Upper GI Dysfunctions

Question 1

GERD

Answer 1

reflux of gastric contents into lower esophagus

no single cause of the disease

incompetent Lower Esophageal Sphincter (LES) - gastric contents move from stomach to esophagus d/t decreased pressure in esophagus when supine, increased abdomen pressure

aggravated by foods, meds, nicotine

Question 2

GERD: RF

Answer 2

• obesity
• cigarette/cigar smoking
• hiatal hernia (diaphragm becomes weekend and part of stomach is actually above diaphragm)

Question 3

GERD: S/Sx

Answer 3

variable from person to person

• heartburn or pyrosis: most common sx (irritation of esophagus by gastric secretions, burning sensation, tightness of lower sternum radiating to throat or jaw)
• dyspepsia: pain or discomfort centered in upper abdomen area
• fullness, bloating
• N/V
• belching, regurgitation
• respiratory sx (wheezing, coughing, dyspnea)
• nocturnal coughing disrupting sleep
• throat irritation
• globus sensation

*GERD can mimic angina

Question 4

GERD: Dx

Answer 4

Upper GI Endoscopy
-look for inflammation, scarring, and strictures

can do bx during endoscopy to look for Ca

Question 5

GERD: Complications

Answer 5

esophagitis: inflammation of esophagus
- esophageal stricture is created with possible ulcers b/c of repeated irritation which causes scarring

barrett’s esophagus: precursor to esophageal Ca

• Sx: heartburn (GERD sx)
• monitor: every 2-3 years w/ endoscopy, bx, radiofrequency

respiratory complications: coughing, bronchospasms, laryngospasms, asthma, bronchitis, pneumonia

dental: erosion of posterior teeth from acid coming up

Question 6

GERD: Interventions

Answer 6

Lifestyle modifications:

• stop smoking
• limit alcohol
• HOB elevated (wedge pillow)
• weight reduction if pt is overweight

Nutritional modifications:

• stay away from trigger foods
• avoid caffeine
• limit seasoning
• avoid late evening meals, nocturnal snacking
• small frequent meals w/ lots of fluids inbetween
• decrease fat content
• don’t lay down after eating

Question 7

GERD: Meds

Answer 7

antacids (tums): offer quick short-lived relief

• most effective if taken 1-3 hours after meals and at bedtime
• neutralizes HCl acid

H2 Receptor Blockers: block action of histamine on H2 blockers to decrease HCl secretion

• ranitidine (Zantac)
• famotidine (Pepcid)

Proton Pump Inhibitor (PPI): decreases incidence of esophageal strictures or complications of chronic GERD, prevention of GERD by inhibiting proton pump secretion of HCl
-omeprazole (Prilosec)

sucralfate (Carafate): antiulcer, acts as a protective layer on the stomach

bethanechole (Urecholine): increase LES pressure, which promotes gastric emptying

Question 8

GERD: Surgical Tx

Answer 8

laparoscopically

reserved for pt w/ complications

Question 9

Hiatal Hernia

Answer 9

herniation of part of the stomach into the esophagus through an opening in the diaphragm

two types:

• sliding: most common
• paraesophageal or rolling: less common, more concerning

Question 10

Hiatal Hernia: Etiology and Pathophysiology

Answer 10

weakened muscle in diaphragm and esophagogastric opening is structurally part of problem

increased intra-abdominal pressure (obesity, pregnancy, ascites, tumors, heavy lifting, etc)

Question 11

Hiatal Hernia: Clinical Manifestations

Answer 11

similar to GERD

• heartburn (pyrosis)
• dyspepsia
• regurgitation
• respiratory symptoms
• chest pain

Question 12

Hiatal Hernia: Complications

Answer 12

GERD
esophagitis
ulcers
hemorrhage
stenosis (narrowing of esophagus)
strangulation
aspiration

Question 13

Hiatal Hernia: Dx

Answer 13

same as GERD

Barium swallow
Endoscopy

Question 14

Hiatal Hernia: Intervention

Answer 14

conservative: reduce intraabdominal pressure (reduce weight, etc)

surgical: reduce hernia, optimize LES pressure, and prevent movement of gastroesophageal junction
- herniotomy
- herniorrhaphy
- fundoplication

surgery done laparoscopically

Question 15

Gastritis

Answer 15

inflammation of gastric mucosa of the stomach - breakdown of normal gastric mucosa which protects stomach against auto-ingestion causing acid to diffuse back into the mucosa resulting in:

• tissue edema, destruction of capillaries
• loss of blood
• possible hemorrhage

one of most common problems
-can be acute or chronic

Question 16

Gastritis: RF

Answer 16

• meds: ASA, NSAIDs, corticosteroids, iron supplements
• alcohol
• spicy foods
• H. Pylori Infection (probably acquired in childhood): triggers breakdown of mucosal barrier with eventual destructive effects
• autoimmune atrophic gastritis: a form of chronic gastritis, immune response that directly affects parietal cells, increases risk of stomach Ca
• bacterial, viral, fungal infections
• other gastric surgical procedures - feeding tube placement
• intense emotional responses (hypersecretion of HCl)

Question 17

Acute Gastritis

Answer 17

Sx: anorexia, N/V, epigastric tenderness and feeling of fullness

in those who abuse alcohol, only sx may be hemorrhage

self-limiting lasting hours to days

body heals itself

Question 18

Chronic Gastritis

Answer 18

loss of cells or decrease in fxn
sx are similar to acute
can lead to pernicious anemia (think B12 def)

Question 19

Gastritis: Dx Studies

Answer 19

• endoscopy: bx used for definitive dx of gastritis
• detection of H. Pylori through breath, urine, serum, gastric secretion, stool tested
• CBC: to detect anemia
• stools: occult blood

Question 20

Acute Gastritis: Interventions

Answer 20

• eliminating the cause and prevention for future problems
• meds: antacids, H2Rs, PPIs
• if severe and in ED or admitted:
• NPO, IV fluids
• antiemetics: ondansetron (Zofran), prochlorperazine (Compazine)
• NG tube: lavage irritating substances or empty stomach
• VS: monitor for hemorrhage, dehydration
• gradual reintroduction of foods
• stop smoking

Question 21

Chronic Gastritis: Interventions

Answer 21

• eliminating causes: ETOH, meds
• H.Pylori tx
• meds: H2R’s or PPI’s to tx sx
• Cobalamin deficiency (B12) - B12 injections (lifelong)
• lifestyle modifications (stop smoking, small meals, avoid irritating foods)
• d/t increased Ca risk, need to be closely monitored

Question 22

Peptic Ulcer Disease

Answer 22

• erosion of GI mucosa from HCl and pepsin
• susceptible areas of GI tract: lower esophagus, stomach, duodenum, post-op gastrojejunal anastomosis

Types:

• acute: superficial erosion and minimal inflammation
• chronic: erosion of muscular wall with formation of fibrous tissue; present continuously for long duration

can be classified by location: gastric or duodenal

Question 23

Gastric Ulcer

Answer 23

Gastric: antrum

• more prevalent in females older than 50 YO
• increased obstruction
• RF: H.Pylori, NSAIDs, bile reflux
• increased mortality
• high recurrence

Question 24

Duodenal Ulcers

Answer 24

1-2cm

• prevalent age 35-45YO
• etiology: H. Pylori
• high HCl secretion
• high risk: COPD, cirrhosis, pancreatitis, hyperparathyroidism, Zollinger-Ellison syndrome, CRF
• occur, disappear, recur

Question 25

PUD: RF

Answer 25

- H. Pylori - Medication-induced injury: NSAIDs especially w/ corticosteroids or anticoagulants - Lifestyle factors: alcohol use, smoking, caffeine, psychologic distress, stress-related mucosal disease in upper GI bleed

Question 26

PUD: Clinical Manifestations

Answer 26

Gastric: epigastric discomfort 1 to 2 hours after meal; burning or gaseous pain; food may worsen sx (perforation is first sx in some patients) Duodenal: burning or cramplike pain in midepigastric or back; 2 to 5 hours after meal Other: bloating, n/v, early satiety (may be silent especially with older adults b/c they take NSAIDs)

Question 27

PUD: Dx

Answer 27

- endoscopy - non-invasive H. Pylori: serology, stool, breath test - other tests: barium contrast, secretin stimulation - labs: CBC, liver enzymes, serum amylase - stool: blood

Question 28

EGD

Answer 28

esophagogastroduodenoscopy directly visualizes the mucosal lining of the stomach with a flexible endoscope ulcers/tumors can be directly seen and biopsies taken

Question 29

PUD: Intervention

Answer 29

conservative care: - adequate rest, no smoking or alcohol, stress management, dietary modifications - pain management: no NSAIDs or ASA for 4-6wks unless administered with PPI, H2R's, or misoprostol - endoscopic evaluation and follow-up; 3-6 months for healing drug therapy: antibiotic therapy: H. Pylori 14 days of PCN -bismuth alone or combined w/ tetracycline and metronidazole Proton pump inhibitors Cytoprotective drug therapy - sucralfate (works best in low pH; give 1 to 2 hours before or after antacid; binds with cimetidine, digoxin, warfarin, phenytoin, and tetracycline) Nutritional therapy: - avoid foods that cause distress or irritation - avoid caffeine and alcohol surgery is uncommon unless complications or cancer

Question 30

PUD: Complications

Answer 30

hemorrhage: most common; duodenal perforation: most lethal, GI contents spill into peritoneal cavity - sx: sudden, severe abdominal pain, radiates to back and shoulders, no relief with food or antacids, abdomen rigid/boardlike, bowel sounds absent, n/v, respirations shallow, pulse increased and weak gastric outlet obstruction: edema, inflammation, pylorospasm, or scar tissue can cause obstruction in distal stomach and duodenum - stomach fills and dilates causing discomfort and pain; worse at end of day - belching and vomiting (projectile) may provide some relief - constipation and anorexia

Question 31

Perforation from PUD: Tx

Answer 31

if untreated, bacterial peritonitis occurs in 6-12 hours immediate focus: stop spillage and restore blood volume - NGT for aspiration and gastric decompression - IV fluids and blood; broad spectrum antibiotics - Other: central line, PA catheter, ECG, urinary catheter - small perforations: self-sealing; monitor for obstruction - large perforations: surgery for closure, suctioning and lavaging of peritoneal cavity

Question 32

Gastric Outlet Obstruction: Tx

Answer 32

``` decompress w/ NGT PPI or H2Rs pain management fluid and electrolyte replacement surgery or balloon dilation (loosen up stenosis that might be there) ``` NGT to suction irrigate per policy monitor I&O reposition patient IV fluids and replace electrolytes Gastric residual (if less than 200ml after clamped for 8-12 hours, begin oral intake, progress to solids) no relief or recurrence, then surgical intervention

Question 33

PUD: Acute Care for Complications

Answer 33

for hemorrhage: monitor VS and NG aspirate for perforation: notify HCP, frequent VS, no oral or NG intake, IV fluids, pain management, antibiotics; prepare for surgery if needed.

Question 34

PUD: Gerontologic Considerations

Answer 34

- increased morbidity and mortality - frequent use of NSAIDs (often for arthritis) - first sx may be GI bleed or decreased Hct - tx plan is similar with emphasis on teaching and prevention