GI Dx 1

Gerd, Stomach- acute/chronic gastritis, gastroenteritis, peptic ulcers, gastric cancer

GERD: priority problems

acute pain

compromised nutrition

→ backward flow of stomach contents into esophagus

→ C/b DEC LES pressure

GERD OA Cx

→ atypical angina

ENT infections

pulm problems: aspiration PNA, sleep apnea, asthma

Barrett esophagus

→ change from squam epi. to columnar tissue

• helps to resist HCl production

• RISK: inc chances of cancer

Esophageal Erosions [Stricture]

→ c/b fibrosis & scarring

• causes narrowing of esophagus & airway

GERD Cues

• Dyspepsia

  • heartburn/indigestion

• Regurgitation

Other s/s

• aepigastric pain

• dysphagia

• morning hoarsness

• Water brash→ hypersecretion

• odynophagia→ painful swallowing

SEVERE s/s

• Regurgitation after meals & lasts 20 min -2hrs

• worsened by lying down

TEACH

• INC fluid intake

• antacids

• upright position

GERD Diagnostics

• 24 Hr esophageal pH monitor

  • transnasal catheter- esophagus [24-48 hrs]

  • wireless capsule fixed to distal esoph. mucosa

  • Pt keeps diary of activites & symptoms for 24-48 hrs

• EGD

  • requires MOD SEDATION

  • flexible endoscope

  • Indicated: those w/ atypical s/s. Can biopsy

GERD: Nutrit. Recommend. & lifestyle

TEACH

• limit foods that LOWER LES pressure, irritate tissue

  • carbonated bvg, caffeine, alc

  • citrus foods, peppermint, chocolate, fatty foods & spicy

AVOID

• heavy lifting

• bending at the waist

• straining [NO] Valsalva

• no eating 3hr b4 sleep

• lying down after eating

Wt. reduction

CPAP

Smoking cessat

Raise HOB to dec regurg & aspirat.→ blocks & pillows

GERD Drug Rx

Drugs that LOWER LES pressure→ reflux

• oral contracept.

• CCB

• Anticholinergics

• Sedatives

• NSAID

• Nitrates

Caution!→ Mg antacids→ check CKD pt levels of Mg, r/o drug toxicity

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[Drugs that help]

• Antacids

• Histamine blockers

• PPI

inhibit secretion, increase elimination & protect mucosa

• PPI → Diarrhea

  • Pantoprazole

  • Esomeprazole

****Long term PPI use→ INC r/o kidney, liver & CV disease

*****OA: PPI & hip fractures

• Calcium is decreased w use of PPI in OA

  • INC r/o osteoporosis

GERD: Stretta Procedure

→ RF used via endoscope to DEC vagal nerve activity

• Post OP instructions

  • - Diet→ Clear liquids→ 24 hrs

  • - soft foods→ custards, mashed potato

  • AVOID→ NSAIDS & ASA for→ 10 days

  • NGT insertion→ 24 hrs→ Rationale: decompress?

  • Meds: continue PPI (prazoles) Liquid med preferable!

• CONTACT HCP → abd pain, dysphagia, bleeding, chest pain, N/V, SOB

GERD: Nissen Fundoplication [Laparoscope MIS]

Lap/Open→ INC LES pressure by wrapping part of stomach around it

• Post OP instructions

• Diet→ soft foods→ 1 week

• Anti-reflux Rx→ 1 month

• AVOID→ carb bvg, caffeine, alc.

  • Heavy lifting, drive→ 1 week

  • remove strips→ 10 days

• Dressing→ remove→ 2 days after

  • REPORT: redness, drainage from incision

  • REPORT: persistent abd. pain/bloating, n/v

    • fever >102 or 100 in OA

GERD: Nissen Fundoplication [Conventional Open Sx]

Convent sx→ Open→ Chest tubes. NGT

• Action alert!

• elevate HOB 30, help pt out of bed & early ambulation

• Splint incision site during coughing to reduce pain

NGT Large Bore

• initial drainage→ dark red

• Drainage w/in 8 hr→ yellow/green

• CHECK placement & patency→ Q4-8H

  • rationale: keep stomach decompressed

  • to avoid reinsertion bc it INC r/o perforation

• Secure device→ avoid displacement!

• Freq oral hygiene

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DIET:

• CLD→ advance to soft→ reg

• frequent small meals ***MONITOR 1st oral feeding

AEROPHAGIA

• air swallowing

• teach→ relax, b4 & after meals, chew food slow

GAS BLOAT SYNDROME

• pt is TEMP unable to burp

• Teach→ avoid carb bvg, gas producing foods (high fat)

  • chewing gum or drinking from a straw

• IF persistent→ Simethicone (sodium bicarb)→ to relieve built up pressure from gas

GERD: Sx→ LINX

→ magnets placed in LES, INC pressure, allows passage of food w/ swallowing

• ACTION ALERT!

• No MRI

• Older device may cause injury

• Newer device: allowed under certain conditions

Gastritis

Causes

• disruption in protective layer of gastric mucosa c/b mucosal injury

• HCl acid diffuses back→ edema, bleeding, erosion of stomach lining

• Long term use NSAIDS

• Alcohol, stress, caffeine, radiation

Acute

• reddened mucous membrane w rugae, mucosal necrosis

Chronic

• Patchy diffuse inflammation

• Atrophy of stomach lining→ loss of parietal cells→ L/o intrinsic factor [needed for absorption of B12→ pernicious anemia]

• INC r/o stomach cancers [chronic H.pylori infection]

Gastritis Cues

ABD→ tenderness, bloating, A/N/V, hematemesis, cramping

Timing→ ask if abrupt or persistent

• Acute: rapid onset EPIgastric pain

  • NVA, hematemesis, melena

  • Dyspepsia

• Chronic: vague report of pain→ relief w food

  • NVA

  • Intolerance to fatty/spicy food

  • pernicious anemia

Hx of exposure→ toxins, lead, benzene, chemo, H.pylori

EGD→ GOLD standard diagnosis!

• Biopsy performed to r/o cancer

Gastritis: Mx

@home unless pt presents w→ hemorrhage, FE imbalance & pain exacerbation

Acute

• fluids. Sx→ partial gastrectomy, pyloroplasty, vagotomy

• Blood transfusion for blood loss

Chronic

• Eliminate causative agent & Rx if pt has underlying condition

  • CKD, Crohn’s

  • Stop use of alc & tobacco

• Drug therapy: gastritis & PUD

• Antacids

• H2RA [blocks histamine a chem that produces HCL]

• PPI

• prostaglandin analogs

• Antimicrobials (for H.Py)

• V B12→ pernicious anemia

Gastritis: Prevention

• Educate!

• Avoid→ high acid foods, alc & smoking, INC protein intake

  • Spicy, high fat (fried), citrus foods

  • YES TO→ high protein food, carbs

• AVOID→ long term NSAID use, ASA, corticosteroids

• Stress reduction techniques

Gastroenteritis Cues

→ inflammation of mucosal membrane of stomach & SI

• Viral & bacterial types

• Self limiting: 2-3 days

Cues

• N/V/D THEN ABD pain (cramping) → dehydration [DEC volume & K]

  • distension & HYPERactive BS

• ASK: time of onset. exposure to pathogens, any FEVER or travel?

• Skin breakdown→ c/b diarrhea

Gastroenteritis ACTION ALERT!

Assess for

• abd distension

• hyperactive BS

• dehydration c/b D/N/V

Cues of dehydration

• Wt. loss

• poor skin turgor

• fever [not common in OA]

• dry mucous membranes

• Orth hypo

• Oliguria [little to no pee]

***MONITOR change in LOC in OA→ common cause of dehydration

Gastroenteritis Rx: Preventing spread & Treatment

• properly cooking food

• hand sanitation

• care w handling poop

Treatment

• @home unless immunocompromised OR OA

• F/E→ replacement PRN → Oral rehydration therapy or IV

• AVOID: drugs that suppress intestinal motility

  • bc it prevents infectious organisms from exiting the body→ FALLS!

DRUG ALERT

• diphenoxylate HCl w/ atropine Sulfate

  • reduces GI motility

  • DONT USE in OA bc it causes drowsiness & falls

PUD: Gastric Ulcer

Pain location→ upper ABD→ 30-60 min after eating & @night

Ulcer:

Hemorrage: hematemisis

PUD: Duodenal Ulcer

Pain location: occurs 1 1/2-3 hrs after eating

@ night awakens pt

RELIEF W FOOD

Reoccurrence: often after a year and def after 2 years

Hemorrhage: melena

PUD: stress ulcer

Burns→ curling ulcer

Head injury→ cushing ulcer

Major trauma. extensive sx procedure

CRF, ARD’s, shock→ HYPOVOLEMIA!!, f/e imbalance

PUD: Labs & diagnostics

Hemoccult testing

• DEC Hg & Hct

• CBC, H&H, gastric pH

Upper GI series &EGD

H. Pylori test

• breath test for urea [+ radioactive carbon response]

• IgG antibodies→ confirm presence of bacteria

PUD cues

• Epigastric pain

• N/

• fullness

• bloating

• early satiety

• nocturnal pain

• ALARM S/S!

• anemia

• hematemesis

• melena

  • heme-+ stool [occult blood]

• A/ Wt. loss

• Persistent Upper ABD pain, Radiating→ back

• Diffuse upper ABD pain

PUD: NON Sx mx

• Drug therapy: same meds for gastritis & PUD

• Antacids

• H2R2 blockers

• PPI

• Mucosal barrier protectant

• Prostaglandin agonists→ INC to inhibit HCl

• Antimicrobials

Nutrition

• bland diet [may relieve s/s] during acute phase

• AVOID-→bedtime snacks

• AVOID alc & tocacco

PUD: Cx→ Hemorrhage Cues & types

Hematemesis

• bleeding @ Upper GI location

  • Dark blood= old blood

  • Bright red blood= new blood (active)

Melena

• minimal bleeding from duodenal

• dark tarry stool. (+) hemoccult

H&H

• DEC→ DEC b/p→ **orthohypo

Mild bleed

• <500 ml. weakness & mild perspiration

Major bleed

• 1L/24 hr→ HYPOVOLEMIC SHOCK!!

  • Low BP, low HR, confusion, DEC response to stimuli [GCS], rapid, weak & thready pulses !!

PUD: Cx Hemorrhage Mngt

• Critical Rescue!

• Priority: ABC’s

  • Admin O2 & ventilation

  • 2 large bore IV [replace fl. /blood loss]

  • Monitor→ VS, LOC, H&H & O2 sat.

• Airway

  • if pt becomes unresponsive→ INTUBATE

• Hypovolemia

  • Fl replacement→ prevent FVO esp. in OA

  • 2 LB IV cath.

  • Isotonic soln. STAT→ 0.9% NS or lactated ringers

  • Blood transfusion→ PRBC. fresh frozen plasma

    • for actively bleeding pt

    • ***If PTT is 1.5x> ?

PUD: Hemorrhage Mngt. [Cont’d]

Monitor

• VS. O2 sat.→ Labs: H&H, major blood loss= 1l/24

  • check for signs of hypovolemic shock

NGT

• LIWS. NPO

Acid suppression

• Protonix & Octreotide

Endoscopic Rx: EGD

Interventional Radiologic Procedures

PUD: pyloric obstruction cues

• A/N/V

• PERSISTANT vomiting

  • check 4 metabolic alkalosis & hypokalemia

Pyloric obstruction Sx mx

Subtotal gastrectomy

pyloroplasty

vagotomy