Management of Patients With Gastric and Duodenal Disorders Part 3

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Management of PatientsWith Gastric andDuodenal
DisordersPart 3

• Miss Iman Shaweesh
• January 2008

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• An individuals nutritional status depends not
  only on the type and amount of intake but also on
  the functioning of the gastric and intestinal
  portions of the gastrointestinal (GI) system.

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Gastritis

• (inflammation of the gastric or stomach
  mucosa) is a common GI problem. Gastritis may be
  acute, lasting several hours to a few days, or
  chronic, resulting from repeated exposure to
  irritating agents or recurring episodes of acute
  gastritis.
• Acute gastritis is often caused by dietary
  indiscretionthe person eats food that is
  contaminated with disease-causing microorganisms
  or that is irritating or too highly seasoned

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Gastritis

• Other causes of acute gastritis include overuse
  of aspirin and other nonsteroidal
  anti-inflammatory drugs (NSAIDs),
• excessive alcohol intake, bile reflux, and
  radiation therapy.
• Severe form of acute gastritis is caused by the
  ingestion of strong acid or alkali, which may
  cause the mucosa to become gangrenous or to
  perforate.

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Gastritis

• Chronic gastritis and prolonged inflammation of
  the stomach may be caused by either benign or
  malignant ulcers of the stomach or by the
  bacteria Helicobacter pylori.
• Chronic gastritis is sometimes associated with
  autoimmune diseases such as pernicious anemia
  dietary factors such as caffeine the use of
  medications, especially NSAIDs alcohol smoking
  or reflux of intestinal contents into the
  stomach.

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Pathophysiology

• In gastritis, the gastric mucous membrane becomes
  edematous and hyperemic (congested with fluid and
  blood) and undergoes superficial erosion (Fig.
  37-1).
• It secretes a scanty amount of gastric juice,
  containing very little acid but much mucus.
  Superficial ulceration may occur and can lead to
  hemorrhage.

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Pathophysiology
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Clinical Manifestations

• The patient with acute gastritis may have
  abdominal discomfort, headache, lassitude,
  nausea, anorexia, vomiting, and hiccupping.
• Some have no symptoms.
• The patient with chronic gastritis may complain
  of anorexia, heartburn after eating, belching, a
  sour taste in the mouth, or nausea and vomiting.
  Patients with chronic gastritis from vitamin
  deficiency usually have evidence of malabsorption
  of vitamin B12 caused by antibodies against
  intrinsic factor.

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Assessment and Diagnostic Findings

• Gastritis is sometimes associated with
  hypochlorhydria (absence or low levels of
  hydrochloric acid HCl) or with hyperchlorhydria
  (high levels of HCl).
• Diagnosis can be determined by endoscopy, upper
  GI radiographic studies, and histologic
  examination of a tissue specimen- biopsy.
• diagnostic measures for detecting H. pylori
  include
• serologic testing for antibodies against the
  H. pylori antigen, and a breath test.

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Medical Management

• The gastric mucosa is capable of repairing itself
  after a bout of gastritis. As a rule, the patient
  recovers in about 1 day.
• nonirritating diet is recommended.
• If bleeding is present, management is similar to
  the procedures used for upper GI tract hemorrhage
• If itcaused by ingestion of strong acids or
  alkalis, treatment consists of diluting and
  neutralizing the offending agent. To neutralize
  acids, common antacids (eg, aluminum hydroxide)

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Medical Management

• to neutralize an alkali, diluted lemon juice or
  diluted vinegar is used.
• If corrosion is extensive or severe, emetics and
  lavage are avoided because of the danger of
  perforation and damage to the esophagus. Therapy
  is supportive and may include nasogastric (NG)
  intubation.analgesic agents and sedatives,
  antacids, and intravenous (IV) fluids.
• Fiberoptic endoscopy may be necessary. In
  extreme cases, emergency surgery may be required
  to remove gangrenous or perforated tissue.

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Medical Management

• Chronic gastritis is managed by modifying the
  patients diet, promoting rest, reducing stress,
  and initiating pharmacotherapy.
• H. pylori may be treated with antibiotics (eg,
  tetracycline or amoxicillin, combined with
  clarithromycin) and a proton pump inhibitor (eg,
  lansoprazole Prevacid), and possibly bismuth
  salts (Pepto-Bismol) (Table 37-1).
• Research is being conducted to develop a vaccine
  against H. pylori

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Histamine 2 (H2) Receptor Antagonists
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Proton (Gastric Acid) Pump Inhibitor
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Gastric and Duodenal Ulcers

• A peptic ulcer is an excavation (hollowed-out
  area) that forms in the mucosal wall of the
  stomach, in the pylorus (opening between stomach
  and duodenum), in the duodenum (first part of
  small intestine), or in the esophagus. A peptic
  ulcer is frequently referred to as a gastric,
  duodenal, or esophageal ulcer, depending on its
  location, or as peptic ulcer disease.

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• Peptic ulcers are more likely to be in the
  duodenum than in the stomach. As a rule they
  occur alone, but they may occur in multiples.
  Chronic gastric ulcers tend to occur in the
  lesser curvature of the stomach, near the
  pylorus.
• In the past, stress and anxiety were thought to
  be causes of ulcers. Research has identified that
  peptic ulcers result from infection with the
  gram-negative bacteria H. pylori

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• Familial tendency may be a significant
  predisposing factor. A further genetic link is
  noted in the finding that people with blood type
  O are more susceptible to peptic ulcers than are
  those with blood type A, B, or AB. There also is
  an association between duodenal ulcers and
  chronic pulmonary disease or chronic renal
  disease.

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• Stress ulcers, which are clinically different
  from peptic ulcers, are ulcerations in the mucosa
  that can occur in the gastroduodenal area. Stress
  ulcers may occur in patients who are exposed to
  stressful conditions.

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Comparing Duodenal and Gastric Ulcers

• DUODENAL ULCER Incidence
• Age 3060
• Male female 231
• 80 of peptic ulcers are duodenal

• GASTRIC ULCER
• Usually 50 and over
• Male female 11
• 15 of peptic ulcers are gastric

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Signs, Symptoms, and Clinical Findings

• DUODENAL ULCER
• Hypersecretion of stomach acid (HCl)
• May have weight gain
• Pain occurs 23 hours after a meal often
  awakened between 12 AM
• ingestion of food relieves pain
• Vomiting uncommon

• GASTRIC ULCER
• Normalhyposecretion of stomach acid (HCl)
• Weight loss may occur
• Pain occurs 1/2 to 1 hour after a meal rarely
  occurs at night may be relieved by vomiting
• ingestion of food does not
• help, sometimes increases
• pain
• Vomiting common

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Comparing Duodenal and Gastric Ulcers

• DUODENAL ULCER
• Hemorrhage less likely than with gastric ulcer,
  but if present melena more common than
  Hematemesis More likely to perforate than
• gastric ulcers

• GASTRIC ULCER
• Hemorrhage more likely to occur than with
  duodenal
• ulcer hematemesis more common than melena

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Comparing Duodenal and Gastric Ulcers

• DUODENAL ULCER
• Malignancy Possibility
• Rare
• Risk Factors
• H. pylori, alcohol, smoking,
• cirrhosis, stress

• GASTRIC ULCER
• Occasionally
• H. pylori, gastritis, alcohol, smoking, use of
  NSAIDs, stress

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Pathophysiology

• Peptic ulcers occur mainly in the gastroduodenal
  mucosa because this tissue cannot withstand the
  digestive action of gastric acid (HCl) and
  pepsin. The erosion is caused by the increased
  concentration or activity of acid-pepsin, or by
  decreased resistance of the mucosa.
• A damaged mucosa cannot secrete enough mucus to
  act as a barrier against HCl.
• The use of NSAIDs inhibits the secretion of mucus
  that protects the mucosa. Patients with duodenal
  ulcer disease secrete more acid than normal,
  whereas patients with gastric ulcer tend to
  secrete normal or decreased levels of acid.

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Pathophysiology

• Stress ulcer is the term given to the acute
  mucosal ulceration of the duodenal or gastric
  area that occurs after physiologically stressful
  events, such as burns, shock, severe sepsis, and
  multiple organ traumas.
• Differences of opinion exist as to the actual
  cause of mucosal ulceration in stress ulcers.
  Usually, it is preceded by shock this leads to
  decreased gastric mucosal blood flow and to
  reflux of duodenal contents into the stomach. In
  addition, large quantities of pepsin are
  released. The combination of ischemia, acid, and
  pepsin creates an ideal climate for ulceration.

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Pathophysiology

• Stress ulcers should be distinguished from
  Cushings ulcers and Curlings ulcers, two other
  types of gastric ulcers.
• Cushings ulcers are common in patients with
  trauma to the brain.
• Curlings ulcer is frequently observed about 72
  hours after extensive burns

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Clinical Manifestations

• As a rule, the patient with an ulcer complains of
  dull, gnawing pain or a burning sensation in the
  midepigastrium or in the back. It is believed
  that the pain occurs when the increased acid
  content of the stomach and duodenum erodes the
  lesion and stimulates the exposed nerve endings.
• pyrosis (heartburn), vomiting, constipation or
  diarrhea, and bleeding. Pyrosis is a burning
  sensation in the esophagus and stomach that moves
  up to the mouth. Heartburn is often accompanied
  by sour eructation, or burping, which is common
  when the patients stomach is empty. Fifteen
  percent of patients with gastric ulcers
  experience bleeding.

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Assessment and Diagnostic Findings

• A physical examination may reveal pain,
  epigastric tenderness, or abdominal distention.
• A barium study of the upper GI tract may show an
  ulcer however, endoscopy is the preferred
  diagnostic procedure because it allows direct
  visualization of inflammatory changes, ulcers,
  and lesions-biopsy.

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• Stools may be tested periodically until they are
  negative for occult blood. Gastric secretory
  studies are of value in diagnosing achlorhydria
  and ZES. H. pylori infection may be determined by
  biopsy and histology with culture.
• There is also a breath test that detects H.
  pylori, as well as a serologic test for
  antibodies to the H. pylori antigen.

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Medical Management

• peptic ulcers treated with antibiotics to
  eradicate H. pylori have a lower recurrence rate
  than those not treated with antibiotics. The
  goals are to eradicate H. pylori and to manage
  gastric acidity. Methods used include
  medications, lifestyle changes, and surgical
  intervention.

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PHARMACOLOGIC THERAPY

• Currently, the most commonly used therapy in the
  treatment of ulcers is a combination of
  antibiotics, proton pump inhibitors, and bismuth
  salts that suppresses or eradicates H. pylori.
• Rest, sedatives, and tranquilizers may add to the
  patients comfort and are prescribed as needed.
  Maintenance dosages of H2 receptor antagonists
  are usually recommended for 1 year.

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STRESS REDUCTION AND REST

• SMOKING CESSATION
• DIETARY MODIFICATION
• SURGICAL MANAGEMENT
• surgery is usually recommended for patients with
  intractable ulcers (those that fail to heal
• after 12 to 16 weeks of medical treatment),
  include vagotomy, with or without pyloroplasty,
  and the Billroth I and Billroth II procedures

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• Severing of the vagus nerve. Decreases gastric
  acid by diminishing cholinergic stimulation to
  the parietal cells, making
• them less responsive to gastrin. May be done
  via open surgical approach,
• laparoscopy, or thoracoscopy

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• A surgical procedure in which a longitudinal
• incision is made into the pylorus and
  transversely sutured closed to enlarge the outlet
  and relax the muscle

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• Removal of the lower portion of the antrum of the
  stomach (which contains
• the cells that secrete gastrin) as well as a
  small portion of the duodenum
• and pylorus. The remaining segment is
  anastomosed to the duodenum (Billroth I) or to
  the jejunum (Billroth II)

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• Removal of distal third of stomach anastomosis
  with duodenum or jejunum.
• Removes gastrin-producing cells in the
• antrum and part of the parietal cells.

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Morbid Obesity

• obesity is the term applied to people who are
  more than two times their ideal body weight or
  whose body mass index (BMI) exceeds 30 kg/m2.
• Another definition of morbid obesity is body
  weight that is more than 100 pounds greater than
  the ideal body weigh.
• Patients with morbid obesity are at higher risk
  for health complications, such as cardiovascular
  disease, arthritis, asthma, bronchitis, and
  diabetes. They frequently suffer from low
  self-esteem, impaired body image, and depression.

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Medical Management

• There is a belief that depression may be a
  contributing factor to weight gain, and treatment
  of the depression with bupropion
• hydrochloride
• Several medications have recently been approved
  for obesity. They include sibutramine HCl
  (Meridia) and orlistat (Xenical). By inhibiting
  the reuptake of serotonin and norepinephrine,
  sibutramine decreases appetite.

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• Gastric bypass and vertical banded gastroplasty
  are the current operations of choice. These
  procedures may be performed laparoscopically or
  by an open surgical technique. In gastric bypass
  surgery, the proximal segment of the stomach is
  transected to form a small pouch with a small
  gastroenterostomy stoma. The Roux-en-Y gastric
  bypass is the recommended procedure for long-term
  weight loss. In this procedure, a horizontal row
  of staples creates a stomach pouch with a 1-cm
  stoma that is anastomosed with a portion of
  distal jejunum, creating a gastroenterostomy. The
  transected proximal portion of the jejunum is
  anastomosed to the distal jejunum.

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NSG Intervention

• Complications that may occur in the immediate
  postoperative period include peritonitis, stomal
  obstruction, stomal ulcers, atelectasis and
  pneumonia, thromboembolism, and metabolic
  imbalances resulting from prolonged vomiting and
  diarrhea.
• small feedings consisting of a total of 600 to
  800 calories per day and encourages fluid intake
  to prevent dehydration.

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• The nurse explains that noncompliance by eating
  too much or too fast or eating highcalorie liquid
  and soft foods results in vomiting and painful
  esophageal distention. The nurse discusses
  dietary instructions before discharge and
  schedules monthly outpatient visits.

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Gastric Cancer

• Most of these deaths occur in people older than
  40 years of age, but they occasionally occur in
  younger people. Men have a higher incidence of
  gastric cancers than women do.
• Diet appears to be a significant factor. A diet
  high in smoked foods and low in fruits and
  vegetables may increase the risk of gastric
  cancer.
• chronic inflammation of the stomach, pernicious
  anemia, achlorhydria, gastric ulcers, H. pylori
  infection, and genetics.

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Pathophysiology

• Most gastric cancers are adenocarcinomas and can
  occur in any portion of the stomach. The tumor
  infiltrates the surrounding mucosa, penetrating
  the wall of the stomach and adjacent organs and
  structures.
• Metastasis through lymph to the peritoneal cavity
  occurs later in the disease.

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Clinical Manifestations

• Some studies show that early symptoms, such as
  pain relieved with antacids, resemble those of
  benign ulcers.
• Symptoms of progressive disease may include
  anorexia, dyspepsia (indigestion), weight loss,
  abdominal pain, constipation, anemia,
• and nausea and vomiting.

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Assessment and Diagnostic Findings

• physical examination is not helpful in detecting
  cancer because most gastric tumors are not
  palpable. Ascites may be apparent if the cancer
  cells have metastasized to the liver.
• Endoscopy for biopsy and cytologic washings is
  the usual diagnostic study, and a barium x-ray
  examination of the upper GI tract may also be
  performed

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• Because metastasis often occurs before warning
  signs develop, a computed tomography (CT) scan,
  bone scan, and liver scan are valuable in
  determining the extent of metastasis.
• A complete x-ray examination of the GI tract
  should be performed when any person older than 40
  years of age has had indigestion (dyspepsia) of
  more than 4 weeks duration.

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Medical Management

• no successful treatment for gastric carcinoma
  except removal of the tumor. If the tumor can be
  removed while it is still localized to the
  stomach, the patient can be cured.
• If the tumor has spread beyond the area that can
  be excised, cure is impossible. Palliative rather
  than radical surgery is performed if there is
  metastasis to other vital organs.
• If a radical subtotal gastrectomy is performed,
  the stump of the stomach is anastomosed to the
  jejunum, as in the gastrectomy for ulcer.

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• Chemotherapeutic medications include cisplatin,
  irinotecan, or a combination of 5-fluorouracil,
  doxorubicin (Adriamycin), and mitomycin-C. Some
  studies are being conducted on the use of
  chemotherapy before surgery. Radiation therapy
  also may be used for palliation. Assessment of
  tumor markers (blood analysis for antigens
  indicative of colon cancer) such as
  carcinoembryonic antigen, CA 19-9, and CA 50 may
  help determine the effectiveness of treatment.