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Care of Patient Care of Patient with GERD & with GERD & Peptic UlcerPeptic Ulcer

63-27363-273

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GERD: BackgroundGERD: Background

Gastroesophageal reflux is a normal Gastroesophageal reflux is a normal physiologic phenomenon in most physiologic phenomenon in most people, particularly after a meal. people, particularly after a meal.

Gastroesophageal reflux disease Gastroesophageal reflux disease (GERD) occurs when the amount of (GERD) occurs when the amount of gastric juice that refluxes into the gastric juice that refluxes into the esophagus exceeds the normal limitesophagus exceeds the normal limit

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Causes of GERDCauses of GERD

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GERD: SymptomsGERD: Symptoms Typical symptoms:Typical symptoms:

Heartburn (Pyrosis):Heartburn (Pyrosis): Most commonMost common Felt as a retrosternal sensation of burning or discomfortFelt as a retrosternal sensation of burning or discomfort Occurs usually after eating or when lying down or Occurs usually after eating or when lying down or

bending over.bending over. Often relieved with milk or waterOften relieved with milk or water

Regurgitation: Regurgitation: Effortless return of gastric and/or esophageal contents Effortless return of gastric and/or esophageal contents

into the pharynx. into the pharynx. It can induce respiratory complications if gastric contents It can induce respiratory complications if gastric contents

spill into the tracheobronchial tree. spill into the tracheobronchial tree.

Atypical symptomsAtypical symptoms Cough, dyspnea, hoarseness, and chestpain Cough, dyspnea, hoarseness, and chestpain

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DiagnosisDiagnosis Role out other potential causes for the heartburn:Role out other potential causes for the heartburn:

CardiacCardiac Peptic ulcerPeptic ulcer EsophagitisEsophagitis

Esophageal Endoscopy:Esophageal Endoscopy: The gold standard as a definitive diagnosisThe gold standard as a definitive diagnosis

Barium swallowBarium swallow Not as definitive in mild casesNot as definitive in mild cases

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Collaborative CareCollaborative Care

Lifestyle modificationsLifestyle modifications

Nutritional therapyNutritional therapy Decrease high-fat foods, avoid milk products Decrease high-fat foods, avoid milk products

at night, and avoid late snacking or mealsat night, and avoid late snacking or meals

Drug TherapyDrug Therapy

Surgical therapySurgical therapy

Endoscopic therapyEndoscopic therapy

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GERD: ComplicationsGERD: Complications

Are related to HCl effect on the Are related to HCl effect on the esophageal mucosa esophageal mucosa EsophagitisEsophagitis

Can complicate to esophageal ulcerationCan complicate to esophageal ulceration

Barrett’s esophagus (esophageal Barrett’s esophagus (esophageal metaplasia)metaplasia)Pre-cancerous lesionPre-cancerous lesion

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Nursing ManagementNursing Management Avoid factors that cause refluxAvoid factors that cause reflux

Stop smokingStop smoking Avoid acid or acid producing foodsAvoid acid or acid producing foods

Elevate HOB ~30°Elevate HOB ~30°

Do not lie down 2 to 3 hours after eatingDo not lie down 2 to 3 hours after eating

Patient teaching (see Table 40-10 in textbook)Patient teaching (see Table 40-10 in textbook)

Drug therapyDrug therapy Evaluate effectivenessEvaluate effectiveness Observe for side effectsObserve for side effects

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Peptic ulcerPeptic ulcer Erosion or excavation of mucosal wall of the Erosion or excavation of mucosal wall of the

esophagus, stomach, pylorus, duodenum esophagus, stomach, pylorus, duodenum

(most common). “Autodigestion”(most common). “Autodigestion”

Requires acid environment to developRequires acid environment to develop

Mucosal defenses impaired; cannot protect from Mucosal defenses impaired; cannot protect from effects of acid/pepsineffects of acid/pepsin

Result from infection with Result from infection with H. pyloriH. pylori or Zollinger- or Zollinger-Ellison syndromeEllison syndrome

Risk factors:Risk factors: Alcohol, smoking, and stress, medicationsAlcohol, smoking, and stress, medications

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Three types of peptic Three types of peptic ulcerulcer

GastricGastric DuodenalDuodenal StressStress

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Gastric ulcerGastric ulcer Most common in the lesser curvature of Most common in the lesser curvature of

stomach near the pylorus stomach near the pylorus

Mucus and bicarb. generally protect Mucus and bicarb. generally protect mucosal barrier from acidmucosal barrier from acid

H. pyloriH. pylori plays a role plays a role

Break in gastric mucosal barrier allows Break in gastric mucosal barrier allows HCl to damage epithelium via “back HCl to damage epithelium via “back diffusion”diffusion”

Bile reflux from duodenum may break Bile reflux from duodenum may break integrityintegrity

Decreased blood flowDecreased blood flow

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Duodenal ulcerDuodenal ulcer

Results from excessive acidResults from excessive acid Associated with protein-rich meals, Ca++, and Associated with protein-rich meals, Ca++, and

vagal stimulation)vagal stimulation)

Rapid emptying of food from stomach Rapid emptying of food from stomach large acid load in duodenumlarge acid load in duodenum

H. pyloriH. pylori infection plays key role in infection plays key role in developmentdevelopment produces substances that damage the mucosa, produces substances that damage the mucosa,

and contributes to higher acid concentrationsand contributes to higher acid concentrations

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Stress ulcerStress ulcer

Occurs after acute medical crisis, surgery, Occurs after acute medical crisis, surgery, or traumaor trauma

Proximal portion of stomach and duodenum Proximal portion of stomach and duodenum are most common sitesare most common sites

Ischemia and elevated HCl contribute to Ischemia and elevated HCl contribute to evolution of erosions evolution of erosions ulcerations ulcerations

May progress to hemorrhageMay progress to hemorrhage

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Duodenal versus Gastric Duodenal versus Gastric ulcersulcers

Gastric Duodenal Normal/hypo-secretion of gastric acid

Hyper-secretion

Pain 1-2 hrs pc meals Pain 2-4 hrs pc meals Food aggravates pain Food may relieve pain Vomiting common Vomiting not common More likely to hemorrhage – manifests as hematemesis

Less likely to hemorrhage, but if occurs, likely to manifest as melena

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Diagnostic testsDiagnostic tests

EsphagogastroduodenoEsphagogastroduodenoscopyscopy Fiberoptic endoscope Fiberoptic endoscope

allows direct allows direct visualization of visualization of esophagus, stomach and esophagus, stomach and duodenum duodenum

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Diagnostic tests: Upper GI Diagnostic tests: Upper GI seriesseries

Patients ingests Patients ingests barium, a barium, a thick, white, milkshake-like thick, white, milkshake-like liquid, liquid, then multiple X-rays. then multiple X-rays. Can detect structural Can detect structural disordersdisorders

After the exam, provide After the exam, provide plenty of liquids for 24 to 48 plenty of liquids for 24 to 48 hours. hours.

The barium may make the The barium may make the stool white for several days. stool white for several days.

If constipation occurs, the If constipation occurs, the doctor may recommend a doctor may recommend a mild laxative. mild laxative.

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Complications of ulcers: Complications of ulcers: HemorrhageHemorrhage

Manifested by:Manifested by: Orthostatic hypotension, Orthostatic hypotension, BP, BP, HR, cool, HR, cool,

clammy skin overt bleedingclammy skin overt bleeding

Hematemesis (bloody vomit) – bright red or Hematemesis (bloody vomit) – bright red or coffee ground (more likely with gastric coffee ground (more likely with gastric ulcer)ulcer)

Melena (bloody or tarry [black] stool) – more Melena (bloody or tarry [black] stool) – more likely with duodenal ulcerlikely with duodenal ulcer

Hgb, Hgb, Hct Hct

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Remember: Management during Remember: Management during Haemorrhage includesHaemorrhage includes

Monitor S/SMonitor S/S

Determine rate amount of blood loss (Hct/hct), Determine rate amount of blood loss (Hct/hct),

NGTNGT

Replace blood, fluid and electrolyte lossReplace blood, fluid and electrolyte loss

saline lavage via NGTsaline lavage via NGT

NGT to low intermittent suctionNGT to low intermittent suction Prevents distensionPrevents distension

Assess amount/rate of bleeding, Assess amount/rate of bleeding,

Medications, oxygen, possible surgeryMedications, oxygen, possible surgery

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Complications: Complications: PerforationPerforation

GI contents empty into peritoneal cavityGI contents empty into peritoneal cavity

Manifested by:Manifested by: Sudden, sharp mid-epigastric pain which can Sudden, sharp mid-epigastric pain which can

shortly spread to all abdomenshortly spread to all abdomen Rigid, tender, board-like abdomenRigid, tender, board-like abdomen Patient assumes the fetal position to reduce Patient assumes the fetal position to reduce

tension on musclestension on muscles

Can lead to shockCan lead to shock

It is a surgical emergencyIt is a surgical emergency

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Remember: Management during Remember: Management during perforation includesperforation includes

NGT to prevent additional spillage of GI NGT to prevent additional spillage of GI contents in peritoneumcontents in peritoneum

Replace blood, fluid, electrolytesReplace blood, fluid, electrolytes

AntibioticsAntibiotics

I & O, NPOI & O, NPO

SURGERY: UrgentSURGERY: Urgent

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Complications: Complications: Pyloric Pyloric obstructionobstruction

Caused by inflammation or edema of Caused by inflammation or edema of the pylorus the pylorus

Stomach cannot empty Stomach cannot empty abdominal abdominal bloating, N & Vbloating, N & V

Persistent vomiting Persistent vomiting Hypokalemia Hypokalemia and metabolic alkalosis and metabolic alkalosis

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Medical Management of Medical Management of ulcersulcers

Conservative Conservative therapy:therapy: Rest: Both physical Rest: Both physical

and emotionaland emotional Dietary Dietary

modificationsmodifications Elimination of Elimination of

smokingsmoking Long term follow Long term follow

up careup care

Pharmaceutical:Pharmaceutical: AntibioticsAntibiotics

To eradicate To eradicate H. PyloriH. Pylori infections infections Recurrence of ulcer is 75-90% as Recurrence of ulcer is 75-90% as

high with infectionhigh with infection

AntiacidsAntiacids Initial drugs of choiceInitial drugs of choice

Histmaine H2 receptor Histmaine H2 receptor antagonistsantagonists

Histamine is the final intracellular Histamine is the final intracellular activator of HCL secretion activator of HCL secretion

Anticholinergic:Anticholinergic: Stop the cholinergic stimulation of Stop the cholinergic stimulation of

HCl secretion and slow gastric HCl secretion and slow gastric motilitymotility

Not commonly used, if used need to Not commonly used, if used need to be used with caution in pts with be used with caution in pts with GlaucomaGlaucoma

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Surgical Management of Surgical Management of ulcerationsulcerations

GastroduodenosGastroduodenostomy (Billroth I) tomy (Billroth I) Removal of the Removal of the

lower portion of lower portion of stomach and small stomach and small portion of portion of duodenum and duodenum and connects connects remaining of remaining of stomach to stomach to duodenumduodenum

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Surgical Management of Surgical Management of ulcerationsulcerations

GastojejunostomyGastojejunostomy Removes lower stomach and Removes lower stomach and

small portion of duodenum.small portion of duodenum. Reconnects stomach to Reconnects stomach to

jejunum.jejunum. Subtotal gastrectomySubtotal gastrectomy - removal distal third of - removal distal third of

stomach, reconnecting to stomach, reconnecting to duodenum or jejunumduodenum or jejunum

Total gastrectomyTotal gastrectomy removal of stomach; removal of stomach;

connects esophagus to connects esophagus to jejunumjejunum

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Dumping syndromeDumping syndrome A complication of gastric surgeryA complication of gastric surgery

S&SS&S vertigo, sweating, palpitations, syncope, pallor, vertigo, sweating, palpitations, syncope, pallor,

tachycardiatachycardia

occurs after eatingoccurs after eating D/t rapid emptying of hypertonic stomach contents into D/t rapid emptying of hypertonic stomach contents into

small intestine small intestine fluid shifts into gut fluid shifts into gut abd. distention abd. distention and cramps and S/S of and cramps and S/S of plasma volume. plasma volume.

Later get rapid elevation of blood glucose followed by Later get rapid elevation of blood glucose followed by insulin secretion and hypoglycemiainsulin secretion and hypoglycemia

ManagementManagement Small frequent mealsSmall frequent meals fat, fat, protein, protein, CHO meals CHO meals liquid between (not with) mealsliquid between (not with) meals Lie down after mealsLie down after meals

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Nursing diagnosesNursing diagnoses

Pain r/t mucosal injuryPain r/t mucosal injury

AnxietyAnxiety

Knowledge deficitKnowledge deficit

Risk for fluid volum deficit r/t Risk for fluid volum deficit r/t hemorrhage or vomitinghemorrhage or vomiting

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Intervention: PainIntervention: Pain MedicationsMedications

Give antacids after meals and at bedtime to decrease Give antacids after meals and at bedtime to decrease gastric acidity; buffers the acid. gastric acidity; buffers the acid.

Give H2 receptor antagonists as prescribed to decrease acid Give H2 receptor antagonists as prescribed to decrease acid secretion secretion

Diet therapyDiet therapy Effectiveness controversialEffectiveness controversial Avoid caffeinated beveragesAvoid caffeinated beverages Exclude foods that cause discomfortExclude foods that cause discomfort Provide frequent, small, bland mealsProvide frequent, small, bland meals Avoid smoking, alcoholAvoid smoking, alcohol

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Intervention: Anxiety & Intervention: Anxiety & Knowledge deficitKnowledge deficit

AnxietyAnxiety Provide emotional supportProvide emotional support Teach and provide relaxation techniquesTeach and provide relaxation techniques Identify and manage sources of stressIdentify and manage sources of stress

Knowledge deficitKnowledge deficit Teach re diet, medications, Teach re diet, medications, Teach the risks associated with continued Teach the risks associated with continued

smokingsmoking Teach S/S of complicationsTeach S/S of complications