Disorders of Digestion and Absorption

nausea and vomiting

unpleasant sensation usually preceding vomiting, may have abdominal pain, pallor, sweating, clammy skin

vomiting

forceful expulsions of stomach contents throught the mouth

projectile vomiting

is forceful ejection of stomach contents

regurgitation

gentle ejection of stomach contents without nausea or retching

• antiemetics

• IV Fluids

• NG tube

• TPN

treatments for nausea and vomiting

• dehydration

• metabolic alkalosis

• aspiration

complications of nausea and vomiting:

hiatal hernia

• opening in the diaphragm thru w/c the esophagis passes becoms enlarged and part of the upper stomach moves up into the lower portion of the thorax

• occurs more often in women than in women

hiatal hernia

it is caused by the lower esophageal sphincter related to increased abdominal pressure, long term bed rest, trauma

type 1: sliding

• occurs when the upper stomach and the gastroesophageal junction are dislplaced upward and slide in and out of the thorax

type 2: rolling / PARAESOPHAGEAL

• occurs when all or part of the stomach pushes through the diaphragm beside the esophagus

• further classified as types II, III, IV

2 types of hiatal hernia

type 1: sliding

what type of hiatal hernia: occurs when the upper stomach and the gastroesophageal junction are dislplaced upward and slide in and out of the thorax

type 2: rolling / PARAESOPHAGEAL

what type of hiatal hernia:

• occurs when all or part of the stomach pushes through the diaphragm beside the esophagus

• further classified as types II, III, IV

type 1: sliding type

what type of hiatal hernia:

• dysphagia

• regurgitation

• heartburn (pyrosis)

• intermittent epigasruc pain or fullness after eating

• hemorrhage, obsyruction and strangulation can occur with any type of hernia

type 2: rolling / paraesophageal

what type of hiatal hernia:

• sense of fullness or chest pain after eating

disgnostics of hiatal hernia:

esophagogastroduodonescopy

what is EGD (it is for hiatal hernia)

• small freq feedins

• not to recline for q hour after eating

• elevate head of bed on 4 to 8 inch blocks

what should be considered for hiatal hernia:

• h2 receptor antagonists: to reduce stomach secretion

  • tagamet

  • zantac

  • pepsid

• antacids: neutralize stomach acids

• reglan, propulsid: increase stomach emptying

drug theraoy for hiatal hernia:

• decrease caffeine, fatty foods, alcohol, acidic and spicy foods, avoiding bedtime snack

diet therapy for hiatal hernia:

fundoplication

stomach fundus is wrapped around the lower part of the esphagus

gastritis

inflammation of the gastric or lining of the stomach (mucosa)

acute

what type of gastritis: lasting several hours to a few days; may develop in acute illnesses

chronic

a type of gastritis that is from repeated exposure to irritating agents or recurring episodes of acute gastritis

erosive, non-erosive

acute gastritis can be classified as:

erosive

what type of acute gastritis: caused by local irritants such as aspirin and other NSAIDS, alcohol abuse and recent exposure o radiation therapy

• this type of acute gastritis is most often caused by infection with helicobacter pylori

• more severe form

• caused by indigestion of strong acid or alkali

• may also develop in acute illlnesses (burns, severe infetion, hepatic, kidney or respi failure)

type a (autoimmune disorders)

type b (underlying causative mechanism)

chronic gastritis is classified to:

• hashimoto thyroiditis

• addison’s disease

• grave’s disease

type a chronic gastritis disorders:

• h. pylori

• long term drug therapy

• reflux of duodenal contents into the stomach

type b chrnoic gastritis disorders:

acute

acute or chronic gastritis:

• epigastric pain or discomfort

• dyspepsia

• ausea and vomiting

• anorexia

• hiccups

• bleeding (hematemesis, melena, hematochezia)

chronic

acute or chronic gastritis:

• anorexia

• heartbirn after eating

• belching

• sour taste in the mouth

• nausea and vomiting

• early satiety

vit. b12 deficiency (pernicious anemia)

poor absorption of certain vitamin in chronic gastritis can lead to:

endoscopy

definitive diagnosis of gastritis

medical management of gastritis:

dumping syndrome

this is common after gastric surgery:

dumping syndrome

dumping syndrome

rapid emptying of gastric contents into the small intestine

interventions on dumping syndrome:

PEPTIC ULCER

• Excavation (hollowed out area) that forms in the mucosal wall of stomach, pylorus, duodenum, esophagus

• Loss of tissue from the lining of the digestive tract. May be acute or chronic.

location

peptic ulcer is classified depending on?

• gastric

• duodenal

• esophageal

what are the classifications of peptic ulcer?

infection ( gram (-)H .pylori bacteria)

what bacteria causes of peptic ulcer

• drugs -Ibuprofen, Aspirin (NSAIDS), Steroids

• stress

• smoking, chewing tobacco

• heavy alcohol

• conditions that cause high gastric acid concentration

• familial tendency

• with blood type”O”(more susceptible)

what are the risk factors of peptic ulcer?

heartburn

pyrosis is also known as what?

• Dull, gnawing pain or burning sensation

• Pyrosis ( heartburn )

• burning sensation in the stomach and esophagus that moves up to the mouth

• accompanied by sour eructation(burping)Vomiting

• Constipation or Diarrhea

• Bleeding

peptic ulcer s/sx

(burping)

eructation

Gastric Ulcers

peptic ulcer or duodenal ulcer: Burning/gnawing pain which occur immediately or 1-2 hrs after meals, more pain w/ food; upper left abd/back

Duodenal Ulcers

peptic ulcer or duodenal ulcer: burning/ cramping pain 2-4 hrs. after meals, beneath xiphoid and back, relieved by antacids/food

Gastric Ulcers

peptic ulcer or duodenal ulcer: N/V, anorexia, wt loss

Duodenal Ulcers

peptic ulcer or duodenal ulcer: Secrete more acid than normal

Gastric Ulcers

peptic ulcer or duodenal ulcer: Secrete normal or decreased levels of acid

Duodenal Ulcers

peptic ulcer or duodenal ulcer: Young men, all social classes, bld type O, chronic illnesses

Gastric Ulcers

peptic ulcer or duodenal ulcer: Older men, working class, bld type A, under stress

Duodenal Ulcers

peptic ulcer or duodenal ulcer: Awake with pain during the night

gnawing, burning, cramping

what are the type of pain?

Gnawing

what type of pain:

• Dull, aching, like hunger

• Epigastric area

• Peptic ulcer

Burning

what type of pain:

• Sharp, hot, fiery

• Epigastric or chest

• GERD, peptic ulcer

Cramping

what type of pain:

• Squeezing, wave-like, tight

• Lower or whole abdomen

• IBS, stomach flu, gas, periods

• Physical Exam

• reveal pain, epigastric tenderness or abdominal distention

• Upper endoscopy

• Biopsy

• Histologic exam of tissue specimen

• Urea breath test

• IgG antibody detection test for H. pylori

• Culture

• Upper GI series (Barium swallow)

• Esophagogastroduodenoscopy

Assessment/Diagnostic findings: PEPTIC ULCER

esophagogastroduodenoscopy (EGD)

This diagnostic procedure examines the esophagus, stomach, and upper duodenum with a small camera (flexible endoscope) which is inserted down the throat

STRESS ULCER

• Occurs after physiologically stressful events ( burns, shock, severe sepsis, multiple organ trauma )

• Curling’s ulcer

• Cushing’s ulcer

classifications of stress ulcer:

Curling’s ulcer

this classification of stress ulcer occurs 72 hrsafter extensive burns

Cushing’s ulcer

this classification of stress ulcer includes head injury, stroke and brain trauma

• hemorrhage

• perforation

• pyloric obstruction

peptic ulcer complications:

• Antibiotics (Metronidazole,Clarithromycin, Tetracycline, Amoxicillin)

• Proton pump inhibitor (Omeprazole)

• Bismuth salts that suppress/eradicate

  H. pylori

  • Triple therapy( 2 Antibiotics + 1 PPI)

  • Quadruple therapy (2 Antibiotics + PPI +

    Bismuth)

• Antacids

• H2 RECEPTOR BLOCKERS

• ANTICHOLINERGICS-Pro-Banthine, Robinul, Bentyl

• Octreotide –suppresses gastrin levels

• Smoking cessation

• Dietary modification

drug therapy for peptic ulcer:

intractable ulcers

those failing to heal after 12-16 weeks of medical treatment ), life threatening hemorrhage, perforation, obstruction, with ZES( ZollingerEllison Syndrome)

surgery

what is recommended for those with intractable ulcers

• vit. B12

• folic acid

• iron

• calcium

• vit. D

gastric surgeries (vagotomy, pyloroplasty, antrectomy) can have serious effects on absorption of what?

GASTRIC (STOMACH) CANCER

• Rare(25,000/yr.), common in males, African American, over 70 and low socioeconomic status. 60% decrease in past 40 yrs.

• No S/Sx in early stages

• Late stages S/Sx: N/V, ascites, liver enlargement, abd. mass

• Mets to bone and lung

• 10% survival rate after 5 yrs.

• n/v

• ascites

• liver enlargement

• abdominal mass

what are the late stages s/sx of gastric (stomach) cancer:

• H. pylori infection, pernicious anemia, chronic gastritis/inflammation, cigarette smoking, obesity, diet high in smoked, salted, pickled foods, low in fruits & veg.,achlorhydria – No HCl, gastric ulcers, previous partial gastrectomy, genetics

risk factors of gastric/stomach cancer:

antacids

early stage s/sx of gastric cancer can be relived by:

• abdominal pain above umbilicus,dyspepsia(indigestion), decrease or loss of appetite, weight loss, bloating after meals, nausea and vomiting, early satiety, fatigue

• Sister Mary Joseph’s nodules

  • palpable nodules around umbilicus

  • sign of GI malignancy

adavance stage s/sx of gastric/stomach cancer:

Sister Mary Joseph’s nodules

• peri-umbilical nodules (small lumps or bumps) that are often indicative of advanced abdominal malignancy, particularly gastrointestinal cancer

• named after Sister Mary Joseph, a surgical nurse who first observed and described this clinical sign in the early 20th century.

OBESITY

• Chronic relapsing disease characterized by an excessive accumulation of body fat & weight gain, 20% over ideal

• Results from a metabolic imbalance, characterized by an excess of caloric consumption relative to caloric expenditures

• heredity

• body build

• metabolism,

• psychosocial factors

• Calorie intake exceeds demands

causes of obesity:

• Vagal blocking therapy

• Intragastric balloon therapy

Non-Surgical Management of obesity

• Bariatric surgery

• Roux-en-Y gastric bypass (RYGB)

• Gastric banding

• Sleeve gastrectomy

• Biliopancreatic diversion w/ duodenal switch

Surgical Management of obesity

Bariatric surgery

work by restricting patient’s ability to eat, interfering w/ ingested nutrient absorption or both

gastroesophageal reflux disease

• acid reflux

• a condition in which the liquid content of the stomach regurgitates into the esophagus

• acid

• pepsin

what components are found in the regurgitated liquid in GERD?

pepsin

an enzyme that is present in the regurgitated liquid in GERD that begins the digestion of proteins in the stomach

• Incompetent lower esophageal sphincter

• Pyloric stenosis

• Hiatal hernia

• Motility disorder

• Associated with: tobacco use, coffee drinking, alcohol consumption, gastric infection w/ H.pylori

Causes of excessive reflux:

• pyrosis

• odynophagia

• esophagitis

• dysphagia

• regurgitation

s/sx of gastroesophageal reflux disease

• Dental erosion

• Ulcerations in the pharynx & esophagus

• Laryngeal damage

• Laryngeal damage

• Adenocarcinoma

• pulmonary complications

GERD can result in:

bilirubin monitorin (bilitec)

used to measure bile reflux patterns, exposure to bile can cause mucosal damage

Fluoroscopy

real-time imaging technique that uses X-rays to create continuous live images of the inside of the body

nissen fundoplication

• wrapping of a portion of the gastric fundus aroudn the pshincter area of the esophagus

• can be performed by the open method or by laparoscopy

types of fundoplication:

6 to 8 inches blocks

with GERD patients, how would you elevate their head?

• Esophagitis

• Barrett’s esophagus

  • precancerous lesion that puts the patient at risk of developing esophageal cancer

• Respiratory complications

  • bronchospasm, laryngospasm, aspiration pneumonia

complications of GERD:

Barrett’s esophagus

precancerous lesion that puts the patient at risk of developing esophageal cancer

Barrett’s esophagus

• Columnar epithelium with goblet cells (like in the intestines)

• Adapts to chronic acid exposure, but not protective

• Chronic acid reflux (GERD) causes the change

• Increased risk of esophageal cancer (adenocarcinoma)

ACHALASIA

• It is also known as CARDIOSPASM

• muscular activity of the esophagus (gullet) is disturbed, which delays the passage of swallowed material

• Absent or ineffective peristalsis of the distal esophagus accompanied by failure of the esophageal sphincter to relax in response to swallowing

• progressive dysphagia

• regurgitation of undigested food

• chest pain or epigastric pain & pyrosis

• Coughing and choking

• if the food enters the wind pipe it can cause aspiration pneumonia

• Weight loss

s/sx of achalasia:

X-ray studies/video-esophagram

the video x-ray of the esophagus are taken after barium is swallowed

Manometry

measures the pressure and movement of muscles in the esophagus

• Oral medication

  • Including nitrates, calcium channel blockers

  • It provide short term relief of the symptoms and many patients experience side effect of the drug

• Dilation of the LES(Lower Esophageal Sphincter)

  • It is done by having patient swallow a tube with a balloon on the end

  • The balloon is placed across the lower sphincter with the help of x-ray and the balloon is blown up suddenly

• Pneumatic dilation

  • stretch the narrowed area of the esophagus

treatment of achalasia