Stomach Disorders

Stomach Disorders Overview

Presented by Dr. Shannon Daly, DNP, MSN-Ed, RNCourse: NURS 2000

Gastritis

Pathophysiology Overview

  • Definition:

    • inflammation of gastric muscosa

      often caused by long term NSAID use

    • can be caused by H.pylori

  • Types:

    • Erosive vs Nonerosive: Erosive gastritis involves the erosion of the gastric lining, while nonerosive gastritis does not have these erosions.

    • Acute vs Chronic: Acute gastritis has a sudden onset and is often temporary, while chronic gastritis develops slowly and lasts for an extended period.

Causes

  • Chronic gastritis is frequently caused by long-term use of NSAIDs (non-steroidal anti-inflammatory drugs), which inhibit the production of prostaglandins that protect the gastric mucosa.

  • Infection with Helicobacter pylori (H. pylori), a gram-negative bacterium, is a significant cause of both acute and chronic gastritis and is key in ulcer formation.

  • Other factors include excessive alcohol consumption, autoimmune diseases, and prolonged exposure to certain medications.

Health Promotion and Maintenance

  • Balanced Diet: Incorporating foods that are rich in fiber and avoiding overly spicy or acidic foods can help maintain gastric health.

  • Regular Exercise: Physical activity can enhance digestion and decrease stress, positively impacting stomach health.

  • Stress-Reduction Techniques: Mindfulness, yoga, and meditation can alleviate stress-related gastric discomfort.

  • Avoidance of alcohol, smoking, and foods that exacerbate gastric distress is crucial.

Assessment

  • Acute Gastritis:

    • Symptoms:

      • Rapid onset of epigastric pain and dyspepsia (indigestion)

      • Potential symptoms of gastric bleeding:

        • Hematemesis (vomiting blood)

        • Melena (black, tarry stools)

  • Chronic Gastritis:

    • Symptoms: Often few and subtle; may include nausea, vomiting, and persistent upper abdominal discomfort.

    • Diagnostic Tool: Esophagogastroduodenoscopy (EGD) is the gold standard for diagnosis, allowing for direct visualization and biopsy if necessary.

Types of Gastritis

  • Acute Gastritis:

    • Common causes: Primarily caused by H. pylori infection or NSAID use.

  • Chronic Gastritis:

    • Type A: Autoimmune gastritis, characterized by antibodies to parietal cells and intrinsic factors, leading to vitamin B12 deficiency.

    • Type B: The most common form, directly associated with H. pylori infection.

    • Atrophic Gastritis: Linked to long-term exposure to toxic substances, alcohol, radiation, or smoking; carries a higher risk of gastric cancer.

Interventions

  • Acute Gastritis: Supportive care includes eliminating causative factors and administering drugs that block or neutralize gastric acid secretion.

  • Chronic Gastritis: Treatment focuses on the underlying cause and may involve vitamin B12 supplementation; eradication therapy for H. pylori includes a combination of proton pump inhibitors and antibiotics.

Peptic Ulcer Disease (PUD)

Overview

  • Peptic ulcers occur when the protective mucosal layers are impaired, exposing the epithelium to corrosive gastric acid and pepsin.

  • Types include duodenal ulcers, gastric ulcers, and stress-induced ulcers.

  • H. pylori is implicated in the majority of cases.

Ulcer Formation

  • Conditions Favoring Gastric Ulcers: Occur due to normal gastric acid secretion coupled with delayed gastric emptying, allowing for acid diffusion back into gastric tissue.

  • Conditions Favoring Duodenal Ulcers: Associated with excessive gastric acid production and rapid gastric emptying.

  • Locations for Peptic Ulcers:

    • Lesser curvature: Gastric ulcers are predominantly found here.

    • Pyloric sphincter: Can be involved in both gastric and duodenal ulcers.

    • Antrum: Common site for duodenal ulcers; can also occur in the cardia, fundus, and greater curvature.

Complications of Ulcers

  • Hemorrhage: Most serious complication, potentially life-threatening.

  • Melena: Characterized by dark, tarry stools indicative of upper GI bleeding.

  • Hematemesis: Vomiting blood, which may appear bright red or resemble coffee grounds.

  • Hematochezia: Fresh blood in the stool.

  • Perforation: Can lead to peritonitis, a medical emergency.

  • Pyloric Obstruction: Impaired gastric outlet can result from swelling and scarring.

  • Intractable Disease: Persistent symptoms that do not respond to treatment.

Upper GI Bleeding

  • Signs of upper GI bleeding include:

    • Bright red or coffee-ground vomitus

    • Melena (dark, tarry stools)

    • Systemic signs such as:

      • Decreased hemoglobin and hematocrit

      • Hypotension

      • Tachycardia

      • Confusion, particularly in older adults.

      • syncope (loss of consciousness)

      • weak peripheral pulses

      • dizziness

  • peptic ulcer disease: etiology and genetic risk

  • Major contributing factors to Peptic Ulcer Disease (PUD) include:

    • Infection with Helicobacter pylori (H. pylori)

    • Prolonged use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

    • Family history of peptic ulcer disease.

    • excess alcohol consumption

Assessment

  • History

    • Inquire about risk factors for stomach disorders:

      • H. pylori infection

      • Previous surgeries

      • Medication history

      • Family history of peptic ulcer disease.

  • Physical Examination:

    • epigastric tenderness and pain

    • rigid, board-like abdomen with rebound tenderness and pain= peritonitis

    • bloody emesis or stools (melena)

  • Psychosocial Assessment: Understand the patient’s stressors and coping mechanisms.

Diagnostic Assessments

  • Tests for H. pylori include:

    • Breath tests

    • Stool antigen tests

    • Hemoglobin assessment

    • Checking for occult blood in the stool.

  • EGD can provide direct visualization and biopsy for definitive diagnosis.

  • Other tests like nuclear medicine scans may be considered to assess complications.

Analysis: Analyze Cues & Hypotheses

  • Hypothesize acute or persistent pain emanating from gastric or duodenal ulceration.

  • Assess the potential for upper GI bleeding due to ulceration or perforation.

Planning and Implementation

  • Address acute or chronic pain

  • Implement drug therapy

  • Conduct nutritional interventions

  • Utilize complementary therapies

  • Manage upper GI bleeding as a medical emergency

  • Assess the need for surgical interventions

Care Interventions

  • Drug Therapy:

    • Common regimens include:

      • Triple Therapy:

        • Involves a proton pump inhibitor (PPI) (lansoprazole) combined with two antibiotics ( metronidazole, tetracycline, clarithromycin, amoxicillin) for 10-14 days to eradicate H. pylori.

      • Quadruple Therapy:

        • May include the addition of bismuth compounds.

        • bismuth (pepto-bismol)

          • Purpose: coats the stomach and intestines.

          • Side effects:

            • black stools, constipation

          • contradiction

            • asprin allery, GI bleeding

          • nursing implication

            • monitor stool consistency: educate on potential side effects

        • antacids: aluminum hydroxide, Tums, milk of magnesia

          • Purpose: neutralizes gastric acids

          • side effects:

            • constipation

            • decreased appetite

            • N/V

            • dry mouth

            • flatulence

          • Precautions

            • caution in pt who have GI perforation or obstruction

            • caution in pt with abdominal pain

          • nursing implication

            • doesn’t need a prescription

            • chew the tablet completely before swallowing

            • drink fluid after taking

            • take before meals and before bedtime

        • sucralfate (carafate)

          • Purpose: treatment of acute duodenal ulcers

          • Side effects: constipation

          • precaution: use cautiously in pt with kidney disease and diabetes

          • nursing implication: to treat constipation, increase dietary fiber and fluid intake

            • given QID, 1 hr before meals and at bedtime

            • do not crush or chew ( can be dissolved in water)

  • Education: Teach patients techniques for stress management and provide guidance on recognizing symptoms of bleeding.

Evaluation of PUD Care

  • Goals for PUD Care:

    • Prevention of active Peptic Ulcer Disease (PUD).

    • Eradication of H. pylori infection.

    • Monitor for pain control and adherence to medication regimens.

    • Implement necessary lifestyle alterations.

    • Detect and manage complications, such as GI bleeding, as they arise.

Gastric Cancer

Pathophysiology Overview

  • Risk Factors: Key risk factors include atrophic gastritis, intestinal metaplasia, H. pylori infection, and dietary factors such as high consumption of pickled foods and nitrates.

  • Spread: Gastric cancer tends to spread through direct extension into the gastric wall and into nearby lymphatic structures, complicating treatment.

Assessment

  • Early-stage gastric cancer may present without symptoms, potentially leading to delays in diagnosis.

  • Symptoms: Advanced symptoms may include dyspepsia, persistent abdominal discomfort, and signs of anemia due to bleeding.

  • Diagnosis: Confirmed via EGD with biopsy to evaluate tissue for malignancy.

Interventions

  • Nonsurgical Options: Radiation and chemotherapy are critical in managing gastric cancer and may be used preoperatively or postoperatively.

  • Surgical Options: Gastrectomy or subtotal (partial) gastrectomy

    • Preoperative care: NGT is inserted to remove secretions

    • Operative procedure:

      • for tumors located in mid-portion or distal (lower) portion of the stomach a subtotal partial gastrectomy is done ( omentum and relevant lymph nodes are removed)

      • for pt with removable growth in the proximal (upper) third of the stomach total gastrectomy is done ( entire stomach, lymph nodes, and omentum are removed)

Gastric Cancer: Health Promotion and Maintenance

  • Postoperative Care: Educate about the prevention of dumping syndrome, which can occur after surgery.

    • rapid emptying of food into the small intestine

    • early usually within 30 mins of eating

    • late usually within 2-3 hrs of eating

  • Diet Management:

    • Recommend small, frequent meals that are high in protein and fat.

    • Restrict roughage and simple carbohydrates.

    • Advise patients to avoid liquids during meals to reduce dumping syndrome symptoms.

    • no milk, sweets or sugars

    • vertigo, tachycardia, syncope, sweating, pallor, palpitation, and desire to lay down

Medications for Gastric Disorders

  • Protonix (pantoprazole) 40mg: Effective in treating symptoms of heartburn and acid reflux by decreasing stomach acid production.

  • Nexium (esomeprazole) 20mg: Used for the control of acid reflux and allows for the healing of gastric ulcers.

  • Dexilant (dexlansoprazole) 60mg: Another proton pump inhibitor that reduces stomach acid.

  • Prevacid (lansoprazole): Commonly prescribed for gastric acid management.

Cases and Clinical Presentation

  • Upper GI Bleeding: Possible causes include esophageal varices, perforation, Mallory-Weiss syndrome, and Dieulafoy lesions.

  • Signs/Symptoms of Upper GI Conditions: Critical indicators include hematemesis, melena, that assist in the diagnosis of underlying conditions.