NCM 116a Notes

Gastrointestinal Disturbances NCM 116

Module focuses on Care of Clients with Problems in Nutrition, and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination, Acute and Chronic conditions.

Reminders for NCM 116 Lecture

• Tardiness is discouraged.

• Absences should be avoided.

• Cheating is prohibited.

• Copy and take down notes diligently.

• Study regularly.

Outline of Topics

• I. Review of Anatomy and Physiology of the Gastrointestinal System

  • a. Gastrointestinal tract

  • b. Accessory Organs

  • c. Process of Ingestion

  • d. Process of Digestion

  • e. Process of Elimination

• II. Assessment of the Gastrointestinal System

  • a. Age Related Changes on the GIT and Accessory Organs

  • b. Physical Assessment

  • c. Laboratory and diagnostic tests

• III. Gastrointestinal Disturbances

  • a. Disturbances in Ingestion

    • i. Gastroesophageal Reflux Disease

  • b. Disturbances in Digestion

    • i. Gastritis

    • ii. Peptic Ulcer Disease

  • c. Disturbances in Absorption

    • i. Crohn's disease

    • ii. Appendicitis

  • d. Disturbances in Elimination

    • i. Bowel Obstruction

    • ii. Hemorrhoids

• IV. Disturbances Affecting the Accessory Organs

  • a. Liver Cirrhosis

  • b. Cholelithiasis/cholecystitis

  • c. Pancreatitis

Gastrointestinal System Anatomy

• Components:

  • Mouth (teeth, tongue)

  • Salivary glands

  • Pharynx

  • Esophagus

  • Stomach

  • Liver

  • Gallbladder

  • Pancreas

  • Small intestine (Duodenum, Jejunum, Ileum)

  • Large intestine (Cecum, Colon, Rectum)

  • Appendix

  • Anus

Esophagus Details

• Upper esophageal sphincter

• Lower esophageal sphincter

Stomach Anatomy

• Muscularis externa:

  • Longitudinal layer

  • Circular layer

  • Oblique layer

• Pyloric sphincter (valve) at pylorus

• Duodenum

• Lesser curvature

• Pyloric canal

• Pyloric antrum

• Greater curvature

• Cardia

• Fundus

• Serosa

• Body

• Lumen

• Rugae of mucosa

Small Intestine Sections

• Duodenum

• Jejunum

• Ileum

Small Intestine Details

• Layers of the Stomach:

  • Mucosa

  • Muscularis mucosa

  • Submucosa

  • Muscle layer

  • Subserosa

  • Serosa

• Hepatic portal vein goes to the liver

• Lumen with microvilli

Large Intestine Sections

• Right colic (hepatic) flexure

• Transverse colon

• Ascending colon

• Ileum

• Left colic (splenic) flexure

• Descending colon

• Cecum

• Vermiform appendix

• Anal canal

• Sigmoid colon

• Rectum

Liver

• Largest internal organ of the body

• Weight: $1,200 - 1,500$ g

• Composed of lobules

• Contains blood vessels (Hepatic Portal vein, Hepatic artery, Hepatic vein)

Functions of the Liver

• 1. Glucose metabolism

  • Glycogenesis: glucose to glycogen

  • Lipogenesis: CHO to fats

  • Glycogenolysis: glycogen to glucose

• 2. CHON (protein) metabolism

  • Synthesis of:

    • Plasma CHON: albumin, alpha and beta globulins

    • Clotting factors: fibrinogen, prothrombin

  • Gluconeogenesis: CHON to glucose

• 3. Fat metabolism

  • Metabolism of triglycerides to fatty acids

  • Bile synthesis: $600 - 1200$ ml, yellow-green in color

    • Functions:

      • Excretion of bilirubin

      • Emulsification of fats, cholesterol, and fat-soluble vitamins

• Bile Composition:

  • Water and electrolytes (Na, K, Ca, Chloride, bicarbonate)

  • Lecithin, fatty acids, cholesterol, bilirubin, bile salts

  • Enterohepatic circulation: Hepatocytes -> Bile -> Intestine

• 4. Storage

  • CHO, CHON, fats

  • Fat-soluble vitamins (A, D, E, K)

  • Water-soluble vitamins

  • Minerals: iron, copper, magnesium

• 5. Detoxification

  • Steroid hormones

  • Drugs

• 6. Ammonia to Urea

• 7. Phagocytosis: Kupffer cells

• 8. Blood Reservoir: between $200 – 400$ ml of blood

• 9. Bilirubin excretion

RBC Destruction

• Extravascular Pathway for RBC Destruction (Liver, Bone marrow, & Spleen)

  • Hemoglobin breaks down into Globin and Heme.

  • Globin becomes Amino acids, which enter the Amino acid pool and are Recycled.

  • Heme becomes Bilirubin, which is Excreted.

  • Iron (Fe2) is Recycled.

Liver Function Question

• An important function of the liver is to: C. Filter the body's blood

Pancreas

• Head of pancreas

• Tail of pancreas

• Lobules

• Acinar cells secrete digestive enzymes.

• Pancreatic islet cells secrete hormones.

• Exocrine cells secrete pancreatic juice.

• Common bile duct

• Pancreatic duct

Gallbladder

• Gallbladder

• Sphincter of Oddi

• Major duodenal papilla

• Liver

• Common hepatic duct

• Cystic duct

• Common bile duct

• Pancreas

• Pancreatic duct

• Duodenum portion of the small intestine

Processes of the Digestive System

• PROCESS OF INGESTION

  • the process of taking in food through the mouth.

• PROCESS OF DIGESTION

  • the mechanical and chemical breakdown of food into small organic fragments.

• PROCESS OF ELIMINATION

  • the elimination of undigested food content and waste products

Steps of the Digestive System

• INGESTION

• PROPULSION

• MECHANICAL DIGESTION

• CHEMICAL DIGESTION

• ABSORPTION

• DEFECATION

Assessment: Age Related Changes on the GIT

• Older than 65 years:

  • Dentures or partial plates and bridges

  • Ill-fitting dentures cause eating problems and can lead to nutritional deficits.

• With advanced age:

  • muscles for swallowing becomes weaker and less coordinated; food particles are retained in the cheek pouches or pharynx.

  • The esophageal sphincter become less efficient at opening and closing, and risk for aspiration increases.

  • Taste buds atrophy, causing inability to distinguish between flavors, particularly between salty and sweet.

• After age 70:

  • parietal cells in the stomach decrease their secretion of hydrochloric acid, enzyme and intrinsic factor.

  • The mucosa of the small intestine becomes less absorptive, and the large intestine may develop diminished motility.

Assessment: Age Related Changes on the Accessory Organs

• Gallstone incidence is higher in older adults

• Secretion of lipase from the pancreas decreases, altering fat digestion, and may contribute to a depressed nutritional state in older adults.

Physical Assessment: Subjective Data

• I. Demographic data

  • Age

  • Gender

  • Culture

  • Occupation

• II. Personal and Family History

  • Previous GI disorders

  • Abdominal surgery

  • History of diabetes, CA of the digestive tract, peptic ulcer, gallbladder disease, hepatitis, alcoholism, intestinal polyps, obesity

• III. Diet History

  • Conditions manifested may result from alterations in dietary intake and absorption of nutrients

  • Inquire about any special diet and food allergies

  • Describe usual foods eaten daily and the time meals are taken

  • Explore any changes that have occurred in eating habits as a result of illness

  • Changes in taste and any difficulty or pain with swallowing

  • Abdominal pain/discomfort accompanies eating, nausea, vomiting, or dyspepsia

  • Unintentional weight loss

  • Alcohol and caffeine consumption

• IV. Socioeconomic Status

  • Ability to obtain food, medications, and medical care

• V. Current Health Problems

  • Chronologic account of the current problem, symptoms, and treatments taken

  • Explore characteristics associated with each symptom

    • Types of pain: burning, gnawing, stabbing

    • Location of pain: point involved site

Physical Assessment: Objective Data

• Mouth

  • Equipment: gloves, penlight, tongue depressor

  • Inspect:

    • Lips – color, moisture, cracking, lesion

    • Inner surfaces of the lips and oral mucosa

    • Tongue – color, coating, ulcers, and variations in size and shape

    • Teeth – evidence of dental caries and note the absence of teeth

    • Gums – pink, moist, and smooth

    • Describe moisture, color, lesion

  • Note unpleasant odors

    • Fetor oris

    • Acetone breath

    • Ammonia

  • Pharynx: use tongue depressor to depress the tongue and examine the pharynx; instruct to say “ah”

  • Palpate

    • U – shape under the tongue for nodules

• Abdomen (IAPP)

  • Preparation:

    • 1. Empty the bladder

    • 2. Lie in a supine position head raised slightly with knees bent or slightly flexed, keeping the arms at the sides to prevent inadvertent tensing of the abdominal muscle

    • RLQ, LUQ, RUQ, LLQ

  • Inspect

    • color, texture, scars, striae, shape, rashes, lesions and dilated blood vessels, symmetry, bulging, muscular position and condition of umbilicus, and movements

    • describe the contour:

      • flat

      • convex (rounded)

      • concave (sunken)

      • Protruberant or distended

  • Auscultate: peristalsis & bruits

    • diaphragm of stethoscope

    • All 4 quadrants: RLQ, LLQ, LUQ, RUQ

    • Bowel sounds: $5 – 35$ gurgles/min

      • Hypoactive: <5 sounds/min

      • Hyperactive: >30 sounds/min in one quadrant and decreased sound in another quadrant

      • Absence: no sound on each of the 4 quadrants for 5 mins

  • Vascular sounds:

    • Bruits (swooshing sound)

    • abdominal aorta, renal arteries, iliac arteries, femoral arteries

    • Peritoneal friction rub – heard over the spleen or liver

    • Venous hum

    • Epigastric, periumbilical region

  • Palpation

    • Done to detect tenderness, sensitivity, masses, swelling, and muscular resistance and to confirm (+) findings

    • Check:

      • liver

      • spleen and kidney

      • urinary bladder distention

    • Types:

      • light palpation

      • deep palpation

  • Percussion

    • Tapping to detect presence of air, fluid, or masses underlying tissues

    • Purpose:

      • To determine the size of solid organ

      • To detect presence of masses, fluid, and air

      • To estimate the size of liver and spleen

    • Notes:

      • Tympany or resonant sound: high - pitched, loud musical sound heard over areas filled with air

      • Dull or flat - medium pitched, soft thudlike sound heard over a solid organ

      • Excessive air occurs with irritation and inflammation

  • Assess Ascites

    • Place patient supine and expose the abdomen

    • Hands at the sides with knees flexed

    • Observe for bulging flanks indicating fluid accumulation

    • If with ascites, measure abdominal girth

Laboratory Tests

• 1. Fecal analysis (stool examination)

  • Fecal occult blood test (FOBT)

  • Stool culture or fecal immunochemical test (FIT)

    • Fecal occult blood test - Analysis of stool for blood

      • Nursing care:

        • Explain the procedure

        • Advise patient to avoid red meat, iron, and high fiber for 1 – 3 days

        • Document the administration of aspirin, vitamin C, and anti-inflammatory drugs

  • Fecal analysis (cont.)

    • Fecal fat test - Analysis of stool for fat

      • Nursing care:

        • Explain the procedure

        • Advise patient to restrict alcohol intake and maintain a high- fat diet 72 hours before the examination

        • Refrigerate the specimen until it can be sent to the laboratory

        • Document current medications

• 2. Serum Bilirubin – to detect abnormal bilirubin metabolism

  • Normal values:

    • Total: $0.3 – 1.9$mg/dl

    • Direct: $0 - 0.3$ mg/dl

  • Explain that a blood sample will be taken; no fasting is required

• 3. Alanine aminotransferase (ALT) – an enzyme used to detect liver disease

  • Normal value: $1 – 45$ International units/L

  • Explain that a blood sample will be taken; no fasting is required

• 4. Aspartate aminotransferase (AST) – An enzyme found in heart, liver, and muscle tissue; to detect acute hepatitis or biliary destruction

  • Normal value: $1 – 36$ units/L

  • Explain that a blood sample will be taken; no fasting is required

• 5. Alkaline phosphatase (ALP) – Enzyme found in bone, liver and placenta; to detect liver tumor in conjunction with other liver findings; rises when there is destruction of the biliary tree

  • Normal value: $35 – 150$ units/L

  • Explain that a blood sample will be taken; no fasting is required

• 6. Albumin – to detect altered CHON metabolism

  • Normal value: $3.5 – 5.5$ g/dL

  • Explain that a blood sample will be taken; no fasting is required

• 7. Prothrombin (PT) – Reduced in patients with liver disease, causing a prolonged clotting time

  • Normal value: $12.0 – 14.0$ sec

  • Explain that a blood sample will be taken; no fasting is required

• 8. Partial thromboplastin time (PTT) – to detect deficiencies of stage II clotting mechanisms; prolonged in liver disease

  • Normal value: $60 – 70$ sec

  • Explain that a blood sample will be taken; no fasting is required

• 9. Activated PTT (APTT) – decreased in liver failure

  • Normal value: $20 – 35$ sec

  • If patient is receiving heparin injections, draw specimen $30 – 60$ mins before next dose

• Helicobacter pylori antibody test – to detect antibodies to H. pylori bacterium in the stomach; H pylori is a risk factor for gastric and duodenal ulcers, chronic gastritis, or ulcerative esophagitis

  • Normal: none present

  • Explain that a blood sample will be taken; no fasting is required

• Esophageal pH Monitoring/24-hour pH testing

  • Probe is placed 5 cm above LES and pH is measured for 24 hours

  • pH less than 4 above the LES = GERD

  • Nursing Care

    • Instruct patient not to use any antacids, chewing gum, lozenges or hard candy during the study

    • For throat discomfort: ice chips or dyclonine hydrochloride (Cepacol) spray

    • To prevent reflux: avoid large meals, caffeine, alcohol, and lying in supine position after meals

Diagnostic Tests

• Radiologic Examination

  • 1. Upper GI Series (UGI) or Barium Swallow

    • To locate obstruction, ulceration, or growths in the esophagus, stomach, and duodenum

    • Nursing care:

      • Light supper: soup, toast, jello, or tea night before the procedure

      • Advise client to be on NPO and avoid smoking 8 – 12 hours before the exam

      • Client will drink 16 – 20 ounces of a chalky liquid (barium sulfate or meglumine diatrizoate {Gastrografin}) before the exam.

      • Following the exam, ensure the client eliminates the barium by giving laxatives and forcing fluids as appropriate.

      • Stool may be white up to 3 days after the test

      • Observe for barium impaction: distended abdomen, constipation

  • 2. Barium enema (BE) – to locate tumors, obstruction, and ulceration

    • Nursing care:

      • Advise client to be on NPO 8 hours before the test

      • Give ordered laxative and enema; bowel must be clear of stool

  • 3. Computed tomography (CT) – to visualize soft tissue and density changes when sonography is inconclusive; to detect tumors, abscesses, trauma, cysts, inflammation and bleeding

    • Nursing care:

      • Advise client to be on NPO for 4 hours when oral contrast is to be used

      • Secure consent

      • Assess for allergy to iodine or shellfish

      • Explain the following:

        • Position will be supine on a special narrow table, and that the body will be in the circular opening of the scanner

        • A strap will be placed over the waist to secure him on the table

        • Clicking noises will be heard from the machine

        • The test takes about 30 mins

        • An IV contrast agent that causes a transitory warm feeling may be given to enhance images

        • Patient will be asked to hold his breath at certain points in the test

        • The machine uses narrow x-ray beams

  • 4. Magnetic Resonance Imaging (MRI) with or without contrast - to evaluate abnormalities in the liver or other abdominal structures

    • Nursing Care:

      • Assess for metal implants or pregnancy (will not do the exam if present)

      • Remove all metal objects including dental bridges

    • Magnetic Resonance Imaging (MRI) (cont.)

    • Nursing Care:

      • NPO 6 hours prior the exam

      • The test will take 30 – 90 mins

      • A thumping sound will be heard during the test

      • There will be a tingling sensation in metal fillings

  • 5. Ultrasound Imaging Ultrasonography – to obtain images of soft tissue that indicate density changes; to diagnose gallstones, tumor, cysts, abscesses, etc

    • Ultrasound of the abdomen, hepatobiliary, and gallbladder

    • Nursing Care:

      • Advise client to remain NPO for 8 – 12 hours prior to the test

Endoscopic Studies

• 1. Upper GI Endoscopy/ Esophagogastroduodenoscopy – to visualize the esophagus, stomach, and duodenum with a lighted tube to detect tumor, ulceration, site of bleeding or obstruction

  • Nursing Care:

    • Preparation

      • Advise client to remain NPO for 8 hours prior to the test

      • Secure consent

    • Endoscopic Studies

    • 1. Esophagogastroduodenoscopy (cont.)

    • After the test

      • Side-lying position

      • Remain on NPO after the test until gag reflex returns

      • NSS gargle, throat lozenges

      • Vital signs q 15 – 30 mins as ordered

      • Watch for signs of perforation

      • Assess for bleeding, neck or throat pain and dyspnea

      • Avoid driving if given sedatives

• 2. Lower GI Endoscopy/Colonoscopy/Proctosigmoidoscopy – to directly view the lining of the colon with a flexible endoscope

  • Nursing Care:

    • Secure consent

    • Clear liquid 1 – 3 days before the test

    • NPO 8 hours before the test

    • Bowel preparation as ordered

    • After the test observe for rectal bleeding and signs of perforation

• 3. Endoscopic Retrograde Cholangiopancreatography (ERCP) - to directly visualize gastrointestinal structures, and to retrieve gallstones from the distal common bile duct, dilate structures, and biopsy tumors.

  • Nursing care:

    • Advise client to be on NPO for 8 hours before the test.

    • Following the test, assess vital signs and gag reflex, and monitor for complications (pancreatitis is the most common).

• 4. Liver biopsy – to remove a tissue sample for microscopic examination and diagnosis of various liver disorders

  • Nursing Care:

    • Secure consent

    • NPO 4 – 8 hours prior to the test

    • Place patient in supine or left lateral position

    • Procedure may take 15 mins

  • Liver biopsy (cont.)

  • Nursing Care:

    • Assess for allergy to local anesthetics

    • Empty the bladder prior to the procedure

    • Check coagulation studies for abnormalities

    • After biopsy, place a small dressing over puncture site; position patient on right side with support to provide pressure over biopsy site for 1 -2 hours; observe for bleeding

  • Liver biopsy (cont.)

  • Nursing Care:

    • Post biopsy

      • Monitor vital signs q 15 mins for 1 hour; then q 30 mins for 4 hours; then q 4 for 24 hours

      • Assess for tenderness at biopsy site

      • Observe for respiratory problems

      • Instruct patient to avoid coughing or straining, that might increase intra-abdominal pressure

      • Refrain from heavy lifting or strenuous activities for 1 – 2 weeks.

Unit III. Disorders of the GIT

• Disturbances in Ingestion

  • GASTROESOPHAGEAL REFLUX DISEASE (GERD)

    • Is the backward flow of stomach contents (chyme) into the esophagus without associated vomiting

    • 10% - heartburn

    • 45% - symptom at least once a month

    • Increases after age 50

    • Occur at any age

    • Prevalence is equal across gender, ethnic and cultural groups

    • 90% with GERD has hiatal hernia

Pathophysiology of GERD

• Causes:

  • Transient relaxation or incompetent Lower Esophageal Sphincter (LES) – relaxation allows fluids or food to reflux into the esophagus from the stomach

  • Development of esophageal stricture

  • Delayed stomach emptying

  • Obesity

  • Pregnancy

  • Hiatal hernia

    • Is the result of a defect in the wall of the diaphragm where the esophagus passes through; this creates protrusion of part of the stomach or the lower part of the esophagus up into the thoracic cavity.

  • Drugs

    • Beta-adrenergic blockers (Inderal)

    • Calcium channel blockers (verapamil)

    • Estrogen, progesterone

    • Diazepam (valium)

    • Theophylline

    • Nicotine

• Pathophysiology

  • Exposure to gastric contents initiates an inflammatory response

  • With repeated exposure, inflammation becomes chronic

  • Normal squamous epithelial cells are replaced with columnar epithelium

Clinical Manifestations of GERD

• Heartburn (dyspepsia) and reflux

• Sour taste in the morning on arising

• Chest pain

• Coughing

• Belching

• Flatulence

• Regurgitation

• Dysphagia or odynophagia

• Dyspepsia

• Hypersalivation

• Esophagitis

Diagnostic Tests and Management of GERD

• Diagnostic tests

  • Upper GI endoscopy

  • Ambulatory esophageal pH monitoring

  • Barium swallow

• Management:

  • Diet therapy

    • Avoid high fat oils and spicy foods

    • Eat 4 – 6 meals a day

    • Eat slowly and chew foods thoroughly

    • Avoid carbonated beverages – it may increase bloating

    • Limit or eliminate alcohol, tomato-based products, caffeine, citrus juice, raw onions, chocolate, coffee, peppermint, and spearmint- these foods may either relax the sphincter or increase acid production

  • Lifestyle changes

    • Wait 2 – 3 hours after eating before lying down

    • Avoid constrictive clothing

    • Lose weight at least 10%

    • Sleep with head of the bed elevated 6 to 8 inches with blocks or foam bolster pillow

    • Quit smoking

    • Participate in activities: exercise, meditation, deep breathing, and laughter

  • Drug therapy

    • Antacids – neutralize stomach acid; 1-2 hrs. after a meal

      • Maalox, Tums, Gaviscon

    • Histamine2- Receptor Antagonist: Suppress acid secretion by blocking H2 receptors on parietal cells; taken with meals; advise to avoid cigarettes, aspirin and other NSAIDs

      • Cimetidine (Tagamet), Ranitidine (Zantac), Nizatidine (Axid), Famotidine (Pepcid)

    • Proton Pump Inhibitors – suppress secretion of gastric acid

      • Omeprazole (Prilosec),Lansoprazole (Prevacid)

    • Misoprostol (Cytotec) – prevents gastric ulcers caused by long-term therapy with NSAIDS

    • Miscellaneous – provides protective coating barrier over ulcer crafter; 30 mins - 1 hour before meal

      • Sucralfate (Carafate)

  • Education

  • Surgery

    • Increase the pressure in the lower LES

    • Laparoscopic procedure: Nissen funduplication

      • the fundus of the stomach is wrapped around the esophagus to create a new valve junction

    • Complication:

      • Precancerous lesions in Barrett esophagus with constant irritation

      • Pneumonitis

      • Dental caries

Gastritis

• Disturbances in Digestion

  • GASTRITIS – A diffuse or localized inflammation of the gastric or stomach mucosa

    • Atrophic gastritis involves all layers of the stomach. It is seen in association with gastric ulcer and malignancies of the stomach.

    • Gastritis associated with uremia is common in patients with kidney failure. The excessive urea that builds up from the kidney failure causes gastric irritation.

    • Untreated chronic gastritis may progress to ulcer formation and upper GI hemorrhage.

• Types

  • 1. Acute

    • Lasting several hours to a few days

    • Short-term inflammatory process due to ingestion of chemical agents

  • 2. Chronic

    • Resulting from repeated exposure to irritating agents or recurring episodes of acute gastritis

      • Types

        • Type A - autoimmune; gastric CA, pernicious anemia

        • Type B - associated with helicobacter pylori infection

• Incidence:

  • Highest in the 5th & 6th decades of life

  • Heavy drinkers and smokers

• Causes: Acute

  • Excessive amount of alcohol

  • Contaminated food

  • Cocaine use

  • Ingestion of medication: corticosteroids and NSAIDs – aspirin and ibuprofen

• Chronic

  • Bacterial infection: Helicobacter pylori (H. pylori)

  • Virus

  • parasites

  • Irritating foods

  • Radiation

  • Ingestion of strong acid and alkali

  • Smoking

• Pathophysiology

  • Damage to the gastric mucosal

  • Disruption to the gastric mucosal barrier

  • Back diffusion of acid and pepsin

  • Inflammation

  • Secretes a scanty amount of gastric juice containing very little acid but much mucus

  • Superficial erosion

• Manifestations:

  • Acute gastritis

    • Anorexia

    • Nausea and vomiting

    • Abdominal pain and cramping

    • diarrhea

    • Epigastric pain

    • Fever

    • Feeling of fullness

    • Dyspepsia

  • Chronic gastritis

    • Vague complaints of epigastric pain that is relieved by food

    • Anorexia

    • Nausea and vomiting

    • Intolerance to fatty and spicy foods

    • Massive hemorrhage

    • Pernicious anemia

• Diagnostic Tests:

  • Endoscopy

  • Upper GI series

• Medical Management:

  • NPO if with nausea and vomiting

  • Bland or liquid diet

  • Fluid-electrolyte replacement

  • Vitamin B12

  • Drugs

    • Antacids: 1-2 hrs after a meal

      • Maalox, Tums

    • H2 receptor antagonist: taken with meals

      • Tagamet (Cimetidine), Zantac (Ranitidine)

    • Cytoprotective drug: 30 mins - 1 hour before meal

      • Carafate (Sucralfate)

    • Antispasmodics to decrease the pain of stomach spasms

• Nursing Diagnosis

  • Alteration in comfort: Pain R/T inflammation of the gastric mucosa

  • Fluid volume deficit R/T vomiting and bleeding

  • Imbalanced nutrition less than body requirements R/T anorexia

Peptic Ulcer Disease

• b. PEPTIC ULCER DISEASE

  • Peptic - from Greek means to digest

    • Any ulceration that forms in the mucosal wall of the stomach, pylorus, duodenum, or in the esophagus

    • Types:

      • Gastric ulcer

      • Duodenal ulcer

  • Gastric Ulcer

    • Ages 55 - 70

    • Male: Female = 1:1

    • Occur less frequently

    • Heal more slowly

  • Duodenal Ulcer

    • Ages 30 - 60

    • Male: Female = $2 -3:1$

    • most common

  • Causes:

    • H. pylori - 80%

    • NSAIDs, ASA, steroids

    • Cigarette smoking

    • Family history of PUD

    • Stress

    • Alcohol

    • Caffeine

    • Gastritis

    • Zollinger-Ellison syndrome

    • Irregular hurried meals

    • Fatty, spicy, highly acidic foods

    • Type A personality

    • Type O blood

    • Genetic

Pathophysiology of Peptic Ulcer Disease

• Breakdown of gastric mucosal barrier

• Release of histamine and cholinergic nerve stimulation

• Increased acid-back diffusion into the mucosal cells

• Erosion and injury to small blood vessels

• Bleeding and edema

• Clinical Manifestations:

  • Gnawing, burning, aching, or hunger-like upper abdomen pain

  • Gastric ulcer: pain 1-2 hrs after a meal, relieved by vomiting; hemorrhage more likely to occur

  • Duodenal ulcer: pain 2-4 hrs after a meal; relieved by food; often awakened between 1-3 am; hemorrhage less likely to occur

• Complications:

  • Hemorrhage

  • Perforation

  • Penetration

  • Pyloric or gastric outlet obstruction

• Diagnostic tests:

  • Barium swallow (upper GI series)

  • Endoscopy

• Medical management:

  • 1. Medications

    • Goal: reduce the symptoms

      • Antacids

      • H2 receptor antagonist: Cimetidine, Ranitidine

      • Cytoprotective drug: Sucralfate

      • Proton pump inhibitor: Losec (Omeprazole)

      • H. Pylori: Amoxicillin/tetracycline, Metronidazole, Bismuth

• 2. Lifestyle Modifications