomach and pyloric sphincter, leading to rapid gastric emptying.
What are the common symptoms of dumping syndrome?
- Generalized weakness
- Sweating
- Palpitations
- Dizziness
- Abdominal cramps
- Borborygmi
- Urge to defecate
How quickly do symptoms of dumping syndrome typically begin after eating?
Within 15 to 30 minutes.
What is postprandial hypoglycemia?
A variant of dumping syndrome caused by uncontrolled gastric emptying of high-carbohydrate fluids into the small intestine, leading to excess insulin release.
What symptoms are associated with postprandial hypoglycemia?
- Sweating
- Weakness
- Mental confusion
- Palpitations
- Tachycardia
- Anxiety
How long after eating do symptoms of postprandial hypoglycemia typically occur?
Generally 2 hours after eating.
What types of surgeries are performed to treat upper gastrointestinal problems?
- Partial gastrectomy
- Gastrectomy
- Vagotomy
- Pyloroplasty
What is bile reflux gastritis?
A condition that results from bile entering the stomach, causing damage to the gastric mucosa and leading to chronic gastritis and PUD.
What are the main symptoms of bile reflux gastritis?
Continuous epigastric distress that increases after meals.
What treatment can be used to manage bile reflux gastritis?
Cholestyramine, which binds with bile salts to reduce gastric irritation.
What is vagotomy?
The surgical procedure involving the severing of the vagus nerve to decrease gastric acid secretion.
What is pyloroplasty?
The surgical enlargement of the pyloric sphincter to facilitate the passage of contents from the stomach.
What are the common long-term postoperative complications from gastric surgery?
- Dumping syndrome
- Postprandial hypoglycemia
- Bile reflux gastritis
What is the focus of postoperative care after gastric surgery?
- Maintaining fluid and electrolyte balance
- Preventing respiratory complications
- Maintaining comfort
- Preventing infection
What is a total gastrectomy?
A surgical procedure involving the resection of the lower esophagus and the entire stomach, with anastomosis to the jejunum.
What is the role of a short rest period after meals in managing dumping syndrome?
It reduces the chance of experiencing dumping syndrome symptoms.
What monitoring is necessary for postoperative care following gastric surgery?
Monitoring for acute postoperative bleeding, fluid balance, and respiratory complications.
What are some complications that morbidly obese patients face after surgery?
Complications include atelectasis, pneumonia, anastomotic leak, deep vein thrombosis, pulmonary embolus, and bleeding.
What is the purpose of using an NG tube after surgery?
The NG tube is used for decompression to decrease pressure on suture lines and allow edema and inflammation to resolve.
What should be observed in the gastric aspirate after surgery?
Observe the gastric aspirate for color, amount, and odor.
What is the expected change in NG aspirate color within the first 24 hours after surgery?
The NG aspirate should gradually darken and change to yellow-green within 36 to 48 hours.
What should be reported immediately regarding NG tube drainage?
Report bright red bleeding that does not decrease after 2 to 3 hours or excessive bleeding (more than 75 ml/hr).
What are the potential complications if the NG tube is not functioning properly?
Complications include rupture of sutures, leakage of gastric contents, bleeding, and abscess formation.
What should be done if the NG tube becomes clogged?
Notify the HCP immediately and gentle irrigations with normal saline solution may be ordered.
What should be maintained while the NG tube is connected to suction?
Maintain IV therapy.
What indicates a possible anastomotic leak?
Signs include tachycardia, dyspnea, fever, abdominal pain, anxiety, and restlessness.
What is the purpose of splinting during deep breathing and coughing?
Splinting protects the abdominal suture line from rupturing.
What dietary changes are recommended for patients after a gastrectomy?
Dietary changes include dividing meals into 6 small feedings, avoiding fluids with meals, and limiting concentrated sweets.
What are the purposes of dietary restrictions after gastrectomy?
Purposes include slowing the rapid passage of food and controlling symptoms of dumping syndrome.
What types of foods should be increased in the diet post-gastrectomy?
Increase protein consumption, particularly meat and eggs.
How should milk and dairy products be introduced after surgery?
Introduce milk and milk products slowly several weeks after surgery.
What types of foods should be avoided to prevent gastric distention?
Avoid carbonated beverages and gas-forming foods.
What types of carbohydrates should be increased in the post-gastrectomy diet?
Increase complex carbohydrates such as bread, vegetables, rice, and potatoes.
What is a long-term complication of total gastrectomy?
Pernicious anemia.
What is intrinsic factor essential for?
The absorption of vitamin B12
Intrinsic factor is produced by the stomach and is crucial for the absorption of vitamin B12 in the intestines.
What are some drug-related causes of gastritis?
- Aspirin
- Bisphosphonates
- Corticosteroids
- Digitalis
- Iron supplements
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
These drugs can irritate the gastric mucosa and lead to gastritis.
What dietary indiscretions can lead to acute gastritis?
- Alcohol binge drinking
- Large quantities of spicy, irritating foods
These factors can cause damage ranging from superficial injury to significant mucosal destruction.
What is the primary infectious agent associated with acute gastritis?
Helicobacter pylori
H. pylori infection is common and can lead to both acute and chronic gastritis.
What are some other risk factors for gastritis?
- Prolonged vomiting
- Reflux of bile salts
- Intense emotional responses
- CNS lesions
These factors can contribute to the inflammation of the gastric mucosa.
What is autoimmune gastritis?
An inherited condition where there is an immune response against parietal cells
It often affects women of northern European descent and is associated with other autoimmune disorders.
What are the consequences of a broken gastric mucosal barrier?
- Tissue edema
- Disruption of capillary walls
- Loss of plasma into the gastric lumen
- Possible bleeding
These consequences arise when HCl acid and pepsin diffuse back into the gastric mucosa.
What are common symptoms of gastritis?
- Nausea
- Vomiting
- Abdominal pain
- Loss of appetite
Symptoms may vary based on the severity and type of gastritis.
What is the impact of NSAIDs on the gastric mucosa?
They inhibit the synthesis of prostaglandins that protect the gastric mucosa
This inhibition makes the mucosa more susceptible to injury and can lead to gastritis.
What is chronic gastritis?
A long-term inflammation of the gastric mucosa that may result from repeated acute gastritis episodes
Chronic gastritis can lead to functional changes in the stomach and increase the risk of stomach cancer.
What is an important dietary recommendation for patients to avoid hypoglycemic episodes?
Limit the amount of sugar with each meal and eat small, frequent meals
This helps manage blood sugar levels effectively.
What is the role of intrinsic factor in the body?
Intrinsic factor is essential for cobalamin (vitamin B12) absorption.
A deficiency in intrinsic factor can lead to pernicious anemia.
What are common symptoms of acute gastritis?
- Anorexia
- Nausea and vomiting
- Epigastric tenderness
- Feeling of fullness
- GI bleeding
GI bleeding is often associated with alcohol use and may be the only symptom in some cases.
How long does acute gastritis typically last?
Acute gastritis is self-limiting, lasting from a few hours to a few days.
The mucosa should heal completely within this time.
What are the manifestations of chronic gastritis?
Similar to acute gastritis; some patients may be asymptomatic.
Loss of parietal cells due to atrophy can result in a lack of intrinsic factor.
What diagnostic studies are used for acute gastritis?
- Patient symptoms and risk factors
- Endoscopic examination with biopsy (occasionally)
- Breath, urine, serum, stool, and gastric tissue biopsy tests for H. pylori
- CBC to check for anemia
- Stools tested for occult blood
- Serum tests for intrinsic factor and antibodies to parietal cells
- Tissue biopsy to rule out gastric cancer
H. pylori is a common cause of gastritis.
What is the primary treatment approach for acute gastritis?
Eliminating the cause and supportive care.
Treatment may include rest, NPO status, IV fluids, and antiemetics.
What are the indications for using an NG tube in severe acute gastritis?
- Monitor for bleeding
- Lavage the precipitating agent from the stomach
- Keep the stomach empty and free of noxious stimuli
Clear liquids should be resumed once symptoms subside.
What medications are commonly used to treat acute gastritis?
- H2 receptor blockers (e.g., cimetidine)
- Proton pump inhibitors (PPIs) (e.g., omeprazole)
These medications help reduce gastric acid secretion.
What lifestyle changes may be necessary for patients with chronic gastritis?
- Abstaining from alcohol
- Smoking cessation
- Following a diet of small, frequent meals
A team approach involving healthcare providers can support these lifestyle changes.
What is the incidence of acute upper GI bleeding in the U.S.?
103 cases per 100,000 adults per year.
The mortality rate in hospitalized patients is 14%.
What factors can influence the severity of upper GI bleeding?
The severity depends on whether the origin is venous, capillary, or arterial.
Arterial bleeding is profuse and bright red, while venous bleeding may present differently.
What is the most common cause of upper GI bleeding?
Peptic ulcers due to H. pylori infection and NSAID use.
About 25% of people on chronic NSAIDs develop ulcers.
What is melena and what does it indicate?
Melena refers to black, tarry stools, indicating slow bleeding from an upper GI source.
The darker the stool, the longer the blood has been in the intestines, undergoing breakdown.
What are the causes of upper GI bleeding from the esophagus?
- Esophageal varices
- Esophagitis
- Mallory-Weiss tear
What might an increased BUN level indicate in patients with significant upper GI bleeding?
- GI tract bacteria breakdown proteins
- Renal hypoperfusion
- Renal disease
What constitutes a massive upper GI hemorrhage?
Loss of more than 1500 mL of blood or 25% of intravascular blood volume
What is the risk percentage of spontaneous cessation of bleeding in patients with massive hemorrhage?
80% to 85%
What is stress-related mucosal disease (SRMD)?
Damage in the GI tract associated with serious illness, ranging from small ulcers to major bleeding
What are common causes of chronic esophagitis?
- GERD
- Smoking
- Alcohol use
- Irritating drugs
What is the primary diagnostic tool for identifying the source of upper GI bleeding?
Endoscopy
When is angiography used in the context of upper GI bleeding?
When endoscopy cannot be done or when bleeding persists after endoscopic therapy
What laboratory studies are important in assessing upper GI bleeding?
- CBC
- Blood urea nitrogen (BUN)
- Serum electrolytes
- Prothrombin time
- Partial thromboplastin time
- Liver enzymes
- Arterial blood gases (ABGs)
- Type and crossmatch for possible blood transfusions
Why are hemoglobin and hematocrit values not immediately helpful in estimating blood loss?
They may not reflect the loss until 4 to 6 hours after fluid replacement
What are the signs and symptoms of shock to identify during emergency assessment?
- Tachycardia
- Weak pulse
- Hypotension
- Cool extremities
- Prolonged capillary refill
- Apprehension
What is one of the best measures of vital organ perfusion?
Urine output
What type of solution is generally started for fluid replacement in upper GI bleeding?
Isotonic crystalloid solution (e.g., lactated Ringer’s solution)
What are the three techniques used in endoscopic hemostasis?
- Mechanical therapy with clips or bands
- Thermal ablation
- Injection (e.g., epinephrine)
What is the goal of endoscopic hemostasis?
To coagulate or thrombose the bleeding vessel
What devices are commonly used in thermal ablation during endoscopic therapy?
- Neodymium: yttrium-aluminum-garnet (YAG) laser
- Monopolar or bipolar electrocoagulation
- Heater probes
- Argon plasma coagulation (APC)
What are the strategies for managing variceal bleeding?
Variceal ligation, injection sclerotherapy, balloon tamponade
See Chapter 48 for detailed information.
When is surgical intervention needed for UGI bleeding?
When bleeding continues despite therapy and there is an identified site of bleeding.
What indicates the choice of surgery in UGI bleeding?
The site of the bleeding.
What is a critical factor in the mortality rates of patients with UGI bleeding?
Increased mortality rates in older patients.
What is the purpose of drug therapy during the acute phase of UGI bleeding?
To decrease bleeding, decrease HCl acid secretion, and neutralize HCl acid.
What type of therapy is often initiated before endoscopy for UGI bleeding?
Empiric PPI therapy with high-dose IV bolus and subsequent infusion.
Why is it important to reduce acid secretion during UGI bleeding?
Because the acidic environment can alter platelet function and interfere with clot stabilization.
What may be given after the acute phase of UGI bleeding?
Antacids, either orally or through the NG tube.
What should be done if the pH level of stomach contents is less than 5?
Intermittent suction may be used or the frequency or dosage of the antacid or antisecretory agent increased.
What is the first step in nursing management for a patient with UGI bleeding?
Perform a thorough assessment.
What vital signs should be monitored in a patient with UGI bleeding?
BP and pulse.
What are signs and symptoms of shock due to blood loss?
Low BP, rapid weak pulse, increased thirst, cold clammy skin, restlessness.
How often should vital signs be monitored in patients with UGI bleeding?
Every 15 to 30 minutes.
What important health information should be assessed in a patient with UGI bleeding?
History of chronic gastritis, medications like aspirin, NSAIDs, corticosteroids, anticoagulants.
What are some functional health patterns to assess in a patient with UGI bleeding?
Alcohol use, nausea, vomiting, weight loss, weakness, dizziness.
What is a possible diagnostic finding in a patient with UGI bleeding?
Hematocrit and hemoglobin levels, hematuria, guaiac-positive stools.
What are the clinical problems associated with UGI bleeding?
Fluid imbalance, inadequate tissue perfusion, impaired GI function.
What are the overall goals for a patient with UGI bleeding?
No further GI bleeding, cause identified and treated, return to normal hemodynamic state.
What is the primary risk associated with patients taking chemotherapy drugs?
Increased risk for GI bleeding due to decreased production of clotting factors and platelets.
Patients with blood disorders or liver disease are also at risk.
What are the initial assessment findings for acute GI bleeding?
- Abdominal pain
- Hematemesis
- Melena
- Nausea
- Abdominal rigidity
- Cool, clammy skin
- Altered level of consciousness
- Slow capillary refill
- Decreased urine output (<0.5 mL/kg/hr)
These findings are critical for determining the severity of the condition.
What are the priority nursing interventions for a patient with acute GI bleeding?
- Assess circulation, airway, and breathing if unresponsive
- Monitor airway, breathing, and circulation if responsive
- Establish IV access with a large bore catheter
- Start fluid replacement therapy
- Initiate ECG monitoring
- Obtain blood for CBC and clotting studies
- Insert an NG tube as needed
- Provide oxygen via nasal cannula or nonrebreather mask
These interventions are essential for stabilizing the patient.
Why is monitoring vital signs critical in patients with CVD?
Dysrhythmias may occur, necessitating close observation.
Patients with cardiovascular disease are particularly vulnerable to changes in their vital signs.
What should be done when an NG tube is present in a patient with GI bleeding?
- Keep the tube in proper position
- Check the aspirate for blood
- Use caution if resistance is felt during aspiration
Resistance may indicate the tip of the NG tube is against the gastric mucosal lining.
What is the purpose of gastric lavage in the context of UGI bleeding?
To remove blood and other contents from the stomach.
The effectiveness of gastric lavage for UGI bleeding is questionable.
What symptoms indicate the onset of delirium tremens in patients with alcohol withdrawal?
- Agitation
- Uncontrolled shaking
- Sweating
- Hallucinations
These symptoms require close monitoring in patients with a history of chronic alcohol use.
What is the recommended approach when beginning oral intake after UGI bleeding?
- Start with clear fluids hourly
- Gradually introduce foods if no signs of problems arise
- Observe for symptoms of nausea and vomiting
- Monitor for recurrence of bleeding
This gradual approach helps ensure patient safety and tolerance.
What are the signs of fluid overload to monitor in older adults or patients receiving large amounts of IV fluids?
- Signs of pulmonary edema
- Auscultate breath sounds
- Observe respiratory effort
- Elevate the head of the bed to prevent aspiration
Fluid overload can lead to serious complications in these patients.
What should patients and caregivers be taught to avoid future bleeding episodes?
- Adherence to drug therapy
- Avoidance of drugs that increase bleeding risk, especially aspirin
Education on medication management is crucial for preventing recurrence.
What is the importance of maintaining an accurate intake and output record in acute care?
To monitor the patient’s fluid balance and guide further interventions.
Accurate documentation is essential for effective patient management.
What toxin causes botulism?
Toxin from Clostridium botulinum
What is the primary source of bacterial food poisoning?
Improperly canned or preserved food
What are the common symptoms of Clostridial food poisoning?
Nausea, vomiting, abdominal pain, constipation, distention
What are the symptoms of Escherichia coli food poisoning?
Bloody stools, hemolytic uremic syndrome, abdominal cramping, profuse diarrhea
What is the onset time for Salmonella food poisoning?
8 hours to several days
What are the symptoms associated with Staphylococcal food poisoning?
Vomiting, nausea, abdominal cramping, diarrhea
What is the treatment for botulism?
Maintain ventilation, polym antitoxin, guanidine
How can bacterial food poisoning be prevented?
Correct food preparation and handling
What percentage of Americans experience foodborne illness annually?
1 in 6 Americans, or 48 million people
What is the most common cause of foodborne illnesses?
Bacteria
At what temperature range do bacteria multiply quickly in food?
Between 40°F and 140°F
What is a key instruction for cooking ground beef safely?
Cook until a thermometer reads at least 160°F
What should you do if served undercooked ground beef in a restaurant?
Send it back for further cooking
What should be done to avoid spreading harmful bacteria while cooking?
Keep raw meat separate from ready-to-eat foods and wash hands and utensils
What type of milk should be consumed to prevent foodborne illness?
Pasteurized milk
How should fruits and vegetables be prepared to ensure safety?
Wash thoroughly, especially those not being cooked
What food product should immunocompromised individuals avoid?
Alfalfa sprouts until safety is confirmed
What are the expected outcomes for a patient with UGI bleeding?
Be free from UGI bleeding, maintain normal fluid volume, understand risk factors
What is the primary characteristic of most strains of Escherichia coli?
Most strains are harmless and live in the intestines of healthy humans and animals.
What severe illnesses can E. coli 0157:H7 cause?
Hemorrhagic colitis and kidney failure.
Who is at higher risk for severe illness from E. coli 0157:H7?
Very young children and older adults.
What are common sources of E. coli 0157:H7 infection?
- Undercooked meats
- Contaminated leafy vegetables
- Contaminated fruits and nuts
- Raw milk
- Unpasteurized or contaminated fruit juices
- Sewage-contaminated water
How is E. coli 0157:H7 primarily transmitted?
Person-to-person contact in families, long-term care, and childcare centers.
What is the incubation period for E. coli 0157:H7 infection?
1 to 10 days after swallowing the organism.
What are the main symptoms of E. coli 0157:H7 infection?
- Diarrhea (often bloody)
- Vomiting
- Abdominal cramping pain
What is a significant systemic complication of E. coli 0157:H7 infection?
Hemolytic uremic syndrome (HUS).
How is E. coli 0157:H7 infection diagnosed?
By detecting the bacteria in the stool.
What should all patients with sudden diarrhea containing blood undergo?
A stool culture for E. coli 0157:H7.
What is the primary treatment for E. coli 0157:H7 infection?
Hydration to maintain blood volume.
Why should patients avoid antidiarrheal agents during E. coli 0157:H7 infection?
They slow GI motility and can prolong the infection.
What are potential treatments for severe cases of E. coli 0157:H7 infection?
- Dialysis
- Plasmapheresis
Why are antibiotics seldom given for E. coli 0157:H7 infection?
They increase the risk of complications and do not appear to treat the infection.
What is hemolytic uremic syndrome (HUS)?
A condition where RBCs are destroyed and kidneys fail, often life-threatening.
What is the mortality rate associated with hemolytic uremic syndrome (HUS)?
Around 5%.
What long-term complications can arise from E. coli 0157:H7 infection?
- Abnormal kidney function
- Hypertension
- Seizures
- Blindness
- Paralysis
What percentage of patients may have abnormal kidney function for years after E. coli 0157:H7 infection?
About one-third.
