Upper GIT disorders

8/9/2019 Upper GIT disorders

1/45

PEPTIC ULCER


2/45

PEPTIC ULCER

A break in the mucous lining of thegastrointestinal tract when it comes in contact

with gastric juice

peptic ulcer occurs in any area of the

gastrointestinal tract exposed to acid- pepsinsecretions, including esophagus, stomach or

duodenum.


3/45

RISK FACTORS H. pylori infection

Low socioeconomic status

Crowded, unsanitary living conditions

Unclean food or water

Use of NSAIDs

Advance age

History of ulcer

Cigarette smoking

Family history of PUD

Psychological stress, alcohol, caffeine consumption


4/45

PATHOPHYSIOLOGY

MANIFESTATIONS pain- gnawing, burning, aching or hungerlike

located at the epigastric region sometimes

radiating at the back

pain occurs when the stomach is empty 2-3

hours after meals and in the middle of the night

Relieved by eating


5/45

MANIFESTATIONS OF PUD

complicationsHEMORRHAGE Occult or obvious blood in the stool

hematemesis

Weakness, dizziness orthostatic hypotention

hypovolemic shock

OBSTRUCTION sensation of epigastric fullness

nausea and vomiting

electrolyte imbalances

metabolic alkalosis


6/45

PERFORATION

severe upper abdominal pain, radiating to theshoulder

rigid boardlike abdomen

absence of bowel sounds

diaphoresis tachycardia

fever


7/45

DIAGNOSTIC TESTS

Upper GI series using barium as a

contrast can detect 80%- 90% of peptic

ulcers. Gastroscopy- allows visualization of the

esophagus, gastric and duodenal mucosa

and direct inspection of ulcers. Tissue can

be obtained for biopsy


8/45

MEDICATIONS eradication of H. pylori combination of two

antibiotics bismuth or proton pump inhibitors( omeprazole, metronidazole and clarithromycinor bismuth subsalicylate, tetracycline andmetronidazole

medications that decrease gastric acid contentinclude proton pump inhibitors and H2 receptorantagonist

agents that protect mucosa sucralfate,bismuth, antacids and prostaglandin analogs


9/45

TREATMENTS

dietary management

Clients are encourage to maintain good

nutrition, consuming balanced meals at regular

intervals.

alcohol intake

smoking should be discourage as it slows the

rate of healing and increases the frequency of

relapses.


10/45

Nursing diagnoses and Interventions

PAIN typically experienced 2-4 hours after

eating , a high levels of gastric acid and pepsin

irritate the exposed mucosa.

assess pain, including location, type, severity,frequency, and duration and its relationship to food

intake

administer proton- pump inhibitors, H2 receptor

antagonists, antacids. Monitor foe effectiveness and

side effects or adverse reactions.

teach relaxation, stress reduction and lifestyle

management techniques.


11/45

SLEEP PATTERN DISTURBANCES- night time

ulcer pain, typically occurs between 1- 3 am,

may disrupt the sleep cycle and result in

inadequate rest.

the importance of taking the medications as prescribed

( bedtime dose)

instruct the client to limit food intake after the eveningmeal, eliminating bedtime snacks. (stimulate the

production of gastric acid and pepsin)

encourage use of relaxation techniques


12/45

IMBALANCE NUTRITION:LESS THAN BODY

REQUIREMENTS

assess current diet, including pattern of food intake,

eating schedule and food that precipitate pain or being

avoided.

refer to dietician for meal planning and meet nutritional

needs monitor for complaints of anorexia, fullness, nausea,

and vomiting

monitor laboratory values for indications of anemia or

other nutritional deficits.


13/45

DEFICIENT FLUID VOLUME- bleeding canlead to hypovolemia and volume deficit, which

can lead to decrease in cardiac output andimpaired tissue perfusion. monitor stool and gastric drainage ( vomitus or

nasogastric tube)

Bright red with possible clots acute hemorrhage

dark red or coffee ground blood has been in thestomach for a period of time

hematochezia- stool containing blood and clots( acutehemorrhage

melena black tarry stool ( less acute bleeding)


14/45

maintain IVF with volume and electrolyte solutions,

administer whole blood or PRBC as ordered.

insert NGT and maintain its position and patency( if

ordered may irrigate with sterile normal saline until

return flow is clear)

monitor hgb and hct, serum electrolyte BUN and CREA.

( digestion and absorption of blood in the GI tract may

result to elevated BUN and CREA.

assess abdomen, including bowel sounds, distention,

girth and tenderness.

maintain bedrest with the head of bed elevated


15/45

DIVERTICULAR DISEASE

are saclike projections of mucosa through

the muscular layer of the colon.

diverticula may occur anywhere in thegastrointestinal tract

affect the large intestine with 90% - 95%

occurring in the sigmoid colon.


16/45

PATHOPHYSIOLOGY

DIVERTICULOSIS

presence of diverticula

asymptomatic

episodic pain ( usually left- sided), constipation or

diarrhea, abdominal cramping, occult bleeding in the

stools, weakness and fatigue

complications include hemorrhage and diverticulitis


17/45

DIVERTICULITIS- inflammation in and around

the diverticular sac.

undigested food and bacteria collect in the

diverticula , forming a hard mass ( fecalith) that

impairs he mucosal blood supply, allowing

bacterial invasion

mucosal ischemia can lead to perforation,

bacterial contamination and can lead to

abscess formation or peritonitis.


18/45

pain it is usually left- sided and may be mild to

severe and either steady or cramping.

constipation or increase frequency in defecation

nausea, vomiting and fever may occur

abdomen is distended with tenderness and s

palpable mass in the left lower quadrant resulting

from inflammatory response


19/45


20/45

Diagnostic tests

WBC count leukocytosis ( increase in

the number of immature wbc) due to

inflammation

hemoccult or guaiac testing

barium enema\abdominal x-ray

CT scan

sigmoidoscopy or colonoscopy


21/45


22/45

Dietary Management

a high fiber diet is recommended- increases

stool bulk , decreases intraluminal pressure andmay reduce spasm.

avoid foods with small seeds like popcorn,berries which could obstruct diverticula

bowel rest is prescribed put patient on NPO withIVF and possibly TPN

feeding is resumed initially clear liquid then soft,low roughage diet


23/45


Impaired tissue integrity: gastrointestinalMonitor VS every 4 hours Tachycardia and

tachypnea may be early indications of increase

inflammation and resulting to fluid shift. Fevermay indicate increase or spread of inflammation

assess abdomen every 4 hours, measureabdominal girth, auscultating bowel sounds,palpating for tenderness

assess for lower intestinal bleeding

maintain IVF, TPN and accurate I and O


24/45

painAsk the client to rate the pain using the pain

scale, document level of pain and note for anychanges in location or character of pain

administer prescribed analgesics or PCA, userelaxation, positioning and distractions.

maintain bowel rest and total body rest reintroduce oral foods and fluids slowly,

providing a soft, low fiber diet with bulk formingagents


25/45

anxiety assess and document the level of anxiety

demonstrate empathy and awareness of the perceivedthreat to health

attend to physical care needs

spend as much time as possible to client

encourage supportive family and friends to remain withthe client

assist client to use and identify appropriate copingmechanism

involve the client and family in care decisions


26/45

CHOLELITHIASIS/ CHOLECYSTITIS

CHOLELITHIASIS is the formation of stones within thegallbladder or biliary tract system.

Bile is formed by the liver and stored in the gallbladder. Bilecontains bile salts, bilirubin, water, electrolytes,cholesterol, fatty acids and lecithin. In the gallbladder,some of the water and electrolytes are absorbed, foodentering the intestine stimulates the gallbladder tocontract and release bile through the common bile duct

and sphincter of oddi in the intestine. The bile salts in thebile increases the solubility and absorption of dietaryfats.


27/45

PATHOPHYSIOLOGY

RISK FACTORS

age

family history of gallstones

race

obesity, hyperlipidemia

rapid weight loss female gender

biliary stasis

diseases or conditions


28/45

CHOLECYSTITIS- is the inflammation of thegallbladder.

Acute cholecystitis usually follows obstruction of thecystic duct by a stone. The obstruction increasespressure within the gallbladder leading to ischemia ofthe gallbladder wall and mucosa. Ischemia can lead tonecrosis and perforation of the gallbladder.

biliary colic- pain involves the entire RUQ and may

radiate to the backright scapula or shoulder. movement or deep breathing may aggravate the pain

last longer 12- 18 hours

anorexia, nausea and vomiting are common

fever with chills


29/45

chronic cholecystitis result from repeated

bouts of acute cholecystitis or from persistent

irritation of the gallbladder wall by the stones.

bacteria may be present

asymptomatic

complications include empyema a collection ofinfected fluid in the gallbladder, gangrene and

perforation with resulting peritonitis or abscess

formation


30/45

Diagnostic Tests

serum bilirubin elevated direct bilirubin mayindicate obstructed bile flow in the biliary duct

CBC- elevated may indicate infection and

inflammation abdominal x-ray gall stones with a high

calcium content

serum amylase and lipase- possible

pancreatitis related to common duct obstruction UTZ of the gallbladder- accurately diagnose

cholethiasis


31/45

medications

ursodiol( actigall) and chenodiol (chenix)- reduce the cholesterol content ofgall stones, leading to gradual dissolution

side effects diarrhea and hepatotoxic

disadvantages long duration ( 2 years ormore) and a high incidence of recurrent

stone formation when treatment isdiscontinued.

antibiotics


32/45

treatment

laparoscopic cholecystectomy ( removal

of the gallbladder)

cholecystostomy drain the gallbladder

choledochostomy- remove stones and

position a T tube in the common bile duct


33/45

dietary management

food may be eliminated during an acute attack NGT is inserted to relieve nausea and vomiting

dietary fat intake may be limited

Shock wave lithotripsy


34/45


pain

Discuss the relationship between fat intake and the

pain- fat entering the duodenum initiates gallbladder

contractions causing pain when gallstones are presentin the ducts

withhold oral food and fluid during episodes of acute

pain

administer analgesic or narcotic analgesia morphine

causes spasm of the colon place in fowlers position

monitor vs including temp.


35/45

imbalanced nutrition : less than body requirements assess nutritional status

evaluate laboratory results refer to dietician or nutritionist

risk for infection monitor vs including temp

assess abdomen every 4 hours

assist to cough and deep breath or use of spirometer, splintabdominal incision with blanket or pillow while coughing

place in fowlers position and encourage ambulation

administer antibiotics


36/45

PANCREATITIS

inflammation of the pancreas, that

involves self- destruction of the pancreas

by its own enzymes through autodigestion.

characterized by release of pancreatic

enzymes into the tissue of the pancreas

itself leading to hemorrhage and necrosis.


37/45

interstitial edematous pancreatitis- leads

to inflammation and edema of pancreatictissue.

necrotizing pancreatitis inflammation ,

hemorrhage and ultimately necrosis of

pancreatic tissue.


38/45

PATHOPHYSIOLOGY

MANIFESTATIONS

ACUTEAbrupt onset of severe epigastric pain and LUQ pain, may radiate to

back

nausea and vomiting, fever

decrease bowel sounds, abdominal distention, rigidity

tachycardia, hypotension,cold clammy skin

possible jaundice CHRONIC

recurrent epigastric and LUQ pain, radiates to the back

anorexia, nausea, vomiting, weight loss

Flatulence, constipation

steatorrhea


39/45

Diagnostic Tests

UTZ can identify gallstones, pancreatic mass,pseudocyst( abnormal collection of fluid, deadtissue, pancreatic enzymes and blood that canlead to a painful mass in the pancreas)

CT scan identify pancreatic enlargement, fluidcollections

Endoscopic retrogradecholangiopancreatography ERCP perform todiagnose chronic pancreatitis

endoscopic UTZ

percutaneous fine needle aspiration biopsy-differentiate from cancer


40/45

medications narcotic analgesics

antibiotics

H2 blocker and proton pump inhibitor to neutralize or decrease gastric

secretions

synthetic hormone- octreotide(

sandostatin) suppresses pancreatic

secretion and may relieve pain


41/45

fluid and dietary management

oral food and fluids are withheld duringacute episodes

NGT may be inserted

IVF , TPN


42/45

surgery

endoscopic transduodenalsphincterotomy- performed if the result of

a gallstone lodge in the sphincter of oddi

to remove the stone


43/45

nursing diagnoses and interventions

pain obstruction of pancreatic ducts and inflammation ,

edema and swelling of the pancreas caused bypancreatic autodigestion, severe epigastric pain, leftupper abdominal or midscapular back pain. Nausea andvomiting assess pain using the pain scale, location,radiation,

duration, and character NPO and maintain the patency of NGT- gastric

secretions stimulate hormones that stimulate pancreaticsecretion , aggravating pain. NGT decreases nausea,vomiting, and intestinal distention.


44/45

maintain on bed rest

assist on comfortable position

Imbalanced nutrition: less than body requirements

monitor laboratory values

weigh daily

maintain stool charting

monitor bowel sounds return of bowel soundsindicates return of peristalsis

administer prescribed IVF to maintain hydration, TPN toprovide fluids, electrolytes and kilocalories


45/45

Documents

Upper GIT disorders