1. (Relates to Chapter 42, “Nursing Management: Upper Gastrointestinal Problems,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

2. 2 Peptic Ulcer Disease (PUD) 500,000 new cases of ulcers diagnosed each year 4 million recurrences each year Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

3. 3 Peptic Ulcer Disease Erosion of GI mucosa resulting from digestive action of HCl acid and pepsin Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

4. 4 Peptic Ulcer Disease Ulcer development can occur in Lower esophagus Stomach Duodenum Margin of gastrojejunal anastomosis after surgical procedures Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

5. 5 Types of PUD Gastric vs. duodenal Location Acute vs. chronic Depends on degree/duration of mucosal involvement Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

6. 6 Types of PUD Acute Superficial erosion Minimal inflammation Short duration, resolves quickly when cause is identified and removed Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

7. 7 Peptic Ulcers Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Fig. 42-10. Peptic ulcers, including an erosion, an acute ulcer, and a chronic ulcer. Both the acute ulcer and the chronic ulcer may penetrate the entire wall of the stomach.

8. 8 Types of PUD Chronic Muscular wall erosion with formation of fibrous tissue Long duration—present continuously for many months or intermittently More common than acute erosion Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

9. 9 Peptic Ulcer of the Duodenum Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Fig. 42-11. Peptic ulcer of the duodenum.

10. 10 Etiology and Pathophysiology Develops only in the presence of an acid environment Excess of gastric acid not necessary for ulcer development Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

11. 11 Etiology and Pathophysiology Pepsinogen is activated to pepsin in presence of HCl acid and at pH of 2 to 3. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

12. 12 Etiology and Pathophysiology Stomach normally protected from autodigestion by gastric mucosal barrier Surface mucosa of stomach is renewed about every 3 days. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

13. 13 Pathophysiology of Ulcer Development Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Fig. 42-12. Disruption of gastric mucosa and pathophysiologic consequences of back diffusion of acids.

14. 14 Etiology and Pathophysiology Mucosa can continually repair itself, except in extreme instances. Water, electrolytes, and water-soluble substances can pass through barrier. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

15. 15 Etiology and Pathophysiology Mucosal barrier prevents back diffusion of acid and pepsin from gastric lumen through mucosal layers to underlying tissue. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

16. 16 Etiology and Pathophysiology Mucosal barrier can be impaired, and back diffusion can occur. Cellular destruction and inflammation occur. Release of histamine Vasodilation Increased capillary permeability Secretion of acid and pepsin Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

17. 17 Relationship of Mucosal Blood Flow and Gastric Mucosal Barrier Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Fig. 42-13. Relationship between mucosal blood flow and disruption of the gastric mucosal barrier.

18. 18 Etiology and Pathophysiology Destroyers of mucosal barrier Helicobacter pylori Produces enzyme urease Mediates inflammation, making mucosa more vulnerable Aspirin and NSAIDs Inhibit syntheses of prostaglandins Cause abnormal permeability Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

19. 19 Etiology and Pathophysiology Destroyers of mucosal barrier (cont’d) Corticosteroids ↓ rate of mucosal cell renewal ↓ protective effects Lifestyle factors Alcohol, coffee, smoking, psychologic stress Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

20. 20 Gastric Ulcers Occur in any portion of stomach Western countries—less common than duodenal ulcers Prevalent in women, older adults Peak incidence >50 years of age Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

21. 21 Gastric Ulcers Risk factors H. pylori Medications Smoking Bile reflux Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

22. 22 Duodenal Ulcers Occur at any age and in anyone ↑ between ages of 35 and 45 years Account for ~80% of all peptic ulcers Familial tendency Person with blood group O ↑ risk Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

23. 23 Duodenal Ulcers Associated with increased HCl acid secretion H. pylori is found in 90% to 95% of patients. Not all individuals with H. pylori develop ulcers. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

24. 24 Duodenal Ulcers Increased risk of duodenal ulcers in those with COPD Cirrhosis of liver Chronic pancreatitis Hyperparathyroidism Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

25. 25 Duodenal Ulcers Increased risk of duodenal ulcers (cont’d) Chronic renal failure Zollinger-Ellison syndrome Smoking and alcohol use Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

26. 26 Stress-Related Mucosal Disease Also called physiologic stress ulcer Acute ulcers that develop after major physiologic insult Trauma or surgery Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

27. 27 Clinical Manifestations Pain high in epigastrium 1 to 2 hours after meals “Burning” or “gaseous” Food aggravates pain as ulcer has eroded through gastric mucosa. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

28. 28 Clinical Manifestations Duodenal ulcer pain Midepigastric region beneath xiphoid process Back pain—if located in posterior aspect 2 to 5 hours after meals “Burning” or “cramplike” Tendency to occur, then disappear, then occur again Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

29. 29 Complications Three major complications include Hemorrhage Perforation Gastric outlet obstruction All considered emergency situations Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

30. 30 Hemorrhage Most common complication of peptic ulcer disease Develops from erosion of Granulation tissue found at base of ulcer during healing Ulcer through a major blood vessel Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

31. 31

32. 32 Perforation Most lethal complication of peptic ulcer Common in large penetrating duodenal ulcers that have not healed and are located on posterior mucosal wall Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

33. 33 Perforation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Fig. 42-14. Duodenal ulcer of the posterior wall penetrating into the head of the pancreas, resulting in walled-off perforation.

34. 34 Perforation Perforated gastric ulcers often located on lesser curvature of stomach Mortality rates higher with perforation of gastric ulcers Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

35. 35 Perforation When ulcer penetrates serosal surface with spillage of contents into peritoneal cavity Size proportionate to length of time ulcer existed Large perforations: Immediate surgical closure Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

36. 36 Perforation Clinical manifestations Sudden, dramatic onset Severe upper abdominal pain spreads throughout abdomen. Tachycardia, weak pulse Rigid, board-like abdominal muscles Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

37. 37 Perforation Clinical manifestations (cont’d) Shallow, rapid respirations Bowel sounds absent Nausea/vomiting History reporting symptoms of indigestion or previous ulcer Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

38. 38 Perforation Bacterial peritonitis may occur within 6 to 12 hours. Difficult to determine from symptoms alone if gastric or duodenal ulcer has perforated Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

39. 39 Gastric Outlet Obstruction Predisposition to gastric outlet obstruction includes Ulcers located in Antrum and prepyloric and pyloric areas of stomach Duodenum Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

40. 40 Gastric Outlet Obstruction Obstruction due to Edema Inflammation Pylorospasm Fibrous scar tissue formation All contribute to narrowing of pylorus. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

41. 41 Gastric Outlet Obstruction Early phase: Gastric emptying normal Over time, ↑ contractile force needed to empty stomach Hypertrophy of stomach wall Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

42. 42 Gastric Outlet Obstruction After long-standing obstruction Stomach dilates and becomes atonic. Clinical manifestations Usually long history of ulcer pain Pain progresses to generalized upper abdominal discomfort. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

43. 43 Gastric Outlet Obstruction Clinical manifestations (cont’d) Pain worsens toward end of day as stomach fills and dilates. Relief obtained by belching or vomiting Vomiting is common. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

44. 44 Gastric Outlet Obstruction Clinical manifestations (cont’d) Constipation is a common complaint. Dehydration, lack of roughage in diet Swelling in stomach and upper abdomen Loud peristalsis Visible peristaltic waves If stomach grossly dilated, may be palpable Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

45. 45 Diagnostic Studies To determine presence and location of ulcer Similar to those used for acute upper GI bleed Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

46. 46 Diagnostic Studies Endoscopy with biopsy Most often used Allows for direct viewing of mucosa Determines degree of ulcer healing after treatment During procedure, tissue specimens can be obtained to identify H. pylori and rule out gastric cancer. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

47. 47 Diagnostic Studies Tests for H. pylori Noninvasive tests Serum or whole blood antibody tests Immunoglobin G (IgG) Will not distinguish between active and recently treated disease Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

48. 48 Diagnostic Studies Noninvasive tests (cont’d) Urea breath test Can determine active infection Stool antigen test Not as accurate as breath test Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

49. 49 Diagnostic Studies Tests for H. pylori (cont’d) Invasive tests Endoscopic procedure Biopsy of stomach Rapid urease test Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

50. 50 Diagnostic Studies Barium contrast studies Reserved for patient who cannot undergo endoscopy Not accurate for shallow, superficial ulcers Used in diagnosis of gastric outlet obstruction Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

51. 51 Diagnostic Studies X-ray studies Ineffective in distinguishing a peptic ulcer from a malignant tumor Do not show degree of healing Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

52. 52 Diagnostic Studies Gastric analysis Analyze gastric contents for acidity and volume NG tube is inserted, and gastric contents are aspirated. Contents analyzed for HCl acid Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

53. 53 Diagnostic Studies Laboratory analysis CBC Anemia Urinalysis Liver enzyme studies Serum amylase determination Pancreatic function Stool examination Presence of blood Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

54. 54 Collaborative Care Medical regimen consists of Adequate rest Dietary modification Drug therapy Elimination of smoking and alcohol Long-term follow-up care Stress management Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

55. 55 Collaborative Care Aim of treatment program Reduce degree of gastric acidity Enhance mucosal defense mechanisms Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

56. 56 Collaborative Care Generally treated in ambulatory care clinics Ulcer healing requires many weeks of therapy. Pain disappears after 3 to 6 days. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

57. 57 Collaborative Care Complete healing may take 3 to 9 weeks. Should be assessed by means of x-rays or endoscopic examination Aspirin and nonselective NSAIDs may be stopped. Smoking cessation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

58. 58 Drug Therapy Use of H 2 R blockers PPIs Antibiotics Antacids Anticholinergics Cytoprotective therapy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

59. 59 Drug Therapy Histamine-2 receptor blockers (H 2 R blockers) Frequently used Block action of histamine on H 2 receptors ↓ HCl acid secretion ↓ conversion of pepsinogen to pepsin ↑ ulcer healing Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

60. 60 Drug Therapy H 2 R blockers (cont’d) Therapeutic effects last up to 12 hours. Oral or IV Examples Cimetidine Ranitidine Famotidine Nizatidine Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

61. 61 Drug Therapy Proton pump inhibitors (PPI) Block ATPase enzyme—important for secretion of HCl acid ↑ effective than H 2 R blockers—reducing acid and promoting healing Examples Esomeprazole Omeprazole Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

62. 62 Drug Therapy Antibiotic therapy Eradicates H. pylori infection Most important in treatment if H. pylori present No single agent has been effective in eliminating H. pylori. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

63. 63 Drug Therapy Antibiotic therapy (cont’d) Usual treatment 7 to 14 days Example of therapy Dual therapy—ranitidine bismuth citrate (Tritec) with clarithromycin (Biaxin) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

64. 64 Drug Therapy Antacids Adjunct therapy for PUD Increase gastric pH by neutralizing HCl acid Effects on empty stomach 20 to 30 minutes If taken after meals, may last 3 to 4 hours Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

65. 65 Drug Therapy Antacids (cont’d) Systemic vs. nonsystemic Systemic Rarely used for PUD Extremely soluble and absorbed into circulation Long-term use can cause alkalosis. Sodium bicarbonate (Alka-Seltzer) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

66. 66 Drug Therapy Antacids (cont’d) Nonsystemic Insoluble and poorly absorbed Magnesium hydroxide (Mag-Ox) Watch for diarrhea. Aluminum hydroxide (Amphojel) Watch for constipation. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

67. 67 Drug Therapy Antacids (cont’d) ↑ sodium preparations: Not to be used in elderly or patients with ↑ BP, heart failure, liver cirrhosis, or renal disease Magnesium preparations: Not to be used in patients with renal failure Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

68. 68 Drug Therapy Antacids (cont’d) Interact unfavorably with some drugs Health care provider must know all drugs being taken before therapy is begun. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

69. 69 Drug Therapy Cytoprotective drug therapy Used for short-term treatment Protection for esophagus, stomach, and duodenum Accelerates ulcer healing Example Sucralfate (Carafate) Misoprostol (Cytotec) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

70. 70 Drug Therapy Anticholinergic drugs Occasionally used ↓ cholinergic stimulation of HCl acid ↓ gastric motility: Not used for gastric outlet obstruction Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

71. 71 Drug Therapy Tricyclic antidepressants Pain relief Anticholinergic properties Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

72. 72 Nutritional Therapy Dietary modifications: Food and beverages irritating to patient are avoided or eliminated. Bland diet may be recommended. Six small meals a day during symptomatic phase Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

73. 73 Therapy Related to Complications Acute exacerbation Treated with same regimen used for conservative therapy Situation is more serious because of possible complications of perforation, hemorrhage, and gastric outlet obstruction. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

74. 74 Therapy Related to Complications Acute exacerbation (cont’d) Accompanied by bleeding, increased pain and discomfort, nausea, and vomiting Endoscopic evaluation Reveals degree of inflammation or bleeding and ulcer location Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

75. 75 Therapy Related to Complications Perforation Immediate focus: Stop spillage of gastric or duodenal contents into peritoneal cavity. Restore blood volume. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

76. 76 Therapy Related to Complications Perforation (cont’d) NG tube is placed into stomach. Continuous aspiration Placement of tube near to perforation site facilitates decompression. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

77. 77 Therapy Related to Complications Perforation (cont’d) Circulating blood volume: Replaced with lactated Ringer’s and albumin solutions Blood replacement in form of packed RBCs may be necessary. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

78. 78 Therapy Related to Complications Perforation (cont’d) Central venous pressure line inserted and monitored hourly Indwelling urinary catheter inserted and monitored hourly ECG—if history of cardiac disease Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

79. 79 Therapy Related to Complications Perforation (cont’d) Broad-spectrum antibiotics Pain medication Open or laparoscopic repair Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

80. 80 Therapy Related to Complications Gastric outlet obstruction Decompress stomach. Correct any existing fluid and electrolyte imbalances. Improve patient’s general state of health. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

81. 81 Therapy Related to Complications Gastric outlet obstruction (cont’d) NG tube inserted in stomach, attached to continuous suction Continuous decompression allows Stomach to regain its normal muscle tone Ulcer to begin to heal Inflammation and edema to subside Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

82. 82 Therapy Related to Complications Gastric outlet obstruction (cont’d) After several days, NG clamped and residual volumes checked Common to clamp tube overnight for 8 to 12 hours and measure residual in morning Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

83. 83 Therapy Related to Complications Gastric outlet obstruction (cont’d) When aspirate below 200 mL Within normal range Oral intake of clear liquids can begin Watch patient carefully for signs of distress or vomiting. As residual ↓, solid foods added and tube removed Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

84. 84 Therapy Related to Complications Gastric outlet obstruction (cont’d) IV fluids and electrolytes Administered according to degree of dehydration, vomiting, electrolyte imbalance Pyloric obstruction: Endoscopically treated with balloon dilations Surgery may be necessary to remove scar tissue. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

85. 85 Nursing Assessment Past health history Medication usage Heartburn Weight loss Black, tarry stools Epigastric tenderness Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

86. 86 Nursing Assessment Nausea and vomiting Abnormal laboratory values Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

87. 87 Nursing Diagnoses Acute pain Ineffective self-health management Nausea Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

88. 88 Nursing Management Overall goals Comply with prescribed therapeutic regimen. Experience a reduction in or absence of discomfort. Exhibit no signs of GI complications. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

89. 89 Nursing Management Overall goals (cont’d) Have complete healing. Lifestyle changes can prevent recurrence. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

90. 90 Nursing Implementation Health promotion Identify patients at risk. Provide early detection and treatment. Encourage patients to take ulcerogenic drugs with food or milk. Teach patient to report to health care provider symptoms related to gastric irritation. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

91. 91 Nursing Implementation Acute intervention General complaints include increased pain, nausea, vomiting, and some bleeding. Convey treatment measures to patient/family. Provide regular mouth care. Cleanse and lubricate nares if NG tube is in place. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

92. 92 Nursing Implementation Acute intervention (cont’d) Vital signs hourly Monitor I/O Physical and emotional rest Sedatives can mask symptoms of shock. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

93. 93 Nursing Implementation Hemorrhage Changes in vital signs, ↑ in amount and redness of aspirate Signal massive upper GI bleeding ↑ amount of blood in gastric contents ↓ pain because blood neutralizes acidic gastric contents Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

94. 94 Nursing Implementation Hemorrhage (cont’d) Maintain patency of NG tube. Prevent blood clot blockage. If blocked, distention results. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

95. 95 Nursing Implementation Perforation Sudden, severe abdominal pain unrelated in intensity and location to pain that brought patient to hospital Possibility of perforation Indicated by a rigid, board-like abdomen Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

96. 96 Nursing Implementation Perforation (cont’d) Severe generalized abdominal and shoulder pain Shallow, grunting respirations Bowel sounds diminished or absent Vital signs every 15 to 30 minutes Stop all oral, NG feeds/drugs until health care provider notified. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

97. 97 Nursing Implementation Perforation (cont’d) IV fluids may be increased to replace volume lost. Ensure any known allergies are reported on chart. Antibiotic therapy is usually started. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

98. 98 Nursing Implementation Perforation (cont’d) Surgical or laparoscopic closure may be necessary if perforation does not heal spontaneously. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

99. 99 Nursing Implementation Gastric outlet obstruction Can occur at any time Likely in patients whose ulcer is located close to pylorus Gradual onset Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

100. 100 Nursing Implementation Gastric outlet obstruction (cont’d) Constant NG aspiration of stomach contents may relieve symptoms. If occurs during treatment of acute exacerbation Regular irrigation of NG tube Repositioning from side to side IV fluids for hydration Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

101. 101 Nursing Implementation Gastric outlet obstruction (cont’d) Accurate I/O Surgery may be performed if conservative treatment not successful Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

102. 102 Ambulatory and Home Care Patient teaching Disease Teach basic etiology/pathophysiology. Drugs Actions, side effects, danger of taking any medication without health care provider approval Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

103. 103 Ambulatory and Home Care Patient teaching (cont’d) Lifestyle changes Appropriate changes in diet Regular follow-up care Discuss medications. Encourage compliance with plan of care. Importance of immediate reporting of N/V, epigastric pain, bloody emesis, or tarry stools Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

104. 104 Surgical Therapy Uncommon because of antisecretory agents Indications for surgical interventions Unresponsive to medical management Concern about gastric cancer Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

105. 105 Surgical Therapy Surgical procedures Billroth I: Gastroduodenostomy Partial gastrectomy with removal of distal 2/3 stomach and anastomosis of gastric stump to duodenum Billroth II: Gastrojejunostomy Partial gastrectomy with removal of distal 2/3 stomach and anastomosis of gastric stump to jejunum Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

106. 106 Surgical Therapy Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Fig. 42-15. A, Billroth I procedure (subtotal gastric resection with gastroduodenostomy anastomosis). B, Billroth II procedure (subtotal gastric resection with gastrojejunostomy anastomosis).

107. 107 Surgical Therapy Surgical therapies (cont’d) Vagotomy Severing of vagus nerve Can be total or selective Pyloroplasty Surgical enlargement of pyloric sphincter Commonly done after vagotomy ↓ gastric motility and gastric emptying If accompanying vagotomy, ↑ gastric emptying Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

108. 108 Postoperative Complications Most common Dumping syndrome Postprandial hypoglycemia Bile reflux gastritis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

109. 109 Postoperative Complications Dumping syndrome 20% of patients experience after surgery. Direct result of surgical removal of a large portion of stomach and pyloric sphincter Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

110. 110 Postoperative Complications Dumping syndrome ↓ ability of stomach to control amount of gastric chyme entering small intestine Large bolus of hypertonic fluid enters intestine ↑ fluid drawn into bowel lumen Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

111. 111 Postoperative Complications Dumping syndrome (cont’d) Occurs at end of meal or 15 to 30 minutes after eating Symptoms include Weakness, sweating, palpitations, dizziness, abdominal cramps, borborygmi, urge to defecate Last no longer than an hour Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

112. 112 Postoperative Complications Postprandial hypoglycemia Variant of dumping syndrome Result of uncontrolled gastric emptying of a bolus of fluid high in carbohydrate into small intestine ↑ blood sugar Release of excessive amounts of insulin into circulation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

113. 113 Postoperative Complications Postprandial hypoglycemia (cont’d) Secondary hypoglycemia occurs with symptoms ~2 hours after meals. Symptoms include sweating, weakness, mental confusion, palpitations, tachycardia, and anxiety. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

114. 114 Postoperative Complications Bile reflux gastritis Surgery can result in reflux alkaline gastritis. Prolonged contact of bile causes damage to gastric mucosa. May result in back diffusion of H + ions through gastric mucosa PUD may reoccur. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

115. 115 Postoperative Complications Bile reflux gastritis (cont’d) Continuous epigastric distress that ↑ after meals Administration of cholestyramine (Questran) relieves irritation. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

116. 116 Nutritional Therapy Postoperatively Start as soon as immediate postoperative period has successfully passed. Patient should be advised to reduce drinking fluid (4 oz) with meals. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

117. 117 Nutritional Therapy Postoperatively Diet should consist of Small, dry feedings daily Low carbohydrates Restricted sugar with meals Moderate amounts of protein and fat 30 minutes of rest after each meal Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

118. 118 Surgical Therapy for PUD Preoperative care Laparoscopic or open surgery techniques Surgeon should educate family/patient on surgical procedure. Nurse can clarify questions. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

119. 119 Surgical Therapy for PUD Postoperative care Similar to postop care after abdominal laparotomy NG tube used to decompress and decrease pressure on suture line Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

120. 120 Surgical Therapy for PUD Postoperative care (cont’d) Aspirate observed for Color Bright red at first with darkening within first 24 hours Color changes to yellow-green within 36 to 48 hours. Amount Odor Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

121. 121 Surgical Therapy for PUD Postoperative care (cont’d) NG suction must be in working order, and patency maintained. Observe for signs of ↓ peristalsis and lower abdominal discomfort. Intestinal obstruction Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

122. 122 Surgical Therapy for PUD Postop care (cont’d) Accurate I/O essential Vital signs every 4 hours Frequent position changes IV therapy Observe for signs of infection. Long-term complication—pernicious anemia Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

123. 123 Gerontologic Considerations ↑ patients >60 years of age ↑ use of NSAIDs First manifestation may be frank gastric bleeding or ↓ hematocrit. Treatment similar to younger adults Emphasis placed on prevention of both gastritis and peptic ulcers Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

124. 124 Diagnostic testing is planned for a patient with a suspected peptic ulcer. The nurse explains to the patient that the most reliable test for determining the presence and location of an ulcer is a(n): 1. Endoscopy. 2. Gastric analysis. 3. Barium swallow. 4. Serologic test for Helicobacter pylori. Audience Response Question Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

125. 125

126. 126 Case Study 55-year-old man complains of pain and burning pressure around stomach 2 to 3 hours after eating. He has a history of former alcohol abuse and smoking. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

127. 127 Case Study He has had 10-lb weight loss in 2 months accompanied by nausea, vomiting, and decreased appetite. EGD reveals ulcers; biopsy sample positive for H. pylori Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

128. 128 Discussion Questions 1. He asks you how this happened. What are his risk factors? 2. What are his treatment options? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

129. 129 Discussion Questions 3. What are complications of peptic ulcer disease? 4. What lifestyle modifications are necessary to ensure healing? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.