Week 4: GI- GERD, Hiatal Hernia, Peptic Ulcer Disease, and GI Bleeding

What is GERD?

Mucosal damage and irritation caused by reflux of stomach acid into the esophagus most likely due to a weak lower esophageal sphincter

What are things that can cause a weak lower esophageal sphincter?

Specific foods, medications, obesity, smoking, NSAIDs, hiatal hernias

What is a hiatal hernia?

Herniation of part of the stomach into the esophagus through an opening in the diaphragm typically caused by structural changes and increased intraabdominal pressure

What is a sliding hiatal hernia?

Junction of the esophagus and stomach moves above the diaphragm

What is a paraoesophageal hernia?

Fundus and greater curvature of the stomach roll up through the diaphragm and form a pocket next to the esophagus

What are s/s of GERD?

Heartburn, chest pain, regurgitation, and respiratory symptoms (wheezing, coughing, dyspnea- due to aspiration)

What are potential complications of GERD?

Esophagitis, esophageal ulcers, Barrett’s esophagus, respiratory complications (aspiration)

What is Barrett’s esophagus?

Esophagus is continuously exposed to acid which causes intestine-like problems in the esophagus (common cause of esophageal cancer)

What are tests that help diagnose GERD?

Endoscopy with biopsy, pH testing, and esophageal manometry (tells us how strong LES is)

What are important things to educate a patient with GERD about?

Can be managed with lifestyle modifications; sleeping with HOB 30degrees, stop smoking, avoid alcohol, avoid reflux-inducing foods, small frequent meals, avoid late night snacking, maintain health weight

What does tx look like for GERD?

Lifestyle modifications, medications (proton pump inhibitors, H2 blockers), Nissen/Toupet fundoplication surgery (pulls stomach down to fix herniation and is wrapped around esophagus to create tighter LES)

What are s/s of hiatal hernia?

Often asymptomatic or s/s consistent with GERD

What are potential complications of hiatal hernias?

Stenosis, ulcerations, and strangulation of the hernia

What are tests that help diagnose hiatal hernias?

Endoscopy with biopsy, pH testing, esophageal manometry (tells us how strong LES is), barium swallow test, upper GI series test

What are nursing interventions for a patient with hiatal hernia?

Similar to GERD, reduce intraabdominal pressure by eliminating constricting garments, avoid lifting/straining, surgical management if symptomatic

What is peptic ulcer disease?

Erosion of the GI mucosa from acid; any part of the GI tract that is in contact with gastric secretions is susceptible to ulcers including lower esophagus, stomach, duodenum, and anastomosis sites after surgeries

What are common causes of peptic ulcer disease?

H. pylori (bacteria from contaminated water), NSAIDs, tobacco, alcohol, stress, family hx

What are tests that help diagnose peptic ulcer disease?

EGD (most common), CBC (checks for anemia- can indicate bleeding ulcer), H. Pylori testing, antibody blood test (doesn’t show active infection)

What are potential complications of peptic ulcer disease?

Hemorrhage (most common), obstruction (acute or chronic), perforation

What are characteristics of gastric ulcers?

Superficial @fundus or antrum of the stomach, normal gastric secretions, higher incidence in older women, increases risk of cancer, s/s include burning epigastric pain 1-2hrs after meals

What are characteristics of duodenal ulcers?

Penetrating @ very beginning of duodenum, increased gastric secretions, higher incidence in middle-aged men, s/s include burning, cramping epigastric pressure 2-5hrs after meals, relief with food/antacids

What are nursing interventions for patient experiencing peptic ulcer disease without complication?

Teach about lifestyle modifications (tobacco, alcohol, avoid OCT meds), avoid foods that increase s/s, educate about s/s of complications

What are nursing interventions for a patient having a hemorrhage?

Assess LOC, VS, skin color, cap refill, O2 sats, ABCs, abd for distention/guarding/peristalsis, bowel sounds, ECG, I&Os, emesis, establish IV access x2 and start fluid replacement therapy, insert NG tube set to low wall suction, keep pt NPO

What are nursing interventions for a patient experiencing an obstruction?

Monitor for gradual s/s including postprandial (after meal) nausea, vomiting, and epigastric pain; insert NG tube set to low wall suction, establish IV access and start fluids and electrolyte replacement, keep pt NPO, prepare for endoscopy or surgery

What are nursing interventions for a patient experiencing a perforation

Monitor for acute onset of severe upper abd pain that is not relieved by food or antacids, assess for rigid-board-like abd, shallow and rapid RR, weak pulse, tachycardia, absent bowel sounds, stop all PO feedings/meds, monitor VS, start IV fluids and antibiotics, prepare pt for surgery

When is surgery used to treat peptic ulcer disease?

When ulcers are persistent and unresponsive to tx or if the ulcers perforate or cause an obstruction

What is a Billroth I surgical resection?

Part of the stomach is resected and the remaining part of the stomach is attached to the duodenum

What is a Billroth II surgical resection?

Part of the stomach is resected and the remaining part of the stomach is attached to the jejunum

What is the main potential complication for peptic ulcer disease surgical interventions (Billroth I &II)?

Dumping syndrome

What is dumping syndrome?

Occurs when part of the stomach has been removed and undigested food dumps into the small intestine instead of entering the small intestine in small amounts; occurs within 15min of a meal

What is the patho behind dumping syndrome?

A large bolus of hypertonic fluid enters the intestine which causes fluid to be drawn into the bowel lumen. This causes a decreased plasma volume, distention of the bowel lumen, and rapid intestinal movement

What are s/s of dumping syndrome?

Generalized weakness, sweating, palpitations, dizziness, abd cramping, borborygmi (gurgling/belly sounds), urge to have BM, diarrhea; within 15min of eating a meal

How is glucose levels impacted by dumping syndrome?

Bolus of undigested food causes brief hyperglycemia which causes excess amounts of insulin to be released; results in hypoglycemia and associated s/s such as weakness, sweating, mental confusion, tachycardia; s/s generally resolve within 2hrs by themselves and do not typically require intervention

What are ways to prevent dumping syndrome?

Divide meals into small feedings that are spaced out, do not take fluids with meals (30-45min before or after), avoid concentrated sweets, protein is encouraged, rest after eating

What is GI bleeding?

Any form of bleeding that occurs in the GI tract including the esophagus, stomach, SI, LI, rectum, and anus

What are common causes of esophageal bleeding? What does it look like?

Esophageal varices (portal HTN), Mallory Weiss Tear (distal tear of the esophagus due to violent coughing or vomiting); acute medical emergency noted with bright red emesis

What are common causes of stomach bleeding?

Peptic ulcers, gastritis, H. Pylori, NSAIDs, reflux, older adults

What are common causes of small intestinal bleeding?

Angiodysplasia (small blood vessels become dilated and bleed), chron’s disease, small bowel tumors

What are common causes of large intestinal bleeding?

Colon cancer or polyps, angiodysplasia

What are common causes of rectal bleeding?

Hemorrhoids, rectal varices, ulcerative colitis noted with bright red bleeding with stool

What is overt GI bleeding and what are s/s of it?

Bleeding that is visible to the eye; hematemesis (bright red), melena (black/tarry stool), hematochezia (bright red or maroon stool), coffee-ground emesis (coagulated blood)

What are s/s of chronic GI bleeding?

Gradual onset of fatigue, orthostatic hypotension, weakness, dizziness, and lightheadedness

What are signs of hypovolemia?

Hypotension, tachycardia, pallor, altered mental status

What are diagnostic tests that help diagnose a GI bleed?

CBC, Coagulation studies, occult blood testing, EGD, colonoscopy, video capsule endoscopy, CT angiography (looks @ vessels of abd)

What should a nurse assess for a patient who has suspected GI bleeding?

S/s, past medical hx, risk factors, VS, abd exam, skin, neuro status, labs, LOC, any active bleeding, I&Os, signs of dehydration, monitor for response to treatment

What are nursing interventions for a patient with acute GI bleeding?

Stabilize the patient, provide O2, establish large-bore IV access, fluid resuscitation, administer blood and fluids, monitor electrolytes, administer meds depending on source of bleeding, monitor for complications

What are proton pump inhibitors given for?

Gastric and esophageal ulcers; decreases acid production with increases the rate of healing of the mucosal linings

What is octreotide given for?

Given for acute GI bleeding because it decreases blood flow to the GI tract and will decrease the rate that the patient is bleeding

What is erythromycin given for?

Increases the rate of gastric emptying with allows clear views during an upper endoscopy

What are potential complications of GI bleeding?

Anemia, hypovolemic shock, perforation, and gastric obstruction

What is balloon tamponade?

Pressure from balloon is applied to the esophageal or stomach wall which should stop bleeding

What is a rapid infuser machine?

Gives RBCs or IV fluids really, really quickly if patient is bleeding out really fast

What are things to educate patients about regarding GI bleeding?

Medication compliance, avoidance of causative agents (NSAIDs, tobacco, alcohol), s/s of recurrent GI bleeding