Lecture 9 Flashcards by denzie hurst

parts of the stomac

top: Fundus
mid: Body
low: Antrum

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Gastritis & Peptic Ulcer Disease (PUD)

Ulcerations of gut mucosa that penetrate
the submucosa
– Gastric (typically near antrum)
– Duodenal (first few cm)

• Areas of breakdown continuously
exposed to gastric acid & pepsin
– Erosion
– Perforation

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Etiology of Peptic Ulcer Disease

H.pylori
infection

Stress &
Severe Illness

Gastritis

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Etiology: Helicobacter pylori

• Gram negative bacteria residing under mucosal layer
– Present in ~90% adults; 10-15% develop symptomatic ulcerations
• Most common cause of gastritis and PUD
– Confirmed by endoscopy
• Mechanisms
– Damages mucosal cells and causes inflammation
• Also implicated in
– Gastric carcinoma
– Atrophic gastritis

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Etiology: Medications / Substance Use

Substances
• Alcohol abuse
– Excessive ethanol can damage gastric
mucosa
• Ingestion of erosive substances
• Tobacco use
– Decreases bicarbonate secretion &amp;
mucosal blood flow
– Exacerbates inflammation
• Poor diet
– Delayed wound / tissue healing

Medications
• NSAIDS and Aspirin
– Corrosive
– Inhibit prostaglandin synthesis
• Prostaglandins: essential for maintaining
mucous and bicarbonate barrier in the
stomach
• Corticosteroids

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Symptomology

Chief complaint: Abdominal discomfort
– Dull, burning, transient pain; usually occurring on empty stomach
• Other symptoms:
– Bloating, burping, nausea, vomiting, anorexia
Can also be asymptomatic!

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Nutritional Implications

• Impaired oral intake
– Pain, N/V, anorexia, malaise etc.
• Involuntary weight loss
• Nutrient imbalances / deficiencies
• Atrophic gastritis
– Risk B12 deficiency d/t lack intrinsic factor à impaired absorption
– Gastric acid enhances bioavailability à low acid states negatively influence
absorption, particularly Fe, Ca

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Nutritional Diagnoses

• Some commonly associated with PUD

• Some commonly associated with PUD
– Inadequate food / oral beverage intake
– Altered GI function
– Involuntary weight loss
– Food and nutrition-related knowledge deficit

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Management of PUD: Pharmacotherapy

• Antacids
– Neutralize acid, prevent formation of
pepsin
• Maalox, Tums, Gaviscon
• Proton pump inhibitors (PPI’s)
– Suppress acid production
• Omeprazole, esomeprazole, lansoprazole,
pantoprazole
• H2-receptor agonists
– Block histamine-stimulated gastric secretions
• Cimetidine, ranitidine

Prostaglandin analogs
– Reduce gastric acid and enhance
mucosal resistance to injury
• Misoprostol
• Mucosal barrier fortifiers
– Form a protective coating- bismuth - dark stool

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H. pylori ”triple therapy”

7-14 day course 2 antibiotics + PPI
– Antibiotics
• Amoxicillin, tetracycline, metronidazole, clarithromycin
– Nelms Table 14.16
• 86-98% eradication rate
• Side effects: nausea, vomiting, abdominal pain
– May reduce compliance

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Management of PUD: Nutrition

• Nutritional goals of care
– Support medical therapy & decrease symptoms
– Prevent weight loss & restore nutrient imbalances
• Nutrition therapy
– Trial restriction of foods that may increase acid secretion
• Black and red pepper, caffeine, coffee (inc. decaf), alcohol
– Avoid foods not tolerated (diet as tolerated or “DAT”)
• Meal considerations: timing & size
– Avoid lying down after eating
– Avoid larger meals close to bedt

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Nutrition: Other Considerations

Historical dietary treatment: milk & cream
– Coat stomach
– Now know they increase gastrin and pepsin secretion
– Do NOT recommend
• pH of food prior to consumption has little effect after
consumption
– Restricting acidic juices/foods not warranted

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Acute Symptomology

• Sharp, sudden, persistent, severe pain
• Melena
– Bloody/black stools
• Hematemesis
– Vomiting blood; “coffee ground emesis”
Serious complications
• Acute or chronic GI bleed
• Perforation
• Obstruction
• i.e. gastric outlet
obstruction

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Surgical Treatment of PUD

• Surgical treatment significantly reduced post-1960
– Secondary to discovery of H. pylori
• Present day, indicated for:
– Severe cases, refractory to treatment
– Complications
• GI bleeds, perforation, obstruction of pyloric sphincter
• Types of surgery
– Vagotomy (with or w/o gastric resection)
– Gastroenterostomy

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Vagotomy

• Interruption of the impulses
(cholinergic stimulation of
stomach) carried by the vagus
nerve to parietal cells
– ↓ acid production
– ↓ response to gastrin
• Truncal vagotomy with
– Pyloroplasty, or
– Antrectomy
• Highly selective vagotomy

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Highly Selective Vagotomy

• Preferred choice to treating PUD
– Use depends on severity of
disease
• Proximal gastric vagotomy to
decrease acid secretion
• Preserves antral motility
• No pyloroplasty
• No rapid gastric emptying

Truncal Vagotomy w/ Pyloroplasty

Vagus nerve cut at distal esophagus
– ↓ antral contraction
– Delayed emptying of solids
– ↓ pylorus relaxation
• Procedure to enhance pyloric drainage
required
• Pyloroplasty
– Surgical revision to widen pyloric canal
– Creates leaky pylorus to enhance
gastric emptying
• ↑ emptying of liquids and solids

Gastric Surgeries (Gastrectomy)

• Resection of part of stomach (partial gastrectomy) and pylorus
– Alternative to pyloroplasty; gastric remnant anastomosed to small intestine
• Gastroduodenostomy (Billroth I)
– Removal of pylorus and/or antrum of stomach
– Anastomosis of proximal end of duodenum to distal end of remnant stomach
• Gastrojejunostomy (Billroth II)
– Removal of antrum
– Anastomosis of remnant stomach to side of jejunum à blind duodenal loop (stapled) to allow for bile and pancreatic secretions to flow into intestine (aid digestion and absorption)
• Roux-en-Y anastomosis
– Close to total gastrectomy
– Jejunum pulled up and anastamosed at distal end of esophagus or gastric remnant
– Duodenum then connected to small bowel to allow bile and pancreatic secretions to flow into
the intestine

Gastric Surgeries (Gastrectomy)

Resection of part of stomach (partial gastrectomy) and pylorus
– Alternative to pyloroplasty; gastric remnant anastomosed to small intestine
• Gastroduodenostomy (Billroth I)
– Removal of pylorus and/or antrum of stomach
– Anastomosis of proximal end of duodenum to distal end of remnant stomach
• Gastrojejunostomy (Billroth II)
– Removal of antrum
– Anastomosis of remnant stomach to side of jejunum à blind duodenal loop (stapled) to allow for bile and pancreatic secretions to flow into intestine (aid digestion and absorption)
• Roux-en-Y anastomosis
– Close to total gastrectomy
– Jejunum pulled up and anastamosed at distal end of esophagus or gastric remnant
– Duodenum then connected to small bowel to allow bile and pancreatic secretions to flow into
the intestine

• Gastroduodenostomy (Billroth I)

– Removal of pylorus and/or antrum of stomach

– Anastomosis of proximal end of duodenum to distal end of remnant stomach

• Gastrojejunostomy (Billroth II)

Removal of antrum
– Anastomosis of remnant stomach to side of jejunum à blind duodenal loop (stapled) to allow for bile and pancreatic secretions to flow into intestine (aid digestion and absorption)

• Roux-en-Y anastomosis

– Close to total gastrectomy
– Jejunum pulled up and anastamosed at distal end of esophagus or gastric remnant
– Duodenum then connected to small bowel to allow bile and pancreatic secretions to flow into
the intestine

Vagotomy

Vagotomy Impaired motor function of the stomach

Total gastric and truncal vagotomy

Gastric stasis and poor gastric emptying

Subtotal gastrectomy with vagotomy

Early satiety Delayed gastric emptying Rapid emptying of hypertonic fluids

Total gastrectomy

``` Early satiety, nausea, vomiting Weight loss Poor availability of bile acids and pancreatic enzymes b/c of anastomotic changes Malabsorption PEM Anemia Dumping syndro B12 deficiency ```

Dumping Syndrome

Physiological response to presence of larger-than-normal amounts of food and liquid in small intestine – Healthy individual: • Food partially digests in stomach 1-3h • Enters duodenum slowly via pyloric sphincter; acidic chyme is neutralized by pancreatic bicarbonate • Secondary to loss of normal regulation of gastric emptying and GI/systemic responses to a meal – Accelerated gastric emptying à food “dumps” too quickly into small bowel – Refined/simple sugars particularly problematic • Rapidly absorb water from body

Post-Gastrectomy Nutrition Goals of Care

``` • Adequate calories and nutrients – Promote healing – Attenuate weight loss – Correct micronutrient deficiencies • Symptom management – Reflux – Early satiety – Dumping syndrome ```

Nutrition Interventions Post-Gastrectomy

``` Dependent on GOals of care reason for surgery - pud with acute complication gastric carcinoma; neojuvant treatment pre-op bariatric surgery ``` ``` Post-operative considerations – EN (small bowel feeding tube) • Pt’s post-op nutritional status – PN • Post-op complications; GIT not functioning, leaks etc. ```