This presentation will discuss the gastrointestinal system in regards to peptic ulcer disease, gastroesophageal reflux disease, and hernias. Here are the learning objectives for this discussion. Make sure that you understand what the purpose of this is and that you'll be able to meet these objectives upon the completion.
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The first thing I want you to do is pause and reflect. I want you to start by stopping the recording and thinking and writing down in these three areas. I want you to think about what you already know about this topic and write down at least three to five items. I want you to stop and think about any of your prior experiences related to the content. I want you to write down your thoughts and feelings related to your experiences.
Lastly, I want you to think about what you don't know about this content. Think about your gaps of knowledge and understanding. and things that you're curious about learning. Write down at least three to five items, then you'll be ready to dive into the content. The pathophysiology of peptic ulcer disease begins with an understanding that it occurs in either the stomach or the duodenum or sometimes in the esophagus.
An ulcer is an excavation, kind of like a hollowed out pit that forms in the mucosa of one of these parts, so either in the stomach and the pylorus, which is the opening between the stomach and the duodenum, in the actual duodenum, and sometimes in the esophagus. The erosion may extend as deeply as the muscle layers or through the muscle layers into the peritoneum. It may penetrate pretty deep. 80 to 95% of gastric and duodenal ulcers are caused by an H.
pylori bacterial infection. They occur mainly in the gastroduodenal mucosa because these tissues cannot withstand the digestive action of the acids and the pepsin, of course, exacerbated from the bacteria. And then as the damage is done, the mucosa that has been injured can't... continue to secrete enough mucus to act as a barrier against the digestive juices.
So it just kind of continuously erodes that area. Patients with duodenal ulcers tend to secrete more acid than normal. Whereas patients with gastric ulcers tend to have normal or even decreased level of acid production, and that contributes to the development of these ulcers. Additionally, the use of NSAIDs is associated with disruption in the normal protective mucosal barrier. So NSAIDs are a risk factor for developing a peptic ulcer disease.
More often, peptic ulcers are in the duodenum than in the stomach, and less frequently in the esophagus. But that can happen because of gastroesophageal reflux disease, which we're going to talk more about here in a little while. In the past, it was believed that stress and anxiety were really the causes of these.
Now, they can aggravate an ulcer, to be sure. but it tends to be H. pylori that is the culprit. However, when a person has an erosion from the H.
pylori coupled with the gastric acids, then stress can increase the severity of it because stress causes our bodies to create more of the acids. So stress can make it exacerbated. it doesn't cause it. There can be a familiar tendency. Sometimes it runs in families.
It has been shown that people with a blood type O are more susceptible to these kind of ulcers than people with other blood types. That could be because genetically they have more acid production. There are things called stress ulcers.
These happen in response to physiological stressful events like a patient who has severe burns or has any form of shock or sepsis can develop a stress ulcer. Now that's not the same thing as what we're talking about here with these regular peptic ulcers. When the ulcer is in the stomach, the gastric ulcer, pain increases when the patient has food because the churning and the increased acid production gets into contact with that injured area and causes pain. So pain will start usually within 30 to 60 minutes of food intake. Because it hurts to eat, patients will often...
avoid eating and experience weight loss. And then they often will vomit because of the pain in the stomach. Duodenal ulcers, on the other hand, if you think about the process of digestion and the food gets turned around in the stomach for a couple of hours, then it gets pushed into the small intestines and enters the duodenum.
So, it can take two to three hours after eating before they'll feel the pain. Eating may actually help decrease the pain. And so this patient is well nourished, maybe even overnourished, because if eating helps the pain go away, then they may eat more frequently to deal with it. And duodenal ulcers are the more common of the two types.
When we're looking at Assessing this patient, we're obviously going to ask about pain. We want them to tell us where it hurts. We want to find out if there's distension or tenderness. Does the pain come and go?
Is it related to food? Does it wake them up at night? Smoking and drinking aggravate ulcers and so we need to find out if they are partaking in those smoking or drinking. Aspirin and NSAIDs use are a concern. We want to know are they throwing up?
Does it have blood in it? Does it look like coffee grounds? Coffee grounds would mean that it has dried blood in it.
Is there blood in the stool? And if it's coming from the upper GI tract, like say the duodenum, then by the time it comes out in the stool, it's really not going to look red like blood. It's going to be dark.
It's going to be black. It's going to look tarry. That's how it's described.
Ask if there's a family history. And then think about signs of anemia. If the patient has a bleeding, ulcer. Then signs of anemia that we would want to look for would be are they fatigued?
Do they have weakness? Are they dyspneic? Do they have palpitations or a headache?
Do they have chest pain, angina? Do they have cognitive impairment, dizziness, pallor, tachycardia, bounding pulses? Make sure you think deeply about why each one of these symptoms would be present in a patient with anemia and understand what's going on in the body that would cause them to have these signs and symptoms. Our medical management is probably going to begin with some diagnostic testing and EGD is an upper GI scope and it can be done with or without a biopsy and that scope can go all the way into the duodenum and so that can visualize those tissues and see if there's an ulcer and how deep and how large it is and if it's bleeding. We can do testing for H.
pylori to find out if this bacteria is present. There are blood tests we probably want to check a CBC. We want to find out what their hemoglobin hematocrit is.
This patient if they've lost a lot of blood we might be doing a blood transfusion for them. Sometimes, sometimes surgery can be done if an ulcer fails to heal. And that would be an ulcer that doesn't fail, that doesn't heal after say 12 to 16 weeks, or it has a life-threatening hemorrhage if it perforates, or if it creates an obstruction so that the... the stomach can't properly empty. When we're talking about testing for H.
pylori, we can do a blood test to look for antibodies. There's a stool test for it and then there's also a breath test that a patient can do. So there's multiple ways to detect H. pylori and then we can also test the stool because even if You can't see it sometimes there will be blood in the stool so we're testing the stool for occult blood. The treatment of choice for peptic ulcer is a combination of antibiotics.
So they'll be prescribed two antibiotics and a proton pump inhibitor to help. decreased acid production while the body heals this ulcer. And sometimes they're prescribed bismuth salts.
It is recommended that this combination drug therapy lasts for 10 to 14 days. Some of our patient teaching will include that they need to take the full course. of the antibiotics, that they should refrain from drinking and smoking.
Additionally, the patient should be told to avoid the use of aspirin and NSAIDs and to continue all of the medication even if they start feeling better. Sometimes a patient will then be placed on a maintenance dose of either an H2 blocker or a PPI for a time frame maybe up to a year to help. maintain their protection from developing a future ulcer.
This image kind of summarizes a lot of the important information about ulcers. You can see that it has the difference between gastric ulcers and duodenal ulcers and the common risk factors that can affect the development of either one of those. And then the other ulcers I mentioned about the stress ulcers, there's a section here that talks about that. Depending upon what injury the patient has that brings on the ulcer, then they're named different kinds.
So some of them are Cushing's ulcers that go with like a brain injury or Curling's ulcer that goes with the patient who has extensive burns to their body. So I would advise you to use this to help make sure you understand all of the connections between similarities as well as the differences of these two conditions. All right, so when we think about our nursing care for this patient, we're doing a lot of education and we're doing medication administration.
We're going to be monitoring for are potential complications which can be quite severe if perhaps this ulcer starts bleeding severely or perforation occurs. Some of our patient teaching will be in the realm of smoking cessation. Additionally, alcohol consumption needs to be reduced or eliminated.
Some of the dietary considerations, they should avoid over secretion of acid and hypermobility in the GI tract. These can be minimized by avoiding temperature extremes in their food and beverages and overstimulation of the consumption of alcohol, coffee. including decaf, which can stimulate acid secretions and other caffeinated beverages.
They should try to kind of have smaller frequent meals if that helps them manage the pain and nausea. Different patients will have different foods that kind of trigger. their signs and symptoms and exacerbate it. So they should be encouraged to take note of what they eat and how it makes them feel so that they can make some adjustments. Some of our care is going to be in helping to relieve pain, but obviously we're not going to want to use NSAIDs or aspirin for that.
Some of the potential complications include a hemorrhage, GI tract bleeding can occur, and these hemorrhaging from peptic ulcers are a very common cause of upper GI tract bleeding, and it can cause, it increases the risk of patient's death if they develop a hemorrhage. associated a 10% increased mortality rate if the patient has a bleeding peptic ulcer. It's difficult to treat that because it's hard to put pressure on the location which is one of our key ways of addressing hemorrhage. So be mindful of watching for a patient who is vomiting bright red blood.
or dark coffee ground appearance of their MSS. Be prepared to assess for other signs and symptoms. So if they are hemorrhaging but it's not showing, they're not vomiting blood, they may be showing signs, other signs of hemorrhage in that they're faint or dizzy or they feel nauseous.
They have a low blood pressure. or a high heart rate or tachypnea. These are all signs that they may be having a bleed.
As soon as we can identify that, we need to do something to correct it. So we need to monitor, we need to inform the provider if we suspect a GI bleed. so that they can take them for a scope and a procedure that will help to cauterize the bleed or stop it from hemorrhaging.
Another potential complication would be perforation. and that's when the erosion of the ulcer goes all the way through and into the peritoneal cavity. It is an abdominal emergency and will require immediate surgery.
Perforation of peptic ulcers additionally obviously will increase the chance of mortality so it is a potentially lethal complication. Penetration is the erosion of the ulcer through the gastric serosa into adjacent structures such as the pancreas or the biliary tract. So it kind of depends on the location of the ulcer to begin with and then as it progressively gets worse and deeper it can start affecting the next set of tissues that it's up against. Symptoms of penetration can include back and epigastric pain that is not relieved by medications, kind of like they had been well controlled on a pain medication, but now whatever we give them, it's not helping.
Signs of... Sorry, changing my... The signs and symptoms of perforation include sudden, severe upper abdominal pain. Pain may be referred to the shoulder, especially to the right side. Vomiting, the patient may faint.
There may be extremely tender and rigid abdomen. If you ever experience a patient that has a board-like abdomen. You go to palpate it and it is rigid.
That is a very poor sign that the patient is experiencing perforation or peritonitis. Hypotension and tachycardia, which are signs that would indicate that the patient may be experiencing shock. Another potential complication is gastric outlet obstruction.
Depending upon the location of the ulcer, you know that part of the body's response is going to be an inflammatory response to the injury. And so between the ulcer and the edema and swelling that happens because of the injury, it's possible that the passageway out of the stomach and into the duodenum can be blocked by the ulcer. And of course, that would also be an emergency because they can't empty the stomach. Some of the signs and symptoms will be nausea and vomiting. They may actually have constipation, feel epigastric fullness, or perhaps no appetite, anorexia.
And it will eventually lead to weight loss because they are unable to eat and process the food. Often an NG tube will be used initially to decompress the stomach because it's a form of a bowel obstruction. Then a surgical procedure can be done to help remove the ulcer or a balloon dilation can be done where it helps to open up that passageway.
while the ulcer is healed. So when we're talking about the psychosocial and holistic caring considerations, these patients have a lot of pain and we want to address the fact that this is a difficult injury, physical condition for them to deal with. It's interfering with their daily living, so we want to be careful about, you know, show our concern for that.
We also want to teach them about the self-care that they need to be doing, educating them and their family about things that have maybe contributed to the ulcer and how to keep it from recurring, how to heal it, you know, taking the medications. quitting for a lot of people. They may have to make modifications to their diet and their lifestyle.
And the patient may be experiencing anxiety and stress related to hospitalization and the treatments, and that's not really going to help that ulcer get any better. so we need to try to help them manage their stress and anxiety as best we can. Here are a couple of graphics to kind of help you understand a little bit more about peritonitis. On the right side are several different causes that are frequently seen that result in peritonitis, and then on the left side is a graphic that shows you treatment, nursing care considerations, your assessment findings, and some other risk factors that contribute to this potential problem. So just look over these and see if they can help you to understand the association between our cause and our symptoms and our treatment, because that's really an important aspect of nursing, that we can connect all those different parts and pieces to get a big picture and understand the whole, and what's happening to the patient, and why the treatments are the right things to do, and how that should help the patient.
I would encourage you to take a moment. To pause and think, I would encourage you to stop and review these potentially, these severe potential complications of peritonitis and perforation. And in order to know if you really understand it, one of the best ways to do that is try to explain it to someone who's not familiar with the information.
So see if you can find someone. and explain the differences and the similarities of peritonitis and perforation to someone who is not familiar with the information. Additionally, see if you can explain why a patient experiencing a peptic ulcer is at an increased risk of hemorrhagic shock. Gastroesophageal reflux disease, commonly referred to as GERD, which is just an abbreviation using the letters from this disease process.
It is a fairly common disorder. It is marked by backflow of gastric contents into the esophagus that causes symptoms and mucosal injury to the esophagus. If you think about the purpose of the esophagus, it is a tube that just shuttles the food from the mouth where it's been chewed up, mixed with digested enzymes in the mouth, and swallowed, and it's a passageway that conducts that food into the stomach.
It has a sphincter at the bottom that is supposed to allow only one way flow, so only should be going down and into the stomach. Okay, now occasionally when we have an illness that causes vomiting, obviously stuff comes back the other direction and empties out of the stomach. But for a person with GERD, what we're seeing is relatively frequent reflux occurring because the sphincter that is supposed to close down is incompetent, so there's backflow.
Sometimes there's pyloric stenosis. Occasionally a hiatal hernia will cause a problem that leads to reflux or a motility disorder to where the stomach motility isn't working properly. The incident of GERD does seem to increase with age.
It is seen. frequently in patients that have irritable bowel syndrome and obstructive airway disorders, peptic ulcers, and angina. GERD is often associated with tobacco use, coffee drinking, alcohol consumption, and gastric infections with H. pylori. Its manifestations include pyrosis, which is the medical name for heartburn, where in the upper abdomen or lower chest, even in the upper areas of the chest, there's this burning sensation, which you can imagine results from the acidic contents of the stomach coming in contact with the esophagus, which is not designed to handle the acids.
Dyspepsia is another symptom and that's just indigestion, regurgitation, dysphasia, hypersalivation, and esophagitis. So that can cause swelling of the esophagus itself. Sometimes the symptoms may actually feel like the patient is having a heart attack.
It does trigger some of the same nerve responses as a heart attack would do. So sometimes the pain can actually be mistaken for a heart attack. It can lead to, depending upon how high up the esophagus the reflux goes, it can affect the teeth and cause dental erosions.
It can cause ulcerations in the pharynx and the esophagus. It can cause esophageal strictures, and it can actually lead to esophageal cancer. And if the reflux is then aspirated, then we can see aspiration pneumonia, pulmonary complications going on because of it.
Assessment and diagnostics. A lot of times a patient history will just tell us if they can describe their symptoms. Additionally, we can do an endoscope to look at the esophagus and the stomach.
Sometimes a barium swallow is done, which is where the patient will consume a liquid of barium. radio-opaque so then they'll take an x-ray and watch the swallowing of that to see if it hangs up if it refluxes those kind of things sometimes patients wear an esophageal ph monitor that will help evaluate the degree of the acid reflux our management begins with educating the patient to avoid situations that will decrease that esophageal sphincter pressure or cause esophageal irritation. So often these patients are overweight and have a lot of abdominal fat and that extra body weight puts more pressure. on the lower esophageal sphincter. So losing weight, not wearing tight-fitting clothes.
Helps like not wearing a tight belt at the waistline can help to avoid increasing that pressure, avoiding the triggers. Foods like caffeine, alcohol, milk tends to be a problem for a lot of people. Foods with mint like peppermint or spearmint and a lot of times carbonated beverages are triggers. that just seem to be more frequently refluxed after a patient consumes them.
Additionally, patients should be advised not to eat or drink a couple of hours before going to bed because acid reflux in the night when you're laying recombinant is a great risk factor for aspiration. Additionally, because of that, we would... advise the patient to elevate the head of the bed by at least 30 degrees.
Now they can do that by you know propping up on pillows. They can do that by having one of those mattresses that that raises and lowers on the angles or simply taking a couple of bricks and putting them at the head of the bed under the headboard. That will raise the whole bed onto an angle and allow that patient.
to sleep at at least a 30 degree angle so that they can avoid it's not going to stop the reflux it will kind of tamp it down because it has to go against gravity but it is going to help reduce the incidence of aspiration some of our medical management is they may do a scope to look and see what's going on. A patient will frequently be given PPIs or H2 receptor blockers to help tamp down the acid production and that helps with when they do reflux there's less acid to do damage to the esophagus and less opportunity for a stricture. If the esophagus does develop scar tissue and have a stricture, then it can cause difficulty in the patient's swallowing. Sometimes patients will have food that just won't clear the esophagus and they'll have to go in and have what's called an esophageal stretch done where they'll use various devices including maybe a balloon or a tube that is expanded.
that kind of breaks down that scar tissue that's formed and opens the esophagus back up more fully that the patient then can swallow better. One of the potential complications that can happen with gastroesophageal reflux disease, it's so common and we often don't think of it as being a dangerous condition, but the damage that can be done over time to the esophagus besides causing this difficulty in swallowing, it actually causes a change in the lining of the esophagus. It causes these cells to morph into a different kind of cell that is more protective so that the esophagus is more protected from the acid reflux.
and when this develops it's called Barrett's esophagus, but it's also a known precursor to esophageal cancer. So it's best if we can get this patient to get this acid under control and decrease those incidences of reflux and that will help protect them from these potential problems down the line. So some of our nursing care considerations are good thorough assessments and monitoring.
If the patient is having reflux that's causing esophageal damage, then they could develop an ulcer in their esophagus, which could potentially turn into a hemorrhaging situation, which would be very, very dangerous and life-threatening. We have to do some teaching on diet choices, on ways to reduce that. that pressure from weight loss to clothing choices, education on the food that they ought to and ought not to eat, changing habits like smoking and drinking, and changing some of their food choices.
You know when I said that they should avoid milk, it's not just milk, sometimes cheeses. Sometimes ice cream. These are dairy products that can also contribute to this and those can be hard things sometimes for patients to have to give up.
So I mentioned a little bit about the potential complications, you know, the development of Barrett's esophagus, the potential for esophageal ulcers, and the potential for aspiration. and aspiration pneumonia. You can imagine the contents of your stomach coming up your esophagus and taking that into your lungs.
So not only are we just talking about something that shouldn't be in the lungs at all, we're talking about an acidic content that could really do some serious damage in the lungs and cause a pneumonia. There is some surgical procedures that can be done. They can do a fundiplication where they take part of the stomach and wrap it around the esophagus. It changes the pathway so that food can still come in, but it's much more difficult for stuff to reflux out. I mentioned a minute ago about the psychosocial holistic care concerns when we're talking about food considerations and the fact that sometimes these patients because of this may be on a medication now for the rest of their lives and and that's something that's sometimes difficult for patients to accept and deal with um and then the patients and the family teaching we're definitely going to be teaching them all about the causes all about the treatments the medications there's always lots of teachings to do about medications and then, you know, the lifestyle changes that have to happen to control this.
Now for a little bit about hiatal hernias. Remember when we talked about the AMP of the GI system, how the esophagus has to pass through an opening in the diaphragm. and then the stomach is on the other side. So a hiatal hernia is when part of the stomach will bulge up through that diaphragm and be on the wrong side of it.
There are two different types. There's a sliding hernia where part of the stomach, just the part that's directly attached to the esophagus, that just kind of slides up and is on the wrong side of the diaphragm. Another kind is a paraesophageal where it's actually a second area in the diaphragm that has a weakness in the muscle and part of the stomach goes up between in an area where nothing is supposed to pass up and down. I have a slide coming up that's going to show that.
image to explain that a little bit better to you. But the manifestations of a hernia, especially a sliding hernia, you're going to have heartburn and regurgitation and dysphagia. But a lot of times patients have a sliding hernia and they have no symptoms at all. So one of the reasons why it's called a sliding hernia is because sometimes It kind of slides up and then comes back down.
So it doesn't always, it's not always present at any given moment. So sometimes the stomach will push back up a little for a while and the patient may be symptomatic. And then after a bit, it relaxes and goes back down on to the other side of the diaphragm and the patient's symptoms are resolved. They are commonly associated. with guard as with any kind of a hernia.
any kind of hernia where any part is of the GI system is kind of pushing through the muscles. Okay, we're going to talk about other kinds of hernias like umbilical hernias and inguinal hernias. But anytime that happens, there's a possibility of hemorrhage, obstruction, and strangulation because if that tissue gets trapped, through that herniation then it can be cut off from its blood supply and can cause like necrosis of the tissue.
The diagnosis and assessment is usually done with an x-ray like a barium swallow If part of the stomach is in above the diaphragm, an EGD, which is an abbreviation for a test called the esophagogastroduodenoscopy, EGD. And that's where they do a scope of the mouth and the throat and the upper GI tract to see what's going on. Additionally, a lot of times dietary changes will be sufficient to manage a hernia.
Having the patient eat smaller meals, more frequent meals that pass easily through the esophagus. They are advised not to lay down for at least an hour after eating. to prevent the reflux and the movement of the hernia. They also should have their head of the bed elevated like we talked about with GERD. Sometimes surgery is done to repair a hernia if the patients are very symptomatic and they can also fix the problem with the GERD at the same time.
when they're doing the surgery. Here are the images that I was saying. You can see on the left side, this is the sliding hernia where the upper portion of the stomach just comes up through the diaphragm in the same area where the esophagus already comes down. so it just kind of slides up sometimes it hangs up there for a while often it just relaxes and comes back down to the other side of the diaphragm the picture on the right however is another section of the diaphragm has a weakened area and part of the stomach has herniated through that section and so you can see how the the perisophageal one on the right has the potential for that tissue that's herniated through the diaphragm to become strangulated, and that could cause obviously some serious complications for the patient.
All right, as far as atal hernias go, often the patient may be in the hospital to have a hernia repair. in which case we're talking about post-op and pre-op care as normal. A lot of these surgical repairs, they attempt to do them laparoscopically, which makes for fewer potential complications. But anything that the hiatal hernia is causing is going to be similar to what goes on with our patient with GERD. We'll want to monitor for all of those same signs and symptoms and the potential complications of like the reflux and the aspiration potential.
And if it's a paraesophageal hernia then that surgical repair is going to be a little bit different and their signs and symptoms are going to be a little different. Psychosocially, once again, this patient needs to be counseled about their diet and their pain management because we wouldn't want them using NSAIDs and aspirins, if at all possible, because of the potential increased risk of bleeding and damage to the GI system. There's not necessarily a medication per se for this. This is more... geared towards lifestyle changes with their eating habits and staying upright rather than reclining after a meal and perhaps some certain dietary that will help them be more comfortable.
All right another opportunity for you to pause and think. I would encourage you to review the similarities and the differences between GERD and hiatal hernias and think about why might these two conditions have similar signs and symptoms. This slide has an image that shows you another kind of hernia. This is not a hiatal hernia or a paraesophageal hernia. This is a hernia that comes through the abdominal wall and part of the bowel has slipped through it.
These images show common locations of other hernias where part of the abdominal wall has weakened and part of the large or small intestines has kind of protruded through that weakness. So it's come through the muscle and yet it's still underneath the skin and the subcutaneous tissue. You can see these locations that are common epigastric, umbilical, inguinal, and femoral.
So I'd like you to kind of consider what kinds of signs and symptoms this might cause the patient. Sometimes these hernias are what's called reducible where if the patient say has an umbilical hernia like the one on this image and it protrudes sometimes the patient can just kind of gently press on it and it will go back under the muscle that's called being reduced sometimes they stay protruding sometimes it impacts the GI system and sometimes it doesn't. Oftentimes it can cause quite a bit of pain, as you can imagine, if that area becomes strangulated, incarcerated from the rest of the GI tract and food passing through could get lodged there and cause that hernia to increase in size. or the food not to be able to pass through the rest and peristalsis kind of gets hung up there, this can be a way that that can cause a bowel obstruction.
So just think about location of it and and the consequence to the GI system if food is trying to pass through and that is is coming through the abdominal wall whether it's strangulated or incarcerated or not. This is the end of the content. Be sure to review these learning objectives. Test yourself on this information.
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