Adult Medical-Surgical Nursing

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Adult Medical-Surgical Nursing

• Gastro-intestinal Module
• Gastritis and Peptic Ulcer

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• Gastritis

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Gastritis

• Gastritis is an acute or chronic inflammation of
  the gastric mucosa
• Risk factors include
• Spicy food
• Overuse of Aspirin, NSAIDs
• Excessive alcohol and caffeinated drinks
• Smoking stressful lifestyle
• Helicobacter pylori or other pathogen

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Gastritis Pathophysiology

• The gastric mucosa is protected from the high
  acidity of hydrochloric acid in the stomach by
  mucus secretion
• Mucosal damage occurs through
• Interference with the amount of acid
  hypersecretion or achlorhydria
• Reduction of mucus production
• Generalised inflammation results. Where acute can
  lead to necrosis, scarring or perforation

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Helicobacter Pylori

• H pylori is an organism which has been closely
  related to gastritis and peptic ulcer
• It can be detected in blood and breath tests
• Where present, treatment includes antibiotics in
  addition to control of peptic acid content

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Gastritis Clinical Manifestations

• Anorexia
• Heartburn after eating
• Flatulence (belching)
• Nausea/ vomiting
• Sour taste in mouth

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Gastritis Diagnosis

• Clinical symptoms and dietary history
• Breath test, stool or serological test for H
  pylori
• Endoscopy
• Inspection
• Gastric washings for H. pylori
• Biopsy
• Serum B12 (may be ? if intrinsic factor affected)

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Gastritis Treatment/ Counselling

• Dietary changes
• ? smoking
• Less stressful lifestyle
• Antibiotics
• Acid reduction through
• H2 receptor inhibitors (Ranitidine)
• Proton pump inhibitors (Lanzoprazole)

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• Peptic Ulcer

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Peptic Ulcer

• The gastric and intestinal wall layers are
  mucosa ? sub-mucosa ? muscle? serosa? peritoneum
• A peptic ulcer is an erosion of the mucosa of the
  stomach, pylorus, duodenum or oesophagus in a
  circumscribed area. It may pass through all
  layers and eventually perforate to the peritoneum
• Multiple ulcers may be present at once

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Gastric Ulcers (15 of total) Main Features

• Later onset usually after 50 years of age
• Similar occurance in male female (11)
• Normal, ? HCl or ? HCl (achlorhydria)
• Epigastric pain occurs after a meal (within the
  following hour), relieved by vomiting
• Associated with weight loss
• Risk of haemorrhage
• Long-term risk for gastric malignancy

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Duodenal Ulcers (80 of total) Main Features

• Affect younger age group (30-60 years)
• Occurence in male female is 2-3 1
• Related to hyperacidity (? HCl secretion)
• Epigastric dull, gnawing pain occurs 2-3 hours
  after food, often awakens the patient, relieved
  by food
• Vomiting not common
• Increased risk of perforation
• Less risk of malignancy

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Peptic Ulcer Aetiology

• Risk factors for peptic ulcer include
• H pylori (70 in gastric 95 in duodenal)
• Genetic link blood group O
• Spicy food also milk and cream
• Smoking
• Stressful lifestyle
• Use of aspirin, NSAIDs, corticosteroids
• Excessive alcohol and caffeinated drinks

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Peptic Ulcer Stress Ulcers

• Stress ulcers are usually found in ICU patients
  (prophylaxis given routinely)
• Related to physiological stress
• Also related to corticosteroid therapy
• Usually preceded by shock (severe trauma, burns,
  sepsis) ? reduced blood flow to the mucosa and
  reflux of duodenal contents to the stomach ?
  outpouring of HCl and pepsin on less protected
  mucosa ? ulceration

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Peptic Ulcer Pathophysiology

• Peptic ulcer is largely related to
• Increased concentration and action of HCl on the
  mucosa (stress, spicy foods, smoking, caffeine,
  alcohol)
• Reduced mucus secretion ? mucosal resistance and
  protection from the digestive action of HCl
  (stress, aspirin, NSAIDs, corticosteroids, H
  pylori)

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Peptic UlcerClinical Manifestations

• Dull, gnawing epigastric or back pain (thought to
  be the effect of acid on exposed nerve endings)
• Relieved by vomiting (gastric) or by food
  (duodenal)
• Tenderness over the epigastrium
• Possible weight loss
• Anaemia if acute or chronic haemorrhage
• Haematemesis or malaena (tarry stool)

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Peptic Ulcer Diagnosis

• History and physical examination
• CBC (anaemia)
• Stool Guiac test for occult blood
• Breath test, stool or serum (antibodies) for
  Helicobacter pylori
• Endoscopy Inspection
• Biopsy of mucosa for histology
• Gastric washings for culture of H pylori

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Peptic Ulcer Medical Management

• Lifestyle changes
• Medical treatment
• Antibiotics (Flagyl and one other antibiotic)
• H2-receptor antagonist (Ranitidine) or
  Proton-pump inhibitor (Lanzoprazole)
• Mucosal protection (Misoprostol)
• (Usually avoid antacids as interfere with
  treatment)

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Peptic Ulcer Surgery

• Surgery is less used now. Mainly for
• Ulcers not healing after 12 16 weeks
• Life-threatening complications
• Haemorrhage
• Perforation/ penetration
• Pyloric obstruction

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Peptic Ulcer Surgery

• Types of surgical procedure
• Vagotomy (resection of the vagus, parasympathetic
  nerve ? HCl secretion)
• Pyloroplasty (with or without vagotomy)
• Gastro-enterostomy (bypass from stomach to
  jejunum)

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Peptic Ulcer Complications Haemorrhage

• Haemorrhage ulcer has eroded a blood vessel
• Haematemesis, especially gastric ulcer fresh
  blood or coffee-ground vomit
• Malaena (more obvious if duodenal ulcer)
• May be an emergency ? hypovolaemic shock
• GXM, IV fluids, vital signs, NG tube, NPO
• Rest, mouth care, surgical prep (if needed)

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Peptic Ulcer Complications Perforation

• Perforation
• Ulcer has perforated layers to the peritoneum
• Acid contents leaking into peritoneum
• Patient in severe shock from extreme pain of
  chemical peritonitis
• Rigid, board-like abdomen, extremely tender
• Hypotension emergency requiring immediate
  resuscitation and preparation for surgery to
  repair

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Peptic Ulcer Nursing Care

• Pre-operative care (may well be emergency)
• General physical check-up, chest Xray, ECG
• Blood profile, IVI, group and cross-match (GXM)
• Breathing exercises to prepare for post-op
• Thrombo-embolic stockings/ prophylactic heparin
• Explanation of operation, consent and emotional
  support

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Peptic Ulcer Nursing Care

• Post-operative care
• Pain relief
• Monitor vital signs, pulse oximetry, IV fluids,
  urine output and fluid balance
• Semi-sitting position once recovered
• Breathing and leg exercises
• NPO initially? graduated intake (mouth care)
• NG tube aspirations, wound, drain care