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
3
GERD: Symptoms

Typical symptoms:

Heartburn (Pyrosis):





Regurgitation:



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
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
 Are
related to HCl effect on the
esophageal mucosa
 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
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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
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Three types of peptic ulcer



Gastric
Duodenal
Stress
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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.
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Complications of ulcers:
Hemorrhage

Manifested by:

Orthostatic hypotension,  BP, HR, cool, clammy skin
overt bleeding

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
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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  abdominal bloating,
N&V
Persistent vomiting  Hypokalemia and
metabolic alkalosis
21
Medical Management of ulcers

Conservative therapy:




Rest: Both physical and
emotional
Dietary modifications
Elimination of smoking
Long term follow up
care

Pharmaceutical:

Antibiotics



Antiacids


Initial drugs of choice
Histmaine H2 receptor antagonists


To eradicate H. Pylori infections
Recurrence of ulcer is 75-90% as high
with infection
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

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

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


occurs after eating



vertigo, sweating, palpitations, syncope, pallor, tachycardia
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

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
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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

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