Nursing: Upper GI Problems

Upper GI Problems Nausea and Vomiting: ​ Nausea: Feeling of discomfort in epigastric area; feeling like you need to vomit Vomiting: Action of “throwing up” or emesis; Forceful ejection of food and secretions Pathophysiology: ​ Stimuli from GI tract, kidneys, heart, or brian send impulses via afferent pathways to receptors in the medulla (vomiting center) to initiate vomiting reflex ​ Chemoreceptor trigger zone (CTZ) in the brainstem responds to stimuli from drugs, toxins, and motion; activates ANS ​ SNS -> tachycardia, tachypnea, diaphoresis ​ PNS -> relaxes LES, increased gastric motility, increased saliva ​ Causes: GI disorders/infections, CNS disorders, CV problem, pregnancy, endocrine/metabolic, medications, anesthesia, chemo, psychological factors, motion ​ Manifestations ​ Anorexia ​ Weight Loss ​ Prolonged: Fluid and electrolyte imbalances ​ Metabolic acidosis/alkalosis ​ Acidosis - loss of HCl acid with vomiting of small intestine contents (less common) ​ Alkalosis - loss of gastric HCl Decreased blood volume Circulatory failure ●​ Assessment ○​ subjective/objective data ■​ Last bowel movment? Is this normal for you? ■​ Has anything changed with your bowel movments? ○​ Identify high-risk patients ○​ Determine precipitating factors ○​ Describe contents of emesis ○​ Describe color and characteristics of emesis ■​ Bright red blood = active bleeding ■​ Coffee-ground color = gastric bleeding ○​ Identify timing/recurrent episodes of n/v ■​ Recurring episodes of n/v with fatigue lasting a few hours to up to 10 days = cyclic vomiting syndrome ●​ Treatment/Nursing considerations: ○​ Identify and treat cause ○​ SYMPTOM RELIEF ■​ Anticholinergic: Scopolamine patches ■​ Antihistamines: Hydroxyzine ■​ Serotonin Antagonists: Ondansetron (Zofran) ■​ Phenothiazines: Chlorpromazine, promethazine, metoclopramide, Reglan (CNS side effects) ●​ Antiemetic drugs - can CNS side effects: confusion, falls ●​ During hospital visit; patient is having issues with keeping food down; ○​ NPO ○​ IV Fluids ○​ NGT ○​ Monitor I/O, assess for dehydration ○​ Aspiration precautions ○​ Dietary consult if needed ●​ Outcomes ○​ Minimal or no N/V ○​ Electrolytes within normal limits (WNL) ○​ Maintain adequate fluid and nutrient intake Gastroesophageal Reflux Disease(GERD): ●​ Chronic mucosal damage d/t reflux of stomach acid into the esophagus (most common upper GI) ○​ Gastric contents come up esophagus, can cause pain, discomfort, esophageal problems ●​ Patho: ○​ Gastric contents are acidic, overwhelm the esophagus defenses, and causes irritation and inflammation ○​ Primary factor: incompetent lower esophageal sphincter (LES) ■​ Caused by food, drugs, obesity, hiatal hernia ■​ Medication induced esophagitis - NSAIDs and K+ ●​ Clinical Manifestations ○​ Heartburn (pyrosis) - most common s/s ■​ Burning, tight sensation under lower sternum spread into throat or jaw ■​ May mimic angina but relieved with antacids ○​ Dyspepsia ■​ Pain/discomfort in upper abdomen ○​ Regurgitation ■​ Hot, bitter, or sour, liquid in mouth or throat ○​ **may complain of cough at night** ●​ Complications ○​ Esophagitis: ulcerations lead to scar tissue, stricture and dysphagia-difficulty swallowing ○​ Barrett’s Esophagus: replacement (metaplasia) of esophageal cells; increases risk for cancer ○​ Respiratory: cough, bronchospasm, laryngospasm, aspiration into respiratory systems, chronic bronchitis, pneumonia (gastric secretions irritate upper airway, aspiration) ○​ Dental erosion of posterior teeth ●​ Diagnostic studies ○​ Upper GI endoscopy**hallmark dx for ANY upper GI issue** ○​ **most often diagnosed using symptoms ○​ barium swallow ○​ Manometric studies - esophageal pressure and motility function ○​ PH monitoring when no evidence of inflammation ○​ Radionuclide studies - reflux of gastric contents and esophageal clearance ●​ Treatment/Nursing Considerations: ○​ Lifestyle modifications ■​ Low-fat diet, small meals ■​ Avoid alcohol, caffeine, and smoking ■​ *Upright position 2-3 hrs after meals ■​ Avoid tight clothing at the waist or bending over after eating ■​ Weight reduction ■​ Avoid eating 3 hrs before bed ■​ HOB - semi-fowlers ■​ Coping with stress, weight management, increased physical activity ●​ Drug Therapy ○​ PPIs: “prazole” -> #1 DRUG for GERD ■​ Decrease HCl secretion and irritation ■​ Decreased incidence of strictures; take before 1st meal ■​ Adverse s/e with with prolonged use: ●​ decreased bone density, ●​ kidney disease, ●​ vitamin B12 deficiency, ●​ risk of dementia ○​ H2 receptor blockers: “tidines” (pepcid, cimetidine, famotidine) ■​ Decrease HCl secretion and irritation ■​ Onset 1 hour duration up to 12 hours ■​ Oral, IV. combined with antacid ○​ Prokinetics: metoclopramide (Reglan) ■​ Extrapyramidal effects (tremor and dyskinesia) ■​ CNS (anxiety and hallucinations) ○​ Antacids (tums, AlkA-Seltzer) ■​ Neutralize acid ■​ Provides quick relief for mild, intermittent symptoms ■​ Short duration: 1-3 hours after meals and at bedtime ■​ Cautious use with older adults, cirrhosis, HTN, and renal pts, due to increased Na+ ●​ Nursing and Interprofessional Management ○​ Surgical therapy: ■​ Nissen Fundoplications:Fundus wrapped around back side of esophagus, secured with sutures to anchor LE below diaphragm ■​ Reduces reflux and enhances LES function in those with complications or persistent symptoms ○​ Nutritional Therapy ■​ Avoid foods that decrease LES pressure: chocolate, fatty food, peppermint, coffee, tea ■​ Avoid irritating foods and soda: spicy foods, acidic foods ■​ Avoid milk and eating before bedtime ■​ Encourage small meals and fluids between meals Hiatal Hernia: ●​ Herniation of part of the stomach into the esophagus through an opening (hiatus) in the diaphragm. ●​ Etiology and patho ○​ Structural: weakened muscle in the diaphragm and esophagogastric opening occurs with aging ○​ Increased abdominal pressure ○​ Two types ■​ Sliding: part of stomach slides thru opening in the diaphragm ■​ Rolling: fundus rolls up and creates a fixed pocket; medical emergency! ●​ Clinical Manifestations: similar to GERD ○​ Heartburn (pyrosis) ○​ Dyspepsia ○​ Regurgitation ○​ Chest pain ●​ Complications: GERD, esophagitis, ulcers, stenosis, strangulation, aspiration ●​ Diagnostic studies: same as GERD = endoscopy OR barium swallow ●​ Nursing and Interprofessional Management ○​ Conservative : Reduce intra abdominal pressure -> don’t wear tight clothes, belts, decrease weight, don’t bend over ○​ Surgical: optimize LES pressure, prevent movement of the gastroesophageal junction ■​ Reduce hernia ■​ Herniotomy ■​ Fundoplication-top part of stomach is folded and sewn to LES ●​ Gerontologic considerations: ○​ Incidence increases with age ○​ Drug concerns: decrease LES pressure (nitrates CCB, antidepressants) ○​ May be asymptomatic ■​ First sign may be severe - esophageal bleeding or respiratory complications from aspiration ESOPHAGEAL DIVERTICULA ●​ Sac-like outpouchings of one or more layers ●​ Three main areas ○​ Above upper esophageal sphincter ○​ Near esophageal midpoint ○​ Above LES ●​ Symptoms ○​ Dysphagia ○​ regurgitation ○​ Chronic cough ○​ Food trapped in pouches causes sour taste and smell ○​ Complications: Perforation of esophagus, malnutrition, aspiration ●​ Diagnosis: endoscopy or barium studies ●​ Treatment ○​ Dietary modifications ○​ Surgery or endoscopic procedures ESOPHAGEAL STRICTURES ●​ Narrowing of the esophagus; most often from GERD ●​ Manifestations: ○​ Dysphagia ○​ Regurgitation ○​ Weight loss ●​ Treatment ○​ Dilation with bougies or balloons using endoscopy or fluoroscopy ○​ Surgical excision with temporary or permanent gastrostomy PEPTIC ULCER DISEASE (PUD) ●​ Erosion of GI mucosa from HCl acid and pepsin ○​ Susceptible ares: lower esophagus, stomach, duodenum, Subtypes: classified by degree and duration of mucosal involvement and by location ○​ Acute: Superficial erosion and minimal inflammation ○​ Chronic: Erosion of muscular wall with formation of fibrous tissue, present continuously for many months intermittently throughout a lifetime ■​ Classified by locations, gastric or duodenal ○​ Gastric: (antrum - lower part of stomach) ■​ Prevalent in females >50 years ■​ Increased obstruction ■​ Risk factors: H.pylori, bile reflux ■​ High recurrence ■​ signs/symptoms: ●​ Burning or gaseous pain ●​ Pain at 1-2 hours after meal**different from duodenal ○​ Food worsens the pain ●​ Perforation: the first symptoms in some patients; causes peritonitis ○​ Duodenal: ■​ Prevalent for ages 35-45 ■​ Etiology: H. pylori ■​ High risk factors: COPD, Cirrhosis, Pancreatitis, Zollinger-Ellison syndrome: digestive disorder that results in too much gastric acid ■​ **Constant phases of appearances and disappearances ■​ signs/symptoms ●​ Burning or cramping across the mid-epigastric line or back; under the xiphoid process ●​ Pain at 2-5 hrs after eating - Duodenum is further down the GI tract ●​ Pain relief w/ antacids ●​ Risk factors ○​ H.pylori ○​ Transmission: from family to child (ora-oral or fecal-oral) ○​ Bacteria produce urease - increased gastric secretion, tissue damage ○​ Medication induced ■​ NSAIDS; especially with corticosteroids or anticoagulants ○​ Lifestyle - alcohol, smoking, coffee, psychological distress/depression ●​ Diagnostic Studies ○​ Endoscopy gives direct visualization; most accurate ○​ Barium contrast ○​ Obtain specimens for H.pylori ○​ Labs: CBC, Liver enzymes, serum amylase ○​ Stool sample to Test for blood - may appear black/tarry ○​ Emesis - coffee ground in appearance ●​ Interprofessional Management ○​ Treatment goal = decrease acid in stomach(PPI)and enhance the mucosal defenses ○​ Conservative care: ■​ Adequate rest, drug therapy, smoking cessation, diet modifications long-term follow-up care ■​ Pain management. NO NSAIDS or ASPIRIN for 4-6 weeks unless administered with PPI, H2RB, or misoprostol. ○​ Medications: ■​ PPIs(proton pump inhibitors)**first like for peptic ulcer disease ●​ Reduces gastric acid secretions ●​ Used with ABX to treat H. Pylori ●​ Adherence to abx, report recurrence of pain or blood in vomit or stool ■​ Sucralfate ●​ Protects esophagus, stomach, and duodenum ●​ Give 1 to 2 hours before or after antacids ■​ Antibiotics ●​ 14 days of penicillin with PPI ●​ Metronidazole is used of allergy to PCN ○​ Nutritional Therapy ■​ AVOID CAFFEINE AND ALCOHOL ○​ Complications ■​ Bleeding, perforation, gastric outlet obstructions ■​ Emergency situation with surgical intervention ●​ GI bleeding, duodenal ●​ Most lethal - perforation ○​ Gi contents spill into the peritoneal cavity. Sudden, severe abd pain radiates to back and shoulders; no relief with food or antacids. ○​ If untreated, bacterial peritonitis occurs in 6--12 hrs ■​ Can lead to sepsis ○​ Immediate focus - stop spillage and restore blood volume ○​ Nursing Implementation ■​ Acute care: NPO, NGT, VS, monitor for shock, I&O, monitor labs, manage pain ■​ Gastric content analysis, check pH, blood or bile ○​ Diagnostics ■​ H&P, Upper Gi endoscopy w/biopsy, CBC, liver enzymes, amylase, tumor markers, stool occult Gastric Surgery: can be used to treat stomach cancer, polyps, perforation, chronic gastritis, PUD ●​ Partial gastrectomy ○​ Gastroduodenostomy- Billroth I ■​ Removal of the distal ⅔ of stomach with anastomosis(fusing of stomach to duodenum) ○​ Gastrojejunostomy-Billroth II ■​ Removal of the distal ⅔ of stomach with anastomosis(fusing of stomach to jejunum) ○​ Gastrectomy: ■​ Total removal stomach (anastomosis of esophagus to jejunum) ○​ Vagotomy: ■​ total or selective; sever vagus nerve; decreases gastric acid secretion ○​ Pyloroplasty ■​ Enlargement of pyloric sphincter Gastric Surgery Complications: ●​ Hemorrhage ●​ Dumping Syndrome: - direct result of surgical removal of a large part of stomach and pyloric sphincter ○​ Gastric chyme enters the small intestine as a large hypertonic bolus and pulls fluid into the bowel lumen causing decreased plasma volume, distention of the bowel lumen, and rapid transit within 15-30 mins of eating ○​ signs/symptoms: Weakness, Sweating, Palpitations, Dizziness, Cramping, Increased bowel sounds(borborygmi), Defecation urge ○​ Lasts about 1 hour, reduced with short rest periods after eating ○​ Treatment: ■​ Reduced with rest after eating: tell patient to lay down for at least 30 min after eating; slows down digestion ●​ Post op complications: ○​ Postprandial hypoglycemia: low BG after eating.. ■​ Uncontrolled high carbohydrate bolus enters small intestine causing excess insulin and resulting hypoglycemia 2 hours after eating ■​ Sweating, weakness, confusion, palpitations, tachycardia, anxiety ○​ Bile reflux gastritis (after reconstruction or removal or pylorus) ■​ Bile reflux causes damage to gastric mucosa, chronic gastritis, and PUD ■​ Epigastric distress temporarily relieved with vomiting ■​ Administer CHOLESTYRAMINE before or with meals ●​ Binds to bile salts thus decreasing amount of reflux ●​ Nursing Management: Gastric Surgery ○​ ***Prevent infection ○​ Monitor for complications ■​ Respiratory comp.(dyspnea, chest pain, cyanosis) ■​ ANASTOMOSIS LEAK ●​ Tachycardia ●​ Fever ●​ Abdominal pain ●​ REQUIRES IMMEDIATE TREATMENT TO PREVENT SEPSIS & DEATH ○​ Hemorrhage: ■​ VS, NG aspirate contents(check for blood) ○​ NGT for decompression; reduces pressure to suture line; decreases edema and inflammation ■​ Observe gastric aspirate: color, amount odor ■​ Blood drainage expected for 2-3 hrs (report excess > 75ml/hr) ■​ Monitor for clots/obstruction ●​ Nursing Management: Nutrition Therapy ○​ **reduced stomach size means reduced meal size! ○​ Small, frequent meals(6 meals) ○​ No fluids with meals, chew thoroughly (takes up space for food) ○​ Avoid simple sugars and extreme food temps ○​ Avoid hypoglycemia GASTRITIS ●​ Inflammation of gastric mucosa ○​ Acute or chronic ○​ Diffuse or localized ●​ Patho: Breakdown in gastric mucosal barrier allowing HCL acid and pepsin to diffuse back into mucosa resulting in edema and possible bleeding ●​ Risk Factors: ○​ NSAID-induced : female, > 60, hx of PUD, Anticoagulants, NSAIDs, chronic disorders ○​ Diet related: binge-drinking alcohol, spicy irritating foods - tomatoes, chocolate, ○​ Genetic: autoimmune gastritis ○​ H. Pylori ○​ Diseases: autoimmune gastritis, burns, crohn’s, hiatal hernia, stress, bile reflux, sepsis, shock ●​ Clinical Manifestations ○​ Acute ■​ Anorexia, N/V, epigastric tenderness, feeling of fullness ■​ Bleeding with alcohol use may be only symptom ■​ Self-limiting - lasts from a few hours to a few days ○​ Chronic ■​ Pernicious anemia: gastric mucosa is damaged so it does not secrete intrinsic factor ●​ Nursing Management ○​ Acute Gastritis ■​ Identify & Eliminate causes ■​ Supportive care; NPO, IV FLUIDS, ANTIEMETICS, MONITOR FOR DEHYDRATION ■​ Severe; NGT to monitor for bleeding, empty stomach ■​ Risk for bleeding ●​ Monitor VS, heme test for vomiting ■​ Drugs: PPIs or H2 receptor blockers ○​ Chronic gastritis ■​ ABX FOR H. Pylori ■​ Cobalamin (B12) for pernicious anemia ■​ Lifestyle: No smoking/alcohol/drugs; 6 small meals per day, non irritating foods UPPER GI BLEEDING ●​ Hematemesis: bloody vomitus ○​ Bright Red: arterial blood loss ○​ Coffee ground: digested blood ●​ Melena: Black Tarry stools from upper GI source ●​ Occult:Guaiac test blood in gastric secretions, vomitus or stool ●​ Causes: (can be difficult to identify) ○​ Stomach and duodenal ■​ H.pylori and NSAIDS ■​ Corticosteroids ■​ Cancer ■​ Gastritis ■​ polyps ○​ Esophageal origin ■​ Chronic esophagitis, Mallory Weiss tear or esophageal varices ●​ Varices: swollen veins in esophageal tract (medical 911!!) ●​ Diagnostics ○​ ENDOSCOPY IS GOLD STANDARD ○​ Angiography - pt cannot be high-risk or unstable ○​ CBC - Hgb & Hct ○​ BUN - GI tract bacteria breakdown protein ○​ Vomitus and stool occult ●​ Interprofessional Management ○​ Massive GI Bleed >1500 ml blood loss ○​ ASSESS FOR SHOCK = tachycardia, weak pulse, low BP, cool extremities, prolonged cap refill, apprehension ○​ Monitor urine output hourly: monitoring kidney function ○​ Hemodynamic monitoring - blood flow and BP in CV system ○​ Oxygen - increased blood O2 sat ○​ Assess FOR PERFORATION AND PERITONITIS - tense, rigid abdomen, bowel sounds ○​ Administer IV fluids ○​ Blood transfusions EMERGENCY ASSESSMENT AND MANAGEMENT ●​ Endoscopy Therapy- FIRST LINE MGMT within 24 hours to determine treatment or surgery ○​ Goal = coagulate or thrombose bleed ○​ clips/bands - compress vessel ○​ Cauterization ○​ Injection (epi or alcohol) ○​ Balloon tamponade ●​ Surgical Therapy ○​ Site identified ○​ Requires more than 2000 ml blood or shock ●​ Drug therapy: ○​ PPIs ○​ Antacids