Upper GI (PUD & GI Bleed)

Question 1

What is PUD?

Answer 1

Erosion of the GI mucosa resulting from the digestive action of HCL and Pepsin

Question 2

Common causes of PUD

Answer 2

Helicobacter pylori - Triggers inflammation
Drugs - NSAIDs
H. pylori + NSAIDs = DOUBLE TROUBLE

Question 3

Other causes of PUD

Answer 3

Alcohol
Smoking
Family History
Stress (can aggravate an existing ulcer)

Question 4

Ulcers associated with H. pylori (think location)

Answer 4

Gastric Ulcer - Most of the time in the antrum of the stomach

Duodenal Ulcer - 80% of Ulcers; 90-95% have H. pylori

Question 5

What is the most accurate diagnostic procedure for PUD

Answer 5

EGD

Question 6

Tests to confirm H. pylori

Answer 6

Non-Invasive = Urea breath testing and stool testing
(Urea = by product of metabolism of H. pyori)

Invasive = Biopsy of antral mucosa and testing for urease (gold standard for diagnosis)

Question 7

Other PUD diagnostic studies

Answer 7

CBC - anemia

Stool - for occult blood

Question 8

Acute Ulcers

Answer 8

Short duration; resolves quickly

Does not penetrate as deeply

Question 9

Chronic Ulcers

Answer 9

4 Times more common
Penetrate deeply
More severe
More long term

Question 10

Complications of PUD

Answer 10

H.O.P.

Hemorrhage - Most common complication
Obstruction
Perforation - Most lethal complication

Question 11

Assessment for Hemorrhage

Answer 11

Assess for change in vital signs
Change in amount &/or redness of gastric aspirate
With hemorrhage, pain may decrease at first

Question 12

Hemorrhage Interventions

Answer 12

Similar to UGI bleed

NG to LWS

Question 13

When does Obstruction happen

Answer 13

Can happen at any time

Question 14

Obstruction is most likely to occur…..

Answer 14

If ulcer is located close to pylorus

Question 15

T/F: Obstruction has a rapid onset of symptoms

Answer 15

False: Obstruction has a gradual onset of symptoms

Question 16

Obstruction interventions

Answer 16

NG to LWS until resolved

Irrigate gut as needed per protocol

Question 17

Onset of Perforation

Answer 17

Sudden and dramatic

Initial phase (0-2 hours) = sudden, severe upper abdominal pain; spreads throughout abdomen; radiates to back; not relieved by food or antacids.

Question 18

Signs of Perforation

Answer 18

Pain:
Sudden, severe upper abdominal pain; spreads throughout abdomen; radiates to back; not relieved by food or antacids.

Abdomen = Rigid/ Board like

Respirations = Shallow and Rapid

Pulse = Weak and Tachycardic

Bowel sounds = May be absent

Question 19

How soon after Perforation can Bacterial Peritonitis occur

Answer 19

Within 6-12 hours

Question 20

Rebound Tenderness

Answer 20

An unexpected finding
Cue of Peritonitis

No pain when compressing on palpation. Pain occurs when you take the pressure off of the abdomen.

Question 21

PUD: Collaborative care

Answer 21

Adequate Rest = Decrease in stress response

Smoking cessation

Individual dietary modifications as needed (no specific diet)

Question 22

PUD: Drug therapy

Answer 22

Stop Aspirin and NSAIDs for 4-6 weeks.
If Aspirin must be continued, give with a PPI

Antibiotics if H. pylori
PPI
Cytoprotective (sucralfate)

Question 23

Refractory PUD: Surgical options

Answer 23

Billroth reconstruction following gastrectomy

Billroth 1 and Billroth 2
Both methods of reconstruction of gut path

Question 24

PUD: Post op Complications

Answer 24

Dumping syndrome

Question 25

What is Dumping Syndrome?

Answer 25

Food (undigested and hyperosmolar) dumps into the small intestine Develops most often when part of the stomach has been removed - Gastrectomy - Fundoplication - Roux-en-Y (Gastric bypass surgery)

Question 26

Dumping Syndrome: Why does it happen?

Answer 26

Bolus of hypertonic food dumps into small intestines. Manifestations are a result of fluid rapidly shifting out of the plasma and into the GI tract.

Question 27

Clinical Manifestations of Dumping Syndrome

Answer 27

Weakness, sweating, palpitations, dizziness | Abdominal cramping, borborygmi, urge to defecate - diarrhea

Question 28

When do symptoms of dumping syndrome occur

Answer 28

15 minutes after eating a hyperosmolar meal

Question 29

T/F: Treatment for Dumping syndrome is to avoid concentrated sweets.

Answer 29

True: avoid drinking them during meals. Drink them between meals.

Question 30

What is a consequence of Dumping Syndrome?

Answer 30

Postprandial Hypoglycemia (after meal hypoglycemia)

Question 31

Postprandial Hypoglycemia: How does it work?

Answer 31

Bolus of fluid high in CHO into small intestines - > Results in hyperglycemia - > Release in excessive amounts of insulin - > results in Hypoglycemia about 2 hours after eating

Question 32

How to manage Dumping Syndrome

Answer 32

No large meals 6 small meals per day Fluids should not be taken with meal (30 mins before or 30 mins after) Avoid concentrated sweets Proteins and fats encouraged to promote rebuilding tissue Post - op Rest period after eating Symptoms are self limiting (months to year)

Question 33

Characteristics of Upper GI bleed

Answer 33

Slow (insidious) vs Sudden onset Hematemesis - Bright red (frank) blood indicates recent/ongoing GI bleed - Coffee ground indicates significant bleed has stopped Melena (black, tarry stool) - Transit time > 8 hours Occult blood - Not apparent by appearance - + for Guaiac

Question 34

Upper GI bleed causes

Answer 34

Esophageal Varices | Stomach and Duodenal Ulcers (~50% of UGI bleeds)

Question 35

Esophageal Varices occurs with...

Answer 35

Severe Portal Hypertension and cirrhosis

Question 36

What device is used for Esophageal Varices bleed?

Answer 36

Sengstakin-Blakemore tube - NG with a balloon that applies direct pressure to the Varices - Pt will ultimately end up in ICU

Question 37

Nursing Interventions for UGI bleed

Answer 37

Monitor Vital Signs closely (Baseline/trend/orthostatic) Assess S/S of Hypovolemia (Rapid loss in blood volume = Hypovolemic Shock) (Change in VS, Increased thirst, Cold clammy skin, Restlessness) Assess S/S of peritonitis (rigid board-like abdomen/Distention/guarding) Monitor Labs H&H/BUN (BUN can increase with GI bleed)

Question 38

Related Nursing Interventions: UGI bleed

Answer 38

Establish large bore IV access - anticipate giving PRBCs NG Lavage to rid stomach of blood Administer appropriate meds Prepare for endoscopy/endotherapy

Question 39

Patient Teaching: UGI bleed

Answer 39

Know/understand meds that are given - Antacids, PPI, H2 blockers, protective barriers, PCN's - Avoid ASA/NSAIDs Teach patient about S/S of GI bleed