Inflammation/PUD/ Gallbladder Disease

ADH2/WK6

GI Health History Components

• Changes, stool

• Age, gender, culture

• GI disorders or abdominal surgeries

• Medications, herbs, supplements

• Smoking or vaping history; chewing tobacco use

• Travel

• Nutrition

• Alcohol, caffeine intake

• Socioeconomic status

• Family history and genetic risk

• Current health problems

• Weight, and any changes in weight/appetite/intake

• Pain with PQRST mnemonic

GI Physical Assessment

RUQ, LUQ, LLQ ,RLQ (Assess each one)

 Inspection (Look for symmetry, discoloration, wounds, bulging) 

 Auscultation (Active/hypo or hyper, important for surgery pts to see if they have passed gas) (also checking for vascular sounds called bruit over the abdominal aorta, if heard, don’t palpate and notify HCP immediately)

 Palpation ( light feeling for the presence of normal organs or abnormal masses)

 Percussion – performed by a health care provider

GI Psychosocial Assessment

• Recognize discussion may feel embarrassing for patient

• Ask about stressful events

• If patient has cancer, they may be experiencing the grieving process

GI issues lab Studies

Serum Tests (CBC, PT, Electrolytes, liver enzymes)

Urine Tests

Stool Tests ( Fatty stools, occult blood

GI issues Imaging Assessment

• X-rays

• Virtual colonoscopy( Done via CT scan)

• CT (quicker imaging) or MRI (good at finding abnormalities/ no metal/ some need antianxiety) - Both Preferred over X-ray

GI Diagnostic Assessments 

• Endoscopy

• Esophagogastroduodenoscopy (EGD)

• Endoscopic retrograde cholangiopancreatography (ERCP)

• Small bowel capsule endoscopy (enteroscopy)

• Colonoscopy (traditional or virtual)

• Sigmoidoscopy • Flexible sigmoidoscopy (View large intestine through the rectum with a camera)

• Ultrasonography (may be endoscopic)

• Liver-Spleen scan

Peptic Ulcer Disease Characteristics 

Occurs when mucosal defenses become impaired;

epithelium not protected from effects of acid and pepsin

Characterized by the erosion of the GI mucosa

Many caused by H.pylori infection (spread oral to oral, fecal to oral)

Types of Peptic Ulcers

Duodenal (most common), gastric, and stress ulcers (less common)

Duodenal Ulcers

 Upper portion of the duodenum

 Most common

 Deep

 Penetrate through mucosa and submucosa into the muscularis/muscle layer

 Floor of ulcer is necrotic

 High gastric acid secretion

Pain is common 2-3 hours after a meal, common to see pain at night because of this

Eating food can decrease pain

Melena - black tarry stools

Gastric Ulcers

 Occurs in the Antrum of the stomach near acid secreting mucosa

 Hydrochloric acid injures epithelium

 Back diffusion of acid

 Dysfunction of pyloric sphincter

pain increases with eating and is common 30 min - 1 hour after meals 

Stress Ulcers

 Acute

 Occur after a medical crisis or trauma (sepsis head trauma)

 NPO

 Critically ill

 Proton pump inhibitors (PPI’s) commonly used to prevent when in hospital

Complications of Ulcers

 Hemorrhage (most serious) If recurring, it is most commonly caused by untreated H.pylori infection

 Perforation (ulcer has made hole in stomach or intestinal lining) - Surgical emergency. can cause peritonitis can be life threatening 

 Pyloric obstruction

 Intractable disease ( gastric cancer

Peptic Ulcer Disease: Risk Factors 

 NSAIDs (increase gastric acid secretion)

 Other substances that alter gastric secretion (caffeine, all coffee, alcohol, smoking

Also check family history and living conditions

Peptic Ulcer Disease: Incidence and Prevalence

 More than 15 million in the U.S.

 Mortality rate has declined over past decades

Peptic Ulcer Disease: Assessment

History

 Assess for causes and risk factors

 History of H. pylori, GI surgeries

 Drugs being taken

Physical Assessment/Signs and Symptoms (view picture on next slide)

 Epigastric tenderness and pain (usually located midline between umbilicus and xyphoid process)

 Dyspepsia most common complaint

 Rigid, board-like abdomen with rebound tenderness and pain = peritonitis 

Psychosocial Assessment - how the disease affects them

Peptic Ulcer Disease Diagnostic

 Testing for H. pylori - done through blood, breath or stool (breath/stool more accurate)

 Hemoglobin and hematocrit (usually low)

 Occult blood in stool 

Others -

 EGD (most accurate means of diagnosing of ulcer giving visualization of the ulcer)

 Nuclear medicine scan (checks for GI bleeding) - often done 1-2 days after treatment to check for improvement

PUD Triple Drug Therapy

Two antibiotics + proton pump inhibitor (PPI)

 PPI- lansoprazole, Antibiotics- Metronidazole & Tetracycline or clarithromycin & amoxicillin for 10 to 14 days.

PUD Quadruple Therapy

PPI with bismuth and two antibiotics

Bismuth therapy often used in pt.’s who are allergic to PCN based meds

Be sure pts do not use NSAIDS as it can lead to an overdose.

Nutrition Therapy for PUD

Eating food can work as an antacid by balancing out stomach acid levels but only provides relief for 30-60 minutes, depending on ulcer and other factors. 

Teach pt to avoid irritating foods like spicy foods, alcohol, tabacco, caffeine

Complementary and Integrative Therapies for PUD

Stress relievers - meditation, yoga, hypnosis

Managing upper GI bleeding for PUD

Nonsurgical management - monitoring for any pt changes

 Remember – active GI bleeding is a life-threatening emergency!

Surgical management - treat pts that have emergencies (perforations) or that do not respond to treatment

PUD Transition Management

 Home care management - ensure they know proper meds and treatment plan.

 Self-management education - help to understand needed lifestyle modifications, notice condition changes and what to do if they occur, and teach risk factors

 Health care resources

Magnesium Hydroxide

Antacid

Give after meals and at bed time

Take with a full glass of water

Don’t give other drugs within 1-2 hours

Can cause hypermagnesemia especially in renal impaired patients

Can cause diarrhea 

Aluminum Hydroxide

Antacid

give one hour after meals and at bed time 

H2 Blockers

Promote ulcer healing and prevent their return.

Examples Famotidine (Pepcid), nizatidine (Axid only given orally), cimetidine (tagemet)

Best at suppressing nocturnal acid production

Famotidine

H2 blocker

Give with or before meals

Mucosal Barrier Fortifiers

Protect the stomach mucosa

Coats stomach

Examples - Sucralfate (carafate), Bismuth (peptdo/no aspirin)

Give one hour before meals, 1 hour after meals, and at bedtime

PPI

Cause profound reduction of stomach acid

Examples - Omeprazole (prilosec), lansoprazole, pantoprazole

Dont crush capsules.

Some can be given IV if pt cant take by mouth

Antimicrobials (antibiotics)

Treat H.pylori infection

Examples erythromycin, amoxicillin, tetracycline, and metronidazole

Cholecystitis Pathophysiology

Inflammation of the gallbladder can be Acute vs. chronic

Acute Cholecystitis

stone obstructs cystic duct (most common), gallbladder neck or common bile duct.

Often caused by Gallstones (cholelithiasis) - often made of cholesterol, bilirubin, bile salts

Begins with attack of biliary colic may occur with tachycardia, pallor, diaphoresis, and extreme exhaustion. pain can radiate to right shoulder

Pain lasts longer than the colic

Anorexia, nausea, vomitins

Chronic Cholecystitis

caused by Repeated bouts of acute cholecystitis or Persistent irritation of the gallbladder wall by stones

may have slowly developing symptoms and may not seek medical attention till severe. Symptoms include: Jaundice, clay-colored stools, and dark urine from biliary obstruction. 

Cholecystitis: Etiology and Genetic Risk

 Familial or genetic tendency

 American Indian, Mexican Americans, or Caucasian

 Obesity

 Women

 Increases serum cholesterol & lipids

 Four F’s - Fat, Forty, Female, and Fertile

Cholecystitis: Incidence and Prevalence

 Usually occurs in affluent countries

 American Indians 60-70%

 Caucasian adults 15%

Cholecystitis History Assessment

Inquire about diet and foods and what occurs when they eat certain foods

Cholecystitis Physical Assessment/Signs & Symptoms

 Abdominal pain

 RUQ- radiates to right shoulder or scapula

 Blumberg sign- severe (Rebound tenderness upon deep palpation, usually preformed by provider)

 Late signs= jaundice, clay colored stool, dark urine, steatorrhea(fatty stools)

Cholecystitis Lab Assessment

Increases in - 

 WBC

 Alkaline phosphatase

 AST

 LDH

 Serum bilirubin levels (can be done directly or indirectly)

Cholecystitis Diagnostic assessment

 X-rays

 Ultrasound

ERCP - view the gallbladder and view the patency of the bowel and pancreatic ducts. done endoscopically

MRCP - magnetic resonance imaging (MRI) to create detailed images of the biliary tract (bile ducts), pancreas, and gallbladder

Cholecystitis Nonsurgical management

 Avoid fatty foods

Hold food for any NV. An antemetic may be ordered. NG tube may be placed for severe NV. Assess hydration status

 Opioid analgesic

 Ketorolac - Toroidal, potent analgesic 

 Urosodiol and Chenodiol- Oral bile acid dissolution (dissolve gallstones) facilitate bile digestion, combines bile salts to fecal matter for excretion.  

 Extracorporeal shock wave lithotripsy (ESWL) - breaks up stones through  sound waves. Pt’s often have drainage bag after to drain bile, check patency and position bag lower than catheter 

Laparoscopic cholecystectomy (Lap chole)

 Treatment of choice for cholecystitis 

 Minimally invasive

 Low risk of complications

 Pt. recovery is quicker

 Post op pain is less severe

 Risk that the surgery may be converted to laparotomy during the procedure

Traditional Cholecystectomy

Abdominal laparotomy

 Severe obstruction - reason to do this instead of laparoscopy 

 Drainage tube- Jackson-Pratt (JP) drain (has a suction component to remove bile)

 Drainage tube- T- tube (common bile duct exploration surgery) keep bag low to for bile to be collected.

Cholecystitis transition management/ care coordination 

Eat nutritious foods

Avoid excessive intake of fatty foods

Weight reduction if needed

Report any repeated abdominal or epigastric pain / vomiting or diarrhea that may occur weeks to months after surgery. Possible signs of PCS (post-cholecystectomy syndrome)