1. Care of Patient with GERD & Peptic Ulcer
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2. 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

3. Causes of GERD

4. 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
Regurgitation:
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

5. 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

6. 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

7. 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

8. Nursing Management Avoid factors that cause reflux Elevate HOB ~30°
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 in textbook)
Drug therapy
Evaluate effectiveness
Observe for side effects

9. 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

10. Three types of peptic ulcer
Gastric
Duodenal
Stress

11. 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

12. 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

13. 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

14. Duodenal versus Gastric ulcers

15. Diagnostic tests Esphagogastroduodenoscopy
Fiberoptic endoscope allows direct visualization of esophagus, stomach and duodenum

16. 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.

17. 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

18. 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

19. 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

20. 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

21. Complications: Pyloric obstruction
Caused by inflammation or edema of the pylorus
Stomach cannot empty  abdominal bloating, N & V
Persistent vomiting  Hypokalemia and metabolic alkalosis

22. Medical Management of ulcers
Conservative therapy:
Rest: Both physical and emotional
Dietary modifications
Elimination of smoking
Long term follow up care
Pharmaceutical:
Antibiotics
To eradicate H. Pylori infections
Recurrence of ulcer is 75-90% as high with infection
Antiacids
Initial drugs of choice
Histmaine H2 receptor antagonists
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

23. 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

24. 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

25. Dumping syndrome A complication of gastric surgery S&S
vertigo, sweating, palpitations, syncope, pallor, tachycardia
occurs after eating
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

26. Nursing diagnoses Pain r/t mucosal injury Anxiety Knowledge deficit
Risk for fluid volum deficit r/t hemorrhage or vomiting

27. 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

28. Intervention: Anxiety & Knowledge deficit
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