Gastritis and irritable bowel syndrome

gastritis and irritable bowel syndrome and their management

1. GASTRITIS AND IRRITABLE BOWEL SYNDROME AND ITS MANAGEMENT -BY SHWETA SHARMA M.SC. I YEAR AIIMS, JODHPUR

2. INTRODUCTION Gastritis is an inflammation, irritation, or erosion of the lining of the stomach. It is one of the most common problems affecting the stomach. It can occur suddenly (acute) or gradually (chronic).

3. EPIDEMIOLOGY •In acute gastritis, the prevalence of eosinophilic gastritis is approximately 6.3 per 100,000 individuals worldwide. •The incidence of new cases of H. pylori infection each year ranges from 3,000 to 10,000 per 100,000 individuals in developing countries. •It has been observed that with advancing age, the incidence of H. pylori infection increases. •In acute gastritis, females are usually more affected than men.

4. ETIOLOGY 1. Drugs- NSAIDs, corticosteroids, etc. 2. Diet- Alcoholic drinking binge, large quantities of spicy, irritating foods and metabolic conditions such as renal failure can also cause acute gastritis. Micro-organisms- Helicobacter pylori infection, Salmonella and staphylococcus Environmental factors- Radiation and smoking 5. Autoimmune gastritis- Autoimmune metaplastic atrophic gastritis

5. 6. Other causes- •Burns •Large hiatal hernia •Physiologic stress •Psychologic stress •Reflux of bile and pancreatic secretions •Renal failure •Sepsis •Shock •Endoscopic procedures •Nasogastric tube

6. PATHOPHYSIOLOGY Acute gastritis- Due to any cause ↓ Gastric mucosal barrier is penetrated ↓ Hydrochloric acid comes into contact with the mucosa ↓ Injury to small vessels ↓ Oedema, haemorrhage, and possible ulcer formation

7. Chronic gastritis- The stomach lining first becomes thickened and erythematous and then becomes thin and atrophic. ↓ Continued deterioration and atrophy ↓ Loss of function of the parietal cells ↓ Acid secretion decreases ↓ Inability to absorb vitamin B12 ↓ Development of pernicious anemia

8. CLINICAL MANIFESTATIONS Acute gastritis: •Epigastric discomfort •Feeling of fullness •Abdominal tenderness •Cramping •Belching •Anorexia •Reflux •Severe nausea and vomiting •Hematemesis •Sometimes GI bleeding is the only manifestation •When contaminated food is the cause of gastritis, diarrhoea usually develops within 5 hours of ingestion Acute gastritis is self-limiting, lasting from a few hours to a few days, with complete healing of the mucosa expected.

9. Chronic gastritis: Manifestations are vague and may be absent because the problem does not cause an increase in hydrochloric acid. •Anorexia •Feeling of fullness •Dyspepsia •Belching •Vague epigastric pain •Nausea •Vomiting •Vitamin B12 deficiency •Pernicious anaemia •Intolerance of spicy and fatty foods

10. DIAGNOSTIC EVALUATION 1.History collection- Drug or alcohol abuse 2.Endoscopy 3.Complete blood count for anaemia 4.Tissue biopsy to rule out gastric carcinoma. 5.Urea breath test for helicobacter pylori infection

11. COMPLICATIONS •Bleeding •Pernicious anaemia •Peptic ulcer •Erosive stomach lining (the stomach tissue wears away) •MALT (mucosa-associated lymphoid tissue) lymphoma •Gastric scarring and strictures with outlet obstruction •Dehydration •Haemorrhage •Gastric perforation •Malnutrition •Gastric cancer

12. MEDICAL MANAGEMENT Acute gastritis: Anti - emetic drugs- Perinorm or Domperidone Antacids- cimetidine, ranitidine, or famotidine If ingestion of NSAIDs is a problem, a prostaglandin E1 (PGE1) analog may be prescribed to protect the stomach mucosa and inhibit gastric acid secretion.

13. Chronic gastritis: Discomfort may lessen with a bland diet, small frequent meals, antacids, H2 receptor antagonists, proton pump inhibitors, and avoidance of food that cause manifestations. If H. pylori bacteria are present, anti-biotics and other medications are administered to eliminate the bacteria. If 1 week of this regimen does not succeed in eliminating the bacteria, the regimen may be repeated for an additional week. If pernicious anemia develops, intramuscular injections of vitamin B12 may be administered monthly for the remainder of the client’s life.

14. SURGICAL MANAGEMENT Subtotal gastrectomy (for perforation or cancer)-A subtotal gastrectomy includes removing the cancerous part of your stomach, nearby lymph nodes, and possibly parts of other organs near the tumor.

15. Pyloroplasty (for pyloric stenosis)-Pyloroplasty is surgery to widen the opening in the lower part of the stomach (pylorus) so that stomach contents can empty into the small intestine (duodenum).

16. Vagotomy -A vagotomy is a surgical procedure that involves removing part of the vagus nerve. Vagotomy reduces gastric acid secretion.

17. Total gastrectomy (for cancer)- It is removal of the entire stomach.

18. DIETARY MANAGEMENT Initially foods and fluids are withheld until nausea and vomiting subside. Once the client tolerates food, the diet includes decaffeinated tea, gelatin, toast, and simple bland foods. The client should avoid spicy foods, caffeine and large, heavy meals. In the continued absence of nausea, vomiting and bloating, the client can slowly return to a normal diet.

19. NURSING MANAGEMENT 1) Acute pain related to irritated stomach mucosa as evidenced by numerical pain scale score. Goal- Patient describes satisfactory pain control at a level less than 3 to 4 on a rating scale of 0 to 10. 2) Imbalanced nutrition, less than body requirement , related to inadequate intake of nutrition as evidenced by weight loss. Goal-Patient will demonstrate behaviors, lifestyle changes to recover and/or keep appropriate weight. 3) Risk for fluid and electrolyte imbalance related to insufficient fluid intake and excessive fluid loss subsequent to vomiting. Goal- The patient will be free from risk of imbalanced fluid volume.

20. 4) Anxiety related to treatment as evidenced by facial expressions. Goal- Patient identifies strategies to reduce anxiety. 5) Deficient knowledge related to disease process and its dietary management as evidenced by frequent questioning. Goal- Patient will have adequate knowledge about disease process and its dietary management.

21. IRRITABLE BOWEL SYNDROME Irritable bowel syndrome (IBS) is a common gastrointestinal disorder involving an abnormal condition of gut contractions (motility) and increased gut sensations (visceral hypersensitivity) characterized by abdominal pain / discomfort, gas, bloating, mucous in stools, and irregular bowel habits with constipation or diarrhoea or alternating diarrhoea and constipation.

22. EPIDEMIOLOGY •Inflammatory Bowel Syndrome affects around 11% of the population globally. •The disorder is usually found in the age group of 15–50 years and may also occur in children and elderly. •The prevalence of IBS in general population of India is 15%. •It affects women 2 to 2.5 times more often than men. •Men report manifestations of diarrhoea more commonly than women. •Women report manifestations of constipation more commonly than men.

23. ETIOLOGY 1. Abnormal gastrointestinal (GI) tract movements. 2. A change in the nervous system communication between the GI and brain. 3. Sensory and motor disorders of the colon. 4. Dietary allergies or food sensitivities. 5. Neurotransmitter imbalance (decreased serotonin levels). 6. Psychologic stressors (e.g. depression, anxiety, sexual abuse, post-traumatic stress disorder)

24. TYPES OF IBS 1. Constipation-predominant: the person tends to alternate constipation with normal stools. Symptoms of abdominal cramping or aching are commonly triggered by eating. 2. Diarrhoea-predominant: the person tends to experience diarrhoea first thing in the morning or after eating. The need to go to the toilet is typically urgent and cannot be delayed. 3. Alternating constipation and diarrhoea (IBS-A OR IBS-M) mixed IBS

25. PATHOPHYSIOLOGY

26. CLINICAL MANIFESTATIONS •Abdominal pain and discomfort •Alterations in bowel pattern (diarrhoea or constipation) •Abdominal distension •Excessive flatulence •Bloating •Urgency and sensation of incomplete evacuation •Fatigue and sleep disturbances

27. DIAGNOSTIC EVALUATION No clear diagnostic markers exist for IBS. So, diagnosis depends on positive clinical features and ruling out diseases by careful clinical examination and investigations. History collection (including psychosocial factors such as stress and anxiety) Physical examination Diagnosis can be made confidently in most patients using Rome III criteria + absence of red flag signs + supportive symptoms which include defecation straining, urgency or a feeling of incomplete bowel movement, passing mucus and bloating.

28. ROME III CRITERIA

29. FLEXIBLE SIGMOIDOSCOPY

30. CT scan X-ray- colonic spasm

31. RED FLAG SIGNS AND SYMPTOMS Unintentional and unexplained wt. loss Rectal bleeding Family history of bowel/ovarian cancer A change in bowel habit to lose and/or more frequent stools persisting for more than 6 weeks in a person aged over 60yrs. Anaemia Abdominal mass Rectal mass Inflammatory markers for IBD

32. To rule out organic causes- •Complete blood count •Erythrocyte sedimentation rate •C-reactive protein •Stool examination for ova and parasites •Antibodies for Coeliac Disease •Sigmoidoscopy when more than 50 years/ red flag signs present •Younger individual with mild symptoms – minimal diagnostic evaluation, •Older – undergo more thorough evaluations

33. MEDICAL MANAGEMENT Loperamide - a synthetic opioid that slows intestinal transit, may be used to treat diarrhoea. Alosetron - a serotonergic antagonist, is used for IBS patients with severe symptoms of pain and diarrhoea (drug should be discontinued if patient develops severe constipation or ischemic colitis). Lubiprostone - for constipation in women. Linaclotide - for constipation in men and women. Low doses of tricyclic antidepressants- to reduce peripheral nerve sensitivity.

34. DIETARY MANAGEMENT Eliminate food stuffs that appear to produce symptoms. Consume high fibre diet for IBS-C. Exclude wheat, dairy and gluten –to avoid pain and bloating. Avoid common gas producing foods such as broccoli and cabbage. Yogurt may be better tolerated than milk products. Probiotics may be used because alterations in intestinal bacteria are believed to exacerbate the condition. Examples of probiotics- Lactobacillus, Bifidobacterium, Saccharomyces boulardii (yeast), etc. Avoid legumes and excess dietary fibre - IBS-D Diet low in FODMAPs (Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols) FODMAPs are short chain carbohydrates poorly absorbed in small intestine and fermented by bacteria in colon to produce gas

35. PSYCHOTHERAPY Psychological therapy is effective in two thirds of patients with IBS who do not respond to standard medical treatment Cognitive behavioral therapy Stress management techniques Acupuncture Hypnotherapy

36. PATIENT COUNSELLING Reassuring the patient is the most successful form of treatment for IBS. Many are concerned that they have developed cancer – more anxiety-more colonic symptoms. Explain functional nature of disorder and how to avoid obvious food precipitants. Emphasize on expected chronicity of symptoms with periodic exacerbations.

37. NURSING MANAGEMENT Reinforce the physician’s explanation of the nature of the disorder, the intervention plan, and the prognosis. Make it clear to the client that the bowel responds to stress, foods, and medications. Emphasize the importance of regular hours, nourishing meals, and adequate sleep, exercise and relaxation. Help the client to establish a regular bowel routine. Advise the client with diarrhoea to limit foods that produce gas or irritate the bowel and to avoid (1) caffeinated and carbonated beverages, (2) alcohol, (3) foods containing indigestible carbohydrates, such as beans, and (4) milk and milk products. Provide empathy and support.

38. RESEARCH ARTICLES 1.Dietary habits and Helicobacter pylori infection: a cross sectional study at a Lebanese hospital A cross-sectional study was conducted on 294 patients in 2016, at a hospital in Northern Lebanon. Participants were interviewed using a structured questionnaire to collect information on socio-demographic and lifestyle characteristics; dietary habits were ascertained via a short food frequency questionnaire (FFQ). H. pylori status (positive vs. negative) was determined after upper GI endoscopy where gastric biopsy specimens from the antrum, body, and fundus region were collected and then sent for pathology analysis. Multivariable logistic regression was conducted to identify the association between socio-demographic, lifestyle, dietary and other health-related variables with H pylori infection. The prevalence of H. pylori infection was found to be 52.4% in this sample. Results of the multivariable analysis showed that H. pylori infection risk was higher among participants with a university education or above, those with a history of peptic ulcers, gastric adenocarcinoma and vitamin D level below normal. In contrast, hyperglycaemia was protective against H. pylori. No relationship between dietary habits and H. pylori infection was found in the adjusted analysis. The study concluded that socio-demographic and clinical variables were associated with H. pylori, but not with dietary factors. Further studies are needed to investigate the effect of diet on H. pylori risk.

39. 2. Epidemiology of Dyspepsia and Irritable Bowel Syndrome (IBS) in Medical Students of Northern India A cross-sectional study was carried out from January to March 2014 at Maulana Azad Medical College, New Delhi, India. A total of 210 students from a Medical College were asked to complete a semi-structured questionnaire based on identification and socio-demographic data, questions pertaining to lifestyle and Rome III criteria. Majority of the subjects (diagnosed with uninvestigated dyspepsia and IBS) were in the age group of 18-20 y with female gender having higher odds for both. The prevalence of dyspepsia was 18% while that of IBS was 16.5%. Consumption of fatty food, cigarettes and low physical activity were observed as most significant correlates . The study concluded that Rome III criteria enables symptom-based diagnosis of dyspepsia and IBS. The prevalence of dyspepsia and IBS in college students from Delhi is observed to be higher. Association with lifestyle related factors highlights the importance of modifications in their prevention.

40. CONCLUSION As discussed throughout the presentation, learning about gastritis and irritable bowel syndrome and their management will help nurses to care for patients of gastritis and irritable bowel disease. Nurses can do assessment of patients with gastritis and irritable bowel disease, observe the sign and symptoms, provide the necessary nursing care and support the patient psychologically. Nurses can also counsel the patients and their family for various options available in treatment for gastritis and irritable bowel syndrome.

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