MedSurg-2 PRELIMS

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● The serous membrane is very soft and produces a lot of mucus

which is why its healing is delayed and surgery is complicated.

The remaining portion of the GI tract is located within the peritoneal cavity.

The stomach is situated in the upper portion of the abdomen to the left of the
midline, just under the left diaphragm.
● It is a distensible pouch with a capacity of approximately 1500
mL. The inlet to the stomach is called the esophagogastric
junction; it is surrounded by a ring of smooth muscle called the
lower esophageal sphincter (or cardiac sphincter), which, on
contraction, closes off the stomach from the esophagus.
● The stomach can be divided into four anatomic regions: the cardia
(entrance), fundus, body, and pylorus (outlet). Circular smooth
muscle in the wall of the pylorus forms the pyloric sphincter and
controls the opening between the stomach and the small intestine.

The small intestine is the longest segment of the GI tract, accounting for about
Anatomy of the Gastrointestinal Tract
two thirds of the total length.
● It folds back and forth on itself, providing approximately 7000 cm
of surface area for secretion and absorption, the process by which
nutrients enter the bloodstream through the intestinal walls.
● The small intestine is divided into three anatomic parts: the upper
part, called the duodenum; the middle part, called the jejunum;
and the lower part, called the ileum.
● The common bile duct, which allows for the passage of both bile
and pancreatic secretions, empties into the duodenum at the
ampulla of Vater.
● The junction between the small and large intestine, the cecum, is
located in the right lower portion of the abdomen.
● The ileocecal valve is located at this junction.
● It controls the passage of intestinal contents into the large intestine
and prevents reflux of bacteria into the small intestine.
● The vermiform appendix is located near this junction. Both the sympathetic and parasympathetic portions of the autonomic nervous
system innervate the GI tract.
The large intestine consists of an ascending segment on the right side of the
abdomen, a transverse segment that extends from right to left in the upper In general, sympathetic nerves exert an inhibitory effect on the GI tract,
abdomen, and a descending segment on the left side of the abdomen. decreasing gastric secretion and motility and causing the sphincters and blood
● The terminal portion of the large intestine consists of two parts: vessels to constrict.
the sigmoid colon and the rectum.
Parasympathetic nerve stimulation causes peristalsis and increases secretory
The rectum is continuous with the anus. A network of striated muscle that activities. The sphincters relax under the influence of parasympathetic
forms both the internal and the external anal sphincters regulates the anal stimulation.
outlet.
The only portions of the tract that are under voluntary control are the upper
The GI tract receives blood from arteries that originate along the entire length esophagus and the external anal sphincter.
of the thoracic and abdominal aorta. Of particular importance are the gastric
artery and the superior and inferior mesenteric arteries.
Function of the Digestive System
Oxygen and nutrients are supplied to the stomach by the gastric artery and to
the intestine by the mesenteric arteries (Fig. 34-2). ● To break down food particles into the molecular form for
digestion
Blood is drained from these organs by veins that merge with others in the ● To absorb into the bloodstream the small molecules produced by
abdomen to form a large vessel called the portal vein. digestion
The GI tract is a 23- to 26-foot-long pathway that extends from the mouth
● To eliminate undigested and unabsorbed foodstuffs and other
through the esophagus, stomach, and intestines to the anus. Nutrient-rich blood is then carried to the liver. The blood flow to the GI tract is waste products from the body
about 20% of the total cardiac output and increases significantly after eating.
Deglutition - swallowing
Chewing and Swallowing
The esophagus is located in the mediastinum in the thoracic cavity, anterior to
the spine and posterior to the trachea and heart. Saliva is secreted from three pairs of glands:
● This collapsible tube, which is about 25 cm (10 inches) in length, ● the parotid,
becomes distended when food passes through it. It passes through ● the submaxillary,
the diaphragm at an opening called the diaphragmatic hiatus. ● and the sublingual glands.
● Between the throat and stomach.
Approximately 1.5 L of saliva is secreted daily. Saliva is the first secretion that the composition of the meal, and other factors. toward the colon. Both movements are stimulated by the presence
comes in contact with food. ● Peristalsis in the stomach and contractions of the pyloric sphincter of chyme.
● Saliva contains the enzyme ptyalin, or salivary amylase, which allow the partially digested food to enter the small intestine at a
begins the digestion of starches (Table 34-1). rate that permits efficient absorption of nutrients. Food, initially ingested in the form of fats, proteins, and carbo-hydrates, is
● Saliva also contains mucus and water, which help to lubricate the ● This food mixed with gastric secretions is called chyme. broken down into absorbable particles (constituent nu-trients) by the process of
food as it is chewed, thereby facilitating swallowing. Hormones, neuroregulators, and local regulators found in the digestion.
gastric secretions control the rate of gastric secretions and ● Carbohydrates are broken down into disaccharides (eg, sucrose,
influence gastric motility (Table 34-2). maltose, galactose) and monosaccharides (eg, glucose, fructose).
● Glucose is the major carbohydrate that the tissue cells use as fuel.
● Proteins are broken down into amino acids and peptides.
● Ingested fats are emulsified into monoglycerides and fatty acids.
● These smaller molecules are then ready to be absorbed.
● Chyme stays in the small intestine for 3 to 6 hours, allowing for
continued breakdown and absorption of nutrients.

Small, finger-like projections called villi are present through-out the entire
intestine and function to produce digestive enzymes as well as to absorb
nutrients.

Absorption is the primary function of the small intestine.


● Vitamins and minerals are not digested but rather absorbed
Swallowing begins as a voluntary act that is regulated by a swallowing center
essentially unchanged.
in the medulla oblongata of the central nervous system.
● Absorption begins in the jejunum and is accomplished by both
● As food is swallowed, the epiglottis moves to cover the tracheal
active transport and diffusion across the intestinal wall into the
opening and prevent aspiration of food into the lungs.
circulation.
● Swallowing, which propels the bolus of food into the upper
● Absorption of different nutrients takes place at different locations
esophagus, thus ends as a reflex action.
in the small intestine.
● The smooth muscle in the wall of the esophagus contracts in a
Small Intestine Function ● Iron and calcium absorption takes place in the duodenum. Fats,
rhythmic sequence from the upper esophagus toward the stomach
proteins, carbohydrates, sodium, and chloride are absorbed in the
to propel the bolus of food along the tract.
The digestive process continues in the duodenum. jejunum.
● During this process of esophageal peristalsis, the lower
● Secretions in the duodenum come from the accessory digestive ● Vitamin B12 and bile salts are absorbed in the ileum. Magnesium,
esophageal sphincter relaxes and permits the bolus of food to
organs— phosphate, and potassium are absorbed throughout the small
enter the stomach.
○ the pancreas, intestine.
● Subsequently, the lower esophageal sphincter closes tightly to
prevent reflux of stomach contents into the esophagus. ○ liver, and
○ gallbladder—and the glands in the wall of the Colonic Function
intestine itself.
Gastric Function
● These secretions contain digestive enzymes and bile. Within 4 hours after eating, residual waste material passes into the terminal
● Pancreatic secretions have an alkaline pH because of high ileum and passes slowly into the proximal portion of the colon through the
The stomach stores and mixes the food with secretions. concentrations of bicarbonate. ileocecal valve.
● It secretes a highly acidic fluid in response to the presence or ● This neutralizes the acid entering the duodenum from the ● This valve, which is normally closed, helps prevent colonic
anticipated ingestion of food. stomach. contents from refluxing into the small intestine.
● This fluid, which may have a pH as low as 1, derives its acidity ● The pancreas also secretes digestive enzymes, including trypsin, With each peristaltic wave of the small intestine, the valve opens briefly and
from the hydrochloric acid (HCl) secreted by the glands of the which aids in digesting protein; amylase, which aids in digesting permits some of the contents to pass into the colon.
stomach. starch; and lipase, which aids in digesting fats.
● The function of this gastric secretion is two-fold: ● Bile (secreted by the liver and stored in the gallbladder) aids in Bacteria make up a major component of the contents of the large intestine.
○ to break down food into more absorbable emulsifying ingested fats, making them easier to digest and ● They assist in completing the breakdown of waste material,
components Aorta and absorb. especially of undigested or unabsorbed proteins and bile salts.
○ to aid in the destruction of most ingested bacteria.
● The stomach can produce about 2.4 L per day of these gastric The intestinal glands secrete mucus, hormones, electrolytes, and enzymes. Two types of colonic secretions are added to the residual material: an
secretions. ● The mucus coats the cells and protects the mucosa from injury by electrolyte solution and mucus.
● Gastric secretions also contain the enzyme pepsin, which is HCl. ● The electrolyte solution is chiefly a bicarbonate solution that acts
important for initiating protein digestion. ● Hormones, neuroregulators, and local regulators found in these to neutralize the end products formed by the colonic bacterial
● Intrinsic factor is also secreted by the gastric mucosa. intestinal secretions control the rate of intestinal secretions and action.
● This compound combines with dietary vitamin B12 so that the also influence GI motility. ● The mucus protects the colonic mucosa from the intraluminal
vitamin can be absorbed in the ileum. ● Intestinal secretions total approximately 1 L/day of pancreatic contents and also provides adherence for the fecal mass.
● In the absence of intrinsic factor, vitamin B12 cannot be absorbed juice, 0.5 L/day of bile, and 3 L/day of secretions from the glands
and pernicious anemia results. of the small intestine. Slow, weak peristaltic activity moves the colonic contents slowly along the
● Peristaltic contractions in the stomach propel its contents toward ● Tables 34-1 and 34-2 summarize the actions of digestive enzymes tract.
the pylorus. and GI regulatory substances. ● This slow transport allows efficient reabsorption of water and
● Because large food particles cannot pass through the pyloric
electrolytes, which is the primary purpose of the colon.
sphincter, they are churned back into the body of the stomach. Two types of contractions occur regularly in the small intestine: segmentation ● Intermittent strong peristaltic waves propel the contents for
● In this way, food in the stomach is agitated mechanically and contractions and intestinal peristalsis. considerable distances.
broken down into smaller particles. ● Segmentation Contractions produce mixing waves that move the ● This generally occurs after another meal is eaten, when
● Food remains in the stomach for a variable length of time, from a intestinal contents back and forth in a churning motion. intestine-stimulating hormones are released.
half-hour to several hours, depending on the size of food particles, ● Intestinal peristalsis propels the contents of the small intestine
● The waste materials from a meal eventually reach and distend the
rectum, usually in about 12 hours.
● As much as one fourth of the waste materials from a meal may
still be in the rectum 3 days after the meal was ingested.

Waste Products of Digestion

Feces consist of undigested foodstuffs, inorganic materials, water, and bacteria.


● Fecal matter is about 75% fluid and 25% solid material.
● The composition is relatively unaffected by alterations in diet,
because a large portion of the fecal mass is of non dietary origin,
derived from the secretions of the GI tract.
● The brown color of the feces results from the breakdown of bile
by the intestinal bacteria.
● Chemicals formed by intestinal bacteria (especially indole and
skatole) are responsible in large part for the fecal odor.
● Gasses formed contain methane, hydrogen sulfide, and ammonia,
among others.
● The GI tract normally contains approximately 150 mL of these
gasses, which are either absorbed into the portal circulation and
detoxified by the liver or expelled from the rectum as flatus.

Elimination of stool begins with distention of the rectum, which reflexively


initiates contractions of the rectal musculature and relaxes the normally closed
internal anal sphincter.
● The internal sphincter is controlled by the autonomic nervous
system;
● The external sphincter is under the conscious control of the
cere-bral cortex.

During defecation, the external anal sphincter voluntarily relaxes to allow


colonic contents to be expelled.
● Normally, the external anal sphincter is maintained in a state of
tonic contraction.
● Thus, defecation is seen to be a spinal reflex (involving the
parasympathetic nerve fibers) that can be inhibited voluntarily by
keeping the external anal sphincter closed.
● Contracting the abdominal muscles (straining) facilitates
emptying of the colon.
● The average frequency of defecation in humans is once daily, but
the frequency varies among individuals.
2. Achalasia ● Computed tomography (CT) of the esophagus, and
Ingestion vs. Digestion ● Endoscopy may be used for diagnosis;

However, the diagnosis is confirmed by manometry, a process in which the


● Ingestion is the intake of food from outside into the body by
esophageal pressure is measured by a radiologist or gastroenterologist.
swallowing or absorbing.
● Digestion involves breakdown of food into particles which can be
absorbed by the body. Management

The patient should be instructed to:


Disturbances in Ingestion: Disorders of the ESOPHAGUS ● eat slowly and drink fluids with meals.

As a temporary measure:
The esophagus is a mucus-lined, muscular tube that carries food from the ● calcium channel blockers (to decrease heart rate) and nitrates
mouth to the stomach. ○ have been used to decrease esophageal pressure and
● It begins at the base of the pharynx and ends about 4 cm below the improve swallowing.
diaphragm (muscular organ that participates in breathing (moves
inferiorly when inhaling so there is extra space for lungs to Injection of botulinum toxin (Botox) to quadrants of the esophagus via
expand)). endoscopy has been helpful because:
● It inhibits the contraction of smooth muscle.
Its ability to transport food and fluid is facilitated by two sphincters. ● Periodic injections are required to maintain remission.
● The upper esophageal sphincter, also called the hypopharyngeal
sphincter, is located at the junction of the pharynx and the If these methods are unsuccessful, pneumatic (forceful) dilation or
esophagus. Achalasia is absent or ineffective peristalsis of the distal esophagus, surgical separation of the muscle fibers may be recommended.
● The lower esophageal sphincter, also called the gastroesophageal accompanied by failure of the esophageal sphincter to relax in response to
sphincter, is located at the junction of the esophagus and the swallowing. Achalasia may be treated conservatively by pneumatic dilation to stretch the
stomach. narrowed area of the esophagus (Fig. 35-6).
● An incompetent lower esophageal sphincter allows reflux Narrowing of the esophagus just above the stomach results in a gradually
(backward flow) of gastric contents. There is no serosal layer of increasing dilation of the esophagus in the upper chest. Pneumatic dilation has a high success rate. Although perforation is a potential
the esophagus; therefore, if surgery is necessary, it is more complication, its incidence is low.
difficult to perform suturing or anastomosis (connect both cut Achalasia may progress slowly and occurs most often in people 40 years of age ● The procedure can be painful; therefore, moderate sedation in the
ends). or older. form of an analgesic or tranquilizer, or both, is administered for
● The sphincter controls the amount of food that enters the stomach. ● The LES (lower esophageal sphincter) closes when the stomach is the treatment.
● When food is present in the stomach, it stimulates the parietal digesting. ● The patient is monitored for perforation.
cells to produce HCl. ● No peristalsis (muscle contractions that move food into the ● Complaints of abdominal tenderness and fever may be indications
digestive tract). of perforation
● Failure of the LES to relax.
1. Dysphagia

Clinical Manifestations
Dysphagia (difficulty swallowing) is the most common symptom of esophageal
disease.
● Most common symptom of esophageal disease The primary symptom of achalasia is:
● Difficulty in swallowing both liquids and solids.
This symptom may vary from an uncomfortable feeling that a bolus of food is ● The patient has a sensation of food sticking in the lower portion of
caught in the upper esophagus (before it eventually passes into the stomach) to the esophagus.
acute pain on swallowing (odynophagia).
As the condition progresses, food is commonly regurgitated, either
Obstruction of food (solid and soft) and even liquids may occur anywhere spontaneously or intentionally by the patient to relieve the discomfort produced
along the esophagus. by prolonged distention of the esophagus by food that will not pass into the
stomach.
Often the patient can indicate that the problem is located in the upper, middle,
or lower third of the esophagus. The patient may also complain of chest pain and heartburn (pyrosis).

There are many pathologic conditions of the esophagus, including: Pain may or may not be associated with eating. There may be secondary
● motility disorders (achalasia, diffuse spasm), pulmonary complications from aspiration of gastric contents.
● gastroesophageal reflux, ● May cause aspiration ammonia
● hiatal hernias,
● diverticula, ● The epiglottis only functions when the body is awake.
● perforation,
● foreign bodies, Assessment and Diagnostic Findings
● chemical burns,
● benign tumors, and
● carcinoma. ● X-ray studies show esophageal dilation above the narrowing at
the gastroesophageal junction. Achalasia may be treated surgically by esophagomyotomy or a Heller
● Barium swallow (Patient drinks dye to better visualize the lower myotomy (Fig. 35-7).
● Possible constricted sphincter. ● The procedure usually is performed laparoscopically, either with a
esophagus during an x-ray),
complete lower esophageal sphincter myotomy and an antireflux the gastroesophageal junction (GEJ) are displaced upward and 4. Gastroesophageal Reflux Disease
procedure (see later discussion of fundoplasty), or without an slide in and out of the thorax (Fig. 35-8A). About 90% of patients
antireflux procedure. with esophageal hiatal hernia have a sliding hernia. Some degree of gastroesophageal reflux (back-flow of gastric or duodenal
● The esophageal muscle fibers are separated to relieve the lower contents into the esophagus) is normal in both adults and children.
esophageal stricture.
Excessive reflux may occur because of:
Although patients with a history of achalasia have a slightly higher incidence ● an incompetent lower esophageal sphincter,
of esophageal cancer, long-term follow-up with esophagoscopy for early ● pyloric stenosis, or
detection has not proved beneficial. ● a motility disorder (movement of food in the stomach [which
causes the food to not be digested properly due to the contents not
being covered in acid completely]).
The incidence of reflux seems to increase with aging.

● Bile can digest fat and it is secreted by the LIVER and stored in
the GALLBLADDER and secreted into the SMALL INTESTINE
to digest the fats.
● Eructation - belch (burping)
● Paraesophageal. A paraesophageal hernia occurs when all or part ● Pylorus - consists of parietal cells (which produces the highest
of the stomach pushes through the diaphragm beside the amount of HCl in the stomach)
esophagus (see Fig. 35-8B). ● Ulcers may be caused by too much acidic content (ex. Duodenal
○ Paraesophageal hernias may be further classified as ulcers due to duodenum being overwhelmed by the amount of
types II, III, or IV, depending on the extent of acidic secretions transferred by the stomach to the small intestine).
herniation, with type IV having the greatest ● Nicotine and Alcohol stimulates the parietal cells to produce more
herniation. acid.

Clinical Manifestations Clinical Manifestations

The patient with a sliding hernia may have: Symptoms of gastroesophageal reflux disease (GERD) may include
● heartburn, ● pyrosis (burning sensation in the esophagus),
● regurgitation, and ● dyspepsia (indigestion),
● dysphagia, but at least 50% of patients are asymptomatic. ● regurgitation,
● dysphagia or odynophagia (difficulty swallowing, pain on
Sliding hiatal hernia is often implicated in reflux. swallowing),
3. Hiatal Hernia ● The patient with a paraesophageal hernia usually feels a sense of ● hypersalivation, and
fullness after eating or may be asymptomatic. ● Esophagitis (inflammation of the esophagus, progresses into
● Reflux usually does not occur, because the gastroesophageal ulceration).
sphincter is intact. The symptoms may mimic those of a heart attack (heartburn). The patient’s
● The complications of hemorrhage, obstruction, and strangulation history aids in obtaining an accurate diagnosis.
can occur with any type of hernia.

Assessment and Diagnostic Findings

Diagnosis is confirmed by:


● X-ray studies,
● Barium swallow, and
● Fluoroscopy (real time videos of the movements inside of the
body).

Management
The esophagus enters the abdomen through an opening in the diaphragm and
empties at its lower end into the upper part of the stomach. Management for an axial hernia includes:
● Normally, the opening in the diaphragm encircles the esophagus ● Frequent, small feedings that can pass easily through the
tightly, and the stomach lies completely within the abdomen. esophagus (temporary management).
● The patient is advised not to recline for 1 hour after eating, to
In a condition known as hiatus (or hiatal) hernia: prevent reflux or movement of the hernia, and
● The opening in the diaphragm through which the esophagus ● To elevate the head of the bed on 4- to 8-inch (10- to 20-cm)
passes becomes enlarged, and part of the upper stomach tends to blocks to prevent the hernia from sliding upward.
move up into the lower portion of the thorax. Surgery is indicated in about 15% of patients.
● Hiatal hernia occurs more often in women than men. Medical and surgical management of a paraesophageal hernia is similar to that
for gastroesophageal reflux; however, paraesophageal hernias may require
There are two types of hiatal hernias: emergency surgery to correct torsion (twisting) of the stomach or other body
● Sliding or type I, hiatal hernia occurs when the upper stomach and organ that leads to restriction of blood flow to that area.
Assessment and Diagnostic Findings Clinical Manifestations

Diagnostic testing may include an endoscopy or barium swallow to evaluate Symptoms experienced by the patient with a pharyngoesophageal pulsion
damage to the esophageal mucosa. diverticulum include:
● Dysphagia,
Ambulatory 12- to 36-hour esophageal pH monitoring is used to evaluate the ● Fullness in the neck,
degree of acid reflux. ● Belching,
● Regurgitation of undigested food, and
Bilirubin monitoring (Bilitec) is used to measure bile reflux patterns. ● Gurgling noises after eating
Exposure to bile can cause mucosal damage The diverticulum, or pouch, becomes filled with food or liquid.

Management When the patient assumes a recumbent position, undigested food is


regurgitated, and coughing may be caused by irritation of the trachea or
aspiration.
Management begins with teaching the patient to avoid situations that decrease
lower esophageal sphincter pressure or cause esophageal irritation. Halitosis (foul odor from the oral cavity) and a sour taste in the mouth are also
● The patient is instructed to eat a low-fat diet; common because of the decomposition of food retained in the diverticulum.
● to avoid caffeine, tobacco, beer, milk, foods containing
peppermint or spearmint, and carbonated beverages; Dysphagia is the primary symptom in diverticula.
● to avoid eating or drinking 2 hours before bedtime;
● to maintain normal body weight; The most common type of diverticulum, which is found three times more
● to avoid tight-fitting clothes; Assessment and Diagnostic Findings
frequently in men than in women, is Zenker’s diverticulum (also known as
● to elevate the head of the bed on 6- to 8-inch (15- to 20-cm) pharyngoesophageal pulsion diverticulum or pharyngeal pouch).
blocks; and ● It occurs posteriorly through the cricopharyngeal muscle in the A barium swallow may determine the exact nature and location of a
● to elevate the upper body on pillows. midline of the neck. It is usually seen in people older than 60 diverticulum.
● to avoid stressful situations (may cause the parietal cells in the years of age.
stomach to produce more acid). ● Other types of diverticula include midesophageal, epiphrenic, and Manometric studies may be performed for patients with epiphrenic
intramural diverticula. diverticula to rule out a motor disorder.
If reflux persists, the patient may be given medications such as:
● antacids or Esophagoscopy usually is contraindicated because of the danger of perforation
● histamine receptor blockers. of the diverticulum, with resulting mediastinitis (inflammation of the organs
● Proton pump (pump that produces acid) inhibitors (medications and tissues that separate the lungs)
that decrease the release of gastric acid, such as lansoprazole
[Prevacid] or rabeprazole [Aciphex]) may be used; however, there Blind insertion of an NG tube should be avoided.
is concern that these products may increase intragastric bacterial
growth and the risk for infection. Management
In addition, the patient may receive prokinetic agents, which accelerate
gastric emptying. These agents include: Because pharyngoesophageal pulsion diverticulum is progressive, the only
● bethanechol (Urecholine), means of cure is surgical removal of the diverticulum.
● domperidone (Motilium), and
● metoclopramide (Reglan). During surgery, care is taken to avoid trauma to the common carotid artery and
○ Metoclopramide has central nervous system internal jugular veins. The sac is dissected free and amputated flush with the
complications with long-term use. esophageal wall.
○ Not given for maintenance purposes.
In addition to a diverticulectomy, a myotomy of the cricopharyngeal muscle
If medical management is unsuccessful, surgical intervention may be is often performed to relieve spasticity of the musculature, which otherwise
necessary. Surgical management involves: seems to contribute to a continuation of the previous symptoms.
● Fundoplication (wrapping of a portion of the gastric fundus
around the sphincter area of the esophagus). Postoperatively, the patient may have a nasogastric tube inserted at the time of
○ Fundoplication may be performed by laparoscopy. surgery. The surgical incision must be observed for evidence of leakage from
the esophagus and a developing fistula (abnormal opening).
aDiverticulum Midesophageal diverticulum are uncommon. Symptoms are less acute, and
● Food and fluids are withheld until x-ray studies show no leakage
usually the condition does not require surgery.
at the surgical site.
A diverticulum is an outpouching of mucosa and submucosa that protrudes ● The diet begins with liquids and progresses as tolerated.
Epiphrenic diverticula are usually larger diverticula in the lower esophagus just
through a weak portion of the musculature.
above the diaphragm. They are thought to be related to the improper
Surgery is indicated for epiphrenic and midesophageal diverticula only if the
functioning of the lower esophageal sphincter or to motor disorders of the
Diverticula may occur in one of the three areas of the esophagus – symptoms are troublesome and becoming worse.
esophagus.
● the pharyngoesophageal or upper are of the esophagus,
● the midesophageal area, or Treatment consists of a diverticulectomy and long myotomy. In-tramural
Intramural diverticulosis is the occurrence of numerous small diverticula
● the epiphrenic area of the esophagus- diverticula usually regresses after the esophageal stricture is dilated.
associated with a stricture in the upper esophagus.
● or they may occur along the border of the esophagus intramurally.
MANAGEMENT OF PATIENTS WITH GASTRIC AND DUODENAL Clinical Manifestations If corrosion is extensive or severe, emetics and lavage are avoided because of
DISORDERS the danger of perforation and damage to the esophagus.
The patient with acute gastritis may have:
Gastritis ● Abdominal discomfort, Therapy is supportive and may include:
● Headache, ● nasogastric (NG) intubation,
● Lassitude (lethargy), ● analgesic agents and sedatives,
Gastritis (inflammation of the gastric or stomach mucosa) is a com-mon GI ● antacids, and
problem. Gastritis may be acute, lasting several hours to a few days, or ● Nausea,
● Anorexia, ● intravenous (IV) fluids.
chronic, resulting from repeated exposure to irritating agents or recurring
episodes of acute gastritis. ● Vomiting, and
● Hiccupping. Fiberoptic endoscopy may be necessary.

Acute gastritis is often caused by dietary indiscretion—the person eats food Some patients, however, have no symptoms.
In extreme cases, emergency surgery may be required to remove gangrenous or
that is contaminated with disease-causing microorganisms or that is irritating perforated tissue.
or too highly seasoned. The patient with chronic gastritis may complain of:
● Other causes of acute gastritis include overuse of aspirin and ● anorexia,
● heartburn after eating, Gastrojejunostomy or gastric resection may be necessary to treat pyloric
other nonsteroidal anti-inflammatory drugs (NSAIDs), obstruction, a narrowing of the pyloric orifice.
● excessive alcohol intake, ● belching,
● bile reflux, and ● a sour taste in the mouth, or
● nausea and vomiting. Chronic gastritis is managed by:
● radiation therapy. ● modifying the patient’s diet,
A more severe form of acute gastritis is caused by the ingestion of strong acid ● promoting rest,
or alkali, which may cause the mucosa to become gangrenous or to perforate. Patients with chronic gastritis from vitamin deficiency usually have evidence
of malabsorption of vitamin B12 caused by antibodies against intrinsic factor ● reducing stress, and
● initiating pharmacotherapy.
Scarring can occur, resulting in pyloric obstruction. Gastritis also may be the
first sign of an acute systemic infection. Assessment and Diagnostic Findings H. pylori may be treated with antibiotics (eg, tetracycline (terramycin) or
amoxicillin, combined with clarithromycin) and a proton pump inhibitor
Antral region - area in the stomach located at the lower section where the Gastritis is sometimes associated with achlorhydria or hypochlorhydria (inhibits acid production) (eg, lansoprazole [Prevacid]), and possibly bismuth
parietal cells are abundant. (absence or low levels of hydrochloric acid [HCl]) or with hyperchlorhydria salts (Pepto-Bismol).
(high levels of HCl).
Chronic gastritis and prolonged inflammation of the stomach may be caused Research is being conducted to develop a vaccine against H. pylori.
by either benign or malignant ulcers of the stomach or by the bacteria Diagnosis can be determined by:
Helicobacter pylori. ● endoscopy,
Chronic gastritis is sometimes associated with autoimmune diseases such as: NURSING PROCESS: THE PATIENT WITH GASTRITIS
● upper GI radiographic studies, and
● pernicious anemia (lack of intrinsic factor to absorb Vit. B12);
● histologic examination of a tissue specimen obtained by biopsy.
● dietary factors such as caffeine; Assessment
● the use of medications, especially NSAIDs; In addition to biopsy, other diagnostic measures for detecting H. pylori include
● alcohol; serologic testing for antibodies against the H. pylori antigen, a 1-minute ultra When obtaining the history, the nurse asks about the patient’s presenting signs
● smoking; or rapid urease test, and a breath test. and symptoms (record in narrative form).
● reflux of intestinal contents into the stomach. ● Does the patient have heartburn, indigestion, nausea, or vomiting?
Medical Management ● Do the symptoms occur at any specific time of the day, before or
Pathophysiology after meals, after ingesting spicy or irritating foods, or after the
ingestion of cer-tain drugs or alcohol?
The gastric mucosa is capable of repairing itself after a bout of gastritis. ● Has there been recent weight gain or loss?
In gastritis, the gastric mucous membrane becomes edematous and hyperemic As a rule, the patient recovers in about 1 day, although the appetite may be
(congested with fluid and blood) and undergoes superficial erosion (Fig. 37-1). ● Are the symptoms related to anxiety, stress, allergies, eating or
diminished for an additional 2 or 3 days. drinking too much, or eating too quickly?
It secretes a scanty amount of gastric juice, containing very little acid but much ● How are the symptoms relieved?
Acute gastritis is also managed by instructing the patient to refrain from ● Is there a history of previous gastric disease or surgery?
mucus. alcohol and food until symptoms subside. ● A diet history plus a 72-hour dietary recall (a list of everything the
● After the patient can take nourishment by mouth, a nonirritating patient ate and drank in the last 72 hours) may be helpful.
Superficial ulceration may occur and can lead to hemorrhage. diet is recommended.
If the symptoms persist, A thorough history is important because it helps the nurse to identify whether
● fluids may need to be administered parenterally. known dietary excesses or other indiscretions are associated with the current
symptoms, whether others in the patient’s environment have similar symptoms,
If bleeding is present, management is similar to the procedures used for upper whether the patient is vomiting blood, and whether any known caustic element
GI tract hemorrhage. has been ingested.

If gastritis is caused by ingestion of strong acids or alkalis, treatment consists The nurse also identifies the duration of the current symptoms, any methods
of: used by the patient to treat these symptoms, and whether the methods are
● diluting and neutralizing the offending agent. effective.
Signs to note during the physical examination include
To neutralize acids, ● abdominal tenderness,
● common antacids (eg, aluminum hydroxide) are used; ● dehydration, and
● evidence of any systemic disorder that might be responsible for
To neutralize an alkali, the symptoms of gastritis.
● diluted lemon juice or diluted vinegar is used.
Nursing Diagnoses The nurse discourages the intake of caffeinated beverages, because caffeine is Patients with pernicious anemia need information about long-term vitamin B12
a central nervous system stimulant that increases gastric activity and injections; the nurse may instruct a family member about administering these
Based on the assessment data, the patient’s major nursing diagnoses may pepsin secretion. injections or make arrangements for the patient to receive the injections from a
include the following: healthcare provider.
● Anxiety related to treatment It also is important to discourage alcohol use.
● Imbalanced nutrition, less than body requirements, related to ● Discouraging cigarette smoking is important because nicotine Finally, the nurse emphasizes the importance of keeping follow-up
inadequate intake of nutrients reduces the secretion of pancreatic bicarbonate and thus appointments with health care providers.
● Risk for imbalanced fluid volume related to insufficient fluid inhibits the neutralization of gastric acid in the duodenum.
intake and excessive fluid loss subsequent to vomiting When appropriate, the nurse refers the patient for alcohol counseling and Evaluation
● Deficient knowledge about dietary management and disease smoking cessation programs.
process Expected Patient Outcomes
● Acute pain related to irritated stomach mucosa Promoting Fluid Balance

Expected patient outcomes may include the following:


Planning and Goals Daily fluid intake and output are monitored to detect early signs of dehydration 1. Exhibits less anxiety
(minimal urine output of 30 mL/hour, minimal intake of 1.5 L/day). 2. Avoids eating irritating foods or drinking caffeinated beverages of
The major goals for the patient may include: alcohol
● reduced anxiety, If food and fluids are withheld, IV fluids (3 L/day) usually are prescribed and a 3. Maintains fluid balance
● avoidance of irritating foods, record of fluid intake plus caloric value (1 L of 5% dextrose in water = 170 a. Has intake of at least 1.5 L daily.
● adequate intake of nutrients, calories of carbohydrate) needs to be maintained. b. Drinks six to eight glasses of water daily
● maintenance of fluid balance, c. Has a urinary output of about 1L daily
● increased awareness of dietary management, and Electrolyte values (sodium, potassium, chloride) are assessed every 24 d. Displayed adequate skin turgor
hours to detect imbalance. e. Adheres to medical regimen
● relief of pain.
f. Selects non irritating foods and beverages
The nurse must always be alert for any indicators of hemorrhagic gastritis, g. Takes mediations a prescribed
NURSING INTERVENTIONS which include: h. Maintains appropriate weight
● hematemesis (vomiting of blood), i. Reports less pain
Reducing Anxiety ● tachycardia, and
● hypotension.
If these occur, the physician is notified and the patient’s vital signs are Gastric and Duodenal Ulcers
If the patient has ingested acids or alkalis, emergency measures may be monitored as the patient’s condition warrants.
needed.
A peptic ulcer is an excavation (hollowed-out area) that forms in the mucosal
The nurse offers supportive therapy to the patient and family during treatment
Relieving Pain wall of the stomach, in the pylorus (opening between stomach and duodenum),
and after the ingested acid or alkali has been neutralized or diluted.
in the duodenum (first part of small intestine), or in the esophagus.
In some cases, the nurse may need to prepare the patient for additional Measures to help relieve pain include: A peptic ulcer is frequently referred to as a gastric, duodenal, or
diagnostic studies (endoscopy) or surgery. ● instructing the patient to avoid foods and beverages that may be esophageal ulcer, depending on its location, or as peptic ulcer disease.
irritating to the gastric mucosa and
The patient usually feels anxious about the pain and the treatment modalities. ● instructing the patient about using medications to relieve chronic Gastric - tends to happen to older people.
The nurse uses a calm approach to assess the patient and to answer all gastritis. Duodenal - 30s to 40s (gastroduodenal junction does not work properly and
questions as completely as possible.
HCl enters the duodenum.
To follow up, the nurse assesses the patient’s level of pain and the extent of Peptic - a sore on the lining of your stomach, small intestine or esophagus
It is important to explain all procedures and treatments according to the comfort obtained from the use of medications and avoidance of irritating
patient’s level of understanding. substances. Erosion of a circumscribed area of mucous membrane is the cause (Fig. 37-2).
This erosion may extend as deeply as the muscle layers or through the muscle
Promoting Optimal Nutrition Promoting Home and Community-Based Care to the peritoneum.

For acute gastritis, Teaching Patients Self-Care Peptic ulcers are more likely to be in the duodenum than in the stomach. As a
● The nurse provides physical and emotional support and helps the rule they occur alone, but they may occur in multiples. Chronic gastric ulcers
patient manage the symptoms, which may include nausea, tend to occur in the lesser curvature of the stomach, near the pylorus. Table
vomiting, heartburn, and fatigue. The nurse evaluates the patient’s knowledge about gastritis and develops an 37-2 compares the features of gastric and duodenal ulcers.
individualized teaching plan that includes information about stress
The patient should take no foods or fluids by mouth—possibly for days—until management, diet, and medications.
the acute symptoms subside, thus allowing the gastric mucosa to heal.
If IV therapy is necessary, the nurse monitors it regularly, along with serum Dietary instructions take into account the patient’s daily caloric needs, food
electrolyte values. preferences, and pattern of eating. The nurse and patient review foods and
other substances to be avoided (eg, spicy, irritating, or highly seasoned foods;
After the symptoms subside, the nurse can offer the patient ice chips followed caffeine; nicotine; alcohol). Consultation with a dietitian may be
by clear liquids. recommended.
● Introducing solid food as soon as possible will provide oral
nutrition, decrease the need for IV therapy, and minimize irritation Providing information about prescribed antibiotics, bismuth salts, medications
to the gastric mucosa. to decrease gastric secretion, and medications to protect mucosal cells from
● As food is introduced, the nurse evaluates and reports any gastric secretions can help the patient recover and prevent recurrence.
symptoms that suggest a repeat episode of gastritis.
A further genetic link is noted in the finding that people with blood type O are ● shock,
more susceptible to peptic ulcers than are those with blood type A, B, or AB. ● severe sepsis (systemic infection), and
● multiple organ traumas.
There also is an association between duodenal ulcers and chronic pulmonary These ulcers are most common in ventilator-dependent patients after trauma or
disease or chronic renal disease. surgery. Fiberoptic endoscopy within 24 hours after injury reveals shallow
erosions of the stomach wall; by 72 hours, multiple gastric erosions are
Other predisposing factors associated with peptic ulcer include chronic use of observed. As the stressful condition continues, the ulcers spread. When the
NSAIDs, alcohol ingestion, and excessive smoking. patient recovers, the lesions are reversed. This pattern is typical of stress
ulceration.
Rarely, ulcers are caused by excessive amounts of the hormone gastrin,
produced by tumors. Differences of opinion exist as to the actual cause of mucosal ulceration in
stress ulcers.
This Zollinger-Ellison syndrome (ZES) consists of: Usually, it is preceded by shock; this leads to decreased gastric mucosal blood
● severe peptic ulcers, flow and to reflux of duodenal contents into the stomach. In addition, large
● extreme gastric hyperacidity, and quantities of pepsin are released. The combination of ischemia, acid, and
● gastrin-secreting benign or malignant tumors of the pancreas. pepsin creates an ideal climate for ulceration.

Stress ulcers, which are clinically different from peptic ulcers, are ulcerations Stress ulcers should be distinguished from Cushing’s ulcers and Curling’s
in the mucosa that can occur in the gastroduodenal area. ulcers, two other types of gastric ulcers.
● Cushing’s ulcers are common in patients with trauma to the
Stress ulcers may occur in patients who are exposed to stressful conditions. brain. They may occur in the esophagus, stomach, or duodenum
and are usually deeper and more penetrating than stress ulcers.
Esophageal ulcers occur as a result of the backward flow of HCl from the ○ May develop in NPO patients
stomach into the esophagus (gastroesophageal reflux disease [GERD]). ● Curling’s ulcer is frequently observed about 72 hours after
extensive burns and involves the antrum (lowermost part) of the
Pathophysiology stomach or the duodenum.

Peptic ulcers occur mainly in the gastroduodenal mucosa because this tissue Clinical Manifestations
cannot withstand the digestive action of gastric acid (HCl) and pepsin.
Symptoms of an ulcer may last for a few days, weeks, or months and may
The erosion is caused by the increased concentration or activity of acid-pepsin, disappear only to reappear, often without an identifiable cause. Many people
or by decreased resistance of the mucosa. have symptomless ulcers, and in 20% to 30% perforation or hemorrhage may
occur without any preceding manifestations.
A damaged mucosa cannot secrete enough mucus to act as a barrier against
HCl. As a rule, the patient with an ulcer complains of
● The use of NSAIDs inhibits the secretion of mucus that protects ● dull, gnawing pain or
the mucosa. ● a burning sensation in the midepigastrium or in the back.
● Patients with duodenal ulcer disease secrete more acid than It is believed that the pain occurs when the increased acid content of the
normal, whereas patients with gastric ulcer tend to secrete stomach and duodenum erodes the lesion and stimulates the exposed nerve
normal or decreased levels of acid (too alkaline or basic). endings.
Peptic ulcer disease occurs with the greatest frequency in people between the
ages of 40 and 60 years. It is relatively uncommon in women of childbearing Sucralfin - treatment of duodenal ulcer Another theory suggests that contact of the lesion with acid stimulates a local
age, but it has been observed in children and even in infants. reflex mechanism that initiates contraction of the adjacent smooth muscle. Pain
ZES (Zollinger-Ellison Syndrome) is suspected when a patient has several is usually relieved by eating, because food neutralizes the acid, or by taking
After menopause, the incidence of peptic ulcers in women is almost equal to peptic ulcers or an ulcer that is resistant to standard medical therapy. alkali; however, once the stomach has emptied or the alkali’s effect has
that in men. It is identified by the following findings: decreased, the pain returns.
● hypersecretion of gastric juice, Sharply localized tenderness can be elicited by applying gentle pressure to the
Peptic ulcers in the body of the stomach can occur without excessive acid duodenal ulcers, and epigastrium at or slightly to the right of the midline.
secretion. ● gastrinomas (islet cell tumors) in the pancreas (tumors).
In the past, stress and anxiety were thought to be causes of ulcers. Research has Other symptoms include:
identified that peptic ulcers result from infection with the gram-negative Ninety percent of tumors are found in the “gastric triangle,” which ● pyrosis (heartburn),
bacteria H. pylori. encompasses the cystic and common bile ducts, the second and third portions ○ Pyrosis is a burning sensation in the esophagus and
of the duodenum, and the neck and body of the pancreas. stomach that moves up to the mouth.
However, ulcers do seem to develop more commonly in people who are ○ Heartburn is often accompanied by sour eructation,
tense; whether this is a contributing factor to the condition is uncertain. In Approximately one third of gastrinomas are malignant. Diarrhea and or burping, which is common when the patient’s
addition, excessive secretion of HCl in the stomach may contribute to the steatorrhea (unabsorbed fat in the stool) may be evident. stomach is empty.
formation of gastric ulcers, and stress may be associated with its increased ● vomiting,
secretion. The patient may have coexisting parathyroid adenomas or hyperplasia and may ● constipation or diarrhea, and
therefore exhibit signs of hypercalcemia. The most common complaint is ● bleeding.
The ingestion of milk and caffeinated beverages, smoking, and alcohol also epigastric pain. H. pylori is not a risk factor for ZES.
may increase HCl secretion.
Stress ulcer is the term given to the acute mucosal ulceration of the duodenal Although vomiting is rare in uncomplicated duodenal ulcer, it may be a
Familial tendency may be a significant predisposing factor. or gastric area that occurs after physiologically stressful events, such as: symptom of a peptic ulcer complication. It results from obstruction of the
● burns, pyloric orifice, caused by either
● muscular spasm of the pylorus or combination of:
● mechanical obstruction from scarring or acute swelling of the ● antibiotics,
inflamed mucous membrane adjacent to the ulcer. ● proton pump inhibitors, and
Vomiting may or may not be preceded by nausea; usually it follows a bout of ● bismuth salts that suppresses or eradicates H. pylori;
severe pain and bloating, which is relieved by ejection of the gastric contents. hista-mine 2 (H2) receptor antagonists and proton pump inhibitors are used to
● Emesis often contains undigested food eaten many hours earlier. treat NSAID-induced and other ulcers not associated with H. pylori ulcers.

Constipation or diarrhea can occur, probably as a result of diet and The patient is advised to adhere to the medication regimen to ensure complete
medications. healing of the ulcer.
● Because most patients become symptom-free within a week, it
Fifteen percent of patients with gastric ulcers experience bleeding. Patients becomes a nursing responsibility to stress the importance of
may present with GI bleeding as evidenced by the passage of tarry stools. following the prescribed regimen so that the healing process can
A small portion of patients who bleed from an acute ulcer have had no continue uninterrupted and the return of chronic ulcer symptoms
previous digestive complaints, but they develop symptoms thereafter. can be prevented.
● GUAIAC test - stool test for occult (microscopic bleeding) blood
Rest, sedatives, and tranquilizers may add to the patient’s comfort and are
Assessment and Diagnostic Findings prescribed as needed. Maintenance dosages of H2 receptor antagonists are
usually recommended for 1 year.

A physical examination may reveal: For patients with ZES, hypersecretion of acid may be controlled with high
● pain, epigastric tenderness, or doses of H2 receptor antagonists. These patients may require twice the normal
● abdominal distention. dose, and dosages usually need to be increased with prolonged use.
A barium study of the upper GI tract may show an ulcer.
Octreotide (Sandostatin), a medication that suppresses gastrin levels, also may
Endoscopy is the preferred diagnostic procedure because it allows direct be prescribed.
visualization of inflammatory changes, ulcers, and lesions.
Patients at risk for stress ulcers may be treated prophylactically with IV H2
Through endoscopy, a biopsy of the gastric mucosa and of any suspicious receptor antagonists and cytoprotective agents (e.g., misoprostol, sucralfate) Stress Reduction and Rest
lesions can be obtained. Endoscopy may reveal lesions that are not evident on because of the risk for upper GI tract hemorrhage. Frequent gastric aspiration
x-ray studies because of their size or location. is performed to allow monitoring of gastric secretion pH. Reducing environmental stress requires physical and psychological
modifications on the patient’s part as well as the aid and cooperation of family
Stools may be tested periodically until they are negative for occult blood. members and significant others.
Gastric secretory studies are of value in diagnosing achlorhydria and ZES.
The patient may need help in identifying situations that are stressful or
H. pylori infection may be determined by biopsy and histology with culture. exhausting.
There is also a breath test that detects H. pylori, as well as a serologic test for ● A rushed lifestyle and an irregular schedule may aggravate
antibodies to the H. pylori antigen. symptoms and interfere with regular meals taken in relaxed
settings and with the regular administration of medications.
Pain that is relieved by ingesting food or antacids and absence of pain on The patient may benefit from regular rest periods during the day, at least during
arising are also highly suggestive of an ulcer. the acute phase of the disease.

Medical Management Biofeedback, hypnosis, or behavior modification may be helpful.

Once the diagnosis is established, the patient is informed that the problem can Smoking Cessation
be controlled.
Studies have shown that smoking decreases the secretion of bicarbonate from
Recurrence may develop; however, peptic ulcers treated with antibiotics to the pancreas into the duodenum, resulting in increased acidity of the
eradicate H. pylori have a lower recurrence rate than those not treated with duodenum.
antibiotics.
Research indicates that continuing to smoke cigarettes may significantly inhibit
The goals are to eradicate H. pylori and to manage gastric acidity. ulcer repair. Therefore, the patient is strongly encouraged to stop smoking.
Smoking cessation support groups and other smoking cessation approaches are
Methods used include helpful for many patients
● medications,
● lifestyle changes
○ Diet (no carbonated beverages, coffee), cigarette Dietary Modification
smoking, stress management)
● surgical intervention. The intent of dietary modification for patients with peptic ulcers is to avoid
oversecretion of acid and hypermotility in the GI tract.
These can be minimized by avoiding:
Pharmacologic Therapy ● extremes of temperature and
● overstimulation from consumption of meat extracts, alcohol,
coffee (including decaffeinated coffee, which also stimulates acid
Currently, the most commonly used therapy in the treatment of ulcers is a
secretion) and other caffeinated beverages, and diets rich in milk ● Is there a family history of ulcer disease?
and cream (which stimulate acid secretion).
In addition, an effort is made to neutralize acid by eating three regular meals a The nurse assesses vital signs and reports tachycardia and hypotension, which
day. may indicate anemia from GI bleeding.
Small, frequent feedings are not necessary as long as an antacid or a histamine
blocker is taken. The stool is tested for occult blood (GUAIAC test), and a physical
examination, including palpation of the abdomen for localized tenderness, is
Diet compatibility becomes an individual matter: performed as well.
● The patient eats foods that can be tolerated and avoids those that
produce pain. Diagnosis

Surgical Management Nursing Diagnoses

The introduction of antibiotics to eradicate H. pylori and of H2 receptor Based on the assessment data, the patient’s nursing diagnoses may include the
antagonists as treatment for ulcers has greatly reduced the need for surgical following:
interventions. Follow-Up Care ● Acute pain related to the effect of gastric acid secretion on
However, surgery is usually recommended for patients with: damaged tissue
● intractable ulcers (those that fail to heal after 12 to 16 weeks of ● Anxiety related to coping with an acute disease
medical treatment), Recurrence within 1 year may be prevented with the prophylactic use of H2
receptor antagonists given at a reduced dose. ● Imbalanced nutrition related to changes in diet
● life-threatening hemorrhage, ● Deficient knowledge about prevention of symptoms and
● perforation, or obstruction, and management of the condition
● for those with ZES not responding to medications. Not all patients require maintenance therapy; it may be prescribed only for
Surgical procedures include: those with two or three recurrences per year, those who have had a
● vagotomy, with or without pyloroplasty, and complication such as bleeding or outlet obstruction, or those who are Collaborative Problems/Potential Complications
● the Billroth I and Billroth II procedures. candidates for gastric surgery but are at too high a risk for surgery.
Patients who need ulcer surgery may have had a long illness. They may be The likelihood of recurrence is reduced if the patient avoids smoking, coffee Potential complications may include the following:
discouraged and have had interruptions in their work role and pressures in their (including decaffeinated coffee) and other caffeinated beverages, alcohol, and ● Hemorrhage
family life. ulcerogenic medications (eg, NSAIDs). ● Perforation
● Penetration
NURSING PROCESS: THE PATIENT WITH ULCER DISEASE ● Pyloric obstruction (gastric outlet obstruction)

Assessment Planning and Goals

The nurse asks the patient to describe the pain and the methods used to relieve The goals for the patient may include
it (e.g., food, antacids). ● relief of pain,
The patient usually describes peptic ulcer pain as burning or gnawing; it ● reduced anxiety,
occurs about 2 hours after a meal and frequently awakens the patient between ● maintenance of nutritional requirements,
midnight and 3 AM. ● knowledge about the management and prevention of ulcer
recurrence, and
Taking antacids, eating, or vomiting often relieves the pain. ● absence of complications.

If the patient reports a recent history of vomiting, the nurse determines how Nursing Interventions
often emesis has occurred and notes important characteristics of the vomitus:
● Is it bright red?
● Does it resemble coffee grounds? Relieving Pain
● Is there undigested food from previous meals?
● Has the patient noted any bloody or tarry stools? Pain relief can be achieved with prescribed medications.

The nurse also asks the patient to list his or her usual food intake for a 72-hour The patient should avoid:
period and to describe food habits (e.g., speed of eating, regularity of meals, ● aspirin,
preference for spicy foods, use of sea-sonings, use of caffeinated beverages and ● foods and beverages that contain caffeine, and decaffeinated
decaffeinated coffee). Lifestyle and habits are a concern as well. coffee, and
● Does the patient use irritating substances? ● meals should be eaten at regularly paced intervals in a relaxed
● Does he or she smoke cigarettes? If yes, how many? setting.
● Does the patient ingest alcohol? If yes, how much and how often? Some patients benefit from learning relaxation techniques to help manage
● Are NSAIDs used? stress and pain and to enhance smoking cessation efforts.

The nurse inquires about the patient’s level of anxiety and his or her perception
of current stressors. Reducing Anxiety
● How does the patient express anger or cope with stressful
situations? The nurse assesses the patient’s level of anxiety.
● Is the patient experiencing occupational stress or problems within Patients with peptic ulcers are usually anxious, but their anxiety is not always
the family? obvious.
Appropriate information is provided at the patient’s level of understanding, all bleeding, is followed by bacterial peritonitis, the perfora-tion must be closed as quickly
questions are answered, and the patient is encouraged to express fears openly. ● rapidly replacing the blood that has been lost, as possible. In a few patients, it may be deemed safe and advisable to perform
Explaining diagnostic tests and administering medications on schedule also ● stopping the bleeding, surgery for the ulcer dis-ease in addition to suturing the perforation.
help to reduce anxiety. ● stabilizing the patient, and Postoperatively, the stomach contents are drained by means of an NG tube. The
● diagnosing and treating the cause. nurse monitors fluid and electrolyte balance and assesses the patient for
The nurse interacts with the patient in a relaxed manner, helps identify peritonitis or localized infection (in-creased temperature, abdominal pain,
stressors, and explains various coping techniques and relaxation methods, such Related nursing and collaborative interventions include the following: paralytic ileus, increased or absent bowel sounds, abdominal distention).
as biofeedback, hypnosis, or behavior modification. ● Inserting a peripheral IV line for the infusion of saline or lactated Antibiotic therapy is administered parenterally as prescribed.
Ringer’s solution and blood products. The nurse may need to
The patient’s family is also encouraged to participate in care and to provide assist with the placement of a pulmonary artery catheter for Pyloric Obstruction
emotional support. hemodynamic monitoring. Blood component therapy is initiated if
there are signs of shock (eg, tachycardia, sweating, coldness of the
extremities). Pyloric obstruction, also called gastric outlet obstruction (GOO), occurs when
Maintaining Optimal Nutritional Status the area distal to the pyloric sphincter becomes scarred and stenosed from
● Monitoring the hemoglobin and hematocrit to assist in evaluating
blood loss spasm or edema or from scar tissue that forms when an ulcer alternately heals
The nurse assesses the patient for malnutrition and weight loss. ● Inserting an NG tube (for lavage) to distinguish fresh blood from and breaks down. The patient has:
After recovery from an acute phase of peptic ulcer disease, the patient is “coffee grounds” material, to aid in the removal of clots and acid, ● nausea and vomiting,
advised about the importance of complying with the medication regimen and to prevent nausea and vomiting, and to provide a means of ● constipation,
dietary restrictions. monitoring further bleeding ● epigastric fullness,
● Administering a room-temperature lavage of saline solution or ● anorexia, and, later,
Monitoring and Managing Potential Complications water. This is controversial; some authorities recommend using ● weight loss.
ice lavage
● Inserting an indwelling urinary catheter and monitoring urinary In treating the patient with pyloric obstruction, the first con-sideration is to
Hemorrhage insert an NG tube to decompress the stomach. Confirmation that obstruction is
output
● Monitoring vital signs and oxygen saturation and adminis-tering the cause of the discomfort is accomplished by assessing the amount of fluid
Gastritis and hemorrhage from peptic ulcer are the two most common causes of oxygen therapy aspirated from the NG tube.
upper GI tract bleeding. ● Placing the patient in the recumbent position with the legs ● A residual of more than 400 mL strongly suggests obstruction.
elevated to prevent hypotension; or, to prevent aspiration from
Hemorrhage, the most common complication, occurs in about 15% of patients vomiting, placing the patient on the left side Usually an upper GI study or endoscopy is performed to confirm gastric outlet
with peptic ulcers. ● Treating hemorrhagic shock obstruction.
● The site of bleeding is usually the distal portion of the duodenum. Decompression of the stomach and management of extracellular fluid volume
● Bleeding may be manifested by hematemesis or melena (tarry If bleeding cannot be managed by the measures described, other treatment and electrolyte balances may improve the patient’s condition and avert the
stools). modalities may be used. Transendoscopic coagulation by laser, heat probe, need for surgical intervention.
○ The vomited blood can be bright red, or it can have a medication, a sclerosing agent, or a combination of these therapies can halt
“coffee grounds” appearance (which is dark) from bleeding and make surgical intervention unnecessary. A balloon dilatation of the pylorus via endoscopy may be beneficial.
the oxidation of hemoglobin to methemoglobin.
There is much debate regarding how soon endoscopy should be performed. If the obstruction is unrelieved by medical management, surgery (in the form
When the hemorrhage is large (2000 to 3000 mL), most of the blood is Some believe that endoscopy should be performed in the first 24 hours after of a vagotomy and antrectomy or gastrojejunostomy and vagotomy) may be
vomited. Because large quantities of blood may be lost quickly, immediate hemorrhage has been stabilized. required.
correction of blood loss may be required to prevent hemorrhagic shock.
Others believe that endoscopy may be performed during acute bleeding, as
When the hemorrhage is small, much or all of the blood is passed in the stools, long as the esophageal or gastric area can be visualized (blood may decrease Management of Patients with Intestinal and Rectal Disorders
which will appear tarry black because of the digested hemoglobin. visibility)
Management depends on the amount of blood lost and the rate of bleeding.
Structural and Obstructive Bowel Disorders
Perforation and Penetration
The nurse assesses the patient for faintness or dizziness and nausea, which may
precede or accompany bleeding.
Perforation is the erosion of the ulcer through the gastric serosa into the
peritoneal cavity without warning. It is an abdominal catastrophe and requires Fin. - John Paolo D. de Dios, SN. BSN 3A
It is important to monitor vital signs frequently and to evaluate the patient for
tachycardia, hypotension, and tachypnea. immediate surgery.
Other nursing interventions include: Penetration is erosion of the ulcer through the gastric serosa into adjacent
● monitoring the hemoglobin and hematocrit, structures such as the pancreas, biliary tract, or gastrohepatic omentum.
● testing the stool for gross or occult blood, and Symp-toms of penetration include back and epigastric pain not relieved by
● recording hourly urinary output to detect anuria or oliguria medications that were effective in the past. Like perforation, penetration
(absence or decreased urine production). (signs of impending usually requires surgical intervention.
shock).
Signs and symptoms of perforation include the following:
Many times the bleeding from a peptic ulcer stops spontaneously; however, the ● Sudden, severe upper abdominal pain (persistent and increasing in
incidence of recurrent bleeding is high. intensity); pain may be referred to the shoulders, especially the
right shoulder, because of irritation of the phrenic nerve in the
Because bleeding can be fatal, the cause and severity of the hemorrhage must diaphragm.
be identified quickly and the blood loss treated to prevent hemorrhagic shock. ● Vomiting and collapse (fainting)
● Extremely tender and rigid (boardlike) abdomen
Management of upper GI tract bleeding consists of: ● Hypotension and tachycardia, indicating shock
● quickly determining the amount of blood lost and the rate of Because chemical peritonitis develops within a few hours after perforation and
Impaired Esophageal Motility

An esophageal motility disorder (EMD) is a disorder of the esophagus that may


cause swallowing difficulties, spasms of pain or regurgitation of food.

Diffuse Spasm

Diffuse spasm is a motor disorder of the esophagus.

The cause is unknown, but stressful situations can produce contractions of the
esophagus. It is more common in women and usually manifests in middle age.

Clinical Manifestations

Diffuse spasm is characterized by:


● difficulty or pain on swallowing (dysphagia, odynophagia) and
● by chest pain similar to that of coronary artery spasm.

Assessment and Diagnostic Findings

● Esophageal manometry,
○ which measures the motility of the esophagus and the
pressure within the esophagus, indicates that
simultaneous contractions of the esophagus occur
irregularly.
● Diagnostic x-ray studies after ingestion of barium show separate
areas of spasm.

Management

Conservative therapy includes administration of sedatives and long-acting


nitrates to relieve pain.
● Calcium channel blockers have also been used to manage diffuse
spasm.
● Small, frequent feedings and a soft diet are usually
recommended to decrease the esophageal pressure and irritation
that lead to spasm.
● Dilation performed by bougienage (use of progressively sized
flexible dila-tors),
● Pneumatic dilation, or
● Esophagomyotomy may be necessary if the pain becomes
intolerable.

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