Chapter 46 Upper Gastrointestinal Problems Part 1 Flashcards
What are the common upper gastrointestinal (GI) problems reviewed in this chapter?
- Nausea and vomiting
- Oral and gastric cancers
- Gastrosophageal reflux
- Ulcerative disease
- Inflammatory and infectious bowel disorders
- GI bleeding
- Structural problems
These conditions impact patient care during upper GI surgery.
What may patients with impaired GI function experience?
- Malnutrition from decreased intake
- Altered fluid balance
- Altered electrolyte balance
- Altered acid-base balance
These issues arise from difficulties in eating, drinking, or talking.
How can pain affect patients with upper GI issues?
- Disrupt sleep
- Cause fatigue
Pain may also impair communication abilities.
What is the risk associated with problems swallowing in patients?
Increased risk for aspiration
Aspiration can lead to serious complications, including pneumonia.
What are the most common manifestations of GI disease?
Nausea and vomiting
These symptoms can indicate a variety of underlying GI issues.
What is nausea?
A feeling of discomfort in the epigastrium with a conscious desire to vomit.
What is vomiting?
The forceful ejection of partially digested food and secretions from the upper GI tract.
Name some conditions unrelated to GI disease that can cause nausea and vomiting.
- Pregnancy
- Infection
- Central nervous system problems (e.g., meningitis, tumor)
- Cardiovascular disease (e.g., myocardial infarction, heart failure)
- Psychological states (e.g., stress, fear)
True or False: Women are less likely to experience nausea and vomiting associated with anesthesia and motion sickness.
False
What coordinates the multiple components involved in vomiting?
A vomiting center in the medulla.
What types of receptors relay information to the vomiting center?
Receptors for afferent fibers found in the GI tract, kidneys, heart, and uterus.
List the structures involved in the act of vomiting.
- Closure of the glottis
- Deep inspiration with contraction of the diaphragm
- Closure of the pylorus
- Relaxation of the stomach and lower esophageal sphincter
- Contraction of abdominal muscles
What is the chemoreceptor trigger zone (CTZ)?
A zone in the brainstem that responds to chemical stimuli from drugs, toxins, and labyrinthine stimulation.
What is the result of sympathetic activation during vomiting?
- Tachycardia
- Tachypnea
- Diaphoresis
What occurs during parasympathetic stimulation related to vomiting?
- Relaxation of the lower esophageal sphincter
- Increased gastric motility
- Increased saliva
What is anorexia?
Lack of appetite.
What complications can arise from prolonged nausea and vomiting?
- Dehydration
- Electrolyte imbalances
- Circulatory failure
What metabolic condition can result from loss of gastric hydrochloric acid?
Metabolic alkalosis.
Fill in the blank: The main goals of care in managing nausea and vomiting are to determine and treat the underlying cause, recognize and correct any complications, and provide _______.
[symptomatic relief]
What is the risk associated with the parenteral route of Promethazine?
Severe tissue injury.
What are 5-HT3 receptor antagonists effective for?
- Chemotherapy-induced vomiting (CINV)
- Postoperative nausea and vomiting (PONV)
- Nausea and vomiting related to migraine headache and anxiety
What is a potential risk of chronic use or high doses of Metoclopramide (Reglan)?
Tardive dyskinesia.
What characterizes tardive dyskinesia?
Involuntary and repetitive movements of the body (e.g., extremity movements, lip smacking).
What is the mechanism of action of scopolamine transdermal?
Block cholinergic pathways to vomiting center
Commonly used to prevent nausea and vomiting.
What are the side effects of scopolamine transdermal?
Dry mouth, somnolence
These side effects can limit its use in some patients.
Which drug is an antihistamine used for nausea and vomiting?
dimenhydrinate (Dramamine)
Other antihistamines include diphenhydramine, hydroxyzine, and meclizine.
What is the primary mechanism of action of cannabinoids like dronabinol?
Inhibit vomiting control mechanism in the medulla oblongata
Cannabinoids are often used in patients undergoing chemotherapy.
List some side effects of cannabinoids.
- Dry mouth
- Amnesia
- Ataxia
- Confusion
- Coordination problems
- Dizziness
- Somnolence
These side effects can affect patient quality of life.
What is the mechanism of action for dexamethasone in preventing nausea?
Not well understood how it prevents nausea and vomiting
Dexamethasone is a corticosteroid often used in cancer treatment.
What are the side effects of dexamethasone?
Hyperglycemia, insomnia, euphoria
These side effects may necessitate monitoring of blood sugar levels.
What type of receptor does amisulpride block?
Dopaminergic receptors in the CTZ
CTZ refers to the chemoreceptor trigger zone in the brain.
List some side effects of amisulpride.
- Chills
- Hypokalemia
- Hypotension
- Abdominal distention
Monitoring for these side effects is important in clinical practice.
What do 5-HT3 (Serotonin) antagonists block?
Action of serotonin
These are commonly used in chemotherapy-induced nausea.
List the side effects of 5-HT3 antagonists.
- Constipation
- Diarrhea
- Headache
- Fatigue
- Malaise
- Liver function tests abnormalities
Regular monitoring of liver function is advised.
What is the action of phenothiazines in treating nausea?
Act in the CNS level of the CTZ and block dopamine receptors
Phenothiazines are often used for severe nausea.
List some side effects of phenothiazines.
- Dry mouth
- Hypotension
- Sedation
- Rashes
- Constipation
These side effects are important to consider when prescribing.
What is the mechanism of action of metoclopramide?
Inhibit action of dopamine
Metoclopramide is used to enhance gastric motility.
What do Substance P/Neurokinin-1 receptor antagonists block?
Interaction of substance P at NK-1 receptor
These antagonists are effective in preventing chemotherapy-induced vomiting.
List some side effects of Substance P/Neurokinin-1 receptor antagonists.
- Anxiety
- Hallucinations
- Extrapyramidal side effects
- Headache
- Hiccups
- Fatigue
- Constipation
- Diarrhea
- Anorexia
Awareness of these side effects is essential for safe use.
What is an oral cannabinoid that may be used to manage CINV?
Dronabinol
Dronabinol is considered when other therapies are ineffective due to its potential for abuse and sedation.
What is the first step in nursing management for patients with nausea and vomiting?
Thorough assessment
Assessment helps to identify patients at high risk and the precipitating factors.
What should be assessed to identify the precipitating cause of nausea and vomiting?
Specific food, timing, prior history, and others’ reactions
This includes determining when the food was eaten and if anyone else who ate it is sick.
What does emesis containing partially digested food several hours after a meal indicate?
Gastric outlet obstruction or delayed gastric emptying
This suggests that food is not moving through the digestive system as it should.
What does the presence of fecal odor and bile in emesis suggest?
Intestinal obstruction below the level of the pylorus
This indicates a significant blockage in the intestines.
What does bile in the emesis suggest?
Obstruction below the ampulla of Vater
This is an important anatomical landmark in the digestive system.
What does bright red blood in emesis indicate?
Active bleeding
This could be due to various conditions such as a Mallory-Weiss tear or esophageal varices.
What does vomitus with a ‘coffee-grounds’ appearance indicate?
Gastric bleeding
The interaction of blood with hydrochloric acid changes its color.
Differentiate between vomiting, regurgitation, and projectile vomiting.
Vomiting: forceful expulsion; Regurgitation: effortless; Projectile vomiting: forceful without nausea
Understanding these differences is crucial for proper assessment.
What often causes projectile vomiting?
Brain and spinal cord tumors
This type of vomiting is typically associated with neurological issues.
What can the timing of nausea and vomiting indicate?
The cause of nausea and vomiting
When is early morning vomiting common?
During pregnancy
What can elicit vomiting during or right after eating?
Emotional stressors
What syndrome is characterized by recurring episodes of nausea, vomiting, and fatigue?
Cyclic vomiting syndrome
What are some clinical problems associated with nausea and vomiting?
- Fluid imbalance
- Electrolyte imbalance
- Nutritionally compromised
- Impaired GI 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 is the common initial treatment for patients with persistent vomiting?
NPO status and IV fluids
What might be required for a patient with persistent vomiting and possible bowel obstruction?
A nasogastric (NG) tube connected to suction
What should be monitored with prolonged vomiting?
- Intake and output
- Vital signs
- Signs of dehydration
What position should a patient who cannot manage self-care be placed in to prevent aspiration?
Semi-Fowler’s or side-lying position
What type of therapy is necessary for a patient with severe vomiting?
IV fluid therapy with electrolyte and glucose replacement
What is the initial fluid of choice for oral rehydration after vomiting?
Water
What is a recommended method for rehydration in a patient recovering from vomiting?
Sip small amounts of fluids (5 to 15 mL) every 15 to 20 minutes
What types of foods are ideal for a recovering patient?
- High in carbohydrates
- Low in fat
- Bland foods like baked potato, rice, cooked chicken, and cereal
What should patients avoid when recovering from nausea and vomiting?
- Coffee
- Spicy foods
- Highly acidic foods
- Foods with strong odors
What should the patient be advised regarding food intake?
Eat slowly and in small amounts
What environmental conditions should be maintained for a patient experiencing nausea?
- Quiet
- Free of noxious odors
- Well-ventilated
What techniques can help in managing nausea?
- Relaxation techniques
- Frequent rest periods
- Diversion
What are some priority nursing interventions for a patient with vomiting?
Assess for signs of dehydration and provide appropriate care
Fill in the blank: The patient with vomiting should be encouraged to manage _______.
[nausea]
What can the timing of nausea and vomiting indicate?
The cause of nausea and vomiting
When is early morning vomiting common?
During pregnancy
What can elicit vomiting during or right after eating?
Emotional stressors
What syndrome is characterized by recurring episodes of nausea, vomiting, and fatigue?
Cyclic vomiting syndrome
What are some clinical problems associated with nausea and vomiting?
- Fluid imbalance
- Electrolyte imbalance
- Nutritionally compromised
- Impaired GI 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 is the common initial treatment for patients with persistent vomiting?
NPO status and IV fluids
What might be required for a patient with persistent vomiting and possible bowel obstruction?
A nasogastric (NG) tube connected to suction
What should be monitored with prolonged vomiting?
- Intake and output
- Vital signs
- Signs of dehydration
What position should a patient who cannot manage self-care be placed in to prevent aspiration?
Semi-Fowler’s or side-lying position
What type of therapy is necessary for a patient with severe vomiting?
IV fluid therapy with electrolyte and glucose replacement
What is the initial fluid of choice for oral rehydration after vomiting?
Water
What is a recommended method for rehydration in a patient recovering from vomiting?
Sip small amounts of fluids (5 to 15 mL) every 15 to 20 minutes
What types of foods are ideal for a recovering patient?
- High in carbohydrates
- Low in fat
- Bland foods like baked potato, rice, cooked chicken, and cereal
What should patients avoid when recovering from nausea and vomiting?
- Coffee
- Spicy foods
- Highly acidic foods
- Foods with strong odors
What should the patient be advised regarding food intake?
Eat slowly and in small amounts
What environmental conditions should be maintained for a patient experiencing nausea?
- Quiet
- Free of noxious odors
- Well-ventilated
What techniques can help in managing nausea?
- Relaxation techniques
- Frequent rest periods
- Diversion
What are some priority nursing interventions for a patient with vomiting?
Assess for signs of dehydration and provide appropriate care
Fill in the blank: The patient with vomiting should be encouraged to manage _______.
[nausea]
What are some important health history factors to consider when assessing nausea and vomiting?
- GI problems
- Chronic indigestion
- Food allergies
- Pregnancy
- Infection
- CNS problems
- Recent travel
- Eating disorders
- Metabolic problems
- Cancer
- CVD
- Renal disease
These factors can influence the patient’s condition and response to treatment.
Which medications are relevant in the assessment of nausea and vomiting?
- Antiemetics
- Digitalis
- Opioids
- Ferrous sulfate
- Aspirin
- Aminophylline
- Alcohol
- Antibiotics
- Chemotherapy
- General anesthesia
Certain medications can contribute to or alleviate symptoms.
What functional health patterns should be assessed in a patient experiencing nausea and vomiting?
- Nutritional-metabolic
- Activity-exercise
- Cognitive-perceptual
- Coping-stress tolerance
These patterns help identify the impact of symptoms on daily life.
What are some subjective data to collect regarding nutritional-metabolic patterns?
- Amount of vomitus
- Frequency of vomiting
- Character and color of vomitus
- Presence of dry heaves
- Anorexia
- Weight loss
Detailed information can indicate the severity of the condition.
Which objective data may indicate dehydration in a patient with nausea and vomiting?
- Lethargy
- Sunken eyeballs
- Pallor
- Dry mucous membranes
- Poor skin turgor
- Decreased urinary output
- Concentrated urine
These signs can help assess the patient’s hydration status.
What specific characteristics of vomitus should be noted during assessment?
- Amount
- Frequency
- Character (e.g., projectile)
- Content (undigested food, blood, bile, feces)
- Color (red, coffee-grounds, green-yellow)
The characteristics can provide insight into the underlying cause of vomiting.
True or False: Abdominal tenderness or pain is a cognitive-perceptual symptom related to nausea and vomiting.
True
This symptom can help identify the cause of nausea.
What possible diagnostic findings are associated with nausea and vomiting?
- Altered serum electrolytes (especially hypokalemia)
- Metabolic alkalosis
- Abnormal upper GI findings on endoscopy or abdominal x-rays
These findings can guide further management and treatment.
What should be done when symptoms occur in a patient with nausea and vomiting?
Stop all foods and drugs until the acute phase is over
This is crucial to prevent further complications.
What action should be taken if a medication is suspected to be causing nausea?
Notify the HCP at once
The healthcare provider may adjust the medication accordingly.
What is the risk of stopping medication without consulting the HCP?
It may have adverse effects on their health
Patients should always consult their healthcare provider before making changes to their medication regimen.
What types of drugs should a patient take for nausea?
Only antiemetic drugs prescribed by the HCP
Over-the-counter drugs may worsen the problem.
Which alternative therapies may reduce PONV?
Acupressure, acupuncture, ginger, and peppermint oil
These methods can provide relief for some patients.
What are the expected outcomes for a patient 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
These outcomes ensure the patient’s recovery and well-being.
What considerations should be made for older adults experiencing nausea and vomiting?
Careful assessment and monitoring due to higher risk for fluid and electrolyte imbalances
Older adults may have underlying health issues that complicate treatment.
Why are older adults at greater risk for complications from fluid and electrolyte replacement?
They may have heart or renal problems
Excess replacement can lead to adverse consequences.
What is the risk for older adults with a decreased level of consciousness?
High risk for aspirating
Monitoring is crucial to prevent aspiration-related complications.
What are the CNS side effects of antiemetic drugs in older adults?
Confusion and increased fall risk
Doses should be reduced for safety.
What should be closely evaluated when administering antiemetic drugs to older adults?
Efficacy of the drugs
This ensures that the treatment is both safe and effective.
What are some causes of oral inflammation and infections?
- Specific mouth diseases
- Systemic problems like leukemia or vitamin deficiency
Understanding the root cause is essential for effective treatment.
Who is at higher risk for oral infections?
Patients who are immunosuppressed
This includes those undergoing chemotherapy or using corticosteroid inhalants.
What is aphthous stomatitis?
Recurrent and chronic form of infection characterized by painful ulcers of mouth and lips
Related to systemic disease, trauma, stress, or unknown causes
What are the manifestations of gingivitis?
Inflamed gingivae and interdental papillae, bleeding during tooth brushing, development of pus, abscess formation
Neglected oral hygiene, malocclusion, missing or irregular teeth, faulty dentistry
What treatments are used for aphthous stomatitis?
- Corticosteroids (topical or systemic)
- Tetracycline oral suspension
Prevention through health teaching and dental care
What is the primary cause of herpes simplex lesions?
Herpes simplex virus (type 1 or 2)
Risk factors include upper respiratory tract infections, excessive exposure to sunlight, food allergies, emotional tension, onset of menstruation
List the treatments for herpes simplex.
- Spirits of camphor
- Corticosteroid cream
- Mild antiseptic mouthwash
- Viscous lidocaine
- Antiviral agents (e.g., acyclovir, valacyclovir)
What is oral candidiasis?
Infection caused by Candida albicans characterized by pearly, bluish white ‘milk-curd’ membranous lesions
Also known as moniliasis or thrush
What are the symptoms of parotitis?
Pain in area of gland and ear, absence of salivation, purulent exudate from gland, redness, ulcers
What treatments are used for parotitis?
- Miconazole buccal tablets (Oravig)
- Nystatin or amphotericin B as oral suspension or buccal tablets
- Antibiotics, mouthwashes, warm compresses
- Good oral hygiene
What are the causes of stomatitis?
- Trauma
- Pathogens
- Irritants (tobacco, alcohol)
- Renal, liver, hematologic diseases
- Side effect of chemotherapy and radiation
What is Vincent’s infection?
Acute necrotizing ulcerative gingivitis caused by fusiform bacteria and Vincent spirochetes
Risk factors include stress, excessive fatigue, and poor oral hygiene
What are the symptoms of Vincent’s infection?
- Painful, bleeding gingivae
- Eroding necrotic lesions of interdental papillae
- Ulcers that bleed
- T Saliva with metallic taste, fetid mouth odor
- Anorexia, fever, malaise
What is the recommended diet for someone with Vincent’s infection?
Soft, nutritious diet
Nutrition deficiencies in B and C vitamins can be a risk factor
Fill in the blank: The treatment for stomatitis includes _______.
[remove or treat cause, oral hygiene with soothing solutions, topical medications, soft, bland diet]
What is a potential risk of oral infections?
Oral infections may predispose the patient to infections in other body organs
For example, the oral cavity can be a reservoir for respiratory heart disease.
What are the main focuses in managing oral problems?
Identifying the cause, eliminating infection, providing comfort measures, and maintaining intake.
What is the effect of regular and good oral and dental hygiene?
Reduces oral infections and inflammation.
What are the two types of oral cancer?
Oral cavity cancer and oropharyngeal cancer.
What term is used for cancers of the oral cavity, pharynx, and larynx?
Head and neck squamous cell carcinoma (HNSCC).
Where do most oral cancer lesions occur?
On the lower lip, lateral border and undersurface of the tongue, labial commissure, and buccal mucosa.
How many Americans are diagnosed with oral cancer each year?
51,540 Americans.
What is the estimated number of deaths from oral cancer each year?
10,030 people.
At what age is oral cancer more common?
After age 35.
What is the average age at diagnosis for oral cancer?
65 years.
How much more common is oral cancer in men compared to women?
2 times more common.
What is the 5-year survival rate for localized oral cancer?
84%.
What is the 5-year survival rate for all stages of oral cavity and pharynx cancer?
65%.
Which demographic has the highest incidence and mortality rates for oral cancer?
Black men.
Which demographic has the highest incidence of esophageal cancer?
Non-Hispanic white men.
Which group has the highest rates of stomach cancer?
Asian Americans and Pacific Islanders, Blacks, and Hispanics.
What is a significant risk factor for oral cancer?
History of tobacco or frequent alcohol use.
What percentage of patients with lip cancer have outdoor occupations?
More than 30%.
What virus contributes to 25% of oral cancer cases?
Human papillomavirus (HPV).
What are common nonspecific symptoms of oral cancer?
Chronic sore throat, sore mouth, and voice changes.
What is leukoplakia commonly referred to as?
Smoker’s patch.
What percentage of leukoplakia lesions transform into cancer?
15%.
What is erythroplasia also known as?
Erythroplakia.
What percentage of erythroplasia cases progress to squamous cell cancer?
More than 50%.
What is a typical presentation of lip cancer?
An indurated, painless ulcer on the lip.
What is a common first sign of tongue cancer?
An ulcer or area of thickening.
What are later symptoms of oral cancer?
Increased saliva, slurred speech, dysphagia, toothache, and earache.
What diagnostic test involves scraping a suspicious lesion?
Oral exfoliative cytologic study.
What is the toluidine blue test used for?
A screening test for oral cancer.
What is a risk factor for oral cancer related to the lip?
Constant overexposure to sun, ruddy and fair complexion
Additional risk factors include recurrent herpetic lesions, pipe stem irritation, syphilis, and immunosuppression.
What are the common manifestations of oral cancer?
Indurated, painless ulcer, leukoplakia, erythroplakia, ulcers, sore spot, rough area, pain, dysphagia, a lump or thickening in the cheek, sore throat, difficulty chewing and speaking
Later signs include slurred speech, toothache, and earache.
What are the risk factors associated with oral cavity cancer?
- Poor oral hygiene
- Tobacco usage (pipe and cigar smoking, snuff, chewing tobacco)
- Chronic alcohol use
- Chronic irritation (jagged tooth, ill-fitting prosthesis, chemical or mechanical irritants)
- HPV
What are the risk factors for tongue cancer?
Tobacco and alcohol use, chronic irritation, syphilis
What are the treatment options for oral cancer?
- Surgery
- Radiation
Fill in the blank: The surgery for removing part of the tongue is called _______.
hemiglossectomy or glossectomy
What surgical procedures are mentioned for oral cancer treatment?
- Mandibulectomy
- Radical neck dissection
- Resection of buccal mucosa
- Hemiglossectomy or glossectomy
True or False: Limited tongue movement is an early sign of oral cancer.
False
What is the purpose of a toluidine blue test in cancer diagnosis?
To stain an area where cancer cells may be present
A negative result does not rule out cancer.
What imaging techniques are used for staging cancer after diagnosis?
CT scan, MRI, and positron emission tomography (PET)
These techniques help assess the extent of cancer spread.
What are the main types of management for oral cancer?
Surgery, radiation, chemotherapy, or a combination of these
Curative treatments are typically surgery and radiation.
What is the most effective treatment for early-stage oral cancer?
Surgery
The type of surgery depends on the tumor’s location and extent.
List some surgical procedures used in the treatment of oral cancer.
- Partial mandibulectomy
- Hemiglossectomy
- Glossectomy
- Resections of buccal mucosa and floor of the mouth
- Radical neck dissection
These procedures vary based on the tumor’s size and location.
What does radical neck dissection involve?
Wide excision of the primary lesion and removal of regional lymph nodes
It may include removal of associated structures like the sternocleidomastoid muscle and internal jugular vein.
Why is radiation therapy usually not performed before surgery?
Radiated tissue becomes fibrotic and heals slower, making removal difficult
Most patients begin radiation about 6 weeks after surgery.
What are the components of the diagnostic assessment for oral cancer?
- History and physical assessment
- Biopsy
- Oral exfoliative cytology
- Toluidine blue test
- CT, MRI, PET scans
These assessments help in diagnosing and staging the cancer.
What is the role of chemotherapy in managing oral cancer?
- Shrink lesions before surgery
- Decrease metastasis
- Sensitize cancer cells to radiation
- Treat distant metastases
Common drugs include fluorouracil, cisplatin, and carboplatin.
When is palliative treatment indicated for oral cancer patients?
When the prognosis is poor, the cancer is inoperable, or the patient opts against surgery
Palliation focuses on symptom management and comfort.
What nutritional support may be required for patients before and after surgery?
- Percutaneous endoscopic gastrostomy (PEG)
- Enteral nutrition (EN)
- Parenteral nutrition (PN)
These supports are crucial for patients unable to ingest nutrients orally.
What are some clinical problems associated with oral cancer?
- Nutritionally compromised
- Pain
- Difficulty coping
Effective management addresses these issues to improve patient quality of life.
What are the overall goals for a patient with oral cancer?
- Maintain a patent airway
- Communicate effectively
- Ensure adequate nutritional intake
- Relieve pain and discomfort
These goals guide nursing management and patient care.
Identify some key aspects of nursing management for oral cancer patients.
- Early detection
- Risk factor education
- Smoking cessation support
Nurses play a vital role in patient education and intervention.
What are the health impacts of good oral hygiene?
- 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
Good oral hygiene is crucial for overall health and can lead to significant improvements in both physical and economic aspects of dental care.
Why is early detection of oral cancer important?
It aids in timely intervention and treatment of potential malignancies.
Patients should be taught to report symptoms such as unexplained pain, unusual bleeding, dysphagia, sore throat, voice changes, or swelling.
What should be done for a person with an ulcerative lesion that does not heal within 2 to 3 weeks?
Refer to a healthcare provider (HCP).
Non-healing lesions can be indicative of serious conditions, including cancer.
What are expected outcomes for a patient with oral cancer post-surgery?
- Have no respiratory complications
- Be able to communicate
These outcomes are essential for a patient’s recovery and quality of life.
What does GERD stand for?
Gastroesophageal reflux disease
GERD is a syndrome characterized by the reflux of stomach acid into the esophagus.
What causes GERD?
- Incompetent lower esophageal sphincter (LES)
- Increased intraabdominal pressure
- Certain foods and drugs
- Obesity
- Cigarette and cigar smoking
- Hiatal hernia
The causes of GERD can vary and often involve a combination of factors.
What is the most common upper GI problem in Americans?
GERD
Approximately 15 million Americans experience GERD symptoms daily.
What is the primary factor causing GERD?
Incompetent lower esophageal sphincter (LES)
An incompetent LES fails to prevent gastric contents from moving into the esophagus.
Fill in the blank: GERD is a symptom of _______ damage caused by reflux of stomach acid into the lower esophagus.
mucosal
The mucosal damage is a key aspect of the syndrome.
What contributes to medication-induced esophagitis?
- Nonsteroidal antiinflammatory drugs (NSAIDs)
- Potassium
Certain medications can irritate the esophageal mucosa, exacerbating GERD symptoms.
What should preoperative care for a patient undergoing a radical neck dissection include?
- Physical preparation for major surgery
- Special emphasis on oral hygiene
- Information on postoperative communication and feeding
Comprehensive care is necessary to address both physical and psychosocial needs.
What is a significant health history factor related to oral cancer?
Recurrent oral herpetic lesions, HPV infection or vaccination, syphilis, exposure to sunlight
These factors are important for assessing risk and history in patients.
What type of medications are associated with oral cancer risk?
Immunosuppressants
These medications may increase susceptibility to infections and malignancies.
What surgical history may be relevant in a patient with oral cancer?
Removal of prior tumors or lesions
Previous surgeries can indicate a history of malignancy or precancerous conditions.
What are common health perception-health management factors in oral cancer patients?
Alcohol and tobacco use, pipe smoking, poor oral hygiene
These behaviors significantly increase the risk of developing oral cancer.
What nutritional-metabolic issues might be present in a patient with oral cancer?
Reduced oral intake, weight loss, difficulty chewing food, increased saliva, intolerance to some foods or temperatures of food
These symptoms can affect the patient’s overall health and nutritional status.
What cognitive-perceptual symptoms may indicate oral cancer?
Mouth or tongue soreness or pain, toothache, earache, neck stiffness, dysphagia, difficulty speaking
These symptoms can significantly impact the patient’s quality of life.
What are some objective data findings in a physical assessment for oral cancer?
Areas of thickening or roughness, ulcers, leukoplakia, or erythroplakia on the tongue or oral mucosa, limited tongue movement
These findings are critical for diagnosis and further evaluation.
What additional objective data might be observed in a patient with oral cancer?
Increased saliva, drooling, slurred speech, foul breath odor
These signs can indicate advanced disease or complications.
What skin findings may be associated with oral cancer?
Indurated, painless ulcer on lip, painless neck mass
These findings can suggest local or regional spread of cancer.
What are possible diagnostic findings for oral cancer?
Positive exfoliative smear cytology, positive biopsy
These tests are essential for confirming the diagnosis of oral cancer.
What is a significant health history factor related to oral cancer?
Recurrent oral herpetic lesions, HPV infection or vaccination, syphilis, exposure to sunlight
These factors are important for assessing risk and history in patients.
What type of medications are associated with oral cancer risk?
Immunosuppressants
These medications may increase susceptibility to infections and malignancies.
What surgical history may be relevant in a patient with oral cancer?
Removal of prior tumors or lesions
Previous surgeries can indicate a history of malignancy or precancerous conditions.
What are common health perception-health management factors in oral cancer patients?
Alcohol and tobacco use, pipe smoking, poor oral hygiene
These behaviors significantly increase the risk of developing oral cancer.
What nutritional-metabolic issues might be present in a patient with oral cancer?
Reduced oral intake, weight loss, difficulty chewing food, increased saliva, intolerance to some foods or temperatures of food
These symptoms can affect the patient’s overall health and nutritional status.
What cognitive-perceptual symptoms may indicate oral cancer?
Mouth or tongue soreness or pain, toothache, earache, neck stiffness, dysphagia, difficulty speaking
These symptoms can significantly impact the patient’s quality of life.
What are some objective data findings in a physical assessment for oral cancer?
Areas of thickening or roughness, ulcers, leukoplakia, or erythroplakia on the tongue or oral mucosa, limited tongue movement
These findings are critical for diagnosis and further evaluation.
What additional objective data might be observed in a patient with oral cancer?
Increased saliva, drooling, slurred speech, foul breath odor
These signs can indicate advanced disease or complications.
What skin findings may be associated with oral cancer?
Indurated, painless ulcer on lip, painless neck mass
These findings can suggest local or regional spread of cancer.
What are possible diagnostic findings for oral cancer?
Positive exfoliative smear cytology, positive biopsy
These tests are essential for confirming the diagnosis of oral cancer.
What is considered GERD in terms of symptom frequency?
Persistent mild symptoms more than twice a week or moderate to severe symptoms once a week
GERD stands for gastroesophageal reflux disease.
What is the most common symptom of GERD?
Heartburn (pyrosis)
Heartburn is characterized by a burning sensation beneath the lower sternum.
Describe heartburn in terms of its sensation and triggers.
Burning, tight sensation beneath the lower sternum, spreading to the throat or jaw; may occur after ingesting food or drugs that decrease LES pressure
LES stands for lower esophageal sphincter.
When should an HCP evaluate heartburn?
If it occurs more than twice a week, is severe, associated with dysphagia, or occurs at night and wakes a person from sleep
Dysphagia refers to difficulty swallowing.
What can GERD-related chest pain mimic?
Angina
Angina is chest pain due to reduced blood flow to the heart.
How does GERD-related chest pain differ from angina in terms of relief?
Antacids relieve GERD-related chest pain
Angina typically does not improve with antacids.
What is dyspepsia?
Pain or discomfort centered in the upper abdomen
Dyspepsia is often associated with GERD.
Define regurgitation in the context of GERD.
Hot, bitter, or sour liquid coming into the throat or mouth
Regurgitation can be a common experience for GERD patients.
List some respiratory symptoms associated with GERD.
- Wheezing
- Coughing
- Dyspnea
Dyspnea refers to difficulty breathing.
What are some otolaryngologic symptoms of GERD?
- Hoarseness
- Sore throat
- Globus sensation
- Hypersalivation
- Choking
Globus sensation is the feeling of a lump in the throat.
What is a common complication of GERD?
Esophagitis (inflammation of the esophagus)
Chronic inflammation can lead to further complications.
What is Barrett esophagus?
Reversible change from flat epithelial cells to columnar epithelial cells in the distal esophagus
Barrett esophagus is a precancerous condition associated with GERD.
What percentage of people with chronic GERD may develop Barrett esophagus?
5% to 30%
Other risk factors for BE include age, gender, ethnicity, and obesity.
What increases the risk of esophageal cancer in patients with Barrett esophagus?
It is a precancerous lesion
Surveillance endoscopy or radiofrequency ablation may be necessary for these patients.
List some respiratory complications that can arise from GERD.
- Cough
- Bronchospasm
- Laryngospasm
- Cricopharyngeal spasm
These complications result from gastric secretions irritating the upper airway.
What diagnostic tests are often used for GERD?
- Endoscopy
- Manometric studies
- Ambulatory esophageal pH monitoring
- Radionuclide tests
These tests help assess the severity of GERD and rule out complications.
What is the primary approach to managing GERD?
Lifestyle modifications, drug therapy, and nutrition therapy
Patient education is crucial for effective management.
What factors decrease lower esophageal sphincter pressure?
- Alcohol
- Chocolate (theobromine)
- Drugs
- Anticholinergics
- B-Adrenergic blockers
- Calcium channel blockers
- Diazepam (Valium)
- Morphine sulfate
- Nitrates
- Progesterone
- Theophylline
- Fatty foods
- Nicotine
- Peppermint, spearmint
- Tea, coffee (caffeine)
These factors can contribute to gastroesophageal reflux disease (GERD) due to their impact on sphincter function.
What medications can increase lower esophageal sphincter pressure?
- Bethanechol (Urecholine)
- Metoclopramide (Reglan)
These medications may help in managing conditions related to low sphincter pressure.
True or False: Alcohol decreases lower esophageal sphincter pressure.
True
Alcohol is known to relax the lower esophageal sphincter, increasing the risk of reflux.
Fill in the blank: _______ is a drug that acts as an anticholinergic and decreases lower esophageal sphincter pressure.
[Anticholinergics]
Anticholinergics can lead to reduced muscle tone in the sphincter.
List three foods that decrease lower esophageal sphincter pressure.
- Fatty foods
- Chocolate
- Peppermint
These foods are known to exacerbate symptoms of reflux.
What is the primary focus of drug therapy for GERD?
Decreasing the volume and acidity of reflux, improving LES function, increasing esophageal clearance, and protecting the esophageal mucosa
LES stands for Lower Esophageal Sphincter.
What are the most common and effective treatments for symptomatic GERD?
Proton pump inhibitors (PPIs) and histamine (H2) receptor blockers
PPIs and H2 receptor blockers are designed to manage symptoms and promote healing.
What lifestyle modification should be taught to patients with GERD?
Elevate the head of the bed 30 degrees and avoid being supine for 2 to 3 hours after a meal
This can be achieved using pillows or blocks under the bed.
What should patients who smoke be encouraged to do?
Stop smoking
Patients may be referred to community resources for assistance.
What is the effect of PPIs on esophagitis compared to H2 receptor blockers?
PPIs are more effective in healing esophagitis than H2 receptor blockers
PPIs should be taken once daily before the first meal.
What is the potential risk associated with long-term PPI use?
Increased risk for hip, wrist, and spine fractures
Patients should take the lowest dose for the shortest duration needed.
What is the onset of action for H2 receptor blockers?
1 hour
Therapeutic effects can last up to 12 hours depending on the specific drug.
Fill in the blank: The neutralizing effects of antacids taken on an empty stomach last only _______.
20 to 30 minutes
Antacids are most effective when taken 1 to 3 hours after meals.
What are common ingredients found in antacids?
Magnesium hydroxide or aluminum hydroxide
Antacids can be single preparations or various combinations.
True or False: Antacids are effective for patients with moderate to severe GERD symptoms.
False
Antacids are not effective in relieving symptoms or healing lesions in such cases.
What adjunctive treatments are mentioned for GERD?
Antacids and prokinetic drugs
Antacids provide quick, short-lived relief of heartburn.
What are the key components of the diagnostic assessment for GERD and Hiatal Hernia?
• History and physical assessment
• Upper Gi endoscopy with biopsy and cytologic analysis
• Esophagram (barium swallow)
• Motility (manometry) studies
• pH monitoring (laboratory or 24 hr ambulatory)
• Radionuclide studies
These assessments help in diagnosing the condition accurately.
What is the recommended conservative management for GERD?
• Elevate head of bed 30 degrees
• Avoid reflux-inducing foods (fatty foods, chocolate, peppermint)
• Avoid alcohol
• Reduce or avoid acidic ph beverages (colas, red wine, orange juice)
These lifestyle changes can significantly alleviate symptoms.
What type of drug therapy is used for GERD management?
• PPls
• H2 receptor blockers
• Antacids
• Prokinetics
These medications help reduce stomach acid and improve gastrointestinal motility.
What are the surgical therapy options for GERD?
• Nissen fundoplication
• Toupet fundoplication
Surgical options are considered when conservative and drug therapies fail.
What are the endoscopic therapy options for GERD?
• Intraluminal valvuloplasty
• Radiofrequency ablation
These procedures aim to improve the function of the lower esophageal sphincter.
What are Proton Pump Inhibitors (PPIs) used for?
To inhibit HCl acid secretion by blocking the proton pump (H+-K+-ATPase)
Examples include dexlansoprazole, esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole.
Name a common side effect of Proton Pump Inhibitors.
Headache
Other side effects include abdominal pain, nausea, diarrhea, vomiting, and flatulence.
What is the mechanism of action for Histamine (H2) Receptor Blockers?
Block the action of histamine on H2 receptors to decrease HCl acid secretion
Examples include cimetidine, famotidine, and nizatidine.
Fill in the blank: Antacids are used to _______.
Neutralize HCl acid
What are the side effects of aluminum hydroxide?
Constipation, phosphorus depletion with chronic use
Aluminum hydroxide is commonly found in antacid formulations.
What are the side effects of calcium carbonate?
Constipation or diarrhea, hypercalcemia, milk-alkali syndrome, renal calculi
Calcium carbonate is another common antacid.
What is the mechanism of action for the drug sucralfate (Carafate)?
Forms a protective layer in the stomach and protects against acid, bile salts, and enzymes
It acts as a cytoprotective agent.
What is the purpose of prokinetic agents like metoclopramide?
Increase gastric motility and emptying
Metoclopramide also helps with reflux.
True or False: Prostaglandin (Synthetic) misoprostol is used to decrease gastric emptying.
False
Misoprostol actually increases gastric emptying.
What are common side effects of prokinetic agents?
CNS side effects ranging from anxiety to hallucinations
Extrapyramidal side effects like tremor and dyskinesias can also occur.
Fill in the blank: Sodium preparations can lead to _______ if used with large amounts of calcium.
Milk-alkali syndrome
What is the effect of cholinergic drugs like bethanechol?
Increase gastric motility and emptying
Cholinergic agents may also help with reflux.
What is a primary action of cytoprotective agents?
Increase production of gastric mucus and bicarbonate secretion
How often may antacids be given to patients?
Hourly
Antacids may be administered either orally or through the NG tube.
What should be tested when an NG tube is in place?
pH level of stomach contents
Periodic aspiration of the stomach contents is necessary.
What action may be taken if the pH level is less than 5?
Intermittent suction may be used or increase frequency/dosage of antacid
This is to manage acid levels effectively.
What factors determine the type and dosage of antacid given?
Side effects and potential drug interactions
Individual patient factors are crucial in determining appropriate antacids.
Why should antacids high in sodium be used cautiously?
In older adults and patients with CVD, liver, and renal disease
Sodium can exacerbate health issues in these populations.
Why should patients with renal failure avoid magnesium preparations?
Risk for magnesium toxicity
Magnesium can accumulate in patients with compromised renal function.
What is the benefit of combining aluminum and magnesium in antacids?
Decreases side effects of both
This combination can provide effective relief with fewer adverse effects.
How do antacids interact with benzodiazepines and pseudoephedrine?
Enhance their effects
This can lead to increased sedation or other enhanced effects.
What effect do antacids have on the absorption rates of certain drugs?
Decrease absorption rates
Drugs affected include thyroid hormones, phenytoin, and tetracycline.
What should be adjusted when administering medications with antacids?
Timing of medication administration
This is necessary to minimize interaction effects.
What is the primary function of prokinetics in upper gastrointestinal problems?
Prokinetics increase LES pressure and improve gastric emptying
This may result in a small improvement in regurgitation and vomiting.
Name some common prokinetic agents.
- Cisapride
- Metoclopramide (Reglan)
- Bethanechol
- Baclofen
Many prokinetics have significant side effects.
What dietary changes may help patients with GERD?
Patients may need to avoid foods that decrease LES pressure, such as:
* Chocolate
* Peppermint
* Fatty foods
* Coffee
* Tea
Foods like tomato-based products, orange juice, cola, and red wine may irritate the esophagus.
What are some recommendations for meal timing in GERD patients?
Avoid late evening meals, nighttime snacking, and milk, especially at bedtime
These habits increase gastric acid secretion.
What is the goal of antireflux surgery?
The goal is to reduce reflux by enhancing LES integrity.
What are the common types of laparoscopic antireflux surgeries?
- Nissen fundoplication
- Toupet fundoplication
What are some complications associated with laparoscopic fundoplication?
- Gastric or esophageal injury
- Splenic injury
- Pneumothorax
- Perforation
- Bleeding
- Infection
- Pneumonia
What symptoms may occur after laparoscopic fundoplication surgery?
Mild dysphagia due to edema, which should resolve
Persistent symptoms such as heartburn and regurgitation should be reported.
What is the LINX Reflux Management System?
A ring of small, flexible magnets that strengthen the weak LES
It is implanted laparoscopically and prevents reflux by keeping the LES closed under resting conditions.
What are some problems associated with the LINX system?
- Nausea
- Swallowing problems
- Pain when swallowing food
Patients with a LINX system cannot have an MRI due to potential 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) hiatal hernia
What characterizes a sliding hiatal hernia?
The junction of the stomach and esophagus is above the diaphragm, and the hernia usually returns to the abdominal cavity when upright.
What characterizes a paraesophageal or rolling hiatal hernia?
The fundus and greater curvature of the stomach roll up through the diaphragm, forming a pocket alongside the esophagus.
What factors may contribute to the development of a hiatal hernia?
- Aging
- Obesity
- Pregnancy
- Ascites
- Tumors
- Intense physical exertion
- Heavy lifting
What are some potential complications of a hiatal hernia?
- GERD
- Esophagitis
- Bleeding from erosion
- Stenosis
- Ulcerations
- Strangulation of the hernia
- Regurgitation with tracheal aspiration
What diagnostic study can show gastric mucosa protruding through the esophageal hiatus?
An esophagram (barium swallow).
What are alternatives to surgery for treating upper gastrointestinal problems?
- Endoscopic mucosal resection (EMR)
- Radiofrequency ablation
What is the purpose of visualization of the lower esophagus?
To provide information on the degree of mucosal inflammation or other abnormalities
Other tests done are similar to those for GERD.
What is the conservative therapy for hiatal hernia?
Similar to that for GERD, including reducing intraabdominal pressure by eliminating constricting garments and avoiding lifting
This is part of the nursing and interprofessional management.
List the surgical treatments 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)
The goals are to reduce the hernia, provide an acceptable LES pressure, and prevent movement of the gastroesophageal junction.
What techniques are often used for surgery to repair hiatal hernia?
Laparoscopic techniques, specifically Nissen or Toupet techniques
The approach used (thoracic or abdominal) depends on the patient.
What factors increase the incidence of hiatal hernia and GERD?
- Weakening of the diaphragm
- Obesity
- Kyphosis
- Other factors that increase intraabdominal pressure
Older patients may take drugs that decrease LES pressure.
What are the first signs of serious issues in older patients with hiatal hernia?
Esophageal bleeding from esophagitis or respiratory complications (e.g., aspiration pneumonia)
These may occur due to aspiration of gastric contents.
What is the overall 5-year survival rate for esophageal cancer?
20%
In 2020, there were 18,400 new cases and 16,170 deaths from esophageal cancer in the United States.
Most esophageal cancers are classified as what type?
Adenocarcinomas
The others are squamous cell tumors.
What are key risk factors for esophageal cancer?
- Barrett’s esophagus (BE)
- Smoking
- Excess alcohol use
- Obesity
Current smoking or a history of smoking has a twice greater risk for esophageal cancer.
Where do most esophageal tumors occur?
In the middle and lower portions of the esophagus
The tumor usually appears as an ulcerated lesion and may penetrate the muscular layer.
What is the most common symptom of esophageal cancer?
Progressive dysphagia
Dysphagia may initially occur only with meat, then with soft foods, and eventually with liquids.
True or False: The cause of esophageal cancer is well understood.
False
The exact cause of esophageal cancer is unknown.
What condition is associated with squamous cell cancer of the esophagus?
Achalasia
Achalasia is marked by delayed emptying of the lower esophagus.
What areas does pain typically occur in esophageal cancer?
Pain typically occurs in the substernal, epigastric, or back areas
Pain usually increases with swallowing and may radiate to the neck, jaw, ears, and shoulders.
What symptoms may occur if the tumor is in the upper third of the esophagus?
Symptoms may include sore throat, choking, and hoarseness
Most patients also experience weight loss.
What occurs when esophageal stenosis is severe?
Regurgitation of blood-flecked esophageal contents is common
Bleeding can occur if the cancer erodes through the esophagus and into the aorta.
What are potential complications of esophageal cancer?
Complications may include esophageal perforation and fistula formation into the lung or trachea
The tumor may also cause esophageal obstruction, especially in late stages.
What is needed to diagnose esophageal cancer?
Endoscopic biopsy is needed to diagnose esophageal cancer.
What is the importance of endoscopic ultrasonography (EUS) in esophageal cancer?
EUS is important in staging esophageal cancer.
What might an esophagram (barium swallow) show?
An esophagram may show narrowing of the esophagus at the tumor site.
What factors determine the treatment for esophageal cancer?
Treatment depends on the tumor’s location and whether invasion or metastasis is present.
What is the prognosis for esophageal cancer?
Esophageal cancer usually has a poor prognosis because it is often diagnosed at an advanced stage.
What is a multimodal approach in treating esophageal cancer?
A multimodal approach includes surgery, endoscopic ablation, chemotherapy, and radiation therapy.
What are the types of surgical procedures for esophageal cancer?
Types include:
* Esophagectomy
* Esophagogastrostomy
* Esophagoenterostomy
Surgical approaches may be open or laparoscopic.
What is minimally invasive esophagectomy?
Minimally invasive esophagectomy is laparoscopic vagal nerve-sparing surgery.
What does endoscopic therapy include?
Endoscopic therapy includes:
* Photodynamic therapy
* EMR
* Radiofrequency ablation
What is photodynamic therapy?
Photodynamic therapy involves an IV injection of porfimer sodium and directing light towards the cancerous area.
What is EMR in the context of esophageal cancer?
EMR involves removing cancer tissue using an endoscope.
What is the purpose of dilation and stent placement?
Dilation increases the lumen of the esophagus and relieves obstruction; stents allow food and liquid to pass through.
What are self-expandable metal stents used for?
Self-expandable metal stents prevent stent migration and tumor ingrowth.
What is the role of radiation therapy in esophageal cancer treatment?
Radiation therapy may be given for palliation of symptoms and can be combined with chemotherapy.
What chemotherapy regimens are used for esophageal cancer?
Regimens may include:
* Carboplatin and paclitaxel
* Cisplatin and irinotecan
* Oxaliplatin, paclitaxel, or cisplatin with fluorouracil or capecitabine
* DCF (docetaxel, cisplatin, fluorouracil)
What is targeted therapy in relation to HER-2 protein?
Some esophageal cancers have too much HER-2 protein, which helps cancer cells grow.
What areas does pain typically occur in esophageal cancer?
Pain typically occurs in the substernal, epigastric, or back areas
Pain usually increases with swallowing and may radiate to the neck, jaw, ears, and shoulders.
What symptoms may occur if the tumor is in the upper third of the esophagus?
Symptoms may include sore throat, choking, and hoarseness
Most patients also experience weight loss.
What occurs when esophageal stenosis is severe?
Regurgitation of blood-flecked esophageal contents is common
Bleeding can occur if the cancer erodes through the esophagus and into the aorta.
What are potential complications of esophageal cancer?
Complications may include esophageal perforation and fistula formation into the lung or trachea
The tumor may also cause esophageal obstruction, especially in late stages.
What is needed to diagnose esophageal cancer?
Endoscopic biopsy is needed to diagnose esophageal cancer.
What is the importance of endoscopic ultrasonography (EUS) in esophageal cancer?
EUS is important in staging esophageal cancer.
What might an esophagram (barium swallow) show?
An esophagram may show narrowing of the esophagus at the tumor site.
What factors determine the treatment for esophageal cancer?
Treatment depends on the tumor’s location and whether invasion or metastasis is present.
What is the prognosis for esophageal cancer?
Esophageal cancer usually has a poor prognosis because it is often diagnosed at an advanced stage.
What is a multimodal approach in treating esophageal cancer?
A multimodal approach includes surgery, endoscopic ablation, chemotherapy, and radiation therapy.
What are the types of surgical procedures for esophageal cancer?
Types include:
* Esophagectomy
* Esophagogastrostomy
* Esophagoenterostomy
Surgical approaches may be open or laparoscopic.
What is minimally invasive esophagectomy?
Minimally invasive esophagectomy is laparoscopic vagal nerve-sparing surgery.
What does endoscopic therapy include?
Endoscopic therapy includes:
* Photodynamic therapy
* EMR
* Radiofrequency ablation
What is photodynamic therapy?
Photodynamic therapy involves an IV injection of porfimer sodium and directing light towards the cancerous area.
What is EMR in the context of esophageal cancer?
EMR involves removing cancer tissue using an endoscope.
What is the purpose of dilation and stent placement?
Dilation increases the lumen of the esophagus and relieves obstruction; stents allow food and liquid to pass through.
What are self-expandable metal stents used for?
Self-expandable metal stents prevent stent migration and tumor ingrowth.
What is the role of radiation therapy in esophageal cancer treatment?
Radiation therapy may be given for palliation of symptoms and can be combined with chemotherapy.
What chemotherapy regimens are used for esophageal cancer?
Regimens may include:
* Carboplatin and paclitaxel
* Cisplatin and irinotecan
* Oxaliplatin, paclitaxel, or cisplatin with fluorouracil or capecitabine
* DCF (docetaxel, cisplatin, fluorouracil)
What is targeted therapy in relation to HER-2 protein?
Some esophageal cancers have too much HER-2 protein, which helps cancer cells grow.
What is Herceptin?
A drug that targets the HER-2 protein and kills cancer cells.
What is the function of Ramucirumab (Cyramza)?
An angiogenesis inhibitor that binds to the receptor for vascular endothelial growth factor (VEGF) and prevents its signaling.
What type of cancers does Ramucirumab treat?
Advanced cancers that start at the gastroesophageal junction.
What is the purpose of nutrition therapy after esophageal surgery?
To provide IV fluids and assess swallowing before starting oral fluids.
What should be given when starting oral fluids post-esophageal surgery?
Water (30 to 60 mL) hourly, progressing to small, frequent, bland meals.
What position should the patient be in after starting fluids?
Upright position for 2 hours to prevent regurgitation.
What are the symptoms of leakage into the mediastinum during enteral nutrition?
Pain, fever, and dyspnea.
What history should be assessed in a patient with esophageal cancer?
History of GERD, hiatal hernia, achalasia, Barrett’s esophagus, and tobacco and alcohol use.
What are common clinical problems for patients with esophageal cancer?
- Pain
- Nutritionally compromised
- Impaired GI function
- Difficulty coping
What are the overall goals for patients with esophageal cancer?
- Relief of symptoms, including pain and dysphagia
- Optimal nutrition intake
- Quality of life appropriate to stage of disease and prognosis
What should health promotion counseling for GERD patients include?
Importance of regular follow-up evaluation and smoking cessation.
What dietary habits should be encouraged for patients with esophageal issues?
Good oral hygiene and intake of fresh fruits and vegetables.
What emotional reactions might patients experience upon diagnosis of esophageal cancer?
Shock, disbelief, and depression.
What type of diet is recommended for patients with esophageal cancer?
A high-calorie, high-protein diet.
What is essential for maintaining oral care preoperatively?
Cleanse the mouth thoroughly, including the tongue, gingivae, and teeth.
What are common postoperative complications for esophageal cancer patients?
- Dysrhythmias
- Anastomotic leaks
- Fistula formation
- Interstitial pulmonary edema
- Acute respiratory distress
How long is the NG tube usually in place post-esophageal surgery?
5 to 7 days.
What should be monitored regarding NG tube drainage?
Assess the drainage and notify the healthcare provider of excess drainage (over 400 to 600 mL in 8 hours).
What measures should be implemented to prevent respiratory complications?
Have the patient turn, cough, deep breathe, and use an incentive spirometer every 2 hours.
What position should the patient be placed in to prevent reflux and aspiration?
Semi-Fowler’s or Fowler’s position.
What might be necessary for long-term care after surgery for esophageal cancer?
Chemotherapy and radiation treatment, and possibly a permanent feeding gastrostomy.
What is the expected outcome for a patient with esophageal cancer regarding airway?
Maintain a patent airway
This is crucial for patient safety and comfort.
What relief should a patient with esophageal cancer experience?
Have relief of pain
Pain management is an important part of cancer care.
What should a patient with esophageal cancer be able to do related to swallowing?
Be able to swallow comfortably and consume adequate intake
This is vital for maintaining nutritional health.
What quality of life aspect is expected for a patient with esophageal cancer?
Have a quality of life appropriate to stage of disease and prognosis
This reflects the holistic approach to cancer care.
What is eosinophilic esophagitis characterized by?
Swelling of the esophagus from an infiltration of eosinophils
EoE is often associated with allergic diseases.
What are the most common food triggers for eosinophilic esophagitis?
- Milk
- Egg
- Wheat
- Rye
- Beef
Identifying and avoiding these triggers is essential for management.
What are common symptoms of eosinophilic esophagitis?
- Severe heartburn
- Difficulty swallowing
- Food impaction
- Nausea
- Vomiting
- Weight loss
These symptoms can significantly impact quality of life.
How is eosinophilic esophagitis diagnosed?
Based on symptoms and biopsy findings of eosinophils infiltrating esophageal tissue obtained from endoscopy
Endoscopy allows for direct visualization and sampling.
What treatments are commonly used for eosinophilic esophagitis?
- Avoiding allergic triggers
- PPIs
- Corticosteroids
Corticosteroids can be used orally or topically.
What is a common side effect of corticosteroid treatment for eosinophilic esophagitis?
Esophageal candidiasis
This fungal infection is a notable risk with corticosteroid use.
What are esophageal diverticula?
Saclilke outpouchings of 1 or more layers of the esophagus
They can lead to various symptoms and complications.
What are the three main areas where esophageal diverticula occur?
- Above the upper esophageal sphincter (Zenker diverticulum)
- Near the esophageal midpoint (traction diverticulum)
- Above the LES (epiphrenic diverticulum)
Zenker diverticulum is the most common type.
What are typical symptoms of esophageal diverticula?
- Dysphagia
- Regurgitation
- Chronic cough
- Aspiration
- Weight loss
These symptoms often result from food becoming trapped.
What complications can arise from esophageal diverticula?
- Malnutrition
- Aspiration
- Perforation
Complications may require surgical intervention.
What is the most common cause of esophageal strictures?
Chronic GERD
Other causes include trauma and radiation.
What symptoms can esophageal strictures cause?
- Dysphagia
- Regurgitation
- Weight loss
These symptoms can severely affect nutrition and quality of life.
How can esophageal strictures be treated?
- Mechanical bougies
- Balloons
- Surgical excision
Dilation may be performed with or without endoscopy.
What is achalasia?
A rare, chronic disorder where peristalsis of the lower two thirds of the esophagus is absent
The exact cause of achalasia is unknown.
What happens to the esophagus in achalasia?
Esophageal obstruction occurs at or near the diaphragm, causing dilation above the affected segment
This leads to accumulation of food and fluid.
What is the most common symptom of achalasia?
Dysphagia
This occurs with both liquids and solids.
What sensation may patients report during or right after a meal?
Globus sensation and/or substernal chest pain
This pain is similar to angina pain.
What is a common symptom experienced by about a third of patients at night?
Nighttime regurgitation
This may contribute to discomfort during sleep.
What condition can cause halitosis and the inability to eructate?
Esophageal disorders
Halitosis refers to foul-smelling breath.
What symptoms may be reported when patients are lying down?
Symptoms of GERD and regurgitation of sour-tasting food and liquids
GERD stands for gastroesophageal reflux disease.
What is a common physical change in patients with esophageal disorders?
Weight loss
This can result from difficulty swallowing.
What diagnostic tests are used to diagnose esophageal disorders?
- Esophagram (barium swallow)
- Manometric evaluation (high-resolution manometry)
- Endoscopic evaluation
These tests help assess esophageal function and structure.
What are the primary goals of treatment for esophageal disorders?
- Relieve dysphagia
- Manage regurgitation
- Improve esophageal emptying
- Prevent megaesophagus
Megaesophagus refers to the enlargement of the lower esophagus.
What does endoscopic pneumatic dilation involve?
Dilating the LES muscle using balloons of progressively larger diameter
The diameters used are 3.0, 3.5, and 4.0 cm.
What is a Heller myotomy?
A surgical procedure where the muscles of the LES are cut
This allows food to pass more easily.
What common complication may require anti-reflux surgery during a Heller myotomy?
GERD with esophagitis and stricture
This is due to the risk of reflux issues post-surgery.
How long does it typically take for a patient to return to usual activities after surgery?
1 to 2 weeks
Recovery time may vary based on individual circumstances.
What is the efficacy of medical therapy compared to invasive procedures?
Medical therapy is less effective
Invasive procedures often provide better outcomes.
What is the role of botulinum toxin injection in treating esophageal disorders?
It provides short-term relief of symptoms and improves esophageal emptying
It promotes relaxation of the smooth muscle.
What types of medications can relax the LES?
- Nitrates (e.g., isosorbide dinitrate)
- Calcium channel blockers (e.g., nifedipine)
These medications are taken sublingually before meals.
What are some limitations of using nitrates and calcium channel blockers?
- Side effects
- Drug tolerance
- Short duration of action
These factors can limit their effectiveness.
What symptomatic treatment can help patients with esophageal disorders?
- Eating a semi-soft diet
- Eating slowly
- Drinking fluid with meals
- Sleeping with the head elevated
These strategies can alleviate discomfort.
What are esophageal varices?
Dilated, tortuous veins occurring in the lower part of the esophagus
They are a result of portal hypertension.
What condition commonly leads to the development of esophageal varices?
Portal hypertension
This is often associated with liver disease.
What is Peptic Ulcer Disease (PUD)?
A condition characterized by erosion of the GI mucosa from the digestive action of HCl acid and pepsin.
PUD affects about 4.6 million people in the United States each year.
What parts of the GI tract are susceptible to ulcer development?
Lower esophagus, stomach, duodenum, and margin of a gastrojejunal anastomosis after surgical procedures.
Any part of the GI tract in contact with gastric secretions can develop ulcers.
How are peptic ulcers classified?
As acute or chronic and by location (gastric or duodenal).
Acute ulcers cause superficial erosion and resolve quickly, while chronic ulcers are long-lasting and can erode through the muscular wall.
What distinguishes acute ulcers from chronic ulcers?
Acute ulcers cause superficial erosion and minimal inflammation, while chronic ulcers are present for many months or intermittently throughout life.
Chronic ulcers are more common than acute ulcers.
What is the role of HCl acid in ulcer development?
Peptic ulcers develop only in an acid environment, but excess HCl acid is not necessary for ulcer development.
Pepsinogen converts to pepsin in the presence of HCl acid at a pH of 2 to 3.
What happens to pepsin activity when pH increases to 3.5 or more?
Pepsin has little or no proteolytic activity.
This can occur when food or antacids neutralize stomach acid levels.
What is the pathophysiology of ulcer development?
Back diffusion of HCl acid into the gastric mucosa causes cellular destruction and inflammation, leading to histamine release, vasodilation, and increased capillary permeability.
This process further increases acid and pepsin secretion.
What is the major risk factor for Peptic Ulcer Disease?
Infection with Helicobacter pylori.
80% of gastric and 90% of duodenal ulcers are related to H. pylori.
What percentage of the population is affected by H. pylori in the United States?
20% of persons younger than 30 years and 50% of those older than 60 years.
Infection likely occurs during childhood through family transmission.
Which ethnic groups have the highest and lowest rates of H. pylori infection?
Highest in Hispanics and lowest in East Asians.
Most individuals infected with H. pylori do not develop ulcers.
What strains of H. pylori are more likely to cause PUD?
CagA-positive strains.
Infection with these strains increases the likelihood of developing peptic ulcer disease.
What allows bacteria to survive in the stomach?
Colonizing the gastric epithelial cells within the mucosal layer
This process helps bacteria withstand the harsh acidic environment of the stomach.
What enzyme do bacteria produce that affects the stomach?
Urease
Urease metabolizes urea, producing ammonium chloride and other damaging chemicals.
What immune response does urease activate?
Antibody production and the release of inflammatory cytokines
This immune response can lead to increased gastric secretion and tissue damage.
What is the primary cause of non-H. pylori peptic ulcers?
NSAID use
NSAIDs are non-steroidal anti-inflammatory drugs that can damage the gastric mucosa.
How do NSAIDs contribute to peptic ulcer disease (PUD)?
Inhibit prostaglandin synthesis, increase gastric acid secretion, and reduce mucosal barrier integrity
Prostaglandins play a crucial role in maintaining the gastric mucosal barrier.
What is the effect of NSAID use in the presence of H. pylori?
Increases the risk for PUD
H. pylori infections can exacerbate the damaging effects of NSAIDs.
Which patients have a higher risk for PUD when taking NSAIDs?
Patients taking corticosteroids or anticoagulants
Corticosteroids affect mucosal cell renewal and decrease protective effects.
What lifestyle factor can cause acute mucosal lesions?
High alcohol intake
Alcohol consumption can damage the gastric mucosa.
What substances stimulate gastric acid secretion?
- Alcohol
- Smoking
- Coffee
These stimulants can exacerbate ulcer conditions.
What factors can delay the healing of ulcers?
- Smoking
- Psychological distress
- Stress
- Depression
These factors can negatively impact the healing process of existing ulcers.
Where can gastric ulcers occur?
Any part of the stomach, most often in the antrum
Gastric ulcers are less common than duodenal ulcers.
In which demographic are gastric ulcers more prevalent?
Women and those over 50 years of age
This demographic shows a higher incidence of gastric ulcers.
What is the shape of gastric ulcers?
Superficial, smooth margins. Round, oval, or cone shaped.
Where are gastric ulcers predominantly located?
Predominantly antrum, also in body and fundus of stomach.
What is the gastric secretion level in gastric ulcers?
Normal to decreased.
What is the peak age for gastric ulcers?
50-60 years.
Is there a cancer risk associated with gastric ulcers?
Yes, there is a cancer risk.
What percentage of gastric ulcers is associated with H. pylori infection?
80%.
What is the location of duodenal ulcers?
First 1-2 cm of duodenum.
What is the peak age for duodenal ulcers?
35-45 years.
Is there a cancer risk associated with duodenal ulcers?
No, there is no cancer risk.
What percentage of duodenal ulcers is associated with H. pylori infection?
90%.
What are some diseases associated with duodenal ulcers?
- COPD
- Pancreatic disease
- Hyperparathyroidism
- Zollinger-Ellison syndrome (ZES)
- Chronic renal failure
What are the clinical manifestations of gastric ulcers?
Burning or gaseous pressure in epigastrium.
What is the timing of pain for gastric ulcers?
Pain 1-2 hr after meals.
How does discomfort with penetrating ulcers change with food?
Aggravation of discomfort with food.
What are the clinical manifestations of duodenal ulcers?
Burning, cramping, pressure-like pain across midepigastrium and upper abdomen.
What is the timing of pain for duodenal ulcers?
Pain 2-5 hr after meals and midmorning, midafternoon, middle of night.
What provides pain relief for duodenal ulcers?
Pain relief with antacids and food.
What is the recurrence rate for gastric ulcers?
High.
What is the recurrence rate for duodenal ulcers?
High.
What is the mortality rate comparison between gastric ulcers and duodenal ulcers in older adults?
The mortality rate from gastric ulcers is greater than that from duodenal ulcers.
What are the main risk factors for gastric ulcers?
- H. pylori
- NSAIDs
- Bile reflux
What percentage of peptic ulcers are duodenal ulcers?
Duodenal ulcers account for about 80% of all peptic ulcers.
At what age is the incidence of duodenal ulcers especially high?
The incidence is especially high between 35 and 45 years of age.
What is the most common factor related to the development of duodenal ulcers?
H. pylori is the most common factor.
What conditions increase the risk of developing duodenal ulcers?
- Chronic obstructive pulmonary disease (COPD)
- Cirrhosis
- Pancreatitis
- Hyperparathyroidism
- Chronic kidney disease
- Zollinger-Ellison syndrome (ZES)
What characterizes Zollinger-Ellison syndrome (ZES)?
ZES is characterized by severe peptic ulceration and HCl acid hypersecretion.
How do the symptoms of gastric ulcers typically present?
Discomfort is generally high in the epigastrium, occurring about 1 to 2 hours after meals, described as ‘burning’ or ‘gaseous’.
When do symptoms occur in duodenal ulcers?
Symptoms occur generally 2 to 5 hours after a meal.
What type of pain is associated with duodenal ulcers?
Pain is described as ‘burning’ or ‘cramplike’, often in the midepigastric region.
What are the common symptoms of duodenal ulcers?
- Bloating
- Nausea
- Vomiting
- Early feelings of fullness
What is the most accurate procedure to determine the presence and location of an ulcer?
Endoscopy is the most accurate procedure.
What is the gold standard for diagnosing H. pylori infection?
A biopsy of the antral mucosa with testing for urease.
What types of tests are available to confirm H. pylori infection?
- Noninvasive tests: serology, stool, breath testing
- Invasive tests: biopsy
What can high fasting serum gastrin levels indicate?
The presence of a possible gastrinoma (ZES).
What laboratory tests may be done in relation to ulcers?
- CBC
- Liver enzyme studies
- Serum amylase
- Stool examination
What is the aim of conservative care for ulcers?
To decrease gastric acidity and enhance mucosal defense mechanisms.
How long does it typically take for pain to disappear after ulcer treatment?
Pain disappears after 3 to 6 days.
How long may complete ulcer healing take?
Complete healing may take 3 to 9 weeks.
What should be done with aspirin and nonselective NSAIDs during ulcer treatment?
They should be stopped for 4 to 6 weeks.
What may be prescribed when aspirin must be continued during ulcer treatment?
Co-administration with a PPI, H2 receptor blocker, or misoprostol.
Fill in the blank: Silent peptic ulcers are more likely to occur in older adults and those taking _______.
NSAIDs
What effect does enteric-coated aspirin have on GI bleeding risk?
Decreases localized irritation but does not reduce overall risk for GI bleeding.
How does smoking affect mucosal healing in patients with ulcers?
Irritating effect on the mucosa and delays mucosal healing.
What lifestyle changes are recommended for ulcer healing?
- Stop or severely reduce smoking
- Adequate physical and emotional rest
- Avoid or restrict alcohol use
What is the focus of drug therapy for ulcers?
Reducing gastric acid secretion and eliminating H. pylori infection.
What therapy is needed for patients with H. pylori infection?
Antibiotics and a PPI.
What is the recommended duration for antibiotic therapy in H. pylori eradication?
14 days.
What should be done if a patient has a penicillin allergy during H. pylori treatment?
Use metronidazole instead of amoxicillin.
What is Talicia and what does it contain?
A rifabutin-based treatment for resistant H. pylori infection containing omeprazole, amoxicillin, and rifabutin.
How do PPIs compare to H2 receptor blockers in ulcer treatment?
PPIs are more effective in reducing gastric acid secretion and promoting ulcer healing.
What is the role of sucralfate in ulcer treatment?
Provides mucosal protection for the esophagus, stomach, and duodenum.
What is a key consideration when administering sucralfate?
Give it at least 60 minutes before or after an antacid.
Which drugs can sucralfate bind to, reducing their bioavailability?
- Cimetidine
- Digoxin
- Warfarin
- Phenytoin
- Tetracycline
What is the action of antacids in ulcer therapy?
Increase gastric pH by neutralizing HCl acid.
What is misoprostol used for?
To prevent gastric ulcers caused by NSAIDs and LDA.
What are the side effects of misoprostol?
- Diarrhea
- Abdominal pain
Why must misoprostol be used with caution in women of childbearing age?
It is teratogenic.
What role do tricyclic antidepressants play in ulcer treatment?
They may contribute to overall pain relief.
