Concepts of Care for Patients with Stomach Conditions: Gastritis, PUD, and Gastric Cancer

Objectives

• Compare the etiology, pathophysiology, clinical manifestations, and management of acute gastritis, chronic gastritis, and peptic ulcer disease.

• Utilize the nursing process as a framework for providing care to patients with acute or chronic gastritis, or peptic ulcer disease.

• Discuss the etiology, pathophysiology, clinical manifestations, and management of gastric cancer.

• Apply the nursing process as a framework for the care of patients with gastric cancer.

Gastritis

Definition and Types

• Gastritis is a common gastrointestinal (GI) problem characterized by inflammation of the stomach lining.

• It involves a disruption of the mucosal barrier that typically protects the stomach from its own digestive juices (hydrochloric acid and pepsin).

• Can be classified as either erosive (involving mucosal damage) or nonerosive.

• Can be acute (rapid onset, short duration) or chronic (prolonged inflammation).

Causes

• Acute Gastritis:

  • Erosive: Typically caused by local irritation, such as from non-steroidal anti-inflammatory drugs (NSAIDs), alcohol, or stress.

  • Non-erosive: Most commonly associated with Helicobacter pylori (H. pylori) infection.

• Chronic Gastritis:

  • Primary cause is H. pylori infection.

  • Prolonged inflammation of the stomach.

  • Presence of ulcers.

  • Injury or atrophy of gastric tissue.

  • Autoimmune diseases.

  • Long-term use of NSAIDs.

Erosive Gastritis Mechanism

• In erosive gastritis, the mucosa, which normally provides a protective barrier to the stomach from hydrochloric acid (HCl), becomes damaged.

• Cells within the stomach lining continue to secrete hydrochloric acid (HCl), pepsinogen, and intrinsic factor, leading to further irritation and damage due to the compromised protective barrier.

Health Promotion/Disease Prevention

• Maintain a balanced diet.

• Engage in regular exercise.

• Practice stress-reduction techniques.

• Limit foods and spices known to cause gastric distress.

• Avoid alcohol consumption and tobacco use.

Symptoms

• Acute Gastritis:

  • Rapid onset of symptoms.

  • Anorexia (loss of appetite).

  • Nausea and vomiting (N/V).

  • Epigastric pain.

  • Hiccups.

  • Dyspepsia (indigestion).

  • Erosive gastritis specifically may result in bleeding, indicated by melena (dark, tarry stools due to upper GI bleeding) or hematemesis (vomiting blood).

• Chronic Gastritis:

  • Often presents with fewer symptoms until ulceration occurs.

  • Fatigue.

  • Pyrosis (heartburn).

  • Belching.

  • Upper abdominal discomfort.

  • Halitosis (bad breath).

  • Early satiety (feeling full quickly).

  • Anorexia, N/V.

  • Intolerance to spicy or fatty foods.

  • May develop pernicious anemia due to malabsorption of Vitamin B_{12}, which occurs when intrinsic factor secretion is impaired due to gastric atrophy.

Diagnosis

• Esophagogastroduodenoscopy (EGD) via an endoscope is considered the gold standard for diagnosing gastritis.

Interventions

Acute Gastritis

• Initial Action: Refrain from consuming alcohol and food until symptoms subside.

• Diet Reintroduction: Slowly re-introduce a non-irritating diet.

• Supportive Therapy: Provide symptomatic relief.

• Causative Factor Elimination: Identify and eliminate the factor causing the acute gastritis.

• Medications: Administer medications that block and buffer gastric acid secretions (e.g., antacids, H2 blockers, proton pump inhibitors).

Chronic Gastritis

• Treatment: Based on the identified causative agent (e.g., H. pylori eradication).

• Lifestyle Modifications: Modify diet, promote adequate rest, reduce stress, and avoid alcohol and NSAIDs.

• Pharmacologic Therapy: Includes specific treatments, such as antibiotics and proton pump inhibitors, for H. pylori infection.

General Interventions for Gastritis

• Reduce Anxiety: Use a calm approach and thoroughly explain all procedures and treatments to the patient.

• Promote Optimal Nutrition:

  • For acute gastritis, initially restrict food and fluids by mouth (NPO).

  • Gradually introduce clear liquids and solid foods as prescribed.

  • Discourage caffeinated beverages, alcohol, and smoking, as these can irritate the stomach lining.

• Promote Fluid Balance:

  • Monitor intake and output (I&O).

  • Closely watch for signs of dehydration, electrolyte imbalance, and hemorrhage.

• Measures to Relieve Pain: Implement prescribed dietary changes and administer appropriate medications.

Management of Potential Complications

Gastric Bleeding

• Assessment for Evidence of Bleeding:

  • Hematemesis (vomiting blood) or melena (black, tarry stools).

  • Symptoms of anemia (fatigue, pallor, weakness).

  • Signs of shock (e.g., hypotension, tachycardia, decreased urine output, altered mental status).

• Treatment:

  • Administer intravenous (IV) fluids to maintain hydration and circulation.

  • Insert a nasogastric tube (NGT) for gastric lavage to remove blood and clots (if ordered).

  • Maintain airway patency and administer oxygen.

  • Initiate treatment for shock as necessary.

  • May require endoscopic coagulation (e.g., injection, cautery) or surgical intervention to control severe bleeding.

Gastric Outlet Obstruction

• Symptoms Include:

  • Nausea and vomiting, especially after eating.

  • Constipation.

  • Epigastric fullness and distention.

  • Anorexia, and later, weight loss.

• Treatment:

  • Insert an NGT to decompress the stomach, relieving pressure and vomiting.

  • Provide IV fluids and electrolytes to correct imbalances caused by vomiting.

  • Diagnostic endoscopy may be required to confirm the obstruction and determine its cause.

Peptic Ulcer Disease (PUD)

Definition and Types

• PUD is characterized by an erosion of the mucosal lining of the stomach, pylorus (the opening from the stomach into the duodenum), duodenum, or esophagus.

• It is frequently associated with an infection of H. pylori.

• Types: Duodenal ulcers, Gastric ulcers, and Stress ulcers.

Assessment and Diagnosis

Recognize Cues: Assessment

• Obtain a comprehensive history, including presenting signs and symptoms, with a particular focus on any bleeding symptoms.

• Assess the patient's pain, including its characteristics, timing, severity, and methods used to relieve it.

• Investigate potential causes and risk factors, such as prescribed medications, dietary intake (including a 72-hour diet diary), dietary associations with symptoms (e.g., predictable pain times), and lifestyle habits (e.g., cigarette and alcohol use).

• Specifically inquire about the use of NSAIDs and corticosteroids.

• Perform an abdominal assessment and monitor vital signs.

Diagnosis

• Endoscopy (EGD): The primary diagnostic tool.

• Lab Studies:

  • H. pylori testing: Can be done through biopsy during EGD, urea breath testing, or stool sample testing.

  • Hemoglobin and Hematocrit (H&H) levels to check for anemia resulting from bleeding.

Manifestations

• Pain: Often described as a dull, gnawing pain or a burning sensation in the mid-epigastrium or back.

• Dyspepsia: Can be described as uncomfortable fullness or hunger.

• Epigastric pain or tenderness, or abdominal distention.

• Hematemesis or melena (indicating GI bleeding).

• Weight loss.

Comparison of Gastric vs. Duodenal Ulcers

Priority Problems

• Acute pain or persistent pain due to gastric and/or duodenal ulceration.

• Potential for upper gastrointestinal (GI) bleeding due to gastric and/or duodenal ulceration or perforation.

Interventions

Managing Acute or Persistent Pain

• Drug Therapy: Prescribed medications to reduce acid secretion (PPIs, H2 blockers), protect the mucosa, or eradicate H. pylori.

• Nutrition Therapy: Dietary modifications to avoid irritants and support healing.

• Complementary & Integrative Therapies: May include stress reduction techniques, acupuncture, or herbal remedies (under medical guidance).

Managing Upper GI Bleeding

• Non-surgical Management: An active GI bleed is a life-threatening emergency! Interventions involve immediate hemodynamic stabilization.

• Surgical Management: May be required for uncontrolled bleeding or complications.

• Patient Education: Regarding medication adherence, lifestyle modifications, and recognizing signs of bleeding.

Management of Potential Complications

Hemorrhage (PUD Specific)

• Assessment for Evidence of Bleeding:

  • Hematemesis or melena.

  • Symptoms of shock or impending shock (e.g., tachycardia, hypotension, cold clammy skin, altered mental status) and anemia (e.g., pallor, fatigue).

• Treatment:

  • Administer IV fluids for resuscitation.

  • Insert an NGT for diagnostic and therapeutic lavage.

  • Provide oxygen and treat shock.

  • May require endoscopic coagulation (e.g., banding, clipping, injection of sclerosing agents) or surgical intervention for severe or persistent bleeding.

Perforation or Penetration (PUD Specific)

• Signs & Symptoms:

  • Sudden, severe epigastric pain.

  • Vomiting and collapse.

  • Tender, board-like abdomen upon palpation due to peritonitis.

  • Symptoms of shock or impending shock.

• Intervention: This is an EMERGENCY! The patient requires immediate surgery to close the perforation and prevent widespread infection.

Pyloric Obstruction (PUD Specific)

• Symptoms Include:

  • Nausea and vomiting after eating.

  • Emesis (vomit) may contain undigested food from previous meals.

  • Epigastric fullness and distention.

  • Anorexia and, later, weight loss.

• Treatment:

  • Insert an NGT to decompress the stomach and relieve vomiting.

  • Provide IV fluids and electrolytes to correct imbalances.

  • Balloon dilation (endoscopic) or surgery may be required to open the constricted pylorus.

Dumping Syndrome

• Signs & Symptoms:

  • Early manifestations (within 10-30 minutes after eating) are related to the rapid emptying of hypertonic chyme into the jejunum, causing fluid shifts into the bowel. Symptoms include feelings of fullness, weakness, faintness, palpitations, sweating, cramping, and diarrhea.

  • Late manifestations (within 2-3 hours after eating) are related to a rapid increase in blood glucose (from quick carbohydrate absorption) followed by an excessive release of insulin, leading to hypoglycemia. Symptoms include dizziness, lightheadedness, and shakiness.

• Management:

  • Administer medications such as Octreotide (to slow GI motility and secretion) or Acarbose (to delay carbohydrate absorption).

  • Monitor intake and output, laboratory values, and patient weight.

  • Provide thorough patient education on dietary modifications (e.g., small, frequent meals, high protein/fat, low carbohydrate, fluids between meals).

Medication Note: Proton Pump Inhibitors (PPIs)

• Question: What is the best time to teach a client to take proton pump inhibitors?

• Answer: A. 30 minutes before a meal.

  • Explanation: Proton pump inhibitors are delayed-release medications that should be swallowed whole and taken approximately 30 minutes prior to a meal. This timing allows the medication to be absorbed and reach the parietal cells to inhibit acid production effectively before food stimulates further acid secretion.

Gastric Cancer

Risk Factors

• H. pylori infection: Considered the largest risk factor.

• Chronic atrophic gastritis.

• Pernicious anemia.

• Achlorhydria (absence of hydrochloric acid in gastric secretions).

• Chronic inflammation of the stomach.

• Presence of gastric ulcers (though most gastric ulcers are not cancerous, chronic irritation is a risk factor).

• Dietary factors, such as high intake of smoked foods, salted fish and meats, and pickled vegetables.

• Smoking.

• Previous subtotal gastrectomy (stomach resection).

• Genetics and family history.

Assessment and Diagnosis

Recognize Cues: Assessment

• Manifestations:

  • Pain relieved by antacids.

  • Dyspepsia (indigestion).

  • Early satiety.

  • Unexplained weight loss.

  • Abdominal pain or discomfort.

  • Loss or decrease in appetite.

  • Bloating after meals.

  • Nausea and vomiting.

• Challenge: Diagnosis of gastric cancer is unfortunately often late due to vague and non-specific symptoms in early stages.

Treatment

• Chemotherapy or Targeted Therapy: Used to shrink tumors, kill cancer cells, or prevent their growth.

• Radiation Therapy: May be used before or after surgery, or for palliative care.

• Surgical Removal of the Tumor: If possible, gastrectomy is the primary treatment for resectable tumors.

• Palliative Care: Provided if the tumor is unresectable or has metastasized, focusing on symptom management and improving quality of life.

Interventions

General Interventions

• Reduce Anxiety: Provide emotional support and clear information.

• Promote Optimal Nutrition: Manage symptoms that impair intake (e.g., nausea, pain) and provide nutritional support.

• Relieve Pain: Administer analgesics and implement non-pharmacologic pain relief measures.

• Provide Psychosocial Support: Crucial due to the often poor prognosis of gastric cancer; allows patients to express fears and concerns.

• Promote Self-Care Activities: Encourage independence as much as possible.

• Education: Educate the patient and family on the types of treatment, what to expect, and potential side effects.

If Surgery is Required (Gastrectomy)

• Manage care to avoid post-operative complications.

• Educate the patient and family about the potential for dumping syndrome and steatorrhea (fatty stools due to malabsorption).

Gastrectomy

Types and Procedures

• Refers to total or subtotal (partial) surgical removal of the stomach.

• Billroth I procedure (subtotal gastric resection with gastroduodenostomy anastomosis): The remaining stomach is anastomosed (reconnected) directly to the duodenum.

• Billroth II procedure (subtotal gastric resection with gastrojejunostomy anastomosis): The remaining stomach is anastomosed to the jejunum (a more distal part of the small intestine), and the duodenal stump is closed.

Preoperative Care

• Manage Pain & Anxiety: Provide comfort measures and emotional support.

• Maintain Nutrition: Optimize nutritional status before surgery; may involve nutritional supplements or enteral feedings.

• Patient Education: Explain the surgical procedure, expected outcomes, and post-operative care.

Postoperative Care

• Vital Signs and Bowel Sounds: Monitor frequently. Report any increase in temperature to the surgeon, as it could indicate infection.

• Nasogastric Tube (NGT) Drainage: Monitor the amount and character of drainage. Notify the provider for an increased amount of bloody drainage, which could indicate hemorrhage.

• Cobalamin (B{12}) Injection: Patients who undergo gastrectomy will require lifelong B{12} injections due to the loss of intrinsic factor-secreting cells (essential for B_{12} absorption), preventing pernicious anemia.

Nutrition Post-Gastrectomy

• Diet: Small, frequent meals of non-irritating foods.

• Food Choices: Prioritize foods high in calories and vitamins A and C, and iron to support healing and prevent deficiencies.

• Dumping Syndrome Prevention: Implement a specific diet and education plan:

  • Six small feedings per day.

  • Low in carbohydrates and sugar.

  • Fluids should be consumed between meals, not with meals, to slow gastric emptying.

Pain Management

• Administer analgesics as prescribed.

• Utilize nonpharmacologic pain relief measures (e.g., repositioning, distraction, relaxation techniques).

Psychosocial Support

• Allow the patient to express fears, concerns, and grief related to their diagnosis and surgical outcome.

• Allow the patient to participate in decisions regarding their care to promote a sense of control.

• Include family members and significant others in discussions and support systems.

• Refer to or involve other support persons or groups as needed.

• Continue patient education throughout the recovery phase.

Postoperative Complications of Gastrectomy

• Hemorrhage: Bleeding from the surgical site or anastomosis.

• Dumping Syndrome: More frequently seen with the removal of a large portion of the stomach and/or the pyloric sphincter. Patients are advised to lie down for 30 minutes after meals to slow gastric emptying.

• Postprandial Hypoglycemia: Occurs 2 to 3 hours after eating, a late manifestation of dumping syndrome.

• Bile Reflux: Due to the loss of the pyloric sphincter, bile can reflux into the stomach remnant, causing epigastric distress.

• Gastric Outlet Obstruction: Can occur due to edema, inflammation, or scarring at the anastomosis site.

Special Considerations for Older Adults

• Question: Is the following statement true or false? Older adults with gastric cancer may have no gastric symptoms.

• Answer: True. Older adults with gastric cancer may present with atypical or no characteristic gastric symptoms, making early diagnosis particularly challenging in this population. They may only present with generalized symptoms like fatigue or weight loss.