 OTHER GI CONDITIONS
 Peptic Ulcer Disease (PUD)
 - PUD is the ulceration of the gastric mucosa
as a result of the digestive action of
hydrochloric acid and pepsin. The condition
may be classified as acute or chronic.
 Types of Peptic Ulcers
 1. Duodenal (most common).
 2. Gastric.
 3. Stress-induced ulcers, drug-induced
ulcers.
 4. Cause by Helicobacter pylori
 Although the ulcers are classified as PUD,
the types are distinctively different.
 Histamine release occurs with the erosion of
the gastric mucosa in both the duodenal and
gastric ulcers.
 This stimulates further secretion of gastric
acid and formation of mucosal edema.
 The continued erosion will eventually
damage the blood vessels leading to
hemorrhage, or to erosion through gastric
mucosa.
 PREDISPOSING RISK FACTORS
 Helicobacter pylori infection
 NSAIDs, Aspirin
 Gastritis, Hyperacidity
 Alcohol ingestion
 Smoking
 Blood Type O
 Type A Personality
 Zollinger-Ellison Syndrome
 Brain Trauma (Cushing’s Ulcer)
 Extensive Burns (Curling’s Ulcer)
 PATHOPHYSIOLOGY
 Prostaglandins play a critical role in
maintaining gastroduodenal mucosal
integrity and repair.
 It therefore follows that interruption of
prostaglandin synthesis can impair mucosal
defense and repair, thus facilitating mucosal
injury via a systemic mechanism.
 A summary of the pathogenetic pathways by
which systemically administered NSAIDs
may lead to mucosal injury
 Characteristics of Duodenal Ulcers
 1. Factors contributing to the development.
 a. Associated with hypersecretion of gastric
juice.
 b. Neuropsychiatric factors.
 (1) People who are under psychological
stress, hard driving, and competitive
demonstrate increased gastric acid
secretions.
 (2) Frustration and stress in later life also
increase gastric juice secretion.
 c. More common in men; incidence
increases in women after menopause.
 d. Smoking, alcohol.
 PATHOPHYSIOLOGY
 Bacterial and host factors important in
determining H. pylori-induced
gastrointestinal disease. MALT, mucosal-
associated lymphoid tissue.
 Clinical Manifestations
 a. Burning, cramping, midepigastric pain.
 b. Pain occurs 2 to 4 hours after meals;
eating generally relieves pain.
 c. Pain is episodic, may occur during the
night, generally absent in the morning.
 d. Tendency toward weight gain (eating
decreases pain).
 e. Nausea and vomiting.
  Characteristics of Gastric Ulcers  Zollinger-Ellison syndrome---client
experiences symptoms characteristic of
 1. Factors contributing to development. PUD, but symptoms are caused from a
gastric tumor that secretes large amounts of
 a. More common in men; incidence gastrin, this stimulates the secretion of
increases with age. gastric acid.
 b. Smoking, alcohol.  Characteristics of Stress ulcers and Drug-
induced ulcers.
 c. Generally not associated with
psychological stress.  1. Types and factors contributing to
development.
 d. Gastric secretions usually normal.
 a. Shock, sepsis, and major trauma may
Duodenal Ulcer result in the development of multiple acute
gastric ulcers.
 25-50 yrs old
 (1) Curling ulcer--associated with severe
 type O
bums; may occur within 24 hours post burn.
 executives, competitive
 (2) Cushing's ulcer--associated with CNS
 well nourished lesion and trauma.

 pain: 2-3 hrs after meals & at night  b. Drug-induced ulcerations.

 relieved by food, antacids, vomiting  (1) Aspirin compounds.

 melena  (2) Prolonged steroid therapy.

Gastric Ulcer  Clinical Manifestations

 50 and over  a. Both types of ulcers often are

asymptomatic prior to major complications.
 type A
 Diagnostics
 lower socioeconomic
 1. Clinical Manifestations.
 malnourished
 2. X-ray of upper GI system.
 pain: empty stomach or shortly after meals
 3. Gastroscopy/Endoscopy
 relieved by antacids, vomiting
 Treatment
 hematemesis
 1. Medical.
 Clinical Manifestations
 a. Antacids .
 a. Burning pain generally in the left
epigastric area.  b. Histamine receptor antagonist-cimetidine
(Tagamet).
 b. Food may relieve pain, but frequently
aggravates pain.  c. Anticholinergic medications for duodenal
ulcers
 c. Pain generally does not occur at night.
 d. Pump inhibitor – Losec, Nexium
 d. Tendency toward weight loss.
 Antimicrobial Therapy

Amoxil , Tetracycline, Flagyl

 Plus: proton pump inhibitor  e. Decrease smoking.

bismuth preparation  f. Decrease activity and psychological stress.

traditional antacids  2. Surgical interventions (generally

indicated in complications).
H2 antagonists
 a. Vagotomy-decreases acid secreting
Plus: Zithromax stimulus to gastric cells.

 Nonabsorbable Antacids  b. Pyloroplasty-widens the pyloric valve to

Calcium carbonate
Magnesium oxide
Aluminum hydroxide
 Histamine H2 receptor antagonist
Cimetidine (Tagamet)
Ranitidine (Zantac)
Famotidine (Pepcid)
 Mucosal Barrier Fortifier
Sucralfate (Carafate)
 Proton pump inhibitors -potent acid
inhibitory agents
Omeprazole (Prilosec)
Lansoprazole (Prevacid)
 Synthetic prostaglandin
Misoprostol (Cytotec)
enhance gastric emptying, may be done in
association with vagotomy.
 c. Gastric resection (Bilroth 1, BilrothII,
partial gastric resection, gastrectomy)-
hemorrhage.
 Surgical Implications
Vagotomy & Gastroenterostomy or
Pyloroplasty
Vagotomy & Antrectomy
Partial Gastrectomy &
Possible Vagotomy
- Billroth I and - Billroth II
 Billroth I: Gastroduodenostomy;
partial gastrectomy, with remaining
segment anastomosed to duodenum
 Billroth II: Gastrojejunostomy;
partial gastrectomy, with remaining
segment anastomosed to jejunum

 Dietary control of symptoms  Total Gastrectomy:

Esophagojejunostomy; removal of
Avoid….. the stomach with attachment of the
esophagus to the jejunum or
 Complications duodenum

hemorrhage  Complications (All types)

perforation  A. Indications of hemorrhage

pyloric obstruction  a. Hematemesis, melena. or both.

 d. Diet modifications.  b. Hypovolemic shock - carefully evaluate

 (1) May be less effective in gastric ulcers.
 (2) Highly individual; foods precipitating
pain are to be avoiding.
the client's blood pressure. Orthostatic
hypotension (a blood pressure decrease of
10 mm Hg or more) may be indicative of
hypovolemia
 - Indications for surgical intervention.
 (1) If bleeding occurs in 48 hours after
medical therapy is begun.
 (2) If multiple blood transfusions are
required within 24 hours.
 B. Perforation of ulcer into the peritoneal
cavity.
 a. Sudden, severe, diffuse, upper abdominal
pain.
 b. Abdominal muscles contract as abdomen
becomes rigid.
 c. Bowel sounds absent.
 d. Respirations become shallow and rapid.
 e. Severity of the peritonitis is proportional
to size of perforation and amount of gastric
spillage
 C. Gastric obstruction.
 a. Generally occurs in clients with a long
history of ulcer disease.
 b. Progression of pain from epigastric to
generalized upper abdominal pain.
 c. Discomfort increases toward the end of
the day.
 d. Relief may he obtained by vomiting.
 e. Increased bowel sounds.
 Nursing Intervention
 Goal: to promote health in clients with PUD.
 1. Assist client to understand disease
process.
 2. Assist client to identify factors which
precipitate pain and discomfort.
 3. Assist client to understand diet therapy
and why it is essential to health
maintenance.
 4. Assist client to understand medication
regimen. Client should not take over-the-
counter medications, especially aspirin
compounds.
 5. Assist client to identify stress factors in
his/her life style. Counseling may be
indicated to help client improve his/her
ability to cope with stress.
 Goal: to relieve pain and promote healing.
 1. Dietary modifications.
 a. Encourage small, frequent meals.
 b. Nonstimulating bland foods are generally
tolerated better during healing of acute
episodes.
 c. Assist client to identify specific dietary
habits which accelerate or precipitate pain.
 d. Promote good nutritional habits.
 2. Decrease activity as indicated by
discomfort.
 Goal: to assess for complications of
hemorrhage and initiate nursing activities
accordingly.
 1. Assess for symptoms indicating
hemorrhage.
 a. Evaluate hemoglobin and hematocrit
levels.
 b. Assess for distention, increase in pain,
and tenderness.
 c. Make frequent assessments of vital signs
and correlate with client's overall condition.
 d. Assess stools and nasogastric drainage for
presence of blood.
 2. If active hemorrhage is identified:
 a. Establish peripheral infusion line,
preferably with large gauge needle for blood
infusion.
 b. Insert indwelling urinary catheter to
monitor urinary output.
 c. Insert nasogas4 tube for removal of
gastric contents and maintain gastric suction.
 d. May implement iced saline lavage.
 e. Administer whole blood transfusion and
IV fluids as indicated.
 f. Position client supine with legs slightly
elevated.
 g. Initiate preoperative preparation as
surgery is indicated
 Goal: to identify complications of dumping
syndrome and initiate preventive nursing
measures postoperative gastric resection
(condition occurs when a large bolus of
gastric chyme and hypertonic fluid enter the
intestine; generally self-limiting within
several months after surgery).
 1. Assess for symptoms of condition.
 a. Weakness.
 b. Dizziness.
 c. Abdominal cramping.
 d. Diaphoresis.
 e. Generally occurs within 15 to 30
minutes after eating.
 f. Condition is usually self-limiting and
resolves in about 6 months.
 2. Prevent dumping syndrome.
 a. Decrease amount of food eaten at one
meal.
 b. Decrease carbohydrates, decrease salt
intake, increase proteins and fats as
tolerated.
 c. No added fluid with meal or for one
hour following meal.
 d. Position client in semi recumbent
position during meals; client should lit down
for 20 to 30 minutes after meals to delay
stomach emptying.
 Dumping syndrome
 Rapid emptying of the gastric
contents into the small intestine
that occurs following gastric
resection
 Rapid emptying of the gastric
contents into the small intestine ®
rapid distention of S.I. ®hypertonic
intestinal contents draw ECF and
ingestion of fluids during mealtime
® stomach empties rapidly
 Clinical Manifestations
 Symptoms occurring 30 minutes
after eating
 Early S/Sx: Nausea and vomiting;
feelings of abdominal fullness and
abdominal cramping; diarrhea
 Later S/Sx: reactive hypoglycemia;
pallor, weakness, dizziness,
palpitations, tachycardia,
 symptoms occurring 30
minutes after eating
 nausea and vomiting
 feelings of abdominal
fullness and abdominal
cramping
 diarrhea
 palpitations and
tachycardia
 perspiration
 weakness and dizziness
 borborygmi
 Prevention
avoid sugar & salt
maintain high-protein, high-fat, low
carbohydrate
avoid drinking fluids with meals
lie down after meals
 Nursing Interventions
 Eat a high-protein, high-fat, low-
carbohydrate diet; avoid sugar and
salt.
 Eat small meals and avoid
consuming fluids with meals; fluids
may be consumed 1 hours before or
1 hour after mealtime
 Lie down after meals for 20-30
minutes

 Take antispasmodic medications as

prescribed to delay gastric
emptying.