Care of Patient with GERD & Peptic Ulcer

63-273 1

GERD: Background

 Gastroesophageal reflux is a normal physiologic phenomenon in most people, particularly after a meal.  Gastroesophageal reflux disease (GERD) occurs when the amount of gastric juice that refluxes into the esophagus exceeds the normal limit 2

Causes of GERD

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GERD: Symptoms

 Typical symptoms:  Heartburn (Pyrosis):     Most common Felt as a retrosternal sensation of burning or discomfort Occurs usually after eating or when lying down or bending over.

Often relieved with milk or water   Regurgitation:   Effortless return of gastric and/or esophageal contents into the pharynx. It can induce respiratory complications if gastric contents spill into the tracheobronchial tree. Atypical symptoms  Cough, dyspnea, hoarseness, and chestpain 4

Diagnosis

 Role out other potential causes for the heartburn:  Cardiac  Peptic ulcer  Esophagitis  Esophageal Endoscopy:  The gold standard as a definitive diagnosis  Barium swallow  Not as definitive in mild cases 5

Collaborative Care

 Lifestyle modifications  Nutritional therapy  Decrease high-fat foods, avoid milk products at night, and avoid late snacking or meals  Drug Therapy  Surgical therapy  Endoscopic therapy 6

GERD: Complications

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Are related to HCl effect on the esophageal mucosa

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Esophagitis

 Can complicate to esophageal ulceration 

Barrett’s esophagus (esophageal metaplasia)

 Pre-cancerous lesion 7

Nursing Management

 Avoid factors that cause reflux   Stop smoking Avoid acid or acid producing foods  Elevate HOB ~30°  Do not lie down 2 to 3 hours after eating  Patient teaching (see Table 40-10 in textbook)  Drug therapy   Evaluate effectiveness Observe for side effects 8

Peptic ulcer

 Erosion or excavation of mucosal wall of the esophagus, stomach, pylorus, duodenum  (most common). “Autodigestion”  Requires acid environment to develop  Mucosal defenses impaired; cannot protect from effects of acid/pepsin  Result from infection with H. pylori or Zollinger-Ellison syndrome  Risk factors:  Alcohol, smoking, and stress, medications 9

Three types of peptic ulcer

   Gastric Duodenal Stress 10

Gastric ulcer

 Most common in the lesser curvature of stomach near the pylorus  Mucus and bicarb. generally protect mucosal barrier from acid  H. pylori plays a role  Break in gastric mucosal barrier allows HCl to damage epithelium via “back diffusion”  Bile reflux from duodenum may break integrity  Decreased blood flow 11

Duodenal ulcer

 Results from excessive acid  Associated with protein-rich meals, Ca++, and vagal stimulation)  Rapid emptying of food from stomach  large acid load in duodenum  H. pylori infection plays key role in development  produces substances that damage the mucosa, and contributes to higher acid concentrations 12

Stress ulcer

 Occurs after acute medical crisis, surgery, or trauma  Proximal portion of stomach and duodenum are most common sites  Ischemia and elevated HCl contribute to evolution of erosions  ulcerations  May progress to hemorrhage 13

Duodenal versus Gastric ulcers

Gastric

Normal/hypo-secretion of gastric acid Pain 1-2 hrs pc meals Food aggravates pain Vomiting common More likely to hemorrhage – manifests as hematemesis

Duodenal

Hyper-secretion Pain 2-4 hrs pc meals Food may relieve pain Vomiting not common Less likely to hemorrhage, but if occurs, likely to manifest as melena 14

Diagnostic tests

 Esphagogastroduodenoscopy  Fiberoptic endoscope allows direct visualization of esophagus, stomach and duodenum 15

Diagnostic tests: Upper GI series

 Patients ingests barium, a thick, white, milkshake-like liquid, then multiple X-rays. Can detect structural disorders  After the exam, provide plenty of liquids for 24 to 48 hours.  The barium may make the stool white for several days.  If constipation occurs, the doctor may recommend a mild laxative. 16

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Complications of ulcers: Hemorrhage

 Manifested by: Orthostatic hypotension,  overt bleeding BP,  HR, cool, clammy skin  Hematemesis (bloody vomit) – bright red or coffee ground (more likely with gastric ulcer)  Melena (bloody or tarry [black] stool) – more likely with duodenal ulcer   Hgb,  Hct 17

Remember: Management during Haemorrhage includes

 Monitor S/S  Determine rate amount of blood loss (Hct/hct),  NGT  Replace blood, fluid and electrolyte loss  saline lavage via NGT  NGT to low intermittent suction  Prevents distension  Assess amount/rate of bleeding,  Medications, oxygen, possible surgery 18

Complications: Perforation

 GI contents empty into peritoneal cavity  Manifested by:    Sudden, sharp mid-epigastric pain which can shortly spread to all abdomen Rigid, tender, board-like abdomen Patient assumes the fetal position to reduce tension on muscles  Can lead to shock  It is a surgical emergency 19

Remember: Management during perforation includes

 NGT to prevent additional spillage of GI contents in peritoneum  Replace blood, fluid, electrolytes  Antibiotics  I & O, NPO  SURGERY: Urgent 20

Complications: Pyloric obstruction

 Caused by inflammation or edema of the pylorus  Stomach cannot empty  N & V abdominal bloating,  Persistent vomiting  metabolic alkalosis Hypokalemia and 21

Medical Management of ulcers

 Conservative therapy:   Rest: Both physical and emotional Dietary modifications   Elimination of smoking Long term follow up care  Pharmaceutical:  Antibiotics  To eradicate H. Pylori infections  Recurrence of ulcer is 75-90% as high with infection    Antiacids  Initial drugs of choice Histmaine H2 receptor antagonists  Histamine is the final intracellular activator of HCL secretion Anticholinergic:   Stop the cholinergic stimulation of HCl secretion and slow gastric motility Not commonly used, if used need to be used with caution in pts with Glaucoma 22

Surgical Management of ulcerations

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Gastroduodenostomy (Billroth I)

 Removal of the lower portion of stomach and small portion of duodenum and connects remaining of stomach to duodenum 23

Surgical Management of ulcerations

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Gastojejunostomy

  Removes lower stomach and small portion of duodenum.

Reconnects stomach to jejunum.

Subtotal gastrectomy

- removal distal third of stomach, reconnecting to duodenum or jejunum

Total gastrectomy

removal of stomach; connects esophagus to jejunum 24

Dumping syndrome

 A complication of gastric surgery  S&S  vertigo, sweating, palpitations, syncope, pallor, tachycardia  occurs after eating   D/t rapid emptying of hypertonic stomach contents into small intestine  fluid shifts into gut  abd. distention and cramps and S/S of  plasma volume.

Later get rapid elevation of blood glucose followed by insulin secretion and hypoglycemia  Management   Small frequent meals  fat,  protein,  CHO meals   liquid between (not with) meals Lie down after meals 25

Nursing diagnoses

 Pain r/t mucosal injury  Anxiety  Knowledge deficit  Risk for fluid volum deficit r/t hemorrhage or vomiting 26

Intervention: Pain

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Medications

 Give antacids after meals and at bedtime to decrease gastric acidity; buffers the acid.  Give H2 receptor antagonists as prescribed to decrease acid secretion 

Diet therapy

 Effectiveness controversial     Avoid caffeinated beverages Exclude foods that cause discomfort Provide frequent, small, bland meals Avoid smoking, alcohol 27

Intervention: Anxiety & Knowledge deficit

 Anxiety  Provide emotional support   Teach and provide relaxation techniques Identify and manage sources of stress  Knowledge deficit  Teach re diet, medications,   Teach the risks associated with continued smoking Teach S/S of complications 28