GI System Lecture 3

Learning Objectives:
At the end of this lecture, you will be able to:
1. Compare the etiology, clinical manifestations, and
management of acute gastritis, chronic gastritis, and
peptic ulcer.
2. Use the nursing process as a framework for care of
patients with gastritis.
JOFRED M. MARTINEZ, RN

patients with peptic ulcer.
4. Describe the dietary, pharmacologic, and surgical
treatment of peptic ulcer.
5. Describe the nursing management of patients who
undergo surgical procedures to treat obesity.
patients with gastric cancer.
patients undergoing gastric surgery.
Learning Objectives (Cont’d.):

8. Identify the complications of gastric surgery and their
prevention and management.
9. Describe the home health care needs of the patient
who has had gastric surgery.
Learning Objectives (Cont’d.):

GASTRITIS
• Gastritis is the 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 food that is
contaminated with disease-causing microorganisms or
that is irritating or too highly seasoned.
• Other causes of acute gastritis include overuse of
aspirin and other nonsteroidal anti-inflammatory drugs
(NSAIDs), excessive alcohol intake, bile reflux, and
radiation therapy.
Gastritis

GASTRITIS
• A more 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.
• 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.
Gastritis

Gastritis
CLINICAL MANIFESTATIONS
• The patient with acute gastritis may have abdominal
discomfort, headache, lassitude, nausea, anorexia,
vomiting, and hiccupping.
• 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.

Gastritis
ASSESSMENT AND DIAGNOSTIC FINDINGS
• Diagnosis can be determined by endoscopy, upper GI
radiographic studies, and histologic examination of a
tissue specimen obtained by biopsy.
• Other diagnostic measures for detecting H. pylori
include serologic testing for antibodies against the H.
pylori antigen, a 1-minute ultrarapid urease test, and a
breath test.

Gastritis
MEDICAL MANAGEMENT
• Acute gastritis is also managed by instructing the
patient to refrain from alcohol and food until symptoms
subside. After the patient can take nourishment by
mouth, a nonirritating diet is recommended.
• If the symptoms persist, fluids may need to be
administered parenterally.
• If bleeding is present, management is similar to the
procedures used for upper GI tract hemorrhage.
• If gastritis is caused by ingestion of strong acids or
alkalis, treatment consists of diluting and neutralizing
the offending agent.

Gastritis
MEDICAL MANAGEMENT
• To neutralize acids, common antacids (eg, aluminum
hydroxide) are used; 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.
• In extreme cases, emergency surgery may be required
to remove gangrenous or perforated tissue.

Gastritis
MEDICAL MANAGEMENT
• Gastrojejunostomy or gastric resection may be
necessary to treat pyloric obstruction, a narrowing of
the pyloric orifice.
• 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).

Gastric and Duodenal Ulcers
• A peptic ulcer is an excavation that forms in the
mucosal wall of the stomach, in the pylorus, in the
duodenum, 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.
• Peptic ulcers are more likely to be in the duodenum
than in the stomach.
• Chronic gastric ulcers tend to occur in the lesser
curvature of the stomach, near the pylorus.

• Peptic ulcer disease occurs with the greatest frequency
in people between the ages of 40 and 60 years.
• It is relatively uncommon in women of childbearing age,
but it has been observed in children and even in
infants. After menopause, the incidence of peptic ulcers
in women is almost equal to that in men.
Clients should not take NSAIDs and prednisone at
the same time due to ↑ risk of GI irritation.

• Peptic ulcer disease occurs with the greatest frequency
in people between the ages of 40 and 60 years.
• It is relatively uncommon in women of childbearing age,
but it has been observed in children and even in
infants. After menopause, the incidence of peptic ulcers
in women is almost equal to that in men.
• Ulcers seem to develop more commonly in people who
are tense.
• The ingestion of milk and caffeinated beverages,
smoking, and alcohol also may increase HCl secretion.

• Familial tendency may be a significant predisposing
factor. People with blood type O are more susceptible
to peptic ulcers.
• Other predisposing factors associated with peptic ulcer
include chronic use of NSAIDs, alcohol ingestion, and
excessive smoking.
• Rarely, ulcers are caused by excessive amounts of the
hormone gastrin, produced by tumors.
• Zollinger-Ellison syndrome (ZES) consists of severe
peptic ulcers, extreme gastric hyperacidity, and gastrin-
secreting benign or malignant tumors of the pancreas.

Gastric and duodenal ulcers have differentiating features:
• Gastric ulcers: common in women in labor; clients are
malnourished in appearance; pain occurs 1/2 to 1 hour
after meals; food doesn’t help but vomiting does;
clients tend to vomit blood (hematemesis).
• Duodenal ulcers: common in executive type
personalities (type A); clients are well nourished in
appearance; pain occurs at night and 2 to 3 hours after
meals; food helps; blood appears in stool (melena).
• Duodenal ulcers are the most common to rupture.
Gastric—eating leads to pain.
Duodenal—eating lessens pain.

• 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.
• 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.

MEDICAL MANAGEMENT
Methods used include medications, lifestyle changes,
and surgical intervention.
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; histamine 2 (H2)
receptor antagonists and proton pump inhibitors are
used to treat NSAID-induced and other ulcers not
associated with H. pylori ulcers.

STRESS REDUCTION AND REST
• Biofeedback, hypnosis, or behavior modification may
be helpful.
SMOKING CESSATION
• Studies have shown that smoking decreases the
secretion of bicarbonate from the pancreas into the
duodenum, resulting in increased acidity of the
duodenum.
DIETARY MODIFICATION
• Avoiding extremes of temperature and overstimulation
from consumption of meat extracts, alcohol, coffee and
other caffeinated beverages, and diets rich in milk and
cream.

SURGICAL MANAGEMENT
• Surgical procedures include vagotomy, with or without
pyloroplasty, and the Billroth I and Billroth II
procedures.

SURGICAL MANAGEMENT

The Patient with Ulcer Disease
ASSESSMENT
• The nurse asks the patient to describe the pain and the
methods used to relieve it (e.g., food, antacids).
• The patient usually describes peptic ulcer pain as burning
or gnawing; it occurs about 2 hours after a meal and
frequently awakens the patient between midnight and 3
AM.
• Taking antacids, eating, or vomiting often relieves the pain.
• Is the vomitus it bright red, does it resemble coffee
grounds, or is there undigested food from previous meals?
NURSING PROCESS:

ASSESSMENT
• Has the patient noted any bloody or tarry stools?
• The nurse also asks the patient to list his or her usual food
intake for a 72-hour period and to describe food habits.
• Does the patient use irritating substances?
• The nurse inquires about the patient’s level of anxiety and
his or her perception of current stressors.
• How does the patient express anger or cope with stressful
situations?
• Is the patient experiencing occupational stress or
problems within the family?
NURSING PROCESS:

ASSESSMENT
• Is there a family history of ulcer disease?
• The nurse assesses vital signs and reports tachycardia
and hypotension, which may indicate anemia from GI
bleeding.
• The stool is tested for occult blood, and a physical
examination, including palpation of the abdomen for
localized tenderness, is performed as well.
NURSING PROCESS:

The Patient with Conditions in the Oral Cavity
NURSING DIAGNOSES
• Acute pain related to the effect of gastric acid secretion
on damaged tissue
• Anxiety related to coping with an acute disease
• Imbalanced nutrition related to changes in diet
• Deficient knowledge about prevention of symptoms and
management of the condition

PLANNING AND GOALS
• The goals for the patient may include relief of pain,
reduced anxiety, maintenance of nutritional
requirements, knowledge about the management and
prevention of ulcer recurrence, and absence of
complications.

NURSING INTERVENTIONS
• RELIEVING PAIN
• REDUCING ANXIETY
• MAINTAINING OPTIMAL NUTRITIONAL STATUS
• PROMOTING HOME AND COMMUNITY-BASED
CARE

POTENTIAL COMPLICATIONS
Potential complications may include the following:
• Hemorrhage
• Perforation
• Penetration
• Pyloric obstruction

EVALUATION
EXPECTED PATIENT OUTCOMES
1. Reports freedom from pain between meals
2. Feels less anxiety by avoiding stress
3. Complies with therapeutic regimen
a. Avoids irritating foods and beverages
b. Eats regularly scheduled meals
c. Takes prescribed medications as scheduled
d. Uses coping mechanisms to deal with stress
4. Maintains weight
5. Is free of complications

Morbid Obesity
• Morbid 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
weight.
• 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.

Morbid Obesity
MEDICAL MANAGEMENT
• Conservative management consists of placing the
person on a weight loss diet in conjunction with
behavioral modification and exercise.
• There is a belief that depression may be a contributing
factor to weight gain, and treatment of the depression
with bupropion hydrochloride (Wellbutrin).
• Some physicians recommend acupuncture and
hypnosis before recommending surgery.

Morbid Obesity
PHARMACOLOGIC MANAGEMENT
• Several medications have recently been approved for
obesity they include sibutramine HCl (Meridia) and
orlistat (Xenical).
SURGICAL MANAGEMENT
• Bariatric surgery, or surgery for morbid obesity, is
performed only after other nonsurgical attempts at
weight control have failed.
• The first surgical procedure to treat morbid obesity was
the jejunoileal bypass.

Morbid Obesity
SURGICAL MANAGEMENT
• Bariatric surgery, or surgery for morbid obesity, is
performed only after other nonsurgical attempts at
weight control have failed.
• The first surgical procedure to treat morbid obesity was
the jejunoileal bypass.
• Gastric bypass and vertical banded gastroplasty are
the current operations of choice. These procedures
may be performed laparoscopically or by an open
surgical technique.

Morbid Obesity
NURSING MANAGEMENT
• 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.
• After bowel sounds have returned and oral intake is
resumed, the nurse provides six small feedings
consisting of a total of 600 to 800 calories per day and
encourages fluid intake to prevent dehydration.
• Patients are usually discharged in 4 to 5 days with
detailed dietary instructions.

Morbid Obesity
NURSING MANAGEMENT
• The nurse instructs patients to report excessive thirst or
concentrated urine, both of which are indications of
dehydration.
• Efforts are directed toward helping them modify their
eating behaviors and cope with changes in body
image.
• The nurse explains that noncompliance by eating too
much or too fast or eating high calorie liquid and soft
foods results in vomiting and painful esophageal
distention.

Morbid Obesity
NURSING MANAGEMENT
• Long-term side effects may include increased risk of
gallstones, nutritional deficiencies, and potential to
regain weight.

Gastric Cancer
• Most of these cases 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.
• The incidence of gastric cancer is much greater in
Japan, which has instituted mass screening programs
for earlier diagnosis.
• 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.

Gastric Cancer
• Other factors related to the incidence of gastric cancer
include chronic inflammation of the stomach, pernicious
anemia, achlorhydria, gastric ulcers, H. pylori infection,
and genetics.

Gastric Cancer
CLINICAL MANIFESTATIONS
• In the early stages of gastric cancer, symptoms may be
absent.
• Symptoms of progressive disease may include
anorexia, dyspepsia (indigestion), weight loss,
abdominal pain, constipation, anemia, and nausea and
vomiting.

Gastric Cancer
• 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.
• 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.

Gastric Cancer
MEDICAL MANAGEMENT
• There is no successful treatment for gastric carcinoma
except removal of the tumor.
• Effective palliation to prevent discomfort caused by
obstruction or dysphagia may be obtained by resection
of the tumor.
• If a radical subtotal gastrectomy is performed, the
stump of the stomach is anastomosed to the jejunum,
as in the gastrectomy for ulcer. When a total
gastrectomy is performed, GI continuity is restored by
means of an anastomosis between the ends of the
esophagus and the jejunum.

Gastric Cancer
MEDICAL MANAGEMENT
• If surgical treatment does not offer cure, treatment with
chemotherapy may offer further control of the disease
or palliation.
• Commonly used chemotherapeutic medications include
cisplatin, irinotecan, or a combination of 5-fluorouracil,
doxorubicin (Adriamycin), and mitomycin-C.
• Radiation therapy also may be used for palliation.

The Patient with Gastric Cancer
ASSESSMENT
• The nurse elicits a dietary history from the patient,
focusing on recent nutritional intake and status.
• Has the patient lost weight?
• If so, how much and over what period of time?
• Can the patient tolerate a full diet?
• If not, what foods can he or she eat?
• What other changes in eating habits have occurred?
Does the patient have an appetite?
• Is the patient in pain?
NURSING PROCESS:

ASSESSMENT
• Do foods, antacids, or medications relieve the pain,
make no difference, or worsen the pain?
• Is there a history of infection with H. pylori bacteria?
• Other health information to obtain includes the patient’s
smoking and alcohol history and the family history.
• A psychosocial assessment, including questions about
social support, individual and family coping skills, and
financial resources, will help the nurse plan for care in
acute and community settings.
NURSING PROCESS:

ASSESSMENT
• After the interview, the nurse performs a complete
physical examination, carefully assesses the patient’s
abdomen for tenderness or masses, and also palpates
and percusses to detect ascites.
NURSING PROCESS:

NURSING DIAGNOSES
• Anxiety related to the disease and anticipated treatment
• Imbalanced nutrition, less than body requirements,
related to anorexia
• Pain related to tumor mass
• Anticipatory grieving related to the diagnosis of cancer
• Deficient knowledge regarding self-care activities

PLANNING AND GOALS
• The major goals for the patient may include reduced
anxiety, optimal nutrition, relief of pain, and adjustment
to the diagnosis and anticipated lifestyle changes.

NURSING INTERVENTIONS
• REDUCING ANXIETY
• MAINTAINING OPTIMAL NUTRITIONAL STATUS
• RELIEVING PAIN
• PROVIDING PSYCHOSOCIAL SUPPORT
• PROMOTING HOME AND COMMUNITY-BASED
CARE

EVALUATION
1. Reports less anxiety
a. Expresses fears and concerns about surgery
b. Seeks emotional support
2. Attains optimal nutrition
a. Eats small, frequent meals high in calories, iron, and
vitamins A and C
b. Complies with enteral or parenteral nutrition as
needed
3. Has less pain

EVALUATION
4. Performs self-care activities and adjusts to lifestyle
changes
a. Resumes normal activities within 3 months
b. Alternates periods of rest and activity
c. Manages tube feedings

Gastric Surgery
• Gastric surgery may be performed on patients with
peptic ulcers who have life-threatening hemorrhage,
obstruction, perforation, or penetration or whose
condition does not respond to medication.
• Surgical procedures include a vagotomy and
pyloroplasty, a partial gastrectomy, and a total
gastrectomy with either an end-to-end or an end-to-
side esophagojejunal anastomosis.

Gastric Surgery
OBSTACLES TO ADEQUATE NUTRITION
DYSPHAGIA AND GASTRIC RETENTION
• Dysphagia may occur in patients who have had truncal
vagotomy, a surgical procedure that can result in
trauma to the lower esophagus.
• Gastric retention may be evidenced by abdominal
distention, nausea, and vomiting. Regurgitation may
also occur if the patient has eaten too much or too
quickly. If gastric retention occurs, it may be necessary
to reinstate NG suction; pressure must be low to avoid
disrupting the suture line.

Gastric Surgery
BILE REFLUX
• Bile reflux gastritis and esophagitis may occur with the
removal of the pylorus, which acts as a barrier to the
reflux of duodenal contents.
• Burning epigastric pain and vomiting of bilious material
manifest this condition. Eating or vomiting does not
relieve the situation. Agents that bind with bile acid,
such as cholestyramine (Questran), may be helpful.
Aluminum hydroxide gel (an antacid) and
metoclopramide hydrochloride (Reglan) have been
used with some success.

Gastric Surgery
DUMPING SYNDROME
• The term dumping syndrome refers to an unpleasant
set of vasomotor and GI symptoms that sometimes
occur in patients who have had gastric surgery or a
form of vagotomy.
• It may be the mechanical result of surgery in which a
small gastric remnant is connected to the jejunum
through a large opening.

Gastric Surgery
DUMPING SYNDROME
• Early symptoms include a sensation of fullness,
weakness, faintness, dizziness, palpitations,
diaphoresis, cramping pains, and diarrhea. Later, there
is a rapid elevation of blood glucose, followed by
increased insulin secretion.
• Vasomotor symptoms that occur 10 to 90 minutes after
eating are pallor, perspiration, palpitations, headache,
and feelings of warmth, dizziness, and even
drowsiness.

Gastric Surgery
DUMPING SYNDROME
• Anorexia may also be a result of the dumping
syndrome.
• Steatorrhea also may occur in the patient with gastric
surgery.

Gastric Surgery
VITAMIN AND MINERAL DEFICIENCIES
• Malabsorption of organic iron, which may require
supplementation with oral or parenteral iron, and a low
serum level of vitamin B12, which may require
supplementation by the intramuscular route.
• Total gastrectomy results in lack of intrinsic factor, a
gastric secretion required for the absorption of vitamin
B12 from the GI tract.
• This complication is avoided by the regular monthly
intramuscular injection of 100 to 1000 μg (usual dose is
300 μg) of vitamin B12.

GI System Lecture 3

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GI System Lecture 3