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Definition:
Oral cancer, also known as mouth cancer, is cancer of the lining of the lips,
mouth, or upper throat. In the mouth, it most commonly starts as a painless white patch, that
thickens, develops red patches, an ulcer, and continues to grow. Oral cancer is a subgroup
of head and neck cancers.
Incidence:
Oral cancer is the third-most-common form of cancer in India with over 77 000 new cases
diagnosed in 2012 (2.3:1 male to female ratio). 

 83 percent, for localized cancer (that hasn’t spread)

 64 percent, for cancer that’s spread to nearby lymph nodes

 38 percent, for cancer that’s spread to other parts of the body

Risk factors :
Tobacco and alcohol use
With both tobacco and drinking alcohol, the risk of oral cancer is 15 times greater.
Other risk factors include HPV infection.
 Chewing paan, and sun exposure .
Causes:
Tobacco
Alcohol
Human papillomavirus
Betel nut
Stem cell transplantation
Premalignant lesion
Staging:
Oral cancer staging is an assessment of the degree of spread of the cancer from its original
source. It is one of the factors affecting both the prognosis and the potential treatment of oral
cancer.

There are four stages of oral cancer.

 Stage 1: The tumor is 2 centimeters (cm) or smaller, and the cancer hasn’t spread to
the lymph nodes.

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 Stage 2: The tumor is between 2-4 cm, and cancer cells haven’t spread to the lymph
nodes.

 Stage 3: The tumor is either larger than 4 cm and hasn’t spread to the lymph nodes, or
is any size and has spread to one lymph node, but not to other parts of the body.

 Stage 4: Tumors are any size and the cancer cells have spread to nearby tissues, the
lymph nodes, or other parts of the body.

Classification: The evaluation of squamous cell carcinoma of the mouth and pharynx
staging uses the TNM classification (tumor, node, metastasis). This is based on the size of
the primary tumor, lymph node involvement, and distant metastasis.

Warning
signs:

(CAUTION)
C - Change in bowel or bladder habits
A - A sore that does not heal
U - Unusual bleeding or discharge
T- Thickening or lump in the breast or elsewhere
I- Indigestion or difficulty in swallowing
O- Obvious change in a wart or mole
N- Nagging cough or hoarse ness of voice

Symptoms of oral cancer include:

 a sore on your lip or mouth that won’t heal

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 mass or growth anywhere in your mouth

 bleeding from a your mouth

 loose teeth

 pain or difficulty swallowing

 trouble wearing dentures

 a lump in your neck

 an earache that won’t go away

 dramatic weight loss

 lower lip, face, neck, or chin numbness

 white, red and white, or red patches in or on your mouth or lips

 a sore throat

 jaw pain or stiffness

Diagnostic measures:

 X-rays to see if cancer cells have spread to the jaw, chest, or lungs

 a CT scan to reveal any tumors in your mouth, throat, neck, lungs, or elsewhere in
your body

 a PET scan to determine if the cancer has traveled to lymph nodes or other organs

 a MRI scan to show a more accurate image of the head and neck, and determine the
extent or stage of the cancer

 an endoscopy to examine the nasal passages, sinuses, inner throat, windpipe, and
trachea.
Treatment :

Mouth cancer can be treated with chemotherapy, radiation therapy and by surgery.

 Radiation :

High energy beams are used to destroy cancerous cells.

External beam of rays are sourced from a machine directly into the oral cavity targeting the
part where cancer has developed.

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If this is not possible, radioactive seeds are implanted in the form of wires (brachytherapy) in
the mouth near the tumor.

Often radiation treatment is given in the early stages of cancer in combination with
chemotherapy.

Radiation therapy can have a negative effect on the body. Some of the side effects of
radiation include:

 a sore throat or mouth

 dry mouth and loss of salivary gland function

 tooth decay

 nausea and vomiting

 sore or bleeding gums

 skin and mouth infections

 jaw stiffness and pain

 problems wearing dentures

 fatigue

 a change in your ability to taste and smell

 changes in your skin, including dryness and burning

 weight loss

 thyroid changes

Chemotherapy :

In this method, powerful chemicals are used to destroy cancerous cells. Drugs can be given in
the form of oral pills or as injection.

Chemotherapy and radiation therapy are used together when there are positive margins, bone
erosion, or positive lymph nodes.

Chemotherapeutic agents used include 5-fluorouracil (5-FU), methotrexate, cisplatin

(Platinol), carboplatin (Paraplatin), paclitaxel (Taxol), docetaxel (Taxotere), cetuximab
(Erbitux), and bleomycin (Blenoxane).

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Chemotherapy drugs can be toxic to rapidly growing noncancerous cells. This can cause side
effects such as:

 hair loss

 painful mouth and gums

 bleeding in the mouth

 severe anemia

 weakness

 poor appetite

 nausea

 vomiting

 diarrhea

 mouth and lip sores

 numbness in the hands and feet

Surgical Therapy.:

Surgery remains the most effective treatment, especially for early-stage disease. Various
surgical procedures may be performed, depending on the location and extent of the tumor.

Some examples are partial mandibulectomy (removal of the mandible), hemiglossectomy

(removal of half of the tongue), glossectomy (removal of the tongue), resections of the buccal
mucosa and floor of the mouth, and radical neck dissection

. Radical neck dissection includes wide excision of the primary lesion with removal of the
regional lymph nodes, the deep cervical lymph nodes, and their lymphatic channels.

The following structures may also be removed or transected (depending on the extent of the
primary lesion): sternocleidomastoid muscle and other closely associated muscles, internal
jugular vein, mandible, submaxillary gland, part of the thyroid and parathyroid glands, and
spinal accessory nerve. A tracheostomy is commonly performed along with the radical neck
dissection. Drainage tubes are inserted into the surgical area and connected to suction to
remove fluid and blood.

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Collaborative Therapy:

• Surgery •( Surgical excision of the tumor • Radical neck dissection)

• Radiation (internal or external) •

Combined surgical resection with radiation and Chemotherapy.

Nutritional Therapy.

Because of depression, alcoholism, or presurgery radiation treatment, patients may be

malnourished before surgery.

A percutaneous endoscopic gastrostomy (PEG) placement may be considered before

radiation treatment or surgery.

After radical neck surgery, the patient may be unable to orally ingest nutrients because of
mucositis, swelling, location of sutures, or difficulty swallowing.

Parenteral fluids are given for the first 24 to 48 hours. After this time, enteral nutrition is
given via an NG, gastrostomy, or nasointestinal tube. (PEG and parenteral and enteral
feedings are discussed in Chapter 40.)

Cervical esophagostomy and pharyngostomy have also been used. Observe for feeding
tolerance and adjust the amount, time, and formula if nausea, vomiting, diarrhea, or distention
occurs.

Give small amounts of water when the patient can swallow. Observe for choking. Suctioning
may be necessary to prevent.

Reconstruction and rehabilitation after oral cancer treatment

People who are diagnosed with advanced oral cancer will likely need reconstructive surgery
and some rehabilitation to assist with eating and speaking during recovery.

Reconstruction can involve dental implants or grafts to repair the missing bones and tissues in
the mouth or face. Artificial palates are used to replace any missing tissue or teeth.

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Rehabilitation is also necessary for cases of advanced cancer. Speech therapy can be provided
from the time you get out of surgery until you reach the maximum level of improvement.

 Reconstruction Of Mouth :

This is certainly a lengthy procedure in which the grafts of the skin, bone and muscle have to
be transplanted and this surgery can alter the appearance of your face. In some cases it can
reduce the speaking ability and may cause difficulty in eating and drinking.

Cope Up Techniques :

 Living with cancer can make you more fatigue and may lower your mood.
 Be optimistic and do gentle exercises daily after consulting your doctor.
 Gentle massage therapy can be done to overcome the fatigue.

Outlook :

 80 people out of 100 with oral cancer in advanced stage can live up to one year.
About 45-50% of the cases can survive up to 10 years.
 Prognosis of mouth cancer depends on your age, size of tumor and its stage.

Tips For Prevention :

 Don’t smoke or drink.

 Eat a healthy diet.
 Conduct a self exam and go for regular dental checkup.

ESOPHAGEAL DISORDERS

GASTROESOPHAGEAL REFLUX DISEASE:

Definition:

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Gastroesophageal reflux disease (GERD) is a chronic symptom of mucosal damage caused

by reflux of stomach acid into the lower esophagus. GERD is not a disease but a syndrome.
GERD is the most common upper GI problem.

Incidence:

Approximately 10% to 20% of the U.S. population experience GERD symptoms (heartburn
or regurgitation) at least once a week. Very common (More than 1 crore cases per year in
India)

Risk factors

Conditions that can increase your risk of GERD include:

 Obesity

 Bulging of the top of the stomach up into the diaphragm (hiatal hernia)

 Pregnancy

 Connective tissue disorders, such as scleroderma

 Delayed stomach emptying

Factors that can aggravate acid reflux include:

 Smoking

 Eating large meals or eating late at night

 Eating certain foods (triggers) such as fatty or fried foods

 Drinking certain beverages, such as alcohol or coffee

 Taking certain medications, such as aspirin

Causes:

 Decrease Pressure • Alcohol • Anticholinergics • Chocolate (theobromine) • Fatty

foods • Nicotine • Peppermint, spearmint • Tea, coffee (caffeine) • Drugs • β-Adrenergic
blockers • Calcium channel blockers • diazepam (Valium) • morphine sulfate • Nitrates •
progesterone • theophylline Lower oesophageal sphincter abnormalities
 Hiatal hernia
 Abnormal oesophageal contractions
 Slow or prolonged emptying of the stomach
Pathophysiology:

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 In normal digestion, the lower esophageal sphincter (LES) opens to allow food to pass
into the stomach and closes to prevent food and acidic stomach juices from flowing back into
the esophagus. Gastroesophageal reflux occurs when the LES is weak or relaxes
inappropriately, allowing the stomach's contents to flow up into the esophagus. The severity
of GERD depends on LES dysfunction as well as the type and amount of fluid brought up
from the stomach and the neutralizing effect of saliva.
clinical manifestation.

Common signs and symptoms of GERD include:

 A burning sensation in your chest (heartburn), usually after eating, which might be
worse at night

 Chest pain

 Difficulty swallowing

 Regurgitation of food or sour liquid

 Sensation of a lump in your throat

If you have night time acid reflux, you might also experience:

 Chronic cough

 Laryngitis

 New or worsening asthma

 Disrupted sleep

 Heartburn ( pyrosis) is a burning,

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 Tight sensation felt intermittently beneath the lower sternum and spreading upward to
the throat or jaw.
 Dysphagia
 Dyspepsia is pain or discomfort centered in the upper abdomen (mainly in or around
the midline as opposed to the right or left hypochondrium)
 Regurgitation is a fairly common manifestation of GERD.
 It is often described as hot, bitter, or sour liquid coming into the throat or mouth.
Hypersalivation (water brash) may also be reported.
 Otolaryngologic symptoms include hoarseness, sore throat, a globus sensation (sense
of a lump in the throat), and choking.
 GERD-related chest pain can mimic angina and is described as burning; squeezing; or
radiating to the back, neck, jaw, or arms.
 Complaints of chest pain are more common in older adults with GERD. Unlike
angina, GERD-related chest pain is relived with antacid.

Diagnostic Evaluation:
History and physical examination
• Upper GI endoscopy with biopsy and cytologic analysis

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• Esophagram (barium swallow)

Ambulatory acid (pH) probe test. A monitor is placed in your esophagus to identify when,
and for how long, stomach acid regurgitates there. The monitor connects to a small computer
that you wear around your waist or with a strap over your shoulder. The monitor might be a
thin, flexible tube (catheter) that's threaded through your nose into your esophagus, or a clip
that's placed in your esophagus.

Esophageal manometry. This test measures the rhythmic muscle contractions in your

esophagus when you swallow. Esophageal manometry also measures the coordination and
force exerted by the muscles of your esophagus.

X-ray of your upper digestive system. X-rays are taken after you drink a chalky liquid that
coats and fills the inside lining of your digestive tract.
Treatment:
• Antacids • Drug therapy (see Table 42-10) • Proton pump inhibitors • H2-receptor blockers
• Prokinetic drug therapy • Cholinergic drugs Surgical • Nissen fundoplication • Toupet
fundoplication Endoscopic • Intraluminal valvuloplasty • Radiofrequency therapy LES,
Lower esophageal sphincter.
Prescription medications

Prescription-strength treatments for GERD include:

 Prescription-strength H-2-receptor blockers. These include prescription-strength

famotidine (Pepcid), nizatidine and ranitidine. These medications are generally well-
tolerated but long-term use may be associated with a slight increase in risk of vitamin
B-12 deficiency and bone fractures.

 Prescription-strength proton pump inhibitors. These include esomeprazole

(Nexium), lansoprazole (Prevacid), omeprazole (Prilosec, Zegerid), pantoprazole
(Protonix), rabeprazole (Aciphex) and dexlansoprazole (Dexilant). Although generally
well-tolerated, these medications might cause diarrhea, headache, nausea and vitamin
B-12 deficiency. Chronic use might increase the risk of hip fracture.

 Medication to strengthen the lower esophageal sphincter. Baclofen may ease

GERD by decreasing the frequency of relaxations of the lower esophageal sphincter.
Side effects might include fatigue or nausea.
Surgery and other procedures

GERD can usually be controlled with medication. But if medications don't help or you wish
to avoid long-term medication use, your doctor might recommend:

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 Fundoplication. The surgeon wraps the top of your stomach around the lower
esophageal sphincter, to tighten the muscle and prevent reflux. Fundoplication is
usually done with a minimally invasive (laparoscopic) procedure. The wrapping of the
top part of the stomach can be partial or complete.

 LINX device. A ring of tiny magnetic beads is wrapped around the junction of the
stomach and esophagus. The magnetic attraction between the beads is strong enough
to keep the junction closed to refluxing acid, but weak enough to allow food to pass
through. The Linx device can be implanted using minimally invasive surgery.

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Nursing Management:
1. Explain the rationale for a low-fat diet.
2. Encourage the patient to eat small, frequent meals to prevent gastric distention.
3. Explain the rationale for avoiding alcohol, smoking (causes an almost immediate, marked
decrease in LES pressure), and beverages that contain caffeine.
4. Advise the patient to not lie down for 2-3 hr after eating, wear tight clothing around the
waist, or bend over (especially after eating).
5. Have the patient avoid eating within 3 hr of bedtime.
6. Encourage the patient to sleep with head of bed elevated on 4- to 6-in blocks (gravity
fosters esophageal emptying).
7. Provide information regarding drugs, including rationale for their use and common side
effects.
8. Discuss strategies for weight reduction if appropriate.
9. Encourage patient and caregiver to share concerns about lifestyle changes and living with
a chronic problem,
10.Elevation of head of bed on 4- to 6-in blocks
11.Avoid reflux-inducing foods (fatty foods, chocolate, peppermint)
12. Avoid alcohol
13. Reduce or avoid acidic pH beverages (colas, red wine, orange juice) .
Complications :

 Narrowing of the esophagus (esophageal stricture). Damage to the lower

esophagus from stomach acid causes scar tissue to form. The scar tissue narrows the
food pathway, leading to problems with swallowing.

 An open sore in the esophagus (esophageal ulcer). Stomach acid can wear away
tissue in the esophagus, causing an open sore to form. An esophageal ulcer can bleed,
cause pain and make swallowing difficult.

 Precancerous changes to the esophagus (Barrett's esophagus). Damage from acid

can cause changes in the tissue lining the lower esophagus. These changes are
associated with an increased risk of esophageal cancer.

Barrett’s esophagus

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Lifestyle and home remedies:

Lifestyle changes may help reduce the frequency of acid reflux. Try to:

 Maintain a healthy weight. Excess pounds put pressure on your abdomen, pushing

up your stomach and causing acid to reflux into your esophagus.

 Stop smoking. Smoking decreases the lower esophageal sphincter's ability to function

properly.

 Elevate the head of your bed. If you regularly experience heartburn while trying to
sleep, place wood or cement blocks under the feet of your bed so that the head end is
raised by 6 to 9 inches. If you can't elevate your bed, you can insert a wedge between
your mattress and box spring to elevate your body from the waist up. Raising your head
with additional pillows isn't effective.

 Don't lie down after a meal. Wait at least three hours after eating before lying down
or going to bed.

 Eat food slowly and chew thoroughly. Put down your fork after every bite and pick
it up again once you have chewed and swallowed that bite.

 Avoid foods and drinks that trigger reflux. Common triggers include fatty or fried
foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine.

 Avoid tight-fitting clothing. Clothes that fit tightly around your waist put pressure on
your abdomen and the lower esophageal sphincter.
Alternative medicine:

 Herbal remedies. Licorice and chamomile are sometimes used to ease GERD. Herbal
remedies can have serious side effects and might interfere with medications. Ask your
doctor about a safe dosage before beginning any herbal remedy.

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 Relaxation therapies. Techniques to calm stress and anxiety may reduce signs and
symptoms of GERD. Ask your doctor about relaxation techniques, such as progressive
muscle relaxation or guided imagery.

PRIMARY NURSING DIAGNOSIS :

Pain related to esophageal reflux and esophageal inflammation.

OUTCOMES: Comfort level; Pain control behavior; Pain level; Symptom control
behavior; Symptom severity.

INTERVENTIONs: Medication administration; Medication management; Pain

management; Positioning; Environmental management: Comfort; Nutritional
monitoring; Weight monitoring.

HIATAL HERNIA
Definition:
It is a herniation of a portion of the stomach into the esophagus through an opening or hiatus,
in the diaphragm. It is also referred to as diaphragmatic hernia and oesophageal hernia. Hiatal
hernia is more common older adults and occur more often in women than in men.
Types : There are two main types of hiatal hernias: sliding and paraesophageal.
1.Sliding: The junction of the stomach and the esophagus is above the diaphragm, and a part
of the stomach slides through the hiatal opening in the diaphragm. This occurs when the
patient is supine, and the hernia usually goes back into the abdominal cavity when the patient
is standing upright. This is the most common type of hiatal hernia.
2. Paraesophageal, or rolling: The esophagogastric junction remains in the normal position,
but the fundus and the greater curvature of the stomach roll up through the diaphragm,
forming a pocket alongside the esophagus. Acute paraesophageal hernia is a medical
emergency.
A. Sliding hernia

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Paraesophageal hernia

Hiatal Hernia Risk Factors

Hiatal hernias happen more often in women, people who are overweight, and people older
than 50.

Hiatal Hernia Causes

Doctors don’t know why most hiatal hernias happen. Causes might include:

 Being born with a larger hiatal opening than usual

 Injury to the area
 Changes in your diaphragm as you age
 A rise in pressure in your belly, as from pregnancy, obesity, coughing, lifting
something heavy, or straining on the toilet

Pathophysiology:

Many factors contribute to the development of hiatal hernia.

Structural changes, such as weakening of the muscles in the diaphragm around the
esophagogastric opening, occur with aging.

Factors that increase intraabdominal pressure, including obesity, pregnancy, ascites, tumors,
intense physical exertion, and heavy lifting on a continual basis, may also predispose patients
to development of a hiatal hernia

Hiatal Hernia Symptoms

Many people with hiatal hernia don’t notice any symptoms. Others may have:

 Heartburn from gastroesophageal reflux disease (GERD)

 Chest pain

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 Bloating
 Burping
 Trouble swallowing
 Bad taste in your mouth
 Upset stomach and vomiting
 Backflow of food or liquid from your stomach into your mouth
 Shortness of breath

Get medical care right away if you have a hiatal hernia and:

 Severe pain in your chest or belly

 Upset stomach
 Vomiting
 Can’t poop or pass gas

These could be signs of a strangulated hernia or an obstruction, which are medical

emergencies.

Hiatal Hernia Diagnosis

To diagnose a hiatal hernia, your doctor may do tests including:

 Barium swallow. You drink a liquid that shows up on an X-ray so your doctor can get a
better look at your esophagus and stomach.
 Endoscopy. Your doctor puts a long, thin tube called an endoscope down your throat. A
camera on the end shows inside your esophagus and stomach.
 Esophageal manometry. A different kind of tube goes down your throat to check the
pressure in your esophagus when you swallow.

Hiatal Hernia Treatment

 Antacids to weaken your stomach acid

 Proton pump inhibitors or H-2 receptor blockers to keep your stomach from making as
much acid
 Prokinetics to make your esophageal sphincter – the muscle that keeps stomach acid from
backing up into your esophagus -- stronger. They also help muscles in your esophagus
work and help your stomach empty.
 Paraesophageal hiatal hernia may require surgeries use a method called laparoscopy.
Nursing management:
Teach the patient to reduce intraabdominal pressure by eliminating constricting garments and
avoiding lifting and straining.
Surgical approaches to hiatal hernias can include reduction of the herniated stomach into the
abdomen, herniotomy (excision of the hernia sac), herniorrhaphy (closure of the hiatal
defect), an antireflux procedure, and gastropexy (attachment of the stomach
subdiaphragmatically to prevent reherniation).
The goals are to reduce the hernia, provide an acceptable LES pressure, and prevent
movement of the gastroesophageal junction.
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Antireflux surgeries for hiatal hernia are laparoscopically per formed Nissen and Toupet
techniques .
A thoracic or an open abdominal approach may be done, depending on the patient.
Gerontologic Consideration:
GASTROESOPHAGEAL REFLUX DISEASE AND HIATAL HERNIA :
The incidence of hiatal hernia and GERD increases with age.
Hiatal hernia is associated with weakening of the diaphragm, obesity, kyphosis, or other
factors (e.g., wearing girdles) that increase intraabdominal pressure.
Medications commonly taken by older patients decrease LES pressure (e.g., nitrates, calcium
channel blockers, antidepressants).
Other agents such as nonsteroidal antiinflammatory drugs (NSAIDs) and potassium can
irritate the esophageal mucosa (medication-induced esophagitis).
Some older adults with hiatal hernia and GERD are asymptomatic or have less severe
symptoms.
The first indications may include esophageal bleeding secondary to esophagitis or respiratory
complications (e.g., aspiration pneumonia) related to aspiration of gastric contents.
The clinical course and management of GERD and hiatal hernia in the older adult are similar
to those for the younger adult.
Changes in lifestyle, including eliminating dietary factors (such as caffeine-containing
beverages and chocolate) and elevating the head of the bed on blocks, may be challenging for
the older adult.
Laparoscopic procedures reduce the risk of surgical repair. An older patient with
cardiovascular and pulmonary problems may not be a good candidate for surgical
intervention.

Hiatal Hernia Lifestyle Changes and Home Remedies

Some changes to your daily life can help with acid reflux symptoms. They include:

 Don’t exercise or lie down for 3 or 4 hours after you eat.

 Avoid acidic foods like orange juice, tomato sauce, and soda.
 Limit fried and fatty foods, alcohol, vinegar, chocolate, and caffeine.
 Eat smaller meals.
 Lift the head of your bed about 6 inches.

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 Don’t wear tight belts or clothes that put pressure on your belly.
 Lose extra pounds.
 Don’t smoke.

Oesophageal Cancer

Definition:

Oesophageal cancer is when abnormal cells in the food pipe (oesophagus) growing an
uncontrolled way. The oesophagus is also known as the gullet. It is the tube that
carries food from your mouth to your stomach.

Incidence:

Most people are over the age of 60 when they are diagnosed.

Esophageal cancer (malignant neoplasm of the esophagus) is not common.

However, the rates are increasing.

Approximately 17,460 new cases of esophageal cancer are diagnosed and 15,070 deaths
occur from esophageal cancer.

The 5-year survival rate is 37% for localized cancer and 18% for regional cancer. The
majority of esophageal cancer.

Fewer than 1 million cases per year (India)

Types:

The two main subtypes of esophageal cancer are:

 Squamous cell carcinoma: This arises from the cells lining the upper part of the
esophagus.

 Adenocarcinoma of the esophagus: This occurs due to changes in the glandular cells

that exist at the junction of the esophagus and the stomach.

Risk factor:

Smoking and poorly controlled acid reflux are significant risk factors for oesophageal cancer.

Rarer types include:

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 choriocarcinoma

 lymphoma

melanoma

 sarcoma

 small cell cancer

The treatment, symptoms, and prognosis are similar for both main types of esophageal
cancer.

Causes:

Staging:

Staging is based on the TNM staging system, which classifies the amount of tumor
invasion (T), involvement of lymph nodes (N), and distant metastasis (M)

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Esophageal Cancer: Symptoms and Signs:

 Dysphagia: As the tumor narrows the passage in the esophagus, pushing food through

becomes harder. This is usually the first noticeable symptom.

 Vomiting: A person vomits food after it gets stuck in the esophagus.

 Weight loss: Dramatic and sudden weight loss might occur.

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 A cough: This becomes more common when trying to swallow. Sometimes, the
individual wmay cough up blood.

 Voice changes: The voice may become hoarse.

 Pain and discomfort: These occur in the throat.

 Acid reflux: This can happen if cancer affects the lower part of the esophagus.

 Chest pain: This relates to acid reflux.

 Pressure or burning in the chest.

 Indigestion or heartburn.

 Frequent choking.

 Pain behind the breastbone or in the throat.

People often experience no symptoms during the initial stages of this cancer.

Diagnostic Evaluation:

 barium swallow or barium meal,

 endoscope.

 Biopsies 

 Esophagogastroduodenoscopy.

Positron emission tomography

 Computed tomography 

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Treatment :

 surgery

 chemotherapy

 radiation therapy

The person may need help to consume food and drink in the following ways:

 If the person cannot swallow, a surgeon may insert a stent to keep the esophagus
clear.

 A nasogastric tube, which a surgeon passes through the nose, may be necessary to
assist feeding while treatment proceeds on tumor.

 A gastrostomy is a feeding hole in the skin that provides direct access to the stomach.

Surgery

The following surgical interventions can help people with esophageal cancer:

 Esophagectomy: This procedure removes part of the esophagus. The surgeon

removes the section of esophagus that contains the tumor and reconnects the
remaining part to the stomach. Sometimes, they use a small section of the large
intestine to help connect the esophagus and the stomach.

 Esophagogastrectomy: In this procedure, the surgeon removes the part of the

esophagus with the tumor, as well as parts of the stomach and nearby lymph nodes. If
the surgeon cannot connect the stomach and esophagus afterward, they may use a
small part of the large intestine to do so.

Other procedures

Other, non-surgical techniques that support the treatment of esophageal cancer, including

 Photodynamic therapy: The doctor injects a special substance into the esophagus

that makes the cells extra sensitive to light. With an endoscope that has a laser at the
end, the surgeon destroys cancer cells by burning them.

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 Chemotherapy: This may take place before or after surgery, or both, and possibly in
conjunction with radiation therapy. Chemotherapy can help remove the cancer, delay
or prevent recurrence, slow down progression, or relieve the symptoms of advanced
cancer. Examples for Chemotherapy cisplatin-based
(or carboplatin or oxaliplatin), fluorouracil (5-FU).

Radiation therapy: Beams of high-energy X-rays, particles, or radiation destroy cancer

cells. Radiation therapy damages the DNA inside the tumor cells, destroying their ability to
reproduce. A doctor can apply radiation therapy externally, through external beam radiation,
or internally, using brachytherapy.

Nursing management:

NURSING DIAGNOSES:

• Chronic pain related to the compression of tumor on surrounding tissues, esophageal

stenosis

• Imbalanced nutrition: less than body requirements related to dysphagia, odynophagia,

weakness, chemotherapy, and radiation therapy

• Ineffective health maintenance related to lack of knowledge of disease process and

treatment, lack of a support system, and chronic debilitating disease

• Anxiety and grieving related to diagnosis of cancer, uncertain future, and poor prognosis

DISCHARGE AND HOME HEALTHCARE GUIDELINES MEDICATIONS.

The patient should be able to state the name, purpose, dosage, schedule, common side effects,
and importance of taking her or his medications.

COMPLICATIONS. Teach the patient to report any dysphagia or odynophagia, which may
indicate a regrowth of the tumor. Teach the patient to inspect the wound daily for redness,
swelling, discharge, or odor, which indicates the presence of infection.

HOME CARE. Teach family members to assist the patient with ambulation, splinting the
incision, and chest physiotherapy. Educate caregivers on nutritional guidelines, food
preparation, tube feedings, and parenteral nutrition, as appropriate. Inform the patient and

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family about the availability of high-caloric, high-protein, liquid supplements to maintain his
or her weight.

Other common complications of esophageal cancer can include:

 Tracheo-esophageal fistulas. Fistulas are actually holes that develop in the area
between the windpipe and the esophagus. ...
 Anemia. If esophageal cancer causes you to bleed heavily, anemia (too few red blood
cells) can occur.
 Weight loss.
 Pneumonia.
 Metastases.

Esophageal Varices
Definition:
1. Esophageal varices are enlarged or swollen veins on the lining of the esophagus. It
can be life-threatening.
2. Varices are veins that are enlarged or swollen. The esophagus is the tube that
connects the throat to the stomach. When enlarged veins occur on the lining of the esophagus,
they are called esophageal varices.
Incidence:
 Cirrhosis is the most common type of liver disease. More than 90% of these patients will
develop esophageal varices sometime in their lifetime, and about 30% will bleed.
Risk Factors:

High portal blood pressure: The higher the portal pressure, the greater the risk of bleeding.

Large varices: Risk of bleeding increases with size of varices.

Severe liver disease: Advanced cirrhosis or liver failure increases the risk.

Ongoing alcohol consumption: In patients with varices due to alcohol, continuing to drink
increases the risk of bleeding.

Red marks on the varices: On endoscopic examination, some varices display long red
streaks and spots which are indicative of high risk of bleeding
 Liver failure or severe cirrhosis : The severity of the liver disease increases the
chance of bleeding.
 Prolonged alcohol use: The risks of variceal bleeding go up significantly if drinking
is a compulsive habit.

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Causes:

 Portal hypertension
 Cirrhosis of liver
 Hepatic veno thrombosis
 Abnormalities of circulation in the splenic vein and superior vena cava.

Stages of esophageal varices:

They are graded according to their size, as follows:

Grade 1 – Small, straight esophageal varices.

Grade 2 – Enlarged, tortuous esophageal varices occupying less than one third of the lume.

Grade 3 – Large, coil-shaped esophageal varices occupying more than one third.

Pathophysiology:

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Signs and symptoms:

Gastrointestinal: 
 Bloating, blood in stool,
 Dark stool from digested blood, or vomiting blood
 Bleeding,
 Difficulty swallowing,
 Enlarged veins around belly button,
 Flapping hand tremor, or web of swollen blood vessels in the skin tar-like or bloody
stools and, in severe cases, shock
 Spider nevi or formation of clusters of tiny blood vessels under the skin resembling a
spider
 Ascites or fluid build-up in the abdomen
 Swollen spleen
CNS:
 Lightheadedness.
 Loss of consciousness in severe cases.
CVS:
 Shock
 Drecreased cerebral hepatic and renal perfusion
Haematology:
Increased ammonia level
Increased serum albumin level
Extremities:
 Palmar erythema or reddening of the skin on the palm of hands
 Dupuytren's contracture which is a hand deformity
Integumentary system:
 Jaundice of the skin and the eyes
 Genito urinary:
 Shrunken testicles
Diagnostic measures:
Invasive procedures:
Complete blood count
Liver function test
Platelet count
Bleeding and clotting time
Non invasive procedures:
Upper GI endoscopy
Ultra sound
CT Scan
MRI
Esophagogastroduodenoscopy: This is the preferred procedure of endoscopy to check for
dilated veins and their sizes, and presence of red streaks and spots to ascertain the risk of
bleeding in the esophagus and the small intestine.

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capsule endoscopy: Those unwilling to undergo an endoscope exam are given a vitamin-
sized capsule which contains a tiny camera to take pictures of the esophagus as it passes.

Management :

Medications to lower blood pressure in the portal vein : A blood pressure drug called beta
blocker is used to reduce blood pressure thereby lowering the chances of bleeding.

Medications to slow blood flow into the portal vein : After a bleeding episode, a drug
called octreotide in combination with endoscopic therapy is continued for 5 days to treat the
bleeding by slowing down blood from the internal organs to the portal vein.

Variceal ligation:

 In this procedure, tiny elastic bands are wrapped around the varices to cut off blood
flow through the varices.
 This can be performed on as many veins as necessary in one session.
 After the bleeding is controlled, patients may be given a drug to prevent bleeding
from starting again.
 Variceal ligation should be repeated every 4 weeks until varices have stopped
bleeding.
 An upper endoscopy should be repeated every 6 to 12 months thereafter to make sure
no varices have reoccurred. Complications associated with variceal ligation include
blood loss, puncture of the esophagus, difficulty swallowing, abnormal heartbeat,
infection, fever and reduced or shallow breathing rate. All of these complications are
rare.

Transjugular intrahepatic portal-systemic shunting (TIPS):

 A small, thin tube called a catheter is inserted into a vein in the neck.
 The catheter is passed through the body to the liver where the hepatic and portal veins
are close. (The hepatic vein carries blood from the liver back to the heart.)
 Next, a wire is passed through the catheter. It is used to poke through the hepatic vein
to the portal vein.
 The wire is removed and a stent (a tiny wire coil) is passed through the catheter to the
connection site.
 The stent is placed in the new channel between the portal and hepatic veins.
 The stent holds the connection site open so blood can flow more easily from the portal
vein to the hepatic vein and exit the liver.
 This reduces the pressure in the portal vein, which reduces the pressure in the varices,
which reduces their risk of bleeding.
 TIPS can be very effective in preventing bleeding, but it also can cause serious
complications, particularly in patients with advanced liver disease, including
confusion and liver failure.

Complication:

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Recurrent haemorrhage

Portal systemic encephalopathy

Hypovolemic shock

Preventing liver damage

People who have liver disease need to avoid toxins that cause additional stress on the liver
and more damage to it. Some suggestions for maintaining a healthier liver include:

 Avoid alcoholic beverages of any kind.

 Limit use of household cleaners and chemicals.
 Eat a healthier diet that is low in fat and high in fruits and vegetables, whole grains
and lean proteins.
 Maintain a healthy body weight (excess body fat puts stress on the liver).

Preventing bleeding

 Medications to reduce blood pressure in the portal vein can reduce the risk of
bleeding. The most commonly used medications are a group called beta blockers.
These include propranolol (Inderal), nadolol (Corgard) and carvedilol (Coreg).

 Patients with a high risk of bleeding may undergo preventive treatment with the same
techniques that are used to stop bleeding. The most commonly used technique is
variceal ligation

Esophageal Diverticula

Definition:

1. Esophageal diverticula, or herniations of the oesophageal musoca, are hollow

outpouchings of the esophageal wall .

2. An esophageal diverticulum is a protruding pouch in the lining of the esophagus. It

forms in a weak area of the esophagus. The pouch can be anywhere from 1 to 4 inches in
length.

Incidence:

While an esophageal diverticulum can occur at any age, it’s most common in people in their
70s and 80s. In addition, people with swallowing disorders are more likely to develop it.

Causes:

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In adults, it’s often associated with increased pressure within the esophagus.

This pressure causes the lining to protrude in a weakened area. Potential causes of this
increased pressure include:

 malfunction of the sphincters on either end of the esophagus.

 inflammation from outside the esophagus

 food not moving properly through the esophagus

 malfunctioning of the swallowing mechanism.

 It can also be a complication of a surgical procedure near the neck, or conditions that
affect collagen, such as Ehler-Danlos syndrome.

Types:
There are three types of esophageal diverticula (plural of diverticulum), based on where
they’re located:

 Zenker’s diverticulum. This type develops near the top of the esophagus.

 Midthoracic diverticulum. This type occurs in the middle part of the esophagus.

 Epiphrenic diverticulum. This type is located in the lower part of the esophagus.

Clinical manifestation:

Common symptoms of an esophageal diverticulum include:

 difficulty swallowing

 feeling like food is caught in the throat

 regurgitating food when bending over, lying down, or standing up

 pain when swallowing

 chronic cough

 bad breath

 chest pain

 neck pain

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 weight loss

 vocal changes

 Boyce’s sign, which is a gurgling sound when air passes through the diverticulum.

Diagnostic Evaluation:

 Barium swallow. It containing barium, which shows up on an X-ray or CT scan. This

allows your doctor to track the movement of fluid through your esophagus.

 Gastrointestinal endoscopy. For this procedure, your doctor inserts a thin,

flexible tube with a camera at the end through your mouth and down your throat in
order to view your esophagus.

 Esophageal manometry. This technique measures the timing and strength of the

contractions of your esophagus.

 24-hour pH test. This test measures the pH in your esophagus over a 24-hour period

to check for signs of stomach acid or bile in your esophagus.

Nonsurgical treatment

Mild esophageal diverticula can usually be managed through lifestyle changes, such as:

 thoroughly chewing your food

 eating a bland diet

 drinking lots of water after you eat to help with digestion.

Over-the-counter antacids can also help with mild symptoms.

Surgical treatment

More severe cases may require surgery to remove the pouch and repair weakened tissue in
the esophagus.

Surgical procedures to do this include:

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 Cricopharyngeal myotomy. This involves making small cuts in the upper sphincter

of the esophagus to widen it, so food can pass more easily through your esophagus.

 Diverticulopexy with cricopharyngeal myotomy. This involves removing a larger

diverticulum by turning it upside down and attaching it to the wall of the esophagus.

 Diverticulectomy and cricopharyngeal myotomy. This involves removing the

diverticulum while performing a cricopharyngeal myotomy. It’s a combination that’s
often used to treat Zenker’s diverticula.

 Endoscopic diverticulotomy. This is a minimally invasive procedure that divides the

tissue between the diverticulum and esophagus, allowing food to drain from the
diverticulum.

Nursing management:
Nursing Assessment

 Obtain history of dysphagia, coughing, throat discomfort, choking, regurgitation of

food.
 Evaluate for halitosis.
 Determine what measures assist the patient with food intake; what foods and fluids
the patient can tolerate.
 Evaluate weight loss and dietary habits.

Nursing Diagnoses

 Imbalanced Nutrition: Less Than Body Requirements, related to dysphagia

 Acute Pain related to symptoms and surgical procedure.

Nursing Interventions
Improving Nutritional Status

 Provide frequent, small meals, which are better tolerated.

 Elevate head of bed for 2 hours after eating.
 Monitor intake and output.
 Weigh daily.

Maintaining Comfort and Preventing Complications

 Preoperatively, or if the condition is nonoperative, implement nursing interventions

similar to those for esophagitis.
 Postoperatively, wound care is similar to that of other surgical incisions of the same
anatomical position (eg, thoracotomy or neck surgery).
 Administer appropriate pain medications, and assess effectiveness.
 Patient may need oral suctioning to control drooling.

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Patient Education and Health Maintenance

 Instruct patient regarding treatment of esophagitis caused by gastroesophageal reflux .

 Instruct patient on importance of good oral hygiene.

Evaluation: Expected Outcomes

 Tolerates oral feedings; maintains weight

 States pain decreased to 2 or 3 on 0-to-10 scale

complications

Over time, an esophageal diverticulum can lead to some health complications.

 Aspiration pneumonia. If an esophageal diverticulum causes regurgitation, it can

lead to aspiration pneumonia. This is a lung infection caused by inhaling things, such
as food and saliva, that usually travel down your esophagus.

 Obstruction. An obstruction near the diverticulum can make it hard, if not

impossible, to swallow. This can also cause the pouch to rupture and bleed.
 Squamous cell carcinoma. In very rare cases, ongoing irritation of the pouch can
lead to squamous cell carcinoma.

GERONTOLOGIC ALERT:

 Hoarseness, asthma, and pneumonitis may be the only signs of esophageal

diverticula in elderly patients.

PEPTIC ULCER DISEASE

Definition:

Peptic ulcer disease refers to ulcerations in the mucosa of the lower esophagus,
stomach, or duodenum.

Incidence:
 The point prevalence of peptic ulcer was 4.72% and the lifetime prevalence was
11.22%.
 The duodenal to gastric ulcer ratio was 17.1:1.
 The prevalence of peptic ulcer increased with age, with a peak prevalence of 28.8%
in the 5th decade of life.

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There are three types of peptic ulcers:

 gastric ulcers: ulcers that develop inside the stomach

 esophageal ulcers: ulcers that develop inside the esophagus

 duodenal ulcers: ulcers that develop in the upper section of the small intestines,
called the duodenum.

 Stress induced and drug induced ulcer

Causes of peptic ulcers

Different factors can cause the lining of the stomach, the esophagus, and the small intestine to
break down. These include:

 Helicobacter pylori (H. pylori), a type of bacteria that can cause a stomach infection
and inflammation

 frequent use of aspirin (Bayer), ibuprofen (Advil), and other anti-inflammatory drugs
(risk associated with this behavior increases in women and people over the age of 60)

 smoking

 drinking too much alcohol

 radiation therapy

 stomach cancer

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Difference between duodenal ulcer and gastritis ulcer

Pathophysiology:

Acid, bile salts, Asprini, NSAID, alcohol, Ischemia, H-Pyloric

Break down of gastric mucosal barrier

Acid back diffusion into mucosa

Destruction of mocoid Histamine

Acid and pepsin release vasodilatation

Mucosal ersion capillary permeability

Loss of plasma into gastric

Destruction of blood vessels mucosa

Bleeding mucosal oedema

Ulceration
Clinical Manifestations:
CNS:
Weakness, fatigue, Headache, irritability, nervous tension, syncope, dizziness
Respiratory:
Respiratory infection, Dyspnea.
CVS:
Bleeding, hypovolemic shock, hypotension, tachycardia, heart burn, chest pain.
GIT:

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Pain, hematemesis, melena

Musculo skeletal :
Muscle weakness
Skin:
Dry skin, cold and clamy skin
Urinary:
Decreased urine output.
GI:
 Gnawing or burning epigastric pain occurring 1½ to 3 hours after a meal
 Nocturnal epigastric, abdominal pain or burning. May awaken patient at night, usually
around midnight to 3 a.m.
 Epigastric tenderness on examination
 Early satiety, anorexia, weight loss, belching (may indicate reflux disease)
 hematemesis, or melena (may indicate hemorrhage)
 changes in appetite
 nausea
 indigestion
 vomiting

Haematology:

Anaemia

Diagnostic Evaluation:

Non-Invasive procedures:
 Upper GI endoscopy with possible tissue biopsy and cytology. Pyloritek, a biopsy
urea test, is up to 95% specific in detecting H. pylori.
 Upper GI radiographic examination (barium study)
 Serial stool specimens to detect occult blood
 Gastric secretory studies (gastric acid secretion test and serum gastric level test)
elevated in Zollinger-Ellison syndrome
 Serology to test for H. pylori antibodies
 C or C-urea breath test to detect H. pylori
 Ultra sound
Invasive procedures:
 Complete count
 Plate count
Management

General Measures

 Eliminate use of NSAIDs or other causative drugs.

 Eliminate cigarette smoking (impairs healing).
 Well-balanced diet with meals at regular intervals. Avoid dietary irritants.

Drug Therapy:

 Multiple drug regimens are used to treat H. pylori.

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Drug Regimens for Eradication of Helicobacter pylori

DRUG DOSAGE DURATION
Omeprazole (Prilosec) 20 mg PO bid 7-14 days
Clarithromycin (Biaxin) 500 mg PO bid
Amoxicillin 1,000 mg PO
bid
Omeprazole (Prilosec) 20 mg bid 10 days
Bismuth subsalicylate (Pepto-Bismol)2 tabs PO qid Days 4-10 only
Metronidazole (Flagyl) 500 mg tid
Tetracycline 500 mg PO qid
Omeprazole (Prilosec) 20 mg bid 7-14 days
Clarithromycin (Biaxin) 250 mg bid
Metronidazole (Flagyl) 500 mg bid

Surgical Management:

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 Gastroduodenostomy (Billroth I).

o Partial gastrectomy with removal of antrum and pylorus of stomach.

o The gastric stump is anastomosed with the duodenum.

 Gastrojejunostomy (Billroth II)

o Partial gastrectomy with removal of antrum and pylorus of stomach.

o The gastric stump is anastomosed with the jejunum.

 Antrectomy

o Gastric resection includes a small cuff of duodenum, the pylorus, and the
antrum (lower half of stomach).

o The duodenal stump is closed, and the jejunum is anastomosed to the stomach.

 Total gastrectomy

o Also called an esophagojejunostomy.

o Removal of the stomach with attachment of the esophagus to the jejunum or

duodenum.

 Pyloroplasty

o A longitudinal incision is made in the pylorus, and it is closed transversely to

permit the muscle to relax and to establish an enlarged outlet.

o Often, a vagotomy is performed at the same time.

 Vagotomy

o The surgical division of the vagus nerve to eliminate the impulses that
stimulate HCL secretion.

o There are three types: selective vagotomy, which severs only the branches that
interrupt acid secretion; truncal vagotomy, which severs the anterior and
posterior trunks to decrease acid secretion and gastric motility; and parietal
vagotomy, which severs only the part of vagus that innervates the parietal
acid-secreting cells.

o Traditionally performed by laparotomy, the vagotomy procedure can also be

done using a laparoscope

Nursing management:

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Nursing Assessment

 Determine location, character, radiation of pain, factors aggravating or relieving pain,

how long it lasts, when it occurs.
 Ask about eating patterns, regularity, types of food, eating circumstances.
 Ask about medications (especially aspirin, anti-inflammatory drugs, or steroids).
 History of illnesses including previous GI bleeds.
 Obtain psychosocial history.
 Perform physical assessment with documentation of positive abdominal findings.
 Take vital signs, including lying, standing, and sitting BPs and pulses, to determine if
orthostasis is present due to bleeding.

Nursing Diagnoses

 Deficient Fluid Volume related to hemorrhage

 Acute Pain related to epigastric distress secondary to hypersecretion of acid, mucosal
erosion, or perforation
 Diarrhea related to GI bleeding
 Imbalanced Nutrition: Less Than Body Requirements related to the disease process
 Deficient Knowledge related to physical, dietary, and pharmacologic treatment of
disease

Nursing Interventions
Avoiding Fluid Volume Deficit

 Monitor intake and output continuously to determine fluid volume status.

 Monitor stools for blood and emesis.
 Monitor hemoglobin and hematocrit and electrolytes.
 Administer prescribed I.V. fluids and blood replacement, as prescribed.
 Insert NG tube as prescribed, and monitor the tube drainage for signs of visible and
occult blood.
 Administer medications through the NG tube to neutralize acidity, as prescribed.
 Prepare patient for saline lavage, as ordered.
 Observe patient for an increase in pulse and a decrease in BP (signs of shock).
 Prepare patient for diagnostic procedure or surgery to determine or stop the source of
bleeding.

Achieving Pain Relief

 Administer prescribed medication.

 Provide small, frequent meals to prevent gastric distention if not NPO.
 Advise patient about the irritating effects of certain drugs and foods.

Decreasing Diarrhea

 Monitor patient's elimination patterns to determine effects of medications.

 Monitor vital signs, and watch for signs of hypovolemia.
 Administer antidiarrheal medication as prescribed.

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 Watch for signs and symptoms of impaired skin integrity (erythema, pain, pruritus)
around anus to promote comfort and decrease risk of infection.

Achieving Adequate Nutrition

 Eliminate foods that cause pain or distress; otherwise, the diet is usually not restricted.
 Provide small, frequent meals that neutralize gastric secretions and may be better
tolerated.
 Provide high-calorie, high-protein diet with nutritional supplements as ordered.
 Administer parenteral nutrition as ordered if bleeding is prolonged and patient is
malnourished.

Educating the Patient About the Treatment Regimen

 Explain all tests and procedures to increase knowledge and cooperation; minimize
anxiety.
 Review the health care provider's recommendations for diet, activity, medication, and
treatment. Allow time for questions, and clarify any misunderstandings.
 Give the patient a chart listing medications, dosages, times of administration, and
desired effects to promote compliance.
 Teach patient signs and symptoms of bleeding and when to notify the health care
provider.

Patient Education and Health Maintenance

 Teach patient signs and symptoms of bleeding and when to notify the health care
provider.
 Promote healthy lifestyle changes to include adequate nutrition, cessation of smoking,
decreased alcohol consumption, stress reduction strategies.
 Teach purpose, dosage, and adverse effects of each medication prescribed.

Complications:
Immediate :
Perforation
Obstruction
Peritonitis
Shock
Sudden and sharp abdominal pain

Late :
Internal Bleeding
Scar tissue
Fainting, excessive sweating, or confusion, as these may be signs of shock
Blood in vomit or stool
Abdomen that’s hard to the touch
Abdominal pain that worsens with movement but improves with lying Completely still
Ulcer perforation

prevention:

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Certain lifestyle choices and habits can reduce your risk of developing peptic ulcers. These
include:

 not drinking more than two alcoholic beverages a day

 not mixing alcohol with medication

 washing your hands frequently to avoid infections

 limiting your use of ibuprofen, aspirin, and naproxen (Aleve)

Maintaining a healthy lifestyle by quitting smoking cigarettes and other tobacco use and
eating a balanced diet rich in fruits, vegetables, and whole grains will help you prevent
developing a peptic ulcer.

GASTRITIS

Definition:

1. Gastritis, an inflammation of the gastric mucosa, is one of the most common

problems affecting the stomach. Gastritis may be acute or chronic and diffuse or localized.

2. Gastritis is an inflammation, irritation, or erosion of the lining of the stomach. It can

occur suddenly (acute) or gradually (chronic).

Incidence:
It has widely spread among the people of different population. As suggested from one study
in India, Gastritis affects 25-33% of the total population. People among the age between 15-
50 years are mainly diseased.
Risk Factors.
 Drug-Related Gastritis: Drugs contribute to the development of acute and chronic
gastritis. NSAIDs, including aspirin, and corticosteroids inhibit the synthesis of
prostaglandins that are protective to the gastric mucosa..

 Diet: Dietary indiscretions can also result in acute gastritis, alcoholic drinking Eating
large quantities of spicy.

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 Helicobacter pylori: An important cause of chronic gastritis is Helicobacter pylori

infection. H. pylori infection is highest in underdeveloped countries and in people of
low socioeconomic status. Infection likely occurs during childhood with transmission
from family members to the child, possibly through a fecal-oral or oral-oral route.

 Other Risk Factors: Bacterial, viral, and fungal infections, including

Mycobacterium species, cytomegalovirus (CMV), and syphilis.

 Autoimmune Gastritis: Autoimmune metaplastic atrophic gastritis (also called

autoimmune atrophic gastritis) is an inherited condition in which there is an immune
response directed against parietal cells.

Patients with autoimmune atrophic gastritis often have other autoimmune disorders.
The loss of parietal cells leads to low chloride levels, inadequate production of intrinsic
factor, cobalamin (vitamin B12) malabsorption, and pernicious anemia. Atrophic gastritis is
associated with an increased risk of stomach cancer.

Causes:

Drugs : Aspirin Corticosteroids • Nonsteroidal anti inflammatory drugs (NSAIDs)

Diet Alcohol : Spicy, irritating food

Micro organisms : Helicobacter pylori • Salmonella organisms • Staphylococcus organisms

Environmental Factors :Radiation • Smoking

Pathophysiologic Conditions: Burns • Large hiatal hernia • Physiologic stress • Reflux of

bile and pancreatic secretions • Renal failure (uremia) • Sepsis • Shock

Other Factors : Endoscopic procedures • Nasogastric tube • Psychologic stress

Types:

Acute gastritis

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Chronic gastritis

Acute gastritis:

Inflammation of the stomach mucosa lasting several hours to few days.caused by:

Irritating food or infected food

Excessive alcohol

Aspirin or NSAID

Bile reflex or radiation

Which may caused the mucosa to become gangrenous to perforation.

Chronic gastritis:

It is a prolonged inflammation either a begin or malignant ulcers or bacteria such as

helicobactor pylori.

Pathophysiology:

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Clinical manifestation:

Acute gastritis: Asymptomatic, Abdominal discomfort with headache, Lassitude, Nausea,

Anorexia, Vomiting, Hiccupping, Haemorrhage, colic and diarrhoea resulting from irritating
food, Recovering in about one day although appetite may be diminished for two to three
days.

Chornic gastritis: Anorexia, Heart burn, Belching, sore taste in the mouth or nausea and
vomiting,

Malabsorption of vitamin B 12.

Diagnostic manifestation:

Invasive procedures

Complete blood count

Blood clotting and bleeding time

Serological test

Non- invasive procedures

Endoscopy

Gastroscopy

Upper gastro- intestinal x- ray

Biopsy with histological examination

Ultra sonography

Management: Acute gastritis:

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. 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. Fiberoptic endoscopy may be necessary.

In extreme cases, emergency surgery may be required to remove gangrenous or perforated tissue.
Gastrojejunostomy or gastric resection may be necessary to treat pyloric obstruction.

Chornic gastritis:

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).

Drug therapy:

Antibiotics and Bismuth Salts .

1.Tetracycline (plus metronidazole, proton pump inhibitor, and bismuth salts)

2.Amoxicillin (plus clarithromycin and proton pump inhibitor such as omeprazole 3.Metronidazole
(Flagyl); use with clarithromycin and proton pump inhibitor

4. Clarithromycin (Biaxin); use with proton pump inhibitor and amoxicillin Bismuth subsalicylate
(Pepto-Bismol); use with antibiotics .

Histamine 2 (H2) Receptor Antagonists :

Cimetidine (Tagamet) Ranitidine (Zantac) Famotidine (Pepcid) Nizantidine (Axid)

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Proton (Gastric Acid) Pump Inhibitor:

Omeprazole (Prilosec) Lansoprazole (Prevacid) Rabeprazole (Aciphex)

Cytoprotective Medications:

Misoprostol (Cytotec) Sucralfate (Carafate)

Nursing management:

Nursing diagnosis:

• Anxiety related to treatment

• Imbalanced nutrition, less than body requirements, related to inadequate intake of nutrients

• Risk for imbalanced fluid volume related to insufficient fluid intake and excessive fluid loss
subsequent to vomiting

• Deficient knowledge about dietary management and disease process • Acute pain related to irritated
stomach

MORBID OBESITY

Definition:

1.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.

2. Morbid obesity is body weight that is more than 100 pounds greater than the ideal body
weight.

3.Obesity is an excessively high amount of body fat or adipose tissue. Obesity is a major
health problem because it increases the risk of numerous other diseases such as diabetes and
cancer.

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Classifications of Body Weight and Obesity:

A number of assessment methods are available, including

1. Body mass index (BMI),

2. Waist circumference,

3.Waist-to-hip ratio (WHR),

4. Body shape.

The most widely used and endorsed measures are BMI and waist circumference.2 These
measures are cost-effective with acceptable reliability and are easily used.

1.Body Mass Index.

 The most common measure of obesity is the body mass index (BMI).

 BMI is calculated by dividing a person’s weight (in kilograms) by the square of the
height in meters.

 Individuals with a BMI less than 18.5 kg/m2 are considered underweight, whereas
those with a BMI between 18.5 and 24.9 kg/m2 reflect a normal body weight.

 A BMI of 25 to 29.9 kg/m2 is classified as being overweight, and those with values
at 30 kg/m2 or above are considered obese.

 The term severely (morbidly, extremely) obese is used for those with a BMI greater
than 40 (kg/m2 individuals who are severely obese)..

Waist Circumference.

Waist circumference is another way to assess and classify a person’s weight .

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People who have visceral fat with truncal obesity are at an increased risk for cardiovascular
disease and metabolic syndrome .

Health risks increase if the waist circumference is greater than 40 inches in men and greater
than 35 inches in women.

Waist-to-Hip Ratio.

The waist-to-hip ratio (WHR) is another tool used to assess obesity. This ratio is a method of
describing the distribution of both subcutaneous and visceral adipose tissue. The ratio is
calculated by using the waist measurement divided by the hip measurement. A WHR less
than 0.8 is optimal, and a WHR greater than 0.8 indicates more truncal fat, which puts the
individual at a greater risk for health complications.

Body Shape. Body shape is another method of identifying those who are at a higher risk for
health problems (Table 41-2). Individuals with fat located primarily in the abdominal area, an
apple-shaped body, have android obesity. Those with fat distribution in the upper legs, a
pear-shaped body, have gynoid obesity. Genetics has an important role in determining a
person’s body shape. Weight and shape are influenced by genetics.3 Epidemiology of
Obesity Currently, more than 35% of adults in the United States are obese. Unless Americans
change their ways, 50% of the U.S. pop

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.

Medical Management:

Conservative management consists of placing the person on a weight loss diet in conjunction
with behavioral modification and exercise; however, diet therapy is usually unsuccessful.
There is a belief that depression may be a contributing factor to weight gain, and treatment of
the depression with bupropion hydrochloride (Wellbutrin) may be helpful (Wangsness,
2000). Some physicians recommend acupuncture and hypnosis before recommending
surgery.

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PHARMACOLOGIC MANAGEMENT :

Several medications have recently been approved for obesity. They include sibutramine HCl
(Meridia) and orlistat (Xenical). By inhibiting the reuptake of serotonin and norepinephrine,
sibutramine decreases appetite. Orlistat reduces caloric intake by binding to gastric and
pancreatic lipase to prevent digestion of fats. Both medications require a physician’s
prescription. Sibutramine may increase blood pressure and should not be taken by people
with a history of coronary artery disease, angina pectoris, dysrhythmias, or kidney disease; by
those taking antidepressants or monoamine oxidase inhibitors; or by pregnant or nursing
women.

Side effects may include dry mouth, insomnia, headache, increased sweating, and increased
heart rate. Side effects of orlistat may include increased bowel movements, gas with oily
discharge, decreased food absorption, decreased bile flow, and decreased absorption of some
vitamins. A multivitamin is usually recommended for patients taking orlistat. Women who
are pregnant or nursing should not take orlistat (Hussar, 2000).

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 jej

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