Upper GI Disorders/Ingestion Flashcards
- GERD
> Esophagitis, Barrett’s esophagus
> Risk for cancer w/chronic irritation - Hiatal hernia
> Sliding & para esophageal - Gastritis
> Acute & chronic
- Peptic ulcer disease (PUD)
- Gastric cancer
?
- Is the most common GI disorder in the US
- Occurs as a result of backward flow of stomach contents into esophagus from LES
- Hiatal hernias inc risk
- During healing, Barrett’s epithelium & esophageal stricture are concerns
GERD (Gastroesophageal Reflux Disease)
Symptoms: Recognize Cues
- History
- May be initially asymptomatic
> Morning hoarseness
> Coughing or wheezing at night
Physical Assessment/ s/s
> Dyspepsia, regurgitation, “lump” in throat
> Auscultate lungs for crackles
Psychosocial Assessment
> How are coping with stress? ETOH use?; tobacco smoking?; diet history
Diagnostics
> Ambulatory esophageal pH monitoring
! EGD: esophagogastroduodenoscopy [definitive]
EGD
- Fiberoptic endoscope threaded through the mouth to duodenum for visual inspection (it will allow for bx or cauterization if needed)
- Hold anticoag’s, asa, NSAIDs before procedure
- NPO 6-8 hrs prior
- Dentures removed
GERD - Health Promotion/Maintenance
- Healthy eating habits; smaller meals
- Limitation of fried, fatty, spicy foods
- Avoid factors that affect Lower Esophageal Sphincter (LES)
- Sit upright for 1 hr >eating
- Eat @ least 3 hrs before going to bed
Factors that decrease LES pressure (! these should be avoided or lessened)
- Caffeinated beverages
- Coffee, tea, & cola
- Chocolate
- Nitrates
- Citrus fruits
- Tomatoes & tomato products
- Alcohol
- Peppermint, spearmint
- Smoking & use of other tobacco products
- Calcium channel blockers
- Anticholinergic rx’s
- High lvls of estrogen & progesterone
- NG tube placement
Gerd - Rx’s
- H2 receptor agonists
- Proton pump inhibitors
- Mucosal protective agents
- Antacids
?
The opening in the diaphragm where the esophagus passes to the stomach becomes relaxed
A portion of the upper stomach tissue then passes through the diaphragm into the chest cavity
Hiatal hernia
- Sliding HH’s = 90%
- Paraesophageal hernias = 10%
> When the stomach enters the thoracic cavity through the diaphragm beside the esophagus (! these are at greater risk for torsion)
Etiology - HH
- R/t inc intraabdominal pressure
> Obesity, pregnancy, heavy lifting
> Intense physical exertion
> Congenital weakness in the diaphragm at the hiatal opening or ascites
Complications - HH
- GERD w/possible aspiration r/t an incompetent LES
- Esophagitis (Barrett’s) w/chronic irritation from gastric contents - may cause a precancerous lesion or a stricture forming @ the site
- Hemorrhage from erosion
- Stenosis, ulcerations
- Strangulation of the stomach
? Symptoms of ?
- Postprandial fullness
- Postprandial breathlessness/suffocation
- CP similar to angina
- Worsening of sx’s while recumbent
Paraesophageal (HH)
? Symptoms of ?
- 50% asymptomatic
- Pyrosis [heartburn]
- Regurgitation
- Dysphagia
- CP
- Belching
Sliding (HH)
A common diagnostic is a barium swallow w/xray or fluoroscopy
Management
- Freq small feedings/low fat foods
- Reduce wt, avoid tight clothing, straining & exercise postprandial
- No reclining 2-3 hr postprandial
- HOB elevated on 4-8 inch blocks w/sleep
- Rx’s & possible surgery
Surgery Recommended when @ risk for or experiencing -
- Volvulus (twisting of GI tract & mesenteric vascularity)
- Bleeding, obstruction
- Strangulation
- Perforation
- Airway obstruction, aspiration
> Surgery done open or laparoscopically
> Hiatus is tightened & stomach is placed back in the abdominal cavity (surgeon may enter abd cavity or thoracic; if latter, anticipate chest tubes)
Additionally, to prevent the stomach from entering the chest cavity or to prevent regurgitation of GERD, a __ __ is implemented
After, the hiatus is tightened and the tip of the stomach is wrapped around the esophagus
Nissen fundoplication
Postop Period
- NGT; advance diet >peristalsis re-established
- Expect temporary dysphagia
- Encourage early ambulation & avoid carbonation; gas-producing foods; chew gum; use straws; & eat high fat foods
> Gas bloat syndrome - simethicone - Pulmonary toilet w/splinting (C&DB, IS)
> Risk for atelectasis & pneumonia
NGT
- N/V sx’s of impaired GI peristalsis can be alleviated
- LWS (low wall suction) empties or decompresses the stomach, minimizing N/V, retching
- Auscultate BS w/suction disconnected
- LWS is 0-80 mmHg (40-60 mmHg preferred)
- Traumatic injury can happen during NGT placement & result in GI bleed
- Prolonged use can cause ulcer formation
- Once pt is passing gas & has positive BS, NGT is clamped (it’s disconnected from suctioning)
Managing the Patient w/a NG Tube >Esophageal Surgery
> Check tube placement every 4-8 hrs
Ensure tube is patent & draining; drainage should turn from bloody to yellowish green by end of first postop day
> Secure tube well to prevent dislodgement
Don’t irrigate or reposition tube w/o hcp order
> Provide meticulous oral care & nasal hygiene q2-4 hrs
> Keep HOB elevated @ least 30°
> When pt can have a small amt of water, place them in a upright position & observe for dysphagia
> Observe for leakage from the anastomosis site (indicated by fever, fluid accumulation, & sx’s of early shock [tachycardia, tachypnea, AMS])
?
Or inflammation of the lining of the mucosa of the stomach; may be acute or chronic
Gastritis
Acute Gastritis - Etiology
- Short-term inflammatory/erosive process of usually the mucosa, caused by bacterial or chemical irritants
Acute Gastritis - Sx’s
> Anorexia, N/V
Abd cramping or diarrhea
Dyspepsia, feeling of fullness
Acute epigastric pain; fever; GI bleed
Acute Gastritis - Management
> Self-limiting when irritant removed
Symptomatic treatment
Irritants
- asa, NSAIDs
- Corticosteroids, stress
- ETOH, tobacco, caffeine
- Radiation exposure
- Bacterial contamination of food or water
- Ingestion of caustic substances
Chronic Gastritis
- 2 types: A & B
Chronic Gastritis - Sx’s
> Vague epigastric pain relieved by food
Anorexia, N/V, intolerance to spicy food, pernicious anemia
May be at higher risk for gastric cancer
Type ?
Is most caused by H. pylori
Type B
Type ?
Autoimmune, genetic, antibodies attack parietal cells
Type A
Chronic Gastritis: Diagnostics
? Which exam is done ?
EGD
Chronic Gastritis: Management
> Avoid rx’s that cause gastritis; avoid irritants
Admin B12 injections, antacids, H2 receptor agonists, proton pump inhibitors, mucosal barriers, prostaglandin analogs, antimicrobials as ordered
Peptic Ulcers
- Gastric - usually near pylorus
- Proximal duodenum
- Stress
Differential Features of Gastric & Duodenal Ulcers
What are 2 of the most common causes of peptic ulcer disease (PUD)?
NSAIDs, H. pylori
Etiology
! H. pylori, NSAIDs
- Excessive secretion of HCl/pepsin
> Stress/steroids
> Milk/calcium
> Caffeine, smoking
> ETOH
> Protein
- Genetics
- Stress ulcers
- Zollinger-Ellison syndrome
H. pylori in stomach mucosa > urease prevents organism from being killed by HCl
Peptic Ulcer Sx’s
- Asymptomatic
- Dyspepsia syndrome: fullness, epigastric discomfort, vague nausea, distention, bloating
- Anorexia, wt loss, & pain worsened by food (gastric); wt gain & pain lessened by food (duod)
- Hematemesis/hemorrhage (gastric); melena/perf (duod)
Diagnostics
- Endoscopy w/bx
- Radiology studies - cxr or barium studies
- Breath test
- H. pylori IgG antibodies in serum
- Stool for OB
- CBC to check anemia
- ELISA
Treatment
- H2 receptor agonists
- Proton pump inhibitors
- Mucosal protective agents
- Antacids
- Antimicrobials
! Complications we’re trying to avoid include bleeding and/or perforation that empties stomach contents systemically
> EGD may be used to stop bleeding or other surgical procedures may be used to address perforation or intractable ulcers
Surgery for Intractable Ulcers
- Vagotomy w/ or w/o pyloroplasty
- Billroth I (gastroduodenostomy)
- Billroth II (gastrojejunostomy)
Complications
- Obstruction - pyloric outlet
- Hemorrhage - hematemesis (coffee-ground emesis/bright red)
> Melena, hematochezia
- Perforation & peritonitis
Nursing Interventions
- Discourage caffeine, spicy foods, tobacco, & ETOH; avoid milk & cream products; ? referral
- NPO for gastric rest; maintain hydration/electrolytes/caloric intake
- Monitor coffee-ground/hematemesis/melena/CBC
- Monitor pain level w/interventions/avoidance of irritants
- Limit anxiety; teach dz process & importance of rx’s
Gastric Cancer - Risk Factors
- Familial clusters - 1st deg relative = 2-3x risk
- Environmental - high nitrates in soil & H2O
- Cultural - diets high in salt, smoked, pickled or dry = atrophic gastritis
- GI surgery, pernicious anemia, achlorhydria, gastric polyps
- Smoking
- H. pylori - chronic gastritis
Gastric Cancer Sx’s
- Asymptomatic in 80% - early
- Vague dyspeptic sx’s - nausea, dyspepsia, bloating, early satiety, anorexia
- Pain & wt loss - late
- Bowel obstruction - late
Gastric Cancer Diagnostics
- EGD w/bx
- EUS
- CT, MRI, PET
- CBC (anemia ?)
- (+) OB stool
- CEA (carcinoembryonic antigen)
Management
- Palliative vs curable
- Radiation
- Chemotherapy
- Surgery
Gastric Resections - Billroth I & II
I
- Anastomosis of gastric segment to duodenum
II
- Anastomosis of gastric segment to proximal jejunum
Postop Care
- Pain rx’s; anxiety
- Pulmonary toilet w/splinting & DVT prevention
- Fowler’s position - optimize drainage
- NGT - well secured/decompressed
- Drsg changes
- IV fluids/electrolytes
- Enteral or parenteral feeding
Complications
! Marginal ulcers / hemorrhage
! Duodenal bile reflux - Questran [lowers cholesterol]
! Vit B12 & folic acid deficiency
! Malabsorption of calcium & Vit D
! Dumping syndrome
! Fistula
! Pyloric obstruction
! Afferent loop syndrome
?
A term that refers to a group of vasomotor sx’s that occur >eating in pts who have had a gastrectomy
Believed to happen as a result of rapid emptying of food contents into SI, which shifts fluid into the gut, causing abd distention
Sx’s can occur within 30 min of eating
Dumping sydrome
Dumping syndrome - Management
- Eat small, frequent meals
- Low Fowler’s position
- Eat a moderate fat, high protein diet
- Limit carbs; no simple sugars
- Minimal liquids w/meals
- Avoid extremes in food temperature
- Rest on left side postprandially for 20-30 min
- Rx’s as ordered
