gastic and duodenal disorders

1. 11
Management of PatientsManagement of Patients
With Gastric andWith Gastric and
Duodenal DisorderDuodenal Disorder

2. 22
An individual’s nutritional status
depends not only on the type and
amount of intake but also on the
functioning of the gastric and intestinal
portions of the gastrointestinal (GI)
system.

3. 33
1.Gastritis
(inflammation of the gastric or stomach
mucosa) is a common GI problem. Gastritis
may be acute, lasting several hours to a few
days, or chronic, resulting from repeated
exposure to irritating agents or recurring
episodes of acute gastritis.
Acute gastritis is often caused by dietary
indiscretion—the person eats food that is
contaminated with disease-causing
microorganisms or that is irritating or too highly
seasoned

4. 44
Gastritis
Other causes of acute gastritis include overuse of
aspirin and other nonsteroidal anti-inflammatory
drugs (NSAIDs),
 excessive alcohol intake, bile reflux, and radiation
therapy.
 Severe form of acute gastritis is caused by the
ingestion of strong acid or alkali, which may cause
the mucosa to become gangrenous or to
perforate.

5. 55
Gastritis
Chronic gastritis and prolonged inflammation of
the stomach may be caused by either benign or
malignant ulcers of the stomach or by the bacteria
Helicobacter pylori.
Chronic gastritis is sometimes associated with
autoimmune diseases such as pernicious anemia;
dietary factors such as caffeine; the use of
medications, especially NSAIDs; alcohol; smoking;
or reflux of intestinal contents into the stomach.

6. 66
Pathophysiology
In gastritis, the gastric mucous membrane
becomes edematous and hyperemic (congested
with fluid and blood) and undergoes superficial
erosion (Fig. 37-1).
It secretes a scanty amount of gastric juice,
containing very little acid but much mucus.
Superficial ulceration may occur and can lead to
hemorrhage.

7. 77
Pathophysiology

8. 88
Clinical Manifestations
The patient with acute gastritis may have
abdominal discomfort, headache, lassitude,
nausea, anorexia, vomiting, and hiccupping.
Some have no symptoms.
The patient with chronic gastritis may complain of
anorexia, heartburn after eating, belching, a sour
taste in the mouth, or nausea and vomiting.
Patients with chronic gastritis from vitamin
deficiency usually have evidence of malabsorption
of vitamin B12 caused by antibodies against
intrinsic factor.

9. 99
Assessment and Diagnostic Findings
Gastritis is sometimes associated with
hypochlorhydria (absence or low levels of
hydrochloric acid [HCl]) or with hyperchlorhydria
(high levels of HCl).
Diagnosis can be determined by endoscopy,
upper GI radiographic studies, and histologic
examination of a tissue specimen- biopsy.
diagnostic measures for detecting H. pylori include
serologic testing for antibodies against the H. pylori
antigen, and a breath test.

10. 1010
Medical Management
The gastric mucosa is capable of repairing itself
after a bout of gastritis. As a rule, the patient
recovers in about 1 day.
nonirritating diet is recommended.
If bleeding is present, management is similar to
the procedures used for upper GI tract
hemorrhage
If itcaused by ingestion of strong acids or alkalis,
treatment consists of diluting and neutralizing the
offending agent. To neutralize acids, common
antacids (eg, aluminum hydroxide)

11. 1111
Medical Management
to neutralize an alkali, diluted lemon juice or
diluted vinegar is used.
If corrosion is extensive or severe, emetics and
lavage are avoided because of the danger of
perforation and damage to the esophagus.
Therapy is supportive and may include
nasogastric (NG) intubation.analgesic agents and
sedatives, antacids, and intravenous (IV) fluids.
 Fiberoptic endoscopy may be necessary. In
extreme cases, emergency surgery may be
required to remove gangrenous or perforated
tissue.

12. 1212
Medical Management
Chronic gastritis is managed by modifying the
patient’s diet, promoting rest, reducing stress, and
initiating pharmacotherapy.
 H. pylori may be treated with antibiotics (eg,
tetracycline or amoxicillin, combined with
clarithromycin) and a proton pump inhibitor (eg,
lansoprazole [Prevacid]), and possibly bismuth
salts (Pepto-Bismol) (Table 37-1).
Research is being conducted to develop a vaccine
against H. pylori

13. 1313

14. 1414
Histamine 2 (H2) Receptor Antagonists

15. 1515
Proton (Gastric Acid) Pump Inhibitor

16. 1616

17. 1717
1.Gastric and Duodenal Ulcers
A peptic ulcer is an excavation (hollowed-out area)
that forms in the mucosal wall of the stomach, in
the pylorus (opening between stomach and
duodenum), in the duodenum (first part of small
intestine), or in the esophagus. A peptic ulcer is
frequently referred to as a gastric, duodenal, or
esophageal ulcer, depending on its location, or as
peptic ulcer disease.

18. 1818
Peptic ulcers are more likely to be in the duodenum than in
the stomach. As a rule they occur alone, but they may
occur in multiples. Chronic gastric ulcers tend to occur in
the lesser curvature of the stomach, near the pylorus.
In the past, stress and anxiety were thought to be
causes of ulcers. Research has identified that
peptic ulcers result from infection with the gram-
negative bacteria H. pylori

19. 1919
Familial tendency may be a significant
predisposing factor. A further genetic link is noted
in the finding that people with blood type O are
more susceptible to peptic ulcers than are those
with blood type A, B, or AB. There also is an
association between duodenal ulcers and chronic
pulmonary disease or chronic renal disease.

20. 2020
Stress ulcers, which are clinically different from
peptic ulcers, are ulcerations in the mucosa that
can occur in the gastroduodenal area. Stress
ulcers may occur in patients who are exposed to
stressful conditions.

21. 2121
Comparing Duodenal and Gastric Ulcers
DUODENAL ULCER
Incidence
Age 30–60
Male: female 2–3:1
80% of peptic ulcers
are duodenal
GASTRIC ULCER
Usually 50 and over
Male: female 1:1
15% of peptic ulcers
are gastric

22. 2222
Signs, Symptoms, and Clinical Findings
DUODENAL ULCER
Hypersecretion of stomach
acid (HCl)
 May have weight gain
Pain occurs 2–3 hours
after a meal; often
awakened between 1–2
AM;
 ingestion of food relieves
pain
Vomiting uncommon
GASTRIC ULCER
Normal—hyposecretion of
stomach acid (HCl)
Weight loss may occur
Pain occurs 1⁄2 to 1 hour
after a meal; rarely occurs
at night; may be relieved
by vomiting;
ingestion of food does not
help, sometimes increases
pain
Vomiting common

23. 2323
Comparing Duodenal and Gastric Ulcers
DUODENAL ULCER
Hemorrhage less likely
than with gastric ulcer,
but if present melena
more common than
Hematemesis More
likely to perforate than
gastric ulcers
GASTRIC ULCER
Hemorrhage more
likely to occur than
with duodenal
ulcer; hematemesis
more common than
melena

24. 2424
Comparing Duodenal and Gastric Ulcers
DUODENAL ULCER
 Malignancy
Possibility
Rare
Risk Factors
H. pylori, alcohol,
smoking,
cirrhosis, stress
GASTRIC ULCER
Occasionally
H. pylori, gastritis,
alcohol, smoking, use
of NSAIDs, stress

25. 2525
Pathophysiology
Peptic ulcers occur mainly in the gastroduodenal
mucosa because this tissue cannot withstand the
digestive action of gastric acid (HCl) and pepsin.
The erosion is caused by the increased
concentration or activity of acid-pepsin, or by
decreased resistance of the mucosa.
 A damaged mucosa cannot secrete enough
mucus to act as a barrier against HCl.
The use of NSAIDs inhibits the secretion of mucus
that protects the mucosa. Patients with duodenal
ulcer disease secrete more acid than normal,
whereas patients with gastric ulcer tend to secrete
normal or decreased levels of acid.

26. 2626
Pathophysiology
Stress ulcer is the term given to the acute mucosal
ulceration of the duodenal or gastric area that
occurs after physiologically stressful events, such
as burns, shock, severe sepsis, and multiple organ
traumas.
Differences of opinion exist as to the actual cause
of mucosal ulceration in stress ulcers. Usually, it is
preceded by shock; this leads to decreased gastric
mucosal blood flow and to reflux of duodenal
contents into the stomach. In addition, large
quantities of pepsin are released. The combination
of ischemia, acid, and pepsin creates an ideal
climate for ulceration.

27. 2727
Pathophysiology
Stress ulcers should be distinguished from
Cushing’s ulcers and Curling’s ulcers, two other
types of gastric ulcers.
 Cushing’s ulcers are common in patients with
trauma to the brain.
 Curling’s ulcer is frequently observed about 72
hours after extensive burns

28. 2828
Clinical Manifestations
As a rule, the patient with an ulcer complains of dull,
gnawing pain or a burning sensation in the midepigastrium
or in the back. It is believed that the pain occurs when the
increased acid content of the stomach and duodenum
erodes the lesion and stimulates the exposed nerve
endings.
 pyrosis (heartburn), vomiting, constipation or diarrhea,
and bleeding. Pyrosis is a burning sensation in the
esophagus and stomach that moves up to the mouth.
Heartburn is often accompanied by sour eructation, or
burping, which is common when the patient’s stomach is
empty. Fifteen percent of patients with gastric ulcers
experience bleeding.

29. 2929
Assessment and Diagnostic Findings
A physical examination may reveal pain, epigastric
tenderness, or abdominal distention.
 A barium study of the upper GI tract may show an
ulcer; however, endoscopy is the preferred
diagnostic procedure because it allows direct
visualization of inflammatory changes, ulcers, and
lesions-biopsy.

30. 3030
Stools may be tested periodically until they are
negative for occult blood. Gastric secretory studies
are of value in diagnosing achlorhydria and ZES.
H. pylori infection may be determined by biopsy
and histology with culture.
There is also a breath test that detects H. pylori,
as well as a serologic test for antibodies to the H.
pylori antigen.

31. 3131
Medical Management
peptic ulcers treated with antibiotics to eradicate
H. pylori have a lower recurrence rate than those
not treated with antibiotics. The goals are to
eradicate H. pylori and to manage gastric acidity.
Methods used include medications, lifestyle
changes, and surgical intervention.

32. 3232
A.PHARMACOLOGIC THERAPY
Currently, the most commonly used therapy in the
treatment of ulcers is a combination of antibiotics,
proton pump inhibitors, and bismuth salts that
suppresses or eradicates H. pylori.
Rest, sedatives, and tranquilizers may add to the
patient’s comfort and are prescribed as needed.
Maintenance dosages of H2 receptor antagonists
are usually recommended for 1 year.

33. 3333
A.STRESS REDUCTION AND REST
SMOKING CESSATION
DIETARY MODIFICATION
SURGICAL MANAGEMENT
surgery is usually recommended for patients with
intractable ulcers (those that fail to heal
after 12 to 16 weeks of medical treatment),
include vagotomy, with or without pyloroplasty,
and the Billroth I and Billroth II procedures

34. 3434
Severing of the vagus
nerve. Decreases gastric
acid by diminishing
cholinergic stimulation to
the parietal cells, making
them less responsive to
gastrin. May be done via
open surgical approach,
laparoscopy, or
thoracoscopy

35. 3535
A surgical procedure in
which a longitudinal
incision is made into
the pylorus and
transversely sutured
closed to enlarge the
outlet and relax the
muscle

36. 3636
Removal of the lower
portion of the antrum of the
stomach (which contains
the cells that secrete
gastrin) as well as a small
portion of the duodenum
and pylorus. The
remaining segment is
anastomosed to the
duodenum (Billroth I) or to
the jejunum (Billroth II)

37. 3737
Removal of distal third
of stomach;
anastomosis with
duodenum or jejunum.
Removes gastrin-
producing cells in the
antrum and part of the
parietal cells.

38. 3838
Morbid Obesity
obesity is the term applied to people who are
more than two times their ideal body weight or
whose body mass index (BMI) exceeds 30 kg/m2.
Another definition of morbid obesity is body weight
that is more than 100 pounds greater than the
ideal body weigh.
Patients with morbid obesity are at higher risk for
health complications, such as cardiovascular
disease, arthritis, asthma, bronchitis, and
diabetes. They frequently suffer from low self-
esteem, impaired body image, and depression.

39. 3939
Medical Management
There is a belief that depression may be a
contributing factor to weight gain, and treatment of
the depression with bupropion
hydrochloride
Several medications have recently been approved
for obesity. They include sibutramine HCl (Meridia)
and orlistat (Xenical). By inhibiting the reuptake of
serotonin and norepinephrine, sibutramine
decreases appetite.

40. 4040
Gastric bypass and vertical banded gastroplasty are the
current operations of choice. These procedures may be
performed laparoscopically or by an open surgical
technique. In gastric bypass surgery, the proximal segment
of the stomach is transected to form a small pouch with a
small gastroenterostomy stoma. The Roux-en-Y gastric
bypass is the recommended procedure for long-term
weight loss. In this procedure, a horizontal row of staples
creates a stomach pouch with a 1-cm stoma that is
anastomosed with a portion of distal jejunum, creating a
gastroenterostomy. The transected proximal portion of the
jejunum is anastomosed to the distal jejunum.

41. 4141

42. 4242
NSG InterventionNSG Intervention
Complications that may occur in the immediate
postoperative period include peritonitis, stomal
obstruction, stomal ulcers, atelectasis and
pneumonia, thromboembolism, and metabolic
imbalances resulting from prolonged vomiting and
diarrhea.
small feedings consisting of a total of 600 to 800
calories per day and encourages fluid intake to
prevent dehydration.

43. 4343
The nurse explains that noncompliance by eating
too much or too fast or eating highcalorie liquid
and soft foods results in vomiting and painful
esophageal distention. The nurse discusses
dietary instructions before discharge and
schedules monthly outpatient visits.

44. 4444
Gastric Cancer
Most of these deaths occur in people older than 40
years of age, but they occasionally occur in
younger people. Men have a higher incidence of
gastric cancers than women do.
Diet appears to be a significant factor. A diet high
in smoked foods and low in fruits and vegetables
may increase the risk of gastric cancer.
chronic inflammation of the stomach, pernicious
anemia, achlorhydria, gastric ulcers, H. pylori
infection, and genetics.

45. 4545
Pathophysiology
Most gastric cancers are adenocarcinomas and
can occur in any portion of the stomach. The
tumor infiltrates the surrounding mucosa,
penetrating the wall of the stomach and adjacent
organs and structures.
Metastasis through lymph to the peritoneal cavity
occurs later in the disease.

46. 4646
Clinical Manifestations
Some studies show that early symptoms, such as
pain relieved with antacids, resemble those of
benign ulcers.
Symptoms of progressive disease may include
anorexia, dyspepsia (indigestion), weight loss,
abdominal pain, constipation, anemia,
and nausea and vomiting.

47. 4747
Assessment and Diagnostic Findings
physical examination is not helpful in detecting
cancer because most gastric tumors are not
palpable. Ascites may be apparent if the cancer
cells have metastasized to the liver.
 Endoscopy for biopsy and cytologic washings is
the usual diagnostic study, and a barium x-ray
examination of the upper GI tract may also be
performed

48. 4848
Because metastasis often occurs before warning
signs develop, a computed tomography (CT) scan,
bone scan, and liver scan are valuable in
determining the extent of metastasis.
A complete x-ray examination of the GI tract
should be performed when any person older than
40 years of age has had indigestion (dyspepsia) of
more than 4 weeks’ duration.

49. 4949
Medical Management
no successful treatment for gastric carcinoma
except removal of the tumor. If the tumor can be
removed while it is still localized to the stomach,
the patient can be cured.
 If the tumor has spread beyond the area that can
be excised, cure is impossible. Palliative rather
than radical surgery is performed if there is
metastasis to other vital organs.
 If a radical subtotal gastrectomy is performed, the
stump of the stomach is anastomosed to the
jejunum, as in the gastrectomy for ulcer.

50. 5050
Chemotherapeutic medications include cisplatin,
irinotecan, or a combination of 5-fluorouracil,
doxorubicin (Adriamycin), and mitomycin-C. Some
studies are being conducted on the use of
chemotherapy before surgery. Radiation therapy
also may be used for palliation. Assessment of
tumor markers (blood analysis for antigens
indicative of colon cancer) such as
carcinoembryonic antigen, CA 19-9, and CA 50
may help determine the effectiveness of treatment.