upper GI Flashcards
N/V
Most common manifestations of GI disease
GI sends impulses to via
afferent pathways to the medulla, and this starts the vomiting process.
obstruction or constipation will cause
vomiting bc things can’t move down
things that cause vomiting (don vomiting)
menningitis, MI - esp. in women, diabetes, anesthesia
Metabolic alkalosis - from loss of what?
from loss of gastric HCl
Metabolic acidosis (not common)
from loss of bicarbonate if contents from small intestine are vomited - if very severe
drugs for vomiting
zofran (seratonin blocker), marinol (cannabis)
vomiting - nursing care
keep pt NPO
vomiting - Gerontologic Considerations
■ More likely to have cardiac or renal insufficiency
■ Increased risk for life-threatening fluid/electrolyte imbalances
■ Increased susceptibility to CNS side effects of antiemetic drugs (use lowest dose possible for least amount of time)
GERD - what gets damaged?
■ Chronic symptom of mucosal damage caused by reflux of stomach acid into the lower esophagus.
■ Most common UGI problem
GERD - Predisposing factors- Incompetent lower esophageal sphincter (LES) (most common) - foods (CAA) and what position?
▪ most common,
▪ gastric contents to move from stomach to the esophagus when Pt is
supine or increased abdominal pressure
▪ Decreased LES pressure can be due to certain foods or drugs (caffeine, alcohol, anticholingerics, etc)
other causes of GERD (gerd is heavy)
▪ Increased intraabdominal pressure (obesity) ▪ Hiatal hernia
clinical manifestations of GERD - heartburn - constant or not?
most common = heartburn (pyrosis). Burning, tight sensation felt beneath lower sternum and spreading upward to throat or jaw
■ Felt intermittently
GERD-related chest pain - more common among who?
▪ Described as burning, squeezing
▪ Radiating to back, neck, jaw, or arms
▪ Can mimic angina
▪ More common in older adults with GERD ▪ Relieved with antacids
Otolaryngologic symptoms of GERD - think throat
▪ Hoarseness
▪ Sore throat
▪ Lump in throat sm
Hypersalivation
▪ Choking
GERD-related chest pain - More common in
older adults with GERD
GERD - repeated exposure
Repeated exposure: scar formation, esophageal stricture, dysphagia
GERD complication (gerd gets complicated at the met)
Barrett’s esophagus (esophageal metaplasia = change from one cell type to another type)
esophageal metaplasia
▪ Replacement of flat epithelial cells with columnar epithelium
▪ Precancerous lesion
▪ Thought to be primarily due to GERD
▪ Diagnosed in 5% to 20% of patients with chronic reflux
▪ Must be monitored every 2–3 years by endoscopy
GERD diagnostics - Upper GI endoscopy (the end of gerd inflammation)
▪ Useful in assessing LES competence, degree of inflammation, scarring, strictures
▪ Obtain biopsy and cytologic specimens
Barium swallow - GERD diagnostics (barium is a protusion)
Can detect protrusion of gastric fundus
GERD - Esophageal manometric (motility) studies (man that’s pressure)
Measure pressure in esophagus and LES
GERD - Radionuclide tests (the radio can see the reflux)
▪ Detect reflux of gastric contents
▪ Evaluate rate of esophageal clearance
GERD diet
▪ Small, frequent meals
▪ Avoid late evening meals
▪ Drink fluids between meals
▪ Chewing gum and oral lozenges
foods that decrease LES pressure (everything you love)
chocolate, peppermint, tomatoes, coffee, tea,
meds for GERD
proton pump and histamine blockers (most popular), Acid protective, Cholinergic, Prokinetic drugs, Antacids
PPI - how to take?
start with one dose before meals
long term PPI associated with (pp on my bones)
bone density
GERD - goal of surgery
Goal of surgical therapy is to enhance the integrity of the LES
GERD surgery only for ppl with
▪ Failure of conservative therapy
▪ Medication intolerance
▪ Barrett’s metaplasia
▪ Esophageal stricture and stenosis ▪ Chronic esophagitis
LINX Reflux Management System - for GERD (link the magnets)
magnets to keep esoph closed. can’t have an MRI with this one
nursing management for GERD (HOB and when to lie down?)
■ Elevate head of bed 30 degrees
■ Do not lie down for 2–3 hours after eating
■ Avoid factors that cause reflux
– Stop smoking
– Avoid alcohol and caffeine
– Avoid acidic foods
■ Stress reduction techniques
■ Weight reduction, if appropriate
■ Small, frequent meals
■ Evaluate effectiveness of medications
■ Observe for side effects of medications
PPI common side effect
headache
antiacids with aluminum (aluminum poop)
cause constipation
anticacids with magnesium cause what? (maggie has diarrhea)
diarrhea
Esophageal Cancer - most are what type?
Most are adenocarcinomas
▪ Others are squamous cell tumors
Adenocarcinomas - better or worse with age?
glands lining esophagus
Resemble cancers of stomach and small intestine
cause unknown
INCREASES with age
Esophageal Cancer risk factors
▪ Barrett’s esophagus
▪ Smoking
▪ Excessive alcohol intake
▪ Obesity
▪ Hx of achalasia (delayed emptying of lower esophagus)
esophageal Majority of tumors located in (tumors go low)
middle and lower portions of esophagus
esophageal Malignant tumor - how does it appear?
▪ Usually appears as ulcerated lesion
▪ May penetrate muscular layer and outside wall of esophagus
▪ Obstruction in later stages
esophageal cancer - when do experience symptoms?
Symptom onset is late
esophageal cancer spreads via
Spreads via lymph system, so Liver and lungs are common sites for mets
Esophageal Cancer Clinical Manifestations (esophageal cancer doesn’t eat meat)
Progressive dysphagia is most common symptom
▪ Initially with only meat, then with soft foods, and eventually with liquids
Weight loss
▪ Regurgitation of blood-flecked esophageal contents
Esophageal Cancer pain - early or late? (esoph is always late with everything)
pain develops late
Esophageal Cancer where is the pain (it hurts esop to swallow)
Substernal, epigastric, or back areas
▪ Increases with swallowing
▪ May radiate to neck, jaw, ears, shoulders
If tumor is in upper third of esophagus, what symptoms? (just 3) esophagus think throat
▪ Sore throat
▪ Choking
▪ Hoarseness
Esophageal Cancer Complications
▪ Hemorrhage
▪ If erodes through esophagus and into aorta
▪ Esophageal perforation with fistula formation
▪ Esophageal obstruction
how to diagnose esophageal cancer
Endoscopy with biopsy
▪ Necessary for definitive diagnosis
esophageal cancer - Endoscopic ultrasonography - used for what? (ultra staging)
Endoscopic ultrasonography (EUS) ▪ Important tool to stage
esophageal cancer prognosis
Poor prognosis
▪ Usually not diagnosed until advanced
esophageal cancer surgery - Esophagectomy
Esophagectomy - removal of part or all of esophagus
esophageal cancer surgery - Esophagogastrostomy (gag to my stomach)
Resection of portion of esophagus and anastomosis of remaining portion to stomach
esophageal cancer - Photodynamic therapy (absorption is photodynamic)
Inject IV porfimer (Photofrin), which is absorbed by cancer tissue
esophageal cancer - stent
Allow food and liquid to pass through stenotic area, helps with nutrition
post esophageal cancer nutrition - how much water and how often? (30 with esophageal cancer surgery)
▪ Swallowing study may be done before patient can have oral fluids
▪ When permitted, water (30–60 mL) is given hourly
▪ Gradual progression to small, frequent, bland meals
after esophageal cancer surgery - symptoms to watch for (3 of them) (esop DFP)
pain, fever, dsypnea - could indicate leakage
esophageal cancer surgery - post op - ng tube drainage - how long is it bloody? (Esop is bloody for 8-12 hours)
▪ NG tube with bloody drainage for 8–12 hours
▪ Changes gradually to greenish yellow
▪ NG tube should not be repositioned or reinserted without surgeon’s approval
stomach cancer - prognosis (stomach cancer not bad)
■ Adenocarcinoma of stomach wall
■ Often metastasized when diagnosed
■ 5-year survival if confined to stomach = 71%
■ 5-year survival with metastasis = 31%
stomach cancer - causes
Etiology—no known specific cause
■ Nonspecific factors: H. pylori, autoimmune-related inflammation, repeated exposure to irritants
stomach cancer - predisposing causes - foods, anemia, habits
Dietary: smoked foods, salted fish and meat, pickled vegetables
– H. pylori infection at early age; Lymphoma of stomach; atrophic gastritis, pernicious anemia, polyps, achlorhydria; smoking, obesity
stomach cancer spreads (the stomach is direct)
by direct extension—liver and adjacent tissue
stomach cancer symptoms
■GI:unexplained weight loss, indigestion, abdominal discomfort/pain, early satiety
■ Anemia: pale, weak, fatigue, dizzy, short of breath, heme + stool
stomach cancer - late signs - not what you think
Metastasis/late signs:
– Supraclavicular lymph node enlargement – Ascites
Stomach Cancer Diagnostic Studies (end the cancer with an endoscopy)
■ H&P
■ Upper GI Endoscopy with biopsy- best tool***
■ EUS, CT, MRI, PET—staging
■ Laparoscopy—determine peritoneal spread
■ Labs: CBC, liver enzymes, amylase, tumor markers
■ Stool—occult blood
stomach cancer treatment - what is the best treatment
surgery is the best
surgery for stomach cancer
gastroctomy - partial or full
billroth surgery for stomach cancer
billroth 1 is 50 -75% of stomach, billroth 2 is just 50%
gastric surgery (stomach cancer) complications post op (surgery in the dumps)
hemmorhage, Dumping syndrome, Postprandial hypoglycemia—variant of dumping syndrome, Bile reflux gastritis—after reconstruction or removal or pylorus
Dumping syndrome
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– –
Gastric chyme enters small intestine as large hypertonic bolus; pulls fluid into bowel lumen causing decreased plasma volume, distention of bowel lumen, and rapid transit within 15 to 30 minutes of eating
See weakness, sweating, palpitations, dizziness, cramping, borborygmi, and defecation urge
Lasts about 1 hour
Reduced with rest after eating
Postprandial hypoglycemia—variant of dumping syndrome
– –Uncontrolled high carbohydrate bolus enters small intestine causing excess insulin and resulting in hypoglycemia ~ 2hours after eating
See: sweating, weakness, confusion, palpitations, tachycardia, anxiety (hypoglycemia reaction)
Bile reflux gastritis—after reconstruction or removal or pylorus - what meds to give? (bile reflux gets chole)
–
– – Bile reflux causes damage to gastric mucosa, chronic gastritis, and PUD
See: epigastric distress temporarily relieved with vomiting Administer cholestyramine—binds bile salts
pre op care - gastric surgery
Teach patient about procedure and postoperative expectations
■ Comfort measures/pain management
■ Cough and deep breath
■ NGT
■ IV fluids
gastric surgery - post op care - splinting?
– Fluid and electrolyte balance
■ IV fluids to oral to solids
■ Monitor I & O, daily weight
– Prevent respiratory complications
■ Respiratory assessment; VS, dyspnea, chest pain, cyanosis
■ Splint incision with cough and deep breathing
■ Analgesia, early ambulation, reposition frequently
– Maintain comfort: pain, nausea/vomiting
gastric surgery - post op care
Prevent infection
■ Monitor VS
■ Assess wound
Monitor for complications (especially if obese):
■ Atelectasis, pneumonia, DVT, PE, pneumothorax
■ Anastomosis leak—tachycardia, dyspnea, fever, abdominal pain, anxiety, restlessness
– Requires immediate treatment to prevent sepsis and death ■ Hemorrhage—VS, NG aspirate
post op care - gastric surgery - NG tube- what does it do?
NGT for decompression; reduces pressure to suture line; decreases edema and inflammation
gastric surgery - post op nutrition
■ Dietician consult; reinforce instructions
■ Enteral feedings or parenteral nutrition
■ Wound healing: potassium, vitamins C, D, K, and B-complex
gastric surgery - post op - Pernicious anemia (cobain has anemia)
Pernicious anemia—loss of intrinsic factor; needed for absorption of cobalamin in terminal ileum; essential for RBCs
– Administer cobalamin, multivitamins with folate, calcium, vitamin D, and iron (life-long therapy)
gastric surgery - Reduced stomach size means reduced meal size (can gast have water?)
– First few weeks: soft, bland, low fiber, high complex carbohydrates, and high
protein
– Small, frequent meals
– No fluids with meals, chew thoroughly
– Avoid simple sugars, lactose, and fried foods
– Avoid extreme food temperatures
– Avoid hypoglycemia—limit sugar with meals; moderate protein and fat
esophageal cancer surgery - coughing and turning? and bed position?
▪ Turning, coughing, and deep breathing every 2 hours
▪ Incentive spirometer use
▪ Positioned in semi-Fowler’s or Fowler’s
▪ Should be maintained at least 2 hours after eating
▪ Monitor for complications
post op - gastric surgery - NG tube - drainage? (Had gastric surgery at 23 and 75)
Observe gastric aspirate: color, amount, odor
Bloody drainage expected for 2 to 3 hours; report excess (greater than 75mL/hr); monitor for clots/obstruction;
post op - gastric surgery - NG tube - irrigation? color of exudate? (Back to normal at 36)
irrigate with NSS to avoid: rupture of sutures, leakage into peritoneal cavity, hemorrhage, and abscess formation
Should darken and change to yellow-green in 36 to 48 hours
