Peptic Ulcer Disease (PUD)/Ulcers
Erosion of GI mucosa from HCl acid and pepsin
Classified by degree and duration of mucosal involvement and by location
Acute—superficial erosion and minimal inflammation
Chronic—Erosion of muscular wall with formation of fibrous tissue; present continuously for many months or intermittently throughout lifetime – more common
Treatment of Ulcers?
Conservative care:
Adequate rest, drug therapy, smoking cessation, diet modifications, long-term follow-up care
Pain management. No NSAIDs or aspirin 4 to 6 weeks unless administered with PPI, H2 receptor blocker, or misoprostol
PPIs, antibiotics, sucralfate, antacids, H2 receptor blockers, May need surgical therapy
Endoscopic evaluation and follow-up; 3 to 6 months for healing
Reasons for it?
Treat stomach cancer, polyps, perforation, chronic gastritis, PUD
What is it?
Inflammation of gastric mucosa
Types?
Hematemesis—bloody vomitus
• Bright red
• Coffee-ground—contact with HCl acid; digested blood
Melena—black, tarry stools from upper GI source
Occult—guaiac test detects blood in gastric secretions, vomitus, or stool
Describe Gastric Ulcers
Gastric: antrum
More prevalent in females older than 50 years
Increased obstruction
Risk factors: Helicobacter pylori, NSAIDs, bile reflux
Increased mortality
High recurrence
Complications of Ulcers & what to do for them?
GI Bleeding
• Monitor VS, NG aspirate
• See interventions for upper GI bleeding
Perforation
• Notify HCP, frequent VS, no oral or NG intake or drugs, IV fluids, pain management, antibiotics; prepare for surgery if able
Gastric outlet obstruction
• NGT to suction, irrigate per policy; monitor I & O, reposition patient; IV fluids and replace electrolytes
• Gastric residual; if less than 200 mL after clamped for 8 to 12 hours, begin oral intake; progress to solids
• No relief or recurrence—surgical intervention
Types?
Partial gastrectomy
-Gastroduodenostomy—Billroth I
-Gastrojejunostomy—Billroth II
Gastrectomy—remove stomach
-Anastomosis of esophagus to jejunum
Vagotomy—total or selective
-Sever vagus nerve; decreased gastric acid secretion
Pyloroplasty
-Enlargement of pyloric sphincter
Manifestations?
Acute:
Anorexia, nausea, vomiting
Epigastric tenderness
Feeling of fullness
Bleeding with alcohol use may be only symptom
Self-limiting – lasts from a few hours to a few days
Chronic:
Like acute
May be asymptomatic
Pernicious anemia due to loss of intrinsic factor
Diagnostics?
Endoscopy is primary tool for discovering source
Angiography – pt. cannot be high-risk or unstable
Labs:
CBC—hemoglobin and hematocrit
BUN—GI tract bacteria breakdown protein
Other: serum electrolytes, PT, PTT, liver enzymes, ABGs, type and crossmatch
Vomitus and stool—gross or occult blood
S/S of Gastric Ulcers?
Gastric:
Epigastric discomfort 1 to 2 hours after meal; burning or gaseous pain; food may worsen
Perforation is first symptom in some patients
Bloating, nausea, vomiting, early feeling of fullness
May be silent (older adults and NSAIDs)
Clinical manifestations of Stomach Cancer?
Stomach cancers often spread before any distressing symptoms occur
GI: unexplained weight loss, indigestion, abdominal discomfort/pain, early satiety
Anemia: pale, weak, fatigue, dizzy, short of breath, heme + stool
Metastasis/late signs:
• Supraclavicular lymph node enlargement
• Ascites – poor prognostic sign
Describe Dumping Syndrome
Gastric chyme enters small intestine as large hypertonic bolus; pulls fluid into bowel lumen causing decreased plasma volume, distention of bowel lumen, and rapid transit within 15 to 30 minutes of eating
Weakness, sweating, palpitations, dizziness, cramping, borborygmi, and defecation urge
Lasts less than 1 hour after eating
Reduced with short rest period after eating
Diagnostics?
Based on symptoms and presence of risk factors
Endoscopy with biopsy
H. pylori infection testing
CBC
Stool for occult blood
Antibodies to parietal cells and intrinsic factor
Treatment Part 1
Massive GI bleed—greater than 1500 mL blood loss or 25% intravascular blood volume
80% to 85% stop spontaneously; still need treatment
Assess for shock
Tachycardia, weak pulse, hypotension, cool extremities, prolonged capillary refill, apprehension
Monitor urine output hourly
One of the best measures of vital organ perfusion
Hemodynamic monitoring – Blood flow and BP in CV system
Oxygen administration – increase blood O2 saturation
Assess for perforation and peritonitis
Tense, rigid abdomen; bowel sounds
Administer IV fluids – generally start with LR solution
Blood/blood product transfusions
Describe Duodenal Ulcer
Duodenal: 1 to 2 cm
Prevalent ages 35 to 45
Etiology: H. pylori
High HCL secretion
High risk: COPD, cirrhosis, pancreatitis, hyperparathyroidism, Zollinger-Ellison syndrome, CRF
Occur, disappear, recur
Diagnostics of Stomach cancer?
H & P
Best - Upper GI Endoscopy with biopsy
EUS, CT, MRI, PET—staging
Laparoscopy—peritoneal spread
Labs: CBC, liver enzymes, amylase, tumor markers
Stool—occult blood
Describe Postprandial Hypoglycemia
Variant of dumping syndrome
Uncontrolled high carbohydrate bolus enters small intestine causing excess insulin and resulting in hypoglycemia ~ 2 hours after eating
Sweating, weakness, confusion, palpitations, tachycardia, anxiety (hypoglycemia reaction)
Treatment for Acute Gastritis?
Acute gastritis:
Identify cause: eliminate, prevent, or avoid it
Supportive care: rest, NPO, IV fluids, antiemetics; monitor for dehydration
Severe: NGT to monitor for bleeding; lavage, empty stomach
Risk for bleeding: monitor VS, heme test vomitus; upper GI bleed strategies
Drugs: PPIs or H2 receptor blockers
Treatment Part 2
Endoscopic Therapy—first line management; within 24 hours to determine treatment or need for surgery
Goal: coagulate or thrombose bleed
• Clips or bands—compress vessel
• Thermal ablation—cauterizes
• Injection (epinephrine or alcohol)
Varices—ligation, injection sclerotherapy, or balloon tamponade
Surgical therapy
Site identified and other interventions failed
If patient requires more than 2000 mL blood transfusion or is still in shock
Drug therapy
Decrease bleeding and HCl neutralization
PPI—IV bolus then infusion
Antacids—after acute phase
S/S of Duodenal Ulcer?
Duodenal:
Burning or cramplike pain in midepigastric or back; 2 to 5 hours after meal
Bloating, nausea, vomiting, early feeling of fullness
May be silent (older adults and NSAIDs)
Treatment of Stomach Cancer?
Surgical therapy—best treatment
Removal of tumor and margin of normal tissue
Location, extent of lesion; patient’s physical condition; HCP’s preference determine open vs laparoscopic
• Lesions in antrum or pylorus—Billroth I or II
• Lesions in fundus—total gastrectomy with esophagojejunostomy
• Surgery is extended as needed when metastasis has occurred to adjacent organs
Preoperative management – correct nutrition deficits; treat anemia
Chemotherapy and radiation therapy
Many chemotherapy drugs are available
May be given intraperitoneal for metastasis
Combined radiation therapy and chemotherapy
• Reduce recurrence
• Provide palliative care by decreasing tumor mass and relief of obstruction
Describe Bile Reflux Gastritis
After reconstruction or removal or pylorus
Bile reflux causes damage to gastric mucosa, chronic gastritis, and PUD
Epigastric distress temporarily relieved with vomiting
Administer cholestyramine before or with meals—binds bile salts
Chronic gastritis:
Evaluate and eliminate cause
Antibiotics for H. pylori
Cobalamin for pernicious anemia (lifelong)
Lifestyle modifications
• No smoking, alcohol or drugs
• 6 small meals/day; nonirritating food
Adhere to prescribed drugs