Gastroduodenal Disorders
Peptic Ulcer Disease
Definition:
A peptic ulcer is a lesion in the mucosa of the lower esophagus, stomach,
pylorus or duodenum (Fig. 1).
The stomach is divided on the basis of the physiologic function into two main
portions.
1) The proximal two third, the fundic gland area, acts as a receptacle for
ingested food and secrete acid and pepsine.
2) The distal third, the pyloric gland area, mixes and propels food into the
duodenum and produces the hormone gastrein.
"Peptic" lesions may occur in the esophagus (esophagitis), m stomach,
(gastritis), or duodenum (duodenities).
Note peptic ulcer sites and common inflammatory sites in the previous Fig.
Pathophysiology/Etiology
1) Helicobacter pylori infection—exact mechanism is unclear.
2) Nonsteroidal anti-inflammatory drug (NSAID)–induced ulcers.
a.
The risk of gastric ulcers is much greater than duodenal ulcers.
b.
Aspirin is the most ulcerogenic NSAID.
3) Hypersecretion of acid:
a.
Believed to be caused by an overactive vagus nerve, which
stimulates the release of gastrin.
b.
Methylxanthines (tea, coffee, cola, and chocolate) and smoking
may also increase gastric acidity
c.
Found in disorders such as Zollinger-Ellison syndrome tumors
of the pancreas which increases secretion of gastrin(multiple
peptic ulcers).
4) Genetic predisposition and stress appear to be controversial factors.
Clinical Manifestations
Gastric ulcers
Lesion.
Location of
lesion.
Clinical
Manifestations
Duodenal ulcers
Superficial; smooth margins;
round, oval or cone shaped.
Antrum. Also in body and
fundus of the stomach.
Penetrating
Pain occurring in the high left
epigastric area radiating to the
back & upper abdomen
Described as dull, aching, and
gnawing
Pain located to the right of the
midline epigastric region
radiating to the back
Describes as burning ,
cramping, pressure like pain
across midepigastrium &
upper abdomen
Pain is worse with food
Pain may increase when the
stomach is empty,
approximately 1½ to 3 hours
after eating.
Patients may report relief from
pain after eating or taking
antacids
Pain may awaken person at
night, periodic and episodic
Not relieved with antacids as
well as with duodenal
Some clients have constant
pain or no clear pattern of
discomfort
Weight loss
Black or tarry stools from
bleeding
First 1-2 cm of duodenum.
Weight gain if food relieves
the pain
Diagnostic Evaluation
1) Upper GI series usually outlines ulcer or area of inflammation
2) Fiberoptic panendoscopy (esophagogastroduodenoscopy)—visualization
of duodenal mucosa; identifies inflammatory changes, ulcers, lesions,
bleeding sites, and malignancy.
3) Cytologic brushings and biopsies may be performed to obtained samples.
4) Serial stool specimens to detect occult blood
5) Gastric secretory studies (gastric acid secretion test and the serum gastric
level test)—elevated in Zollinger-Ellison syndrome
6) Serum test for H. pylori antibodies may be positive.
Management
A. Specific Pharmacotherapy
1) H2 receptor antagonists, such as cimetidine (Tagamet), ranitidine
(Zantac), famotidine (Pepcid)—inhibit action of histamine on the H2
receptors of the parietal cells, thus reducing gastric acid output and
concentration.
2) Antisecretory or proton pump inhibitor drug omeprazole (Prilosec)—
inhibits the production of hydrochloric acid in the stomach. Heals ulcers
quickly (in 4 to 8 weeks).
3) Cytoprotective drug sucralfate (Carafate)—adheres to and protects the
ulcer surface by forming a protective barrier against acid, bile, pepsin.
4) Acid-neutralizing agents (antacids)—provide additional relief of
symptoms. Not used alone as treatment.
5) Antisecretory and cytoprotective drug misoprostol (Cytotec)—
prostoglandin analogue inhibits hydrochloric acid production in the
stomach.
6) Antidiarrheal agent bismuth subsalicylate (Pepto-Bismol)—has
antibacterial action against H. pylori and enhances mucosal protection
through bicarbonate and prostaglandin production.
7) Antibiotics such as tetracycline and metronidazole (Flagyl) used with
bismuth as “triple therapy” to eradicate H. pylori.
8) For NSAID ulcers—discontinue NSAID and treat as mentioned above. If
NSAID is restarted, administer with misoprostol.
B. Dietary Measures
1) Well-balanced diet, high fiber content, meals at regular intervals ( 6
meals a day).
2) Avoid caffeine, colas, and alcohol.
3) Avoid smoking—decreases healing rate and increases recurrence.
C. Surgery Indicated in emergency situations for uncontrolled bleeding or
bleeding that developed despite chronic drug maintenance therapy.
1) Vagotomy: (cutting of vagus nerve) To eliminate the stimulus that
triggers gastric acid secretion by the gastric cells; can choose to cut all or
portions
2) Subtotal gastrectomy
a.
The resected portion includes a small cuff of the duodenum,
pylorus, and from two thirds to three quarters of the stomach.
b.
The duodenum or side of the jejunum is anastomosed to the
remaining portion of the stomach.
3) Total gastrectomy esophagus is anastomosed to jejunum
Complications
1) GI hemorrhage
2) Ulcer perforation
3) Gastric outlet obstruction
Post Operative Complications:
1) Dumping Syndrome.
2) Postprandial hypoglycemia.
1-Dumping syndrome: The term used for a group of unpleasant vasomotor and gastro intestinal
symptoms includes reducing the reservoir capacity of the stomach,
associated with meal having a hyperosmolar composition.
 Occur after gastric surgery in approximately one third to one half of
patients.
 The stomach no longer has control over the amount of gastric chyme
entering the small intestine.
 Consequently
a) A large bolus of a hypertonic fluid enters the intestine and result in
fluid being drawn into the bowel lumen. This creates a decrease in
plasma volume.
b) Distension of the bowel lumen (as a result of this bowel shift) which
stimulate intestinal motility and the urge to defecate.
 The onset of symptoms occurs at the end of the meal or within 15-30 min
after eating, lasts for no longer than an hour after meals.
 The patient usually describes
a) Feeling of generalized weakness, sweating, palpations, tachycardia,
and dizziness. (Theses symptoms attributed to the sudden
decreases in plasma volume).
b) Abdominal cramp, borborygmi, and the urge to defecate.
2-Postprandial Hypoglycemia.
 As a bolus of fluid high in carbohydrate get into the small intestine results
in hyperglycemia and the release of excessive amounts of insulin into the
circulation.
 A secondary hypoglycemia then occurs 2 hours after meals.
 The immediate ingestion of sugared fluid or candy relieves the
hypoglycemic symptoms.
 To avoid similar occurrence: the patient should be instructed to limit the
amount of sugar consumed with each meal , and to eat small frequent
meals with moderate amount of proteins and fat.
Nursing Assessment
1) Determine location, character, radiation of pain, factors aggravating or
relieving pain, how long it lasts, when it occurs.
2) Ask about eating patterns, regularity, types of food, eating circumstances.
3) Take a social history of alcohol consumption and smoking.
4) Ask about medications (especially aspirin, anti-inflammatory drugs, or
steroids).
5) Determine if GI bleeding has been experienced.
6) Take vital signs, including lying, standing, and sitting blood pressures
and pulses, to determine if orthostasis is present due to bleeding.
Nursing Diagnoses
A. Fluid Volume Deficit related to hemorrhage
B. Pain related to epigastric distress secondary to hypersecretion of acid,
mucosal erosion, or perforation
C. Diarrhea related to GI bleeding or antacid therapy
D. Altered Nutrition, Less Than Body Requirements, related to the disease
process
E. Knowledge Deficit related to physical, dietary, and pharmacologic
treatment of disease.
Nursing Interventions
A. Avoiding Fluid Volume Deficit
1) Monitor intake and output continuously to determine fluid volume status.
2) Observe stools for occult blood.
3) Monitor hemoglobin and hematocrit and electrolytes.
4) Administer prescribed IV fluids and blood replacement, as prescribed.
5) Insert an NG tube as prescribed and monitor the tube drainage for signs
of visible and occult blood.
6) Administer medications through the NG tube to neutralize acidity, as
prescribed.
7) Prepare patient for saline lavage, as ordered.
8) Observe the patient for an increase in pulse and a decrease in blood
pressure (signs of shock).
B. Achieving Pain Relief
1) Encourage bed rest to reduce physical activity and to separate patient
from usual environment if pain continues.
2) Provide small, frequent meals to prevent gastric distention if not NPO.
3) Teach the patient that caffeine, alcoholic beverages, and nicotine may
increase gastric acidity and promote erosion of the gastric mucosa.
4) Advise the patient about the irritating effects on the gastric mucosa of
certain drugs, such as aspirin, NSAIDs, and certain antibiotics.
5) Administer prescribed medication
C. Decreasing Diarrhea
1) Monitor patient’s elimination patterns to determine effects of
medications.
2) Monitor vital signs and watch for signs of hypovolemia. Persistent
diarrhea may be a sign of bleeding.
3) Restrict foods and fluids that promote diarrhea: raw vegetables, fruits,
whole grain cereals, carbonated drinks.
4) Administer antidiarrheal medication as prescribed.
5) Watch for signs of impaired skin integrity (erythema, soreness) around
anus to promote comfort and decrease risk of infection.
D. Achieving Adequate Nutrition
1) Eliminate foods that cause pain or distress; otherwise, the diet is usually
not restricted.
2) Provide small, frequent feedings on time. This will decrease distention
and the release of gastrin. Frequent feedings also help neutralize gastric
secretions and dilute stomach contents. However, eating small, frequent
meals or snacks can lead to acid rebound, which occurs 2 to 4 hours after
eating.
3) Advise the patient to avoid coffee and other caffeinated beverages as well
as carbonated drinks; these may increase acid.
4) Advise the patient to avoid extremely hot or cold food or fluids, to chew
thoroughly, and to eat in a leisurely fashion for better digestion.
5) Administer parenteral nutrition if bleeding is prolonged and patient is
emaciated, as ordered.
E.
Educating About the Treatment Regimen
1) Explain all tests and procedures to increase knowledge and cooperation;
minimize anxiety.
2) Review the health care provider’s recommendations for diet, activity,
medication, and treatment. Allow time for questions, and clarify any
misunderstandings.
3) Give the patient a chart listing medications, dosages, times of
administration, and desired effects to promote compliance.
4) Instruct the patient to notify health care provider immediately if there is
any evidence of bleeding, tarry stools, or dizziness; may indicate an acute
bleeding episode.
Patient Education/ Health Maintenance
Teach the patient the following:
1) Modify lifestyle to include health practices that will prevent recurrences
of ulcer pain and bleeding.
2) Plan for rest periods and avoid or learn to cope with stressful situations;
avoid fatigue.
3) Avoid specific foods known to cause the individual patient distress and
pain.
4) Recognize signs of potential problems (midepigastric pain). Reinstitute
anti-ulcer medication if necessary.
5) Take antacids 1 hour after meals, at bedtime, and when needed. Warn the
patient that antacids may cause changes in bowel habits.
6) Do not take H2 receptor antagonists at the same time as sucralfate. This
reduces the therapeutic effects of the drugs.
Evaluation
A. Vital signs stable; intake and output equal
B. Demonstrates improved comfort
C. Decreased frequency of stools
D. Eating several meals a day; reports no loss of weight
E. Can describe peptic ulcer disease, its treatment, and complications;
complies with treatment regimen
Appendicitis
Definition:
Appendicitis is inflammation of the vermiform appendix caused by an
obstruction of the intestinal lumen from infection, stricture, fecal mass, foreign
body, or tumor.
Pathophysiology/Etiology
1) Obstruction is followed by inflammation of the appendix, edema,
infection, and mucous ulceration, ischemia and the lumen filled with pus.
2) As intraluminal tension develops, necrosis and perforation usually occur.
3) Appendicitis can affect any age group, but is most common in males 10
to 30 years old.
Clinical Manifestations
1) Generalized or localized abdominal pain in the epigastric or periumbilical
areas and the upper right abdomen. Within 2 to 12 hours, the pain
localizes in the right lower quadrant and intensity increases.
2) Local tenderness at the mc Burny's point
3) Rebound tenderness, involuntary guarding.
4) Rovsing's sign by palpating left lower quadrant cause pain in the right
lower quadrant.
5) Anorexia, moderate malaise, mild fever, nausea and vomiting.
6) Usually constipation occurs; occasionally diarrhea.
7) Late, tachycardia and fever.
8) If appendix ruptures, pain becomes more diffuse, abdominal distension
from paralytic ileus and the condition worsen
Diagnostic Evaluation
1) Physical examination consistent with clinical manifestations.
2) White blood cell (WBC) count reveals moderate leukocytosis (10,000 to
16,000/mm) with shift to the left (increased neutrophils).
3) Abdominal x-ray may visualize shadow consistent with fecalith in
appendix.
4) Pelvic sonogram can visualize appendix and rule out ovarian cyst.
Management
Surgery
a) Simple appendectomy or laparoscopic appendectomy.
b) Preoperatively maintain bed rest, NPO status, IV hydration, possible
antibiotic prophylaxis, and analgesia.
Complications
1) Perforation (in 95% of cases)
2) Abscess
3) Peritonitis
Nursing Assessment
1) Obtain history for location and extent of pain.
2) Auscultate for presence of bowel sounds; peristalsis may be absent or
diminished.
3) On palpation of the abdomen, assess for tenderness anywhere in the right
lower quadrant, but often localized over McBurney’s point (point just
below midpoint of line between umbilicus and iliac crest on the right
side).
4) Assess for rebound tenderness in the right lower quadrant as well as
referred rebound when palpating the left lower quadrant.
5) Assess for positive psoas sign by having the patient attempt to raise the
right thigh against the pressure of your hand placed over the right knee.
Inflammation of the psoas muscle in acute appendicitis will increase
abdominal pain with this maneuver.
6) Assess for positive obturator sign by flexing the patient’s right hip and
knee and rotating the leg internally. Hypogastric pain with this maneuver
indicates inflammation of the obturator muscle.
Nursing Diagnoses
1) Pain related to inflamed appendix
2) Risk for Infection related to perforation
Nursing Interventions
A. Relieving Pain
1) Monitor pain level, including location, intensity, pattern.
2) Assist patient to more comfortable positions, such as semi-Fowler’s and
knees up.
3) Restrict activity that may aggravate pain, such as coughing and
ambulation.
4) Apply ice bag to abdomen for comfort.
5) Give analgesics only as ordered after diagnosis is determined.
6) Avoid indiscriminant palpation of the abdomen to avoid increasing the
patient’s discomfort.
7) Do not give antipyretics to mask fever and do not administer cathartics,
because they may cause rupture.
B. Preventing Infection
1) Monitor frequently for signs and symptoms of worsening condition
indicating perforation, abscess, or peritonitis: increasing severity of pain,
tenderness, rigidity, distention, ileus, fever, malaise, tachycardia.
2) Administer antibiotics as ordered.
3) Promptly prepare patient for surgery.
Evaluation
1) Verbalizes increased comfort with positioning and analgesics
2) Afebrile; no rigidity or distention
Peritonitis
Definition
Peritonitis is a generalized or localized inflammation of the peritoneum, the
membrane lining the abdominal cavity and covering visceral organs. Usually it
is result from bacterial infection.
Pathophysiology/Etiology
A. Primary Peritonitis Acute, diffuse, relatively rare
1) Occurs primarily in young females; often due to pathogenic bacteria
(streptococci, pneumococci, gonococci) introduced through uterine tubes
or through hematogenous spread.
2) In patients with nephrosis or cirrhosis, the offending organism is most
often Eschericia coli.
B. Secondary Peritonitis Contamination by GI secretions.
1) Complication of appendicitis, diverticulitis, peptic ulceration, biliary tract
disease, colon inflammation, volvulus, strangulated obstruction,
abdominal neoplasm.
2) May occur after abdominal trauma: gunshot wound, stab wound, blunt
trauma from motor vehicle accident.
3) Postoperative complication
a) May occur after intraoperative intestinal spillage.
b) Compromised patients are vulnerable (those with diabetes,
malignancy, malnutrition, or receiving steroid therapy).
Clinical Manifestations
1) Initially, local type of abdominal pain tends to become constant, diffuse,
and more intense.
2) Abdomen becomes extremely tender and muscles become rigid:
rebound tenderness and ileus may be present; patient lies very still,
usually with legs drawn up.
3) Percussion—resonance and tympany due to paralytic ileus; loss of liver
dullness may indicate free air in abdomen.
4) Auscultation—decreased bowel sounds.
5) Nausea and vomiting often occur; peristalsis diminishes; anorexia is
present.
6) Elevation of temperature and pulse as well as leukocytosis.
7) Fever; thirst; oliguria; dry, swollen tongue; signs of dehydration.
8) Weakness, pallor, diaphoresis, and cold skin are a result of the loss of
fluid, electrolytes, and protein into the abdomen.
9) Hypotension and hypokalemia may occur.
10) Shallow respirations may result from abdominal distention and upward
displacement of the diaphragm.
Note: With generalized peritonitis, large volumes of fluid may be lost into
abdominal cavity (can account for losses to 5 L/day).
Diagnostic Evaluation
1) WBC to show leukocytosis (leukopenia if severe).
2) Arterial blood gases—may show metabolic acidosis with respiratory
compensation.
3) Urinalysis—may indicate urinary tract problems as primary source.
4) Peritoneal aspiration (paracentesis)—to demonstrate blood, pus, bile,
bacteria (gram staining), amylase.
5) Abdominal x-rays—may show gas and fluid collection in small and large
intestines, generalized dilatation.
6) CT of abdomen—may reveal abscess formation.
7) Laparotomy—to identify the underlying cause.
Management
1) Treatment of inflammatory conditions preoperatively and postoperatively
with antibiotic therapy—may prevent peritonitis. Broad-spectrum
antibiotic therapy to cover aerobic and anaerobic organisms is initial
treatment, followed by specific antibiotic therapy after culture and
sensitivity results.
2) Bed rest, NPO status.
3) Parenteral replacement of fluid and electrolytes.
4) Analgesics for pain; antiemetics for nausea and vomiting.
5) Nasogastric intubation to decompress the bowel.
6) Possibly rectal tube to facilitate passage of gas.
7) Operative procedures to close perforations, remove infection source (i.e.,
inflamed organ, neurotic tissue), drain abscesses, and lavage peritoneal
cavity.
8) Abdominal paracentesis may be done to remove accumulating fluid.
Complications
1) Intraabdominal abscess formation (ie, pelvic subphrenic space)
2) Septicemia
Nursing Assessment
1) Assess for abdominal distention and tenderness, guarding, rebound,
hypoactive or absent bowel sounds to determine bowel function.
2) Observe for signs of shock—tachycardia and hypotension.
3) Monitor vital signs, arterial blood gases, complete blood count,
electrolytes, and central venous pressure to monitor hemodynamic status
and assess for complications.
Nursing Diagnoses
A. Pain related to peritoneal inflammation
B. Fluid Volume Deficit related to vomiting and interstitial fluid shift
C. Altered Nutrition, Less Than Body Requirements, related to GI
symptomatology
Nursing Interventions
A. Achieving Pain Relief
1) Place the patient in semi-Fowler’s position before surgery to enable less
painful breathing.
2) After surgery, place the patient in Fowler’s position to promote drainage
by gravity.
3) Provide analgesics as prescribed.
B. Maintaining Fluid/Electrolyte Volume
1) Keep patient NPO to reduce peristalsis.
2) Provide IV fluids to establish adequate fluid intake and to promote
adequate urinary output, as prescribed.
3) Record accurately intake and output, including the measurement of
vomitus and NG drainage.
4) Minimize nausea, vomiting, and distention by use of NG suction,
antiemetics.
5) Monitor for signs of hypovolemia: dry mucous membranes, oliguria,
postural hypotension, tachycardia, diminished skin turgor.
C. Achieving Adequate Nutrition
1) Administer TPN, as ordered, to maintain positive nitrogen balance until
patient can resume oral diet.
2) Reduce parenteral fluids and give oral food and fluids per order, when the
following occur:
a) Temperature and pulse return to normal.
b) Abdomen becomes soft.
c) Peristaltic sounds return (determined by abdominal auscultation).
d) Flatus is passed and patient has bowel movements.
Patient Education/ Health Maintenance
1) Teach patient and family how to care for open wounds and drain sites, if
appropriate.
2) Assess the need for home care nursing to assist with wound care and
assess healing; refer as necessary.
Evaluation
A. Minimal analgesics needed; abdomen soft, nontender, and no distention
B. Balanced intake and output, no evidence of dehydration or electrolyte
imbalances
C. Bowel sounds present; tolerating soft diet.