Stomach disorders

STOMACH DISORDERS

1. WELCOME

2. PRESENTED BY, UMADEVI.K MSC NURSING MEDICAL SURGICAL NURSING DPT KERALA BANGALORE

3. SEMINAR ON INTERVENTIONS FOR THE CLIENTS WITH DISORDERS OF STOMACH

4. SUBTOPICS GASTRITIS PEPTIC ULCERATIVE DISEASE ZOLLIGER ELLISON SYMDROME GASTRIC CANCER

5. ALERT MIND AND THINK CRITICALLY BEFORE DOING

6. GASTROINTESTINAL SYSTEM

7. STRUCTURE OF STOMACH AND ADJACENT ORGANS

8. REGIONS OF ABDOMEN

9. INTRODUCTION The stomach is an organ between the esophagus and the small intestine. It is where digestion of protein begins. The stomach has three tasks. It stores swallowed food. It mixes the food with stomach acids. Then it sends the mixture on to the small intestine. There are many types of chronic disorders which affect the stomach. However since the symptoms are localized to this organ, the typical symptoms of stomach problems include nausea, vomiting, bloating, cramps, diarrhea and pain. Disorders of the stomach are very common and induce a significant amount of morbidity and suffering in the population. Data from hospitals indicate that more than 25% of the population suffers from some type of chronic stomach disorder including abdominal pain and indigestion. These symptoms occur for long periods and cause prolonged suffering, time off work and a poor quality of life.

10. GASTRITIS

11. DEFINITION Gastritis occurs when the lining of the stomach becomes inflamed or swollen. OR Gastritis, an inflammation or irritation of the lining of the stomach

12. TYPES   GASTRITIS     ACUTE CHRONIC TYPE A ( FUNDAL) TYPE B (ANTRAL) SUPERFICIAL HYPERATROPIC ATROPIC

13. OTHER TYPES ACUTE STRESS GASTRITIS PHEGMONOUS GASTRITIS EROSIVE AND HEMORRHAGIC GASTRITIS CHEMICAL ENVIRONMENTAL

14. INCIDENCE Mortality rate of 65% ( PHLEGMONOUS) No sexual predilection More common in adults, than in children Second most common cancer-related death. Korea, Japan, China, Taiwan high rates. 22,000 diagnosed annually in US. 14 th most common cancer. Difficult to cure, as advanced disease.

15. RISK FACTORS Helicobactor pylori infection Age Gastric irritants Chemotherapy and radiation therapy

16. ETIOLOGY Medications Medical and surgical conditions Infections Intake of spicy foods Alcohol Chemotherapy and radiationtherapy Swallowed foreign bodies (paper clips or pins)  Trauma

17. Chronic vomiting Smoking Extreme stress Eating corrosive substances Pernicious anemia Bile reflux

18. PATHOPHYSIOLOGY A MUCOSAL BARRIER COMPOSED OF PROSTAGLANDINS NORMALLY PROTECTS STOMACH TISSUE FROM AUTODIGESTION OF ACID WHEN THE BARRIERS IS BROKEN BECAUSE OF ETIOLOGICAL FACTOR,ACID CAN DIFFUSE INTO THE MUCOSA

19. ALLOWS HCL TO ENTER THERE BY INCREASES THE SECRETION OF PEPSINOGEN AND RELEASE OF HISTAMINE FROM MAST CELLS INJURY TO SMALL VESSELS EDEMA,HEMORRHAGE AND ULCER FORMATION

20. CLINICAL FEATURES ASYMPTOMATIC Upper central abdominal pain Nausea and Vomiting Belching (if present, usually does not relieve the pain much) Bloating Feeling full after only a few bites of food Loss of appetite Unexplained weight loss  

21. In more severe gastritis, Bleeding may occur inside the stomach. Pallor, sweating, and rapid heart beat. Feeling faint or short of breath Chest pain or severe stomach pain Vomiting large amounts of blood Bloody bowel movements or dark, sticky, very foul-smelling bowel movements

22. DIAGNOSTIC EVALUATION complete history and physical exiamination H. pylori tests Breath test Tissue test Barium x rays Stool test Blood tests: Blood cell count Presence of H. pylori Urinalysis X-rays ECGs An electrocardiogram(ECG, EKG) might be ordered if the patient's heartbeat is rapid or they are having chest pain. Stomach biopsy, to test for gastritis and other conditions

23. COMPLICATIONS Blood loss gastric cancer GI bleeding Reflux esophagitis PUD Chronic gastritis

24. MANAGEMENT MEDICAL MANAGEMENT During acute phase bed rest ,NPO,IV fluids Fluid and electrolyte balance (I/O Chart) For severe case NG tube intubation substances that trigger gastritis symptoms ANTIEMETICS FOR VOMITING   ANTACIDS

25. ANTIBIOTICS Amoxicillin Clarithromycin ( Biaxin ) Metronidazole ( Flagyl ) Tetracycline CYTO PROTECTIVE AGENTS Coating agents: These medications protect the stomach's lining. Sucralfate ( Carafate ) - Coats and protects the stomach lining Misoprostol ( Cytotec ) -

26. Magnesium-containing antacids Aluminum-containing antacids Calcium-containing antacids H2 antagonist (ranitidine , emetidine ) Proton pump inhibitors (PPIs) - omeprazole ( Prilosec ) For patient with pernicious anemia;regular vit B12 Injection blood transfusion and fluid replacement Stop taking aspirin, ibuprofen

27. PARTIAL GATRECTOMY ( partial surgical removal of the stomach .)

28. VAGOTOMY Vagotomy is the surgical cutting of the vagus nerve  

29. PYLOROPLASTY ( Pyloroplasty is an elective surgical procedure in which the lower portion of the stomach, the pylorus, is cut and resutured

30. Dietary management smaller, more frequent meals Avoid any foods which is irritating Limiting excessive use of alcohol Foods containing flavonoids , Mulltivitamins

31. 6-8 glasses of water Omega 3 fatty acids to redude inflammation Probiotics

32. NURSING DIAGNOSIS AND MANGAMENT PAIN related to irritation of gasric mucosa Nausea and vomiting related to multiple etiologies as manifested by episodes of nausea and vomiting Fluid volumedeficit related to prolonged vomiting and inability to ingest digest and absorb food and fluid as manifested by decreased urinary output,increased urine concentration,increased pulse rate,hypotension

33. Anxiety related to lack of knowledge of cause of the problegem,treatment plan and follow up care as manifested by verbalization of lack of knowledge Risk for altered nutrition less than body requirement related to nausea and vomiting as manifested by lack of interest in food,weight loss.

34. PAIN INTERVENTIONS ASSESS INTENSITY DURATION AND LOCATION OF PAIN COMFORT POSITION AND MEASURES MEDICATIONS REVIEW FACTORS AGRAVETING PAIN DIETARY MODIFICATIONS NAUSEA AND VOMITING Observe for potential complications Position the patient: To prevent aspiration Conscious: semi fowler’s Unconscious: lateral Provide good oral care measures Suction mouth

35. FLUID VOLUME DEFICIT Moniter vital signs,capillary refill,status Daily fluidintake and output are monitored to detect early signs of dehydration (minimum 1.5 lit/day) Iv fluids 3L/day is administered usually Identify actions to regain optimal fluid balance Eg : Specific Fluid intake schedule ANXIETY Offer Supportive therapy to the patient Explain all the procedures before doing Provide calm and restful environment Help the patient to identify and initiate positive coping behaviors in the past

36. Nurses role Assessment GOALS implementing interventions

37. PREVENTION Avoid those things that irritate or inflame the stomach's lining. Aspirin NSAIDs Smoking Caffeine and other caffeine-like substances Alcohol

38. GASTRITIS FOLLOW UP Avoid those things that irritate the stomach or cause symptoms to flare up. Take all medications as prescribed by the health care provider. Return for medical attention if symptoms worsen or persist. Report any new symptoms to a health care provider .

39. PEPTIC ULCERATIVE DISEASE

40. DEFINITION A peptic ulcer, also known as PUD or peptic ulcer disease is the most common ulcer of an area of the gastrointestinal tract that is usually acidic and thus extremely painful. It is defined as mucosal erosions equal to or greater than 0.5 cm. OR Peptic ulcer is the erosion of GI mucosa resulting from the action of HCL and pepsin that forms in the pylorus of stomach ,in the duodenum or in the esophagus

41. CLASSIFICATION By Region/Location Duodenum (called duodenal ulcer) Oesophagus (called esophageal ulcer) Stomach (called gastric ulcer) Meckel's diverticulum (called Meckel's diverticulum ulcer; is very tender with palpation)

42. Modified Johnson Classification of peptic ulcers : Type I: Ulcer along the body of the stomach, most often along the lesser curve at incisura angularis along the locus minoris resistantiae . Type II: Ulcer in the body in combination with duodenal ulcers. Associated with acid oversecretion . Type III: In the pyloric channel within 3 cm of pylorus. Associated with acid oversecretion . Type IV: Proximal gastroesophageal ulcer Type V: Can occur throughout the stomach. Associated with chronic NSAID use (such as aspirin).

43. INCIDENCE The incidence of duodenal ulcers has dropped significantly during the last 30 years, while the incidence of gastric ulcers has shown a small increase, mainly caused by the widespread use of NSAIDs Nowadays peptic ulcer disease is about just as common among women than among men Duodenal ulcers are most frequent among individuals 30 to 55 years of age, while gastric ulcers are more common among individuals 55 to 70 years of age

44. RISK FACTORS An increased risk of peptic ulcers if: Smoking may increase the risk of peptic ulcers in people who are infected with H. pylori. Alcoholism Have uncontrolled stress

45. Factors associated with an increased risk of duodenal ulcers in the setting of NSAID use include history of previous peptic ulcer disease, advanced age, female sex, high doses or combinations of NSAIDs, long-term NSAID use, concomitant use of anticoagulants, and severe comorbid illnesses. Little evidence suggests that caffeine intake is associated with an increased risk of duodenal ulcers.

46. ETIOLOGICAL FACTORS INFECTION DRUGS HYPERSECRETORY Gastrinoma Basophilic leukemias Cystic fibrosis Short bowel syndrome Lifestyle factors Severe physiologic stress Genetic factors

47. Additional etiologic factors Any of the following may be associated with PUD: Hepatic cirrhosis Chronic obstructive pulmonary disease Allergic gastritis and eosinophilic gastritis Cytomegalovirus infection Graft versus host disease Corrosive gastropathy Celiac disease Autoimmune disease

48. PATHOPHYSIOLOGY Peptic ulcers are defects in the gastric or duodenal mucosa that extend through the muscularis mucosa. Irritation of gastric or duodenal mucosa due to various etiological factors Epithelial cells of the stomach and duodenum secrete mucus in response to irritation of the epithelial lining and as a result of cholinergic stimulation

49. The superficial portion of the gastric and duodenal mucosa exists in the form of a gel layer, which is impermeable to acid and pepsin Other gastric and duodenal cells secrete bicarbonate, which aids in buffering acid that lies near the mucosa. Prostaglandins of the E type (PGE) increases the production of both bicarbonate and the mucous layer. In the event of acid and pepsin entering the epithelial cells, additional mechanisms are in place to reduce injury

50. Within the epithelial cells, ion pumps in the basolateral cell membrane help to regulate intracellular pH by removing excess hydrogen ions . Through the process of restitution, healthy cells migrate to the site of injury Mucosal blood flow removes acid that diffuses through the injured mucosa and provides bicarbonate to the surface epithelial cells.

51. S SIGNS AND SYMPTOMS Bloating and abdominal fullness; Nausea, and copious vomiting; Loss of appetite and weight loss; Pain Hematemesis   Melena (Nausea or vomiting Unexplained weight loss Appetite changes(loss of appetite) Bloating Heartburn Waterbrash

52. COMPLICATIONS Gastrointestinal bleeding Perforation Penetration Gastric outlet obstruction. Cancer Exacerbation Gastric outlet obstruction Peritonitis

53. DIAGNOSIS History collection and physical examination Testing for Bacterial Infection Blood TesT  Blood tests such as The enzyme-linked immunosorbent assay (ELISA) CBC Breath Tests Tissue Tests Barium X-rays

54. MANAGEMENT GOALS OF TREATMENT The main goal for peptic ulcer treatment is the immediate relief of pain in the patient. to eliminate the conditions that aggravate it and to prevent recurrence. Relief of discomfort and protection of gastric mucosa from complications.

55. 3 stages in medical treatment. These are ; the preventive ,( by providing information and educating the population on how to identify symptoms and avoiding the causes of the disease) curative and (where patients suffering the disease undergo treatment) rehabilitation phases of treatment.( patient recovery and prevention of disease recurrence).

56. MEDICAL MANAGMENT Antibiotic medications Pain Relief through Medications Medications that block acid production and promote healing(PPI) Medications to reduce acid production. (H2 BLOCKERS) Antacids that neutralize stomach acid .

57. Medications that protect the lining of your stomach and small intestine NON MEDICAL MANAGEMENT .Lifestyle changes Eating meals at regular intervals. avoid or manage stressful conditions Avoid smoking Maintain proper diet and avoid food or beverages which upset the gastric mucosa like coffee, tea, colas and alcohol.

58. Ulcers that fail to heal Peptic ulcers that don't heal with treatment are called refractory ulcers. These reasons may include: Not taking medications according to directions. The fact that some types of H. pylori are resistant to antibiotics. Regular use of tobacco. Regular use of pain relievers that increase the risk of ulcers Extreme overproduction of stomach acid, such as occurs in Zollinger -Ellison syndrome An infection other than H. pylori Stomach cancer Other diseases that may cause ulcer-like sores in the stomach and small intestine, such as Crohn's disease Treatment for refractory ulcers generally involves eliminating factors that may interfere with healing, along with using different antibiotics

59. SURGICAL INTERVENTIONS   vagotomy Vagotomy is the surgical cutting of the vagus nerve

60. Truncal or total abdominal vagotomy

61. SELECTED TOTAL GASTRIC VAGOTOMY

62. Highly selective vagotomy (HSV)

63. Thoracoscopic vagotomy

64. PYLOROPLASTY ( Widening the opening of the bottom of the stomach ANTRECTOMY surgical removal, of a part of the stomach known as the antrum

65. GASTRODUEODENOSTOMY(BILLROTH 1 ) Removal of lower portion of antrum of stomach(which contains cells that secrete gastrin )as well as small portion of dueodenum and pylorus.the remaining segment is anostomised with dueodenum

66. GASTROJEJUNOSTOMY(BILLROTH 2) Gastrojejunostomy (GJ) is a surgical procedure in which an anastomosis is created between the stomach and the proximal loop of the jejunum. .

67. SUBTOTAL GASTRECTOMY WITH BILLROTH 1 AND 2 ANASTOMOSIS) Removal of distal part of stomach and anastomised with dueodenum and jejunum LOW HIGH

68. DIETARY MANAGEMENT IT INCLUDES; Avoiding spicy foods, coffee, and alcohol increasing consumption of bland foods and milk. Avoiding High–fiber diets INTAKE Diets high in vitamin A Avoid Green tea Probiotics

69. NURSING DIAGNOSIS AND MANAGEMENT Nursing diagnosis Increased risk of GI bleeding and perforation of stomach, related to gastric or intestinal wall erosion. Increased risk of pyloric obstruction as complication of the peptic ulcer. increased risk of anemia due to acute or chronic GI bleeding, related to ulcer. Pain and heartburn, related to diagnosis of peptic ulcer.. Appetite changes and weight changes due to symptoms of the ulcer.increased risk of aspiration due to vomiting, related to ulcer. Anxiety related to the symptoms of disease and fear of the unknown.

70. Goals 1 . Reduce or completely eliminate contributing factors. 2. Assist with stress management. 3. Promote adequate nutrition. 4. Prevent avoidable injury. 5. Then surgical intervention prescribed, prevent postoperative complications. 6. Relief or diminish symptoms.

71. Interventions 1. Assess, report , and record signs and symptoms and reactions to treatment. 2. Monitor fluids input and output closely. 3. Administer antacid agents, analgesics, H2-receptors antagonists, anticholinergics , sedatives as prescribed, monitor for side effects. 4. Monitor client’s vital signs and signs of possible GI bleeding or perforation closely. 5. Monitor laboratory tests results (CBC, electrolytes, Hb levels) for abnormal values. 6. Undertake appropriate intervention in case of GI bleeding, vomiting, or perforation. 7. Provide prescribed diet – avoid irritating foods, coffee, etc. 8. Prepare client and his family for surgical intervention if required for recurrent ulcer, hemorrhage, or perforation. 9. For client after surgical intervention provide postoperative care and inform about possible postoperative complications, such as dumping syndrome. 10. Provide emotional support to client, explain all procedures to decrease anxiety and to obtain cooperation. 11. Instruct client regarding disease progress, diagnostic procedures, treatment and its complications, home care, daily activities, diet, restrictions and follow-up.

72. Nursingmanagement 1 . Assess for chronic use of certain medications (such as aspirin, steroids). 2. Collect information of complaints that brought client to the hospital. 3. Obtain history of onset and progression of symptoms. 4. Obtain information of diet, use of alcohol and tobacco, ingestion of irritating foods, previous diseases or infections of GI tract, emotional stress. 5. Assess connection of pain attacks to meals, certain drugs, ingestion of coffee, alcohol. 6. Perform complete physical assessment including weight, vital signs, signs of GI bleeding, and acute abdomen. 7. Assess diagnostic tests and procedures for abnormal values. Evaluation 1. Reports increased comfort, decreased anxiety. 2. Verbalizes absence of heartburn and pain. 3. No evidence of nausea, vomiting, GI bleeding, or acute abdomen. 4. Maintains stable vital signs, fluid balance, and body weight. 5. Laboratory tests results shows no abnormalities. 6. No postoperative complications. 7. Demonstration of understanding of disease progress, diagnostic and treatment procedures, prevention, and need for follow-up.  

73. ZOLLINGER ELLLISSON SYNDROME

74. Zollinger -Ellison syndrome is a condition in which there is increased production of the hormone gastrin , causing the stomach to produce excess hydrochloric acid Zollinger –Ellison syndrome is a triad of gastric acid hypersecretion , severe peptic ulceration, and non-beta cell islet tumor of pancreas ( gastrinoma )

75. Incidence andRisk factors Incidence Annual incidence is estimated at 1-2 cases per million. The condition is slightly more common in females than males (sex ratio of 1.3:1). ZES is usually diagnosed in the fifth decade of life Risk factors Multiple endocrine neoplasia type 1 syndrome, characterised by other endocrine tumours .

76. Causes Zollinger -Ellison syndrome is caused by tumors, usually found in the head of the pancreas and the upper small intestine. These tumors produce the hormone gastrin and are called gastrinomas . High levels of gastrin cause production of too much stomach acid.

77. Due to tumours ( gastrinomas ) Production of excess gastrin Gastrin works on stomach parietal cells Secrete more hydrogen ions into the stomach lumen.  

78. In addition, gastrin acts as a trophic factor for parietal cells parietal cell hyperplasia.   Increase in the number of acid-secreting cells   cells produces acid at a higher rate   development of multiple peptic ulcers in the stomach and duodenum (small bowel).  

79. Signs and Symptoms Abdominal pain Diarrhea Vomiting blood (occasional) Signs include ulcers in the stomach and small intestine. Gnawing, burning pain in the abdomen This pain is usually located in the area between the breastbone and the navel. Sensation of pressure, bloating, or fullness This pain usually develops 30 to 90 minutes after a meal, and is often relieved by antacids. Pain or burning sensation in the abdomen that travels up toward the throat

80. This is caused by heartburn, or gastroesophageal reflux and occurs when stomach contents back up into the esophagus Vomiting The vomit may contain blood or resemble coffee grounds. Diarrhea Stools may be foul smelling. Black, tarry stools Blood in the stools will turn them dark red or black, and make them tarry or sticky. Nausea Fatigue Weakness Weight loss

81. Diagnostic tests   Tests include: Abdominal CT scan Calcium infusion test Endoscopic ultrasound Exploratory surgery Gastrin blood level Octreotide scan Secretin stimulation test

82. Complications Bleeding Perforation Fluid and electrolyte imbalance Complications Failure to locate the tumor during surgery Intestinal bleeding or hole (perforation) from ulcers in the stomach or duodenum Severe diarrhea and weight loss Spread of the tumor to other organs (most often liver and lymph nodes)

83. Treatment Medications Histamine H2-receptor antagonists (such as famotidine and ranitidine) are used to slow down acid secretion   proton pump inhibitors ::These drugs reduce acid production by the stomach, and promote healing of ulcers in the stomach and small intestine. They also relieve abdominal pain and diarrhea. omeprazole , lansoprazole , etc  

84. Surgery Cure is only possible if the tumors are surgically removed, or treated with chemotherapy   to remove a single gastrinoma is done if there is no evidence that it has spread to other organs (such as lymph nodes or the liver). Surgery on the stomach ( gastrectomy ) to control acid production is done rarely.  

85. Prognosis Even with early diagnosis and surgery to remove the tumor, the cure rate is relatively low. However, gastrinomas grow slowly, and patients may live for many years after the tumor is discovered. Acid-suppressing medications are very effective at controlling the symptoms of too much acid production.

86. NURSING DIAGNOSIS AND MANAGEMENT Nursing diagnosis 1. Increased risk of GI bleeding and perforation of stomach, related to gastric or intestinal wall erosion. 2. Increased risk of pyloric obstruction as complication of the peptic ulcer. 3. Increased risk of anemia due to acute or chronic GI bleeding, related to ulcer. 4. Pain and heartburn, related to diagnosis of peptic ulcer. 5. Appetite changes and weight changes due to symptoms of the ulcer. 6. Increased risk of aspiration due to vomiting, related to ulcer. 7. Anxiety related to the symptoms of disease and fear of the unknown.

87. GASTRIC CANCER

88. Stomach cancer, or gastric cancer, refers to cancer arising from any part of the stomach. Stomach cancer causes about 800,000 deaths worldwide per year. Gastric cancer was once the second most common cancer in the world. OR A gastric carcinoma is a malignant tumour arising from the epithelium of the stomach

89. INCIDENCE Stomach cancer is the fourth most common cancer worldwide It is more common in men and in developing countries. Frequency United States The American Cancer Society estimates that 21,130 cases of gastric cancer was diagnosed in the year 2009 (12,820 in men, 8,310 in women) and that 10,620 persons diedof the disease. Gastric cancer is the seventh leading cause of cancer deaths.   International Once the second most common cancer worldwide, stomach cancer has dropped to fourth place, after cancers of the lung, breast, and colon and rectum. However, stomach cancer remains the second most common cause of death from cancer Ratesof the disease are highest in Asia and parts of South America and lowest in North America. The highest death rates are recorded in Chile, Japan, South America, and the former Soviet Union. Metastasis occurs in 80-90% of individuals with stomach cancer, with a six month survival rate of 65% in those diagnosed in early stages and less than 15% of those diagnosed in late stages.

90.   Mortality/Morbidity survival rate for curative surgical resection ranges from 30-50% for patients with stage II disease and from 10-25% for patients with stage III disease. The operative mortality rate less than 3%. high death rate (Approximately 800,000 per year) making it the second most common cause of cancer death worldwide after lung cancer   Race The rates of gastric cancer are higher in Asian and South American countries than in the United States. Japan, Chile, and Venezuela have developed a very rigorous early screening program that detects patients with early stage disease ( ie , low tumor burden). These patients appear to do quite well.

91. In fact, in many Asian studies, patients with resected stage II and III disease tend to have better outcomes than similarly staged patients treated in Western countries. In the United States, Asian and Pacific Islander males and females have the highest incidence of stomach cancer, followed by black, Hispanic, white, American Indian, and Inuit populations. Sex In the United States, gastric cancer affects slightly more men than women Worldwide, however, gastric cancer rates are about twice as high in men as in women. Age Most patients are elderly at diagnosis. common in 50 – 70 yrs

92. STAGES The clinical stages of stomach cancer are: Stage 0. Limited to the inner lining of the stomach.. (Stage I) (Stage 1A. Penetration to the second or third layers of the stomach. (Stage 1B) .. the second layer and nearby lymph nodes .   .

93. Stage II. Penetration to the second layer and more distant lymph nodes, or the third layer and only nearby lymph nodes, or all four layers but not the lymph nodes Stage III. Penetration to the third layer and more distant lymph nodes, or penetration to the fourth layer and either nearby tissues or nearby or more distant lymph nodes. Stage IV. Cancer has spread to nearby tissues and more distant lymph nodes, or has metastatized to other organs

94. ETIOLOGICAL FACTORS Diet   Smoking . Helicobacter pylori infection Previous gastric surgery Genetic factors Li- Fraumeni syndrome familial adenomatous polyposis and Peutz-Jeghers syndrome Epstein-Barr virus Pernicious anemia Obesity Radiation exposure Bisphosphonates

95. DIFFERENTIAL DIAGNOSIS Esophagitis Gastric Ulcers Gastritis, Acute Gastritis, Atrophic Gastritis, Chronic Gastroenteritis, Bacterial Gastroenteritis, Viral Lymphoma, Non-Hodgkin Malignant Neoplasms of the Small Intestine

96. PATHOPHYSIOLOGY Initiation,prioliferation and progression The tumour growth is insiduos and follows a pattern of continuos infiltration. Cancer of stomach may spread by direct extension along the mucosal surface and infiltration through the gastric wall

97. Once the stomach wall has been penetrated by tumour growth adjascent organs and structures that may become involed are the esophagus , dueodenum , omentum,liver and pancreas Distant maetastasis is falicitated by rich lymphatic plexuses in the stomach wall. Seeding of tumour cells into the peritoneal cavity occurs late in the course of disease

98. CLINICAL FEATURES SYMPTOMS Abdominal fullness or pain which may occur after eat a small meal Dark stools Difficulty swallowing, which becomes worse over time Excessive belching General decline in health Loss of appetite Nausea Vomiting, which may contain blood Weakness or fatigue Weight loss SIGNS Diagnosis is often delayed because symptoms may not occur in the early stages of the disease.patients may self-treat symptoms that gastric cancer has in common with other, less serious gastrointestinal disorders (bloating, gas, heartburn, and a sense of fullness).

99. DIAGNOSTIC TESTS The following tests can help diagnose gastric cancer: History collection and physical examination Complete blood count (CBC) to check for anemia Esophagogastroduodenoscopy (EGD) with biopsy to examine the stomach tissue Stool test to check for blood in the stools   Endoscopy: Upper Gastrointestinal Series/Barium Radiography Endoscopic Ultrasound Computed Tomography (CT) Scan Positron Emission Tomography (PET Magnetic Resonance Imaging (MRI) Chest X-Ray

100. COMPLICATIONS Mortality 1-2% Anastamotic leak, bleeding, ileus , transit failure, cholecystitis , pancreatitis, pulmonary infections, and thromboembolism . Late complications include dumping syndrome, vitamin B-12 deficiency, reflux esophagitis , osteoporosis.

101. MANAGEMENT Surgery Chemotherapy Radiation therapy Biological therapy Radical surgery

102. Surgery Endoscopic mucosal resection (EMR)

103. Endoscopic submucosal dissection (ESD)

104. Gatrectomy

105. RADICAL SURGERY CRS(CYTO REDUCTIVE SURGERY) + HIPEC (HYPERTHERMIC INTRAPERITONEAL CHEMOTHERAPY )

106. Chemotherapy   Some drugs used in stomach cancer treatment have included: 5-FU (fluorouracil) capecitabine , BCNU ( carmustine ), methyl-CCNU ( Semustine ), and doxorubicin( Adriamycin ), Mitomycin C, and cisplatin and taxotere Clinical researchers have explored the benefits of giving chemotherapy before surgery to shrink the tumor, or as adjuvant therapy after surgery to destroy remaining cancer cells.

107.   Radiation Radiation therapy (also called radiotherapy) is the use of high-energy rays to damage cancer cells and stop them from growing. When used, it is generally in combination with surgery and chemotherapy, or used only with chemotherapy in cases where the individual is unable to undergo surgery. Radiation therapy may be used to relieve pain or blockage by shrinking the tumor for palliation of incurable disease.

108. Multimodality therapy While previous studies of multimodality therapy (combinations of surgery, chemotherapy and radiation therapy) gave mixed results The combination of chemotherapy and radiation therapy in patients with nonmetastatic , completely resected gastric cancer is benefited. Patients were randomized after surgery to the standard group of observation alone, or the study arm of combination chemotherapy and radiation therapy. Those in the study arm receiving chemotherapy and radiation therapy survived on average 36 months; compared to 27 months with observation

109. Residual Disease R Status Tumor status following resection. Assigned based on pathology of margins. R0- no residual gross or microscopic disease. R1- microscopic disease only. R2- gross residual disease. Long term survival only in R0 resection

110. “D” Nomenclature Describes extent of resection and lymphadenectomy . D1- removes all nodes within 3cm of tumor. D2- D1 plus hepatic, splenic , celiac, and left gastric nodes. D3- D2 plus omentectomy , splenectomy , distal pancreatectomy , clearance of porta hepatis nodes. Current standards include a D1 dissection only.

111. NURSING DIAGNOSIS AND INTERVENTIONS Pain related to underlying disease process and sideffects of surgery,chemotherapy and radiation therapy  

112. Imbalanced nutrition less than body requirements related to inability to ingest,digest or absorb nutrients

113. Activity intolerance related to generalized weakness ,abdominal discomfort and nutritional deficits

114. Anxiety related to lack of knowledge of diagnostic tests,unknown diagnostic outcomes,disease process

115. Anticipatory grieving related to percoieved unfavourable diagnosis and impending death.

116. PREVENTION Avoiding risk factors and increasing protective factors may help to prevent stomach cancer and includes avoiding; Certain medications like NSAIDS Certain diet like spicy foods Smoking Alcoholism Stress Helicobacter infection

117. RESEARCH STUDY RESEARCH IN STOMACH CANCER Current Areas of Stomach Cancer Research Stomach cancer research scientists are testing new approaches for treatment, including:   Anticancer drugs and drug combinations Different methods, doses, and schedules of radiation therapy Combination therapy (which includes chemotherapy, surgery, and radiation therapy).   Other research trials are studying the effectiveness of using biological therapy to treat the disease. This therapy uses substances made by the body or in a laboratory to boost, direct, or restore the body's natural defenses against cancer. This type of treatment is also called biotherapy or immunotherapy.

118. RESEARCH STUDIES RELATED TO GASTRITIS New study identifies potential vaccine to prevent gastritis, ulcer disease, gastric cancer February 2, 2011 A new study led by researchers at Rhode Island Hospital in collaboration with the University of Rhode Island (URI) and EpiVax . Inc, a privately owned vaccine development company in Providence, RI, has identified a potential vaccine capable of reducing colonization of Helicobacter pylori (H. pylori) -- known cause of gastritis, ulcer disease and cancer.

119. RESCENT RESEARCH RELATED TO GASTRIC CARCINOMA Risk of Cancer from Heartburn Pills The group of medicines which can alleviate heartburn quickly and is the most widely prescribed class of drugs in Britain can actually increase the risk of cancer, reveals a recent study.   The group of medicines which can alleviate heartburn quickly and is the most widely prescribed class of drugs in Britain can actually increase the risk of cancer, reveals a recent study. Researchers said that the class of drugs commonly prescribed for heart burn known as proton pump inhibitors (PPIs), can increase the risk of cancer, heart disease and infections. Even though the drugs controlled symptoms of acid reflux, they actually increased the risk of cancer rather then reducing it. Peter Weissberg , medical director of the British Heart Foundation, said: "Doctors need to be sure they are really necessary." - JULY 25 2012  

120. CONCLUSION There is a plethora of literature concerning gastritis and peptic ulcer disease caused by the bacterium Helicobacter pylori. Nevertheless, there is still much to be learned about this bacterium and its effects on the human body. It may not be known exactly how H. pylori is transmitted but at least we are able to detect and eradicate the bacterium with relative ease and efficiency. Many new ways to help prevent and inhibit the activity of H. pylori are being discovered. Now it is up to the scientists to discover even better ways to treat the disease caused by this bacterium and to find ways to prevent the disease. When H. pylori’s mode of transmission is finally discovered, it may lead to more efficient ways to prevent transmission and infection. As a nurse its very important to give health education as primary prevention and also secondary and tertiary prevention once disease occurred.

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