Chapter 57: Coordinating care for patients with stomach disorders

gastric folds and pits

- this area secretes most of the gastric juices consisting of digestive enzymes and hydrochloric acid

surface mucous cells

- secretes alkaline fluid that protects the stomach lining

mucous neck cells

secrete acidic mucin

parietal cells

- produce hydrochloric acid which is not actually produced in the cell but made with hydrogen and chloride ions produced in the cell. this protects from microorganisms.

- produces intrinsic factor which attaches to B12 molecules and protects from corrosive digestive enzymes until it reaches the small intestine where it can be absorbed and used by the body

chief cells

-produced pepsinogen which is the precursor of pepsin. pepsin is activated by HCl acid and breaks down smaller proteins into peptides.

- produces gastric lipase which aids in digestion of fat.

G cells

release gastric, stimulates the release of HCl acid and pepsinogen ensuring there is enough digestive enzymes when food is in the stomach

stomach

part of the Upper GI system responsive for much of the digestive process

nutritional

a person's ______________ status depends not only on the type and amount of intake but also on proper gastric functioning. although only a few diseases affect the stomach, they can be very serious and life threatening.

epithelial

the ______________ cells in the mucosal layer of the stomach have a high turnover rate and are replaced every 4 to 5 days. because of the regenerative abilities of the mucosal layer, injury to this

acute gastritis

- characterized by an acute mucosal inflammatory process that may be accompanied by hemorrhage into the mucosa

- chronic ingestion of irritating foods and alcohol

- complication of acute illnesses such s traumatic injuries, burns, severe infection, hepatic renal or respiratory failure, or major surgery

- rapid onset

chronic gastritis

prolonged, persistent, or intermittent inflammation of the gastric mucosa and is characterized by patchy, diffuse inflammation of the mucosal lining of the stomach

- over a wide area

- include helicobacter pylori gastitis (most common), autoimmune gastritis and atrophic gastritis

atrophic gastritis

type of chronic gastritis that is seen most often in older adults

h. pylori

NSAIDs

bile

causes of gastritis

- ____ __________

- alcohol

- ___________ (naproxen, iburpofen)

- Crohn's disease

- TB

- ____________ reflux

parietal

causes of chronic gastric and prolonged inflammation of the stomach include:

- H pylori

- chronic local irritation

- associated with the presence of antibodies to ___________ cells and intrinsic factors

cytokine

aspirin

hemorrhage

- The agents that cause gastritis cause injury by different mechanisms.

- In general, the infectious and inflammatory causes result in immune cell infiltration and _____________ production, which damage mucosal cells.

- Irritating agents such as alcohol, ___________ , and bile generally work to disrupt the mucosal barrier, causing mucosal damage by back diffusion of hydrogen ions.

- This allows gastric juices to come into contact with the gastric tissue, producing mucosal reddening, edema, and superficial surface erosion. Ulceration may occur and can lead to ____________

intrinsic

the ____________ factor is critical for absorption of vitamin B12. when body stores of vitamin B12 are depleted hemoglobin cannot be synthesized and pernicious anemia results

pernicious anemia

- decrease in RBC

- can affect memory and neuro function

- classic symptom is beefy red tongue (smooth)

pain

vomiting

loss

appetite

tarry

clinical manifestations of gastritis:

- epigastric ______(may be exacerbated by spicy foods)

- nausea and ____________

- weight ________

- decreased __________

- __________ black stools

atrophic gastritis

what type of gastritis might present with no symptoms?

dehydration

bleeding

in patients with acute gastritis or exacerbations of chronic gastritis, there may be evidence of _______________ or upper GI ______________. with significant fluid or blood loss, the patient may develops signs of hypovolemic shock which include pallor, tachycardia, and hypotension

endoscopy

an upper Gi x-ray series or _____________ and histological examination of a tissue specimen obtained by biopsy may be useful for ruining out disorders that can suggest gastritis, such as gastric polyps and gastric neoplasms

endoscopy with biopsy

gold standard for diagnosing gastritis

urea breath test

detects if you have active infection with H pylori.

- baseline test is first obtained

- swallow a capsule that has urea in it and Carbon-13. blood carries the CO2 to the lungs and is expelled in the breath.

- the amount of CO2 is compared to the baseline sample. a positive test reveals low levels levels of exhaled Carbon-13.

6-12

clear

heavier

solid

treatment of gastritis:

GI rest should be provided by __-___ hours of NPO status, then slow reintroduction of ______ liquids (broth, tea, gelatin, carbonated beverages) followed by ingestion of _________ liquids (cream soups, puddings, milk (careful can make better at first then make it worse)), and finally a gradual reintroduction of ________ foods.

spicy

caffeine

NSAIDs

patients with gastritis should avoid:

- ________ foods

- decaffeinated coffee

- ___________

- ___________

- citrus

- aspirin

6

how many small meals should a patient with gastritis consume?

antacids

used for gastritis

- decrease the acidity of the stomach does not prevent the acid from being produced

PPI

30-60 mg IV twice a day to maintain a gastric pH greater than 4

sucralfate

provides a physical barrier

- mucosal barrier fortifier

- 1 hour before and 2 hours after meals and at bedtime

- food may interfere

- do not give within 30 min of other drugs especially antacids

b12

what vitamin is given with chronic gastritis?

vagotomy

- used for gastritis for severe hemorrhagic

- surgery to sever the vagus nerve to reduce secretion of acid within the stomach

- The vagal nerve does supply the proximal ⅔ of the stomach

- Decreases amount of stomach acid produced

- Increase in infections

partial or total gastrectomy

- used for gastritis that causes severe hemorrhagic gastritis

- removal of the stomach

- Part or all of the stomach is removed

- Intestine joined to stomach

Pyloroplasty

- used for hemorrhagic gastritis

- enlarges the pylorus opening

- widens the pylorus to guarantee stomach emptying even without vagus nerve stimulation

infection

semi fowlers

NG

bowel

Vagotomy and gastric resection nursing interventions:

- Open surgery

- Monitor the incision for __________

- place the patient in ________ _________ to maintain lung expansion

- Monitor ______ tube drainage

Scant normal in first 12-24 hours

Do not reposition

- If you feel like your NG is not draining properly call the doctor

- Monitor _________ sounds: Guides how much food you can give patient

B12

D

folate

teach the patient to take vitamin and mineral supplements due to decrease in absorption:

- vitamin ________

_ vitamin _______

- calcium

- iron

- ___________________

gastric ulcers

- normal gastric acid secretion with prolonged emptying

- 90% associated with H pylori

duodenal ulcers

- increased gastric acid production

- increase stomach emptying

- 70% associated with H pylori

peptic ulcer disease

erosions are breaks in the surface epithelium that do not have measurable depth.

- this term is used broadly to include ulcerations and erosions in the stomach and duodenum from a variety of causes.

- types include gastric and duodenal

- occur between the ages of 25-64 years of age majority of the time

- equal among men and women.

duodenal ulcers

- make up about 80% of peptic ulcers, affect the proximal part of the small intestine following a chronic course, and are characterized by remissions and exacerbations (with complications that necessitate surgery in about 5% to 10% of patients).

- More common in O blood type

- Pain in right epigastrum: 2-3 after meals, Bedtime, Wake up between 1-2 a.m.

- Pain relieved with food

gastric ulcers

- chronic ones often occur in the lesser curvature of the stomach near the pylorus

- cause pain during the meal

- gnawing substenral pain

- malnourished

- pain is in the left midline area

gastrodudoenal

peptic ulcer disease occur in ______________ mucosa as this tissue cannot withstand digestive action of gastric acid and pepsin.

H pylori

in a peptic ulcer resulting from ____ _________, acid is not the dominant cause of bacterial infection but contributes to the consequences

NSAIDs

peptic ulcer disease resulting from ___________ has both topical and systemic origins

pain

what is the number one most common symptom of peptic ulcer disease?

duodenal

burning epigastric pain aggravated by fasting and improved with food or antacids (which neutralize the acid) is a symptom complex associated with a ___________________ ulcer.

gastric

with a __________ ulcer, pain is triggered or worsened by eating, usually occurring shortly after meals with little or no relief from antacids

endoscopy

peptic ulcer disease is diagnosed during __________, laboratory, and radiological tests.

- upper GI _____________ is the preferred procedure

Noninvasive testing

__________ _________ for PUD includes serum antibody testing, urease breath testing, and stool antigen testing.

CBC

a ________ is collected with PUD to rule out ulcer perforation

WBC

peritonitis is diagnose with _______. which is a complication of PUD.

low hematocrit

a complication of PUD is anemia which is diagnosed with a _______ ___________ level.

4-8 weeks

how long does somebody with an ulcer caused by H-pylori take antibiotics for?

antacids

used for peptic ulcer disease and neutralize gastric acid

H-2 receptor antagonists

used for peptic ulcer disease and work by decreasing acid production.

- ranitidine

- nizatidine

- cimetidine

- famotidine

- block gastric acid secretion stimulated by histamine, gastrin, and acetylcholine

perforation

complication of peptic ulcer disease that can turn into penetration into attached sutures and obstruction.

- sudden severe pain

and absent bowel sounds

- rigid abdominal muscles

gastric adenocarcinoma

there is an increased risk of ___________ _____________________, a malignant tumor arising from glandular tissue, in patients with H pylori

hemorrhage

caused by bleeding from granulation tissue or erosion of an ulcer into an artery or vein.

- complication of peptic ulcer disease

Mallory-weiss syndrome

complication of PUD that is characterized as a tear in the mucosa at the gastroesophageal junction that can occur as a result of severe vomiting, trauma, or seizures

peritonitis

- PUD complication that is a surgical emergency and life threatening

- starts with hyperactive bowel sounds, sudden severe pain which may radiate to the right shoulder

- cardinal signs: abdominal pain, tendernes, distention

- patient assumes a fetal position to decrease tension on the abdominal muscles

- pain is worse with movement

- can turn into bacterial septicemia and hypovolemic shock

- increased WBC

- peristalsis diminishes, paralytic lies develops (no bowel sounds)

board

fever

tachycardia

urinary

hiccups

nursing care for peritonitis (complication of PUD):

- assess for abdominal wall rigidity classic finding is a _____________ like abdomen

- monitor for __________ b.c of the infectious process

- assess for ______________ in response to fever and decreased circulating blood volume

- observe for dry mucous membranes and decreased _______________ ____________ seen with third spacing

- N/V may be present

- _________________ may occur from diaphragmatic irritaiton

- keep NPO and prepare for surgery

- report and document findings

- administered ordered fluids and antibiotics

surgical management

PUD:

- only required with non healing and bleeding ulcers

- minimally invasive procedures allow ulcers to be removed or bleeding controlled

- most have oversewing of a bleeding ulcer, or a patch of a perforated ulcer or distal gastrectomy

- major operations include bilateral vagotomy, pyloroplasty, and gastrectomy

- more conventional surgical interventions are indicated for perforation, lack of response to conservative treatment, suspected cancer, or complications

pyloroplasty

- used for PUD

-this is a drainage procedure

- longitudinal sectioning of pyloric ring

- incision is closed traverse

- going to increase the pylorus opening to allow the stomach to empty faster

curling's stress ulcer

- related to ischemia due to decreased blood flow to GI and mucosal damage

- develops 24 hours after a burn

- related to increased acid due to increased intracranial pressure or over secretion of cortisol

-sepsis

GI bleed

- life threatening

- high morbidity and mortality

- hemoglobin target is a 7 for optimal mortality

- risk for dehydration and electrolyte imbalance

- hypovolemia

NS or LR

what two fluids are given for hypovolemia related to a GI bleed?

gastric ulcer

GI bleeped with bright red or coffee ground vomitius (hematemesis)

duodenal ucler

GI bleeding with Selena (tarry or dark, sticky) stools

decreased

increased

peripheral

confusion

H and H

key features of a GI bleed:

- ____________ BP

- ______________ HR

- weak ________________ pulses

- acute _________________ in older adults

- vertigo

- dizziness or light-headedness

- syncope

- decrease in _____ and ______

salem sump

nasogastric small vent tube within a large suction tube to use for a GI bleed

- has a vent to prevent adherence to the stomach wall

gastric lavage

- washing out of the stomach

- place the patient on the left side

- use approximately 300 mL at room temp NS, sterile water or tap water

- used for GI bleed

low intermittent suction

used for patients with GI bleed

- prevents adherence to the stomach to prevent injury

- a type of suction

nonselective beta blockers

- medication class used for esophageal varices

- propranolol

-carvediolol

EGD

- used to find a GI bleed

- can use somatostatin, clips or epinephrine

- patient will pass the clip

catheter directed embolization

intervention to stop bleeding for GI bleed

- using imaging to guide catheters or other instruments inside the vascular system. Through local anesthesia and optional mild IV sedation, patients are relaxed and pain-free during procedure. The Radiologist then uses coils, balloons, or particles to embolize (block) veins. By sealing a faulty vein or the blood flow to an abnormality it allows the body to help heal itself and redirect blood to where it is needed.

gastric cancer

- more common in lower socioeconomic groups

- affects males 2xs more than females

- causes are unknown

- diet appears to be a significant factor, with a diet rich in foods with additives such as smoked foods, pickles vegetables, and salted fish and meats increase the risk

- dietary nitrates have also been proposed as a possible cause

- greater in patients with low gastric acidity achlorhydria, such as those with severe atrophic gastritis associated with intestinal metaplasia and pernicious anemia

- malignant epithelial tumor that infiltrates the mucous producing cells of the stomach

distal portion

gastric cancer is most frequently found in the __________ _______________

gastric carinogensis

multifactorial and multistep process, starting from chronic gastritis and progressing over many years to atrophy, intestinal metaplasia, dysplasia, and eventually adenocarcinoma. The risk of developing gastric cancer correlates best with the severity and extent of atrophic gastritis and gastric atrophy.

late

indigestion

loss

epigastric

mass

ulcerlike

hematemesis

Clinical manifestations of gastric cancer:

- Often are asymptomatic until ___________ in their course

-_____________, anorexia, weight __________, vague _____________ pain, vomiting, and an abdominal __________

- The patient may experience ______________ pain unrelieved by antacids, typically occurring after meals.

- Because these symptoms are vague, patients and health-care providers tend to dismiss symptoms or treat the patient for acid disease, which makes early detection difficult.

- Massive ___________________ or melena, black tarry stools with a foul odor due to the degradation of blood in the small intestine and colon, is uncommon, but secondary anemia may occur after occult blood loss.

EGD (esophagogastroduodenoscopy)

the visual examination of the lining of the esophagus, stomach, and upper duodenum using a flexible fiber-optic endoscope

barium

biopsy

cytological

types of diagnostic tests for Gastric Cancer:

- ____________ x-ray studies

- endoscopic studies with ___________

- _______________ studies of gastric secretions

gastric dysplasia

abnormal gastric cells

- it is the universal precursor to gastric adenocarcinoma

- in severe cases gastric resection is considered when the abnormality is widespread or multifocal

laparoscopic

in early stages of gastric cancer, _____________________ surgery plus adjuvant chemotherapy(anthracycline such as 5-fluoruracil) or radiation may be curative option

dumping syndrome

- most common problem after a partial gastrectomy

- after pyloric resection or bypass, concentrated chyme (partially digested food) may enter the small bowel rapidly, causing abdominal distention

- early clinical manifestations include dizziness, tachycardia, pallor, sweating, and palpations

protein

carbs

lay down

drink

small

prevention of dumping syndrome:

- increase _______________

- decrease ____________

- decrease juice and sugary fruits

- _______ __________ after eating

- do not ___________ with meals

- __________ meals more frequently