Peptic Ulcers & GER/GERD Flashcards
What are peptic ulcers ?
erosion of the GI mucosa due to the digestive action of HCl acid and pepsin
- acute or chronic
What are acute peptic ulcers ?
- superficial erosion
- minimal inflammation
- short duration
- resolves quickly when cause is identified and removed
What are chronic peptic ulcers ?
- long duration
- eroding through the muscular wall with the formation of fibrous tissue
- present continuously for many months or intermittently throughout the person’s lifetime
What are some risk factors for Peptic Ulcers ?
- Acid environment (increase in acid causes inflammation and histamine release which causes more secretion of acid and pepsin)
- H. pylori bacterial infection
- Medical-induced injury: NSAIDS & Aspirin
- Lifestyle: alcohol, coffee psychologic stress, smoking
What are the 2 types of peptic ulcers ?
gastric & duodenal
- mortality is greater in gastric because they tend to affect those over 50 yrs
What are some characteristics of gastric ulcers ?
- greater in women
- peak age is 50-60 yrs
- increase mortality
- more common in people of lower socioeconomic status
- increased with smoking, drug use (aspirin, NSAIDS), H.pylori, and alcohol use
- increased with incompetent pyloric sphincter and bile reflux
What are some characteristics of Duodenal ulcers ?
- greater in men but increasing in women (especially postmenopausal)
- peak age is 35-45 hrs
- associated with psychological stress
- increased with smoking, drug use and alcohol use
- associated with other disease (COPD, pulmonary disease, pancreatic disease, hyperparathyroidism, Zollinger-Ellison’s, chronic renal failure)
What are some clinical manifestations of gastric ulcers ?
- pain in left epigastrum, back and upper abdomen
- “burning & gaseous” pain
- 1 to 2 hours after a meal
- if ulcer is through the mucosa the pain is worse when eating
What are some clinical manifestations of duodenal ulcers ?
- mid-epigastric pain, beneath xiphoid process, or back pain
- “burning or cramplike” pain
- 2-5 hrs after a meal
- food may relieve pain
Why does the pain occur hours after a meal in duodenal ulcers ?
food moving from the stomach to the duodenum takes a few hours so when it finally reaches the duodenum then that is when acid is secreted again to further digest the food which irritates the ulcers here
- food makes pain lessen because it helps neutralize the acid
What are some diagnostic studies for Peptic ulcers ?
- endoscopy with or without biopsy
- test for H. pylori (breathing test or biopsy)
- barium contrast studies (only if endoscopy isn’t possible)
- gastric analysis
- Labs: CBC, liver enzyme studies and stool examination (looking for problems that could cause complications)
What is some nursing care for an Endoscopy ?
- before procedure: NPO for 6-12 hrs
- after procedure: NPO until gag reflex returns (1-2 hours)
- monitor for pain, bleeding, unusual difficult swallowing, elevated temperature
- minor throat discomfort: lozenges, saline gargle
- bed rest until fully alert
- inform pt that they may experience some bloating, belching and flatulence
What are some symptoms of hemorrhage with peptic ulcers ?
most common: due to erosion
- change in vital signs (if lots of blood loss)
- bleeding per stool or NG output
- lower RBC count
What are some symptoms of perforation ?
EMERGENCY
- in large duodenal ulcers or those on lesser curvature of stomach
- acute pain
- rigid/board-like abdomen
- elevated WBCs
- may need antibiotic and go into surgery
What is gastric outlet obstruction ?
sudden onset of narrowing of pylorus due to edema, inflammation or scar tissue
- S&S: increased gastric residual, vomiting, constipation
What is the tx for hemorrhage of ulcers ?
- NG tube to suction for 1-2 days
- IV fluids and electrolytes (blood transfusion if needed)
- careful I/O monitoring
- endoscopy
What is the tx for perforation ?
- notify provider immediately
- NG tube to suction
- antibiotics
- IV fluids: usually lactated ringer’s
- prepare for emergency surgery
What is the tx for gastric outlet obstruction ?
- NG tube to suction
- fluid and electrolytes
What is the function of antacids with PUD ?
increase gastric PH by neutralizing acid
- Tums, Mylanta, Maalox
What is the function of Histamine Receptor Blockers with PUD ?
decreases HCl acid secretion by blocking action of histamine on H2 receptors
- Famotidine (Pepcid)
- side effects: N,V,D, constipation, HA, thrombocytopenia
What is the function of Proton Pump Inhibitors ?
decreased HCl acid secretion by blocking enzyme that is important for the secretion of HCl acid
- Esomeprazole/Nexium & Pantoprazole (protonix)
What is the function of Sucralfate for ulcers ?
provides a physically protective coating
- used primarily in addition with other meds
- interacts with digoxin, warfarin, and dilantin
- can cause mild constipation
What is the function of Misoprostol/Cytotec for ulcers ?
Synthetic Prostaglandin: decreases acid secretion in the parietal cells of the stomach and provides some physical protection
- for gastric ulcers
- used primarily in addition with other meds
- may be used if Aspirin and/or NSAIDS can’t be discontinued
- contraindicated in pregnancy
What is the difference between the Bilroth 1 and 2 ?
in both the bottom/distal portion of the stomach is resected
- 1: the stomach is joined to the duodenum
- 2: stomach bypasses the duodenum and is joined to the jejunum
What is a vagotomy ?
cut of the vagus nerve which reduces acid production
- Truncal Vagotomy: cut main trunk of vagus nerve which significantly reduces stomach acid production but can cause other complications
- Selective: specific branch of vagus nerve that reduces acid production but preserves other gastric functions
What is dumping syndrome ?
associated with meals having a hyperosmolar composition (food is moving too quickly through the small intestine)
- causes a spike in insulin
- S&S: generalized weakness, sweating palpation, and dizziness
What is Postprandial Hypoglycemia ?
a bolus of fluid high in carbohydrate goes into the small intestine causing excessive amounts of insulin into circulation
- S&S: sweating, weakness, mental confusion, palpation, tachycardia, and anxiety
What is Bile Reflux Gastritis ?
prolonged contact of bile causes damage to gastric mucosa
- administration of Questran relieves irritation
- bile is the problem now and it can more easily reflux up into the stomach
What is some Post-Op care for pt’s of gastric surgery ?
- risk for pernicious anemia
- maintain NG tube until fluids can be tolerated (IV fluids before then)
- careful GI assessment and incision care
- small portions of fluid and food daily (small frequent meals)
- low carbohydrates
- restricted sugar with meals
- moderate amounts of protein and fat
- 30 mins of rest after each meal
What are some gerontologic considerations for PUD ?
increased in patients greater then 60 yrs
- increased use of NSAIDS for overall pain
- first manifestation may be frank gastric bleeding or decreased hematocrit
- tx is similar to younger adults
- emphasis on prevention of both gastric and peptic ulcers
What is GERD ?
mucosal damage caused by reflux (backflow) of stomach acid into the esophagus, causing irritation / esophagitis
What is GER ?
the transfer of gastric contents into the esophagus
- peak is in 4 month infants and generally resolves spontaneously around 12 months of age as their esophageal sphincter grows stronger
- becomes GERD when complications occur
What are some predisposing conditions to GER/GERD ?
- incompetent lower esophageal sphincter (certain meds & foods exacerbate this)
- Foods: caffeine, chocolate, peppermints
- Meds: anticholinergics
- decreased esophageal clearance
- increased intraabdominal pressure (obesity, Hhiatal hernia)
What are some S&S of GERD in adults ?
- heartburn/pyrosis (more than twice a week, especially in older adults needs to be evaluated further)
- dyspepsia: pain/discomfort in upper abdomen that is usually midline
- coughing/wheezing
- dyspnea
- posteating bloating
- belching
- early satiety
- regurgitation
- hypersalivation
- N/V
- feeling of lump in throat or food stopping
- dysphagia
- sore throat
What are some S&S of GER in infants ?
- spitting up, vomiting
- crying/irritable with arching of back
- weight loss, failure to thrive
- gagging, choking at end of feedings
- respiratory problems (aspiration)
- apnea or ALTE (apparent life-threatening event)
What are some S&S of GER in children ?
- heartburn
- abdominal pain
- non cardiac chest pain
- chronic cough
- dysphagia
- nocturnal asthma
- recurrent pneumonia
What are some complications of GER/GERD ?
- esophagitis (irritation of lining of the esophagus)
- esophageal strictures (resulting from scar tissue) which can lead to dysphasia
- Barrett’s esophagus (precancerous lesions)
- bronchitis
- aspiration (pnemonia)
- bronchospasms
- laryngospasma
- ulceration of esophagus
- upper GI bleeding
- dental erosion
What are some diagnostic test of GER/GERD ?
- history of symptoms
- barium swallow
- endoscopy
- esophageal biopsy
- gastric secretions/24 hr pH study
- scintiscan (child eats and different pics are taken at various times over 4 hr or even days later) aka a gastric emptying study
What are some potential complications of a Endoscopy ?
- perforation of the esophagus, stomach and duodenum
- bleeding from a biopsy site
- pulmonary aspiration of gastric contents
- over sedation from medication during test
- hypotension induces by the sedative medication
- local IV phlebitic reaction to the injection of sclerosing sedative medication
What are some modifications of GER for infants ?
- infants who are growing with no respiratory complications do not need modifications
- change to soy formula
- frequent burping
- smaller more frequent feedings
- thicken feeding with rice cereal
- weight monitoring
What are some GER/GERD lifestyle changes ?
- small, frequent meals (4-6 per day)
- drink adequate fluids w meals to aide food passage
- eat slowly and chew well to add saliva to the food
- avoid extremely hot or cold foods, spies, fats, alcohol, coffee, chocolate, and citrus
- avoid eating and drinking for 3 hrs before retiring to prevent nocturnal reflux
- elevate HOB
- lose weight, if overweight, to decrease the gastroesophageal pressure gradient
- avoid tobacco and salicylates
What is the purpose of Histamine 2 Receptor Antagonists with GER/GERD ?
decreases gastric acid secretion by inhibiting the H2 receptors
- Famotidine (Pepcid), Ranitidine (Zantac) , Nixatidine (Axid)
- side effects: N,V,D, constipation, HA, thrombodytopenia
What is the purpose of Proton Pump Inhibitors (PPIs) with GER/GERD ?
decrease stomach HCl acid secretions by inhibiting the proton pump mechanism responsible for secreting H ions
- Omeprazole (Prilosec), Esomeprazole (Nexium), Pantoprazole (Protonix)
- take before 1st meal of the day
- side effects: N,V,D, constipation, low bone density, predisposition of GI infections like C.Diff so report diarrhea to provider
What is the purpose of Gastrointestinal Stimulants with GER/GERD ?
stimulates the smooth muscle of the GI tract and increases the rate of gastric emptying
- Metoclopramide (Reglan)
- side effects: sedation, dry mouth diarrhea,
What is the purpose of Antiacids with GER/GERD ?
neutralizes the acid secretions and promotes gastric mucosal defense mechanism
- Gaviscon, Mylanta, Tums
- take 30 mins before 1-3 hrs after a meal to provide temporary relief
- only med that can’t be given to kids
What is Nissen Fundoplication ?
where the top part of the stomach (fundus) is wrapped around the lower esophagus and sutured in place to make the sphincter stronger and tighter
What is some Post-Op care after surgery for GERD ?
- deep breathing, control N/V and pain
- start on liquid diet and slowly advance to soft, then solids
- side effects: difficulty swallowing, bloating, and increased flatulence
- complications: general anesthetic complications, bleeding, tearing of the esophagus slippage of the wrap
