Chapter 47

Management of patient with

gastric and duodenal disorder
By : GLENDA S.CASUNDO
ROSSIE MAE N. DIGDIGAN
• A person’s nutritional status depends not only on the type and amount of intake but also
on the functioning of the gastric and intestinal portions of the gastrointestinal system.

• Gastritis
• Is a common GI problem, accounting for approximately 2 million visits to outpatient
clinics annually in the united states. It affects women and men equally and is more
common in older adults gastritis maybe acute, lasting several hours to a few days, or
chronic, resulting from repeated exposure to irritating agents or recurring episodes of
acute gastritis.
Clinical manifestation

• The patient with acute gastritis may have a rapid onset of symptoms, such as
abdominal discomfort, headalthache, lassitude, nausea, anorexia, vomiting
and hiccupping which can last from few hours to a few days. Erosive gastritis
may cause bleeding, which may manifest as blood in vomit or as black tarry
stools.
Assessment and diagnostic findings

• Gastritis is sometimes associated with achlorhydria (lack of hydrochloric acid),

hypochlorhydria high level oh HCI. Diagnosis is determined by an endoscopy
and histologic examination of a tissue specimen obtained by biopsy.
Medical management
• The gastric mocusa is capable of repairing itself after an episode of acute
gastritis. As a rule, the patient recovers in about 1 day although the appetite
maybe diminished for an additional 2 or 3 days. Acute gastritis is also
managed by instructing the patient to refrain from alcohol until symptoms
subside.
Nursing management
• If the patient has ingested acids or alkalis, emergency measures may be
necessary the nurse offers supportive therapy to the patient and family
during treatment and after the ingested acid or alkali has been neutralized or
diluted.
Promoting optimal nutrition
• For acute gastritis, the nurse provides physical and emotional support and helps
the patients manage the symptoms, which may include nausea, vomiting, heartburn
and fatigue. The patient should take no foods or fluids by mouth possibly for a
few days until the acute symptoms subside, thus allowing the gastric mucosa to
heal.
Promoting fluid balance

• Daily fluid intake and output are monitored to detect early sign of
dehydration. If food and oral fluids are with held, IV fluids usually are
prescribed and a record of fluid intake plus caloric value needs to be
determined. Electrolyte value needs are assessed ever 24 hours to detect any
imbalance.

Relieving pain
• Measures to help relieve pain include instructing the patient to avoid foods
and beverages that may irritate the gastric mocusa as well as the correct us of
medications to relieve gastritis.
Promoting home and community based care
• The nurse evaluates the patient’s knowledge about gastritis and develops a
individualized education plan that includes information about stress
management, diet and medication. Dietary instruction take into account the
patient’s daily caloric needs as well as cultural aspects of food preferences
and pattern of eating.
Peptic ulcer disease

• A peptic ulcer maybe referred to as a gastric, duodenal or esophageal ulcer

depending on its location. A peptic ulcer is an excavation that forms in the
mocusal wall of the stomach, in the pylorus in the duodenum or in the
esophagus.
Clinical manifestation
• Symptoms of an ulcer may last for a few days, weeks or months and may
disappear only to reappear, often without an identifiable cause. As a rule the
patient with an ulcer complains of dull, gnawing pain or a burning sensation
in the midepigastrium ferentiate gastric ulcer from duodenal ulcers.
Assessment and diagnostic findings
• A physical examination may reveal pain, epigastric tenderness or abdominal
distention. Upper endoscopy is the preferred diagnostic procedure because it
allows direct visualization of inflammatory changes, ulcer, and lesions.
Through endoscopy a biopsy of gastric mucosa and any suspicious lesions
can be obtained.
Medical management
• Once the diagnosis is established, the patient is informed that the condition can
be managed. Recurrence may develop, however peptic ulcers treated with
antibiotics to eradicate H.pylori have a lower recurrence rate than those not
treated with antibiotics.

Pharmacologic therapy
• Currently, the most commonly used therapy for peptic ulcers is a combination of
antibiotics, proton pump inhibitor, and bismuth salts that suppress or eradicate
H.pylori.
Smoking sensation

• Smoking decrease the secretion of bicarbonate from the pancreas into the
duodenum, resulting in increased acidity of the duodenum. Research indicates that
continued smoking may significantly inhibit ulcer repair. Therefore the patient is
encouraged to stop smoking.

Dietary medication
• The intent of dietary modification for patient with peptic ulcers is to avoid over
secretion of acid and hypermotility in the GI tract.
Surgical management
• The introduction of antibiotics to eradicate H.pylori as treatment for ulcers
has greatly reduced the need for surgical intervention. However surgery is
usually recommended for patients with intractable ulcers, life threatening
hemorrhage, perforation or obstruction and for those with ZES that is
unresponsive to medications.
Follow-up care
• Recurrence of peptic ulcer disease within 1 year may be prevented with the
prophylactic use taken at the reduced dose. Not all patients require
maintenance therapy. It may be prescribed only for those with two or three
recurrence per year, those who had a complication such as bleeding or gastric
outlet obstruction or those for whom gastric surgery poses too high risk.
Assessment
• The nurse asks the patient to describe the pain. Its pattern and whether or
not it occurs predictably and strategies used to relieve it. If patient reports a
recent history of vomiting, the nurse determines how often emesis has
occurred and notes important characteristics of the vomitus.
Diagnosis
• Based on the assessment data, nursing diagnosis may include the following:
• Acute pain related to the effect of gastric acid secretion on damaged tissue.
• Anxiety related to an acute illness
• Imbalanced nutrition; less than body requirement related to changes in diet.
Collaborative problems/potential complication
• Hemorrhage
• Perforation
• Penetration
• Gastric outlet obstruction
Planning 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 complication.

Nursing intervention
• Pain relief can be achieved with prescribed medications. The patient should avoid aspirin
and other NSAIDs and alcohol. In addition meals should be eaten at regularly paced
intervals in a relaxed setting.
Reducing anxiety
• The nurse assesses the patient’s level of anxiety. Explaining diagnostic test
and administering medication as scheduled help reduced anxiety. The nurse
interacts with the patient in relaxed manner; help identify stressor and
explains various coping techniques and relaxation method, such as
biofeedback, hypnosis, or behavior modification.
Obesity
• It is not merely a condition; rather, it is a metabolic disease that is characterized by
fat accumulated to the extent that health is impaired. Obesity is a rapidly growing
problem; approximately 66% of all adults are overweight or obese.

Medical management
• There are general approaches to treating obesity; lifestyle modification,
pharmacotherapy, and bariatric surgery.
Lifestyle modification
• The lifestyle medication approach to treating obesity consists of placing a person
on a weight loss diet in conjunction with behavioral modification and exercise.
Diet therapy is the most commonly prescribed therapy; it is generally safe and can
be highly effective.

Pharmacologic management
• Patients who are not successful at meeting weight loss goals from lifestyle
modification may be prescribed anti obesity medication. Orislat (xenical), which is
available both by prescription and over the counter as Alli, reduce calorin intake
by binding to gastric and pancreatic lipase to prevent digestion fats.
Surgical therapy
• Bariatric surgery- for obesity is performed only after other nonsurgical attempts
at weight control have failed. Most insurance companies will only authorize
bariatric surgery after a patient who is obese tries 6 to 18 months of a medically
supervised diet that fails to reach its goal of weight loss.

Assessment
• Preoperatively, the nurse assesses for contraindication to major abdominal
surgery. Has the patient attempted to lose weight by non-operative means such
as nutritional counseling dieting, or an exercise program.
Nursing diagnosis
• Deficient knowledge about the dietary limitations during immediate preoperative and post
operative phases.
• Anxiety related to impending surgery
• Acute pain related to surgical procedure
• Risk for deficient fluid volume related to nausea, gastric irritation, and pain
• Risk for infection related to anastomotic leak
• Imbalanced nutrition; less than body requirement related to dietary restrictions
• Disturbed body image related to body changes from bariatric surgery
• Risk for constipation and/or diarrhea related to gastric irritation and surgical changes in
anatomic structures from bariatric surgery
Collaborative problem/potential complication
• Hemorrhage
• Bile reflux
• Dumping syndrome
• Dysphagia
• Bowel of gastric outlet obstruction
Planning and goals
• Preoperative goals include that the patient will become knowledgeable about the
preoperative and postoperative dietary routine/restriction and will have decreased
anxiety about the surgery.
Nursing intervention
• The nurse counsels the patient anticipating bariatric surgery to ingest nothing but
clear liquids for a specified period of time preoperatively. The patient diet will be
quite limited postoperatively.

Reducing anxiety
• The nurse provides the patient preparing for bariatric surgery anticipatory guidance
of what to expect during the surgery and postoperatively. In addition, the nurse may
encourage the patient to join bariatric surgery support group preoperatively, with the
intent that the patient will continue to participate in this group postoperatively.
Relieving pain
• After surgery, analgesics agents may be administered as prescribed to relieve pain and
discomfort. Patients are usually prescribed opoids agents via patient controlled
analgesia pumps.

Ensuring fluid volume balance

• Patients who had bariatric surgery most commonly receive IV fluid for the first several
hours postoperatively. Once they awake and alert on the surgical unit they are
encouraged to begin intake of sugar free oral liquids.
Preventing infection/anastomic leak
• Disruption at the site of anastomosis may cause leakage of gastric contents
into the peritoneal cavity, causing infection and possible sepsis.
Gastric cancer
• Although the incidence of gastric or stomach cancer continues to
decrease.Gastric cancer is a more common diagnosis among older adults,
with the median age at diagnosis of 70 years in men and 74 years in women
Clinical manifestation
• Symptoms of early disease, such as pain relieved by antacids, resemble those
of benign ulcers and are seldom definitive. Symptoms of progressive disease
include dyspepsia, early safety, weight loss, abdominal pain just above the
umbilicus, loss or decrease in appetite, bloating after meals, nausea and
vomiting and symptoms similar to those peptic ulcer disease.
Assessment and diagnostic findings
• Physical examination is usually not helpful in detecting the cancer because
most early gastric tumors are not palpable. Advanced gastric cancer may be
palpable as mass.
• X-ray examination of the upper tract may also be performed.
• CT scanning complete the diagnosis studies, particularly to assess for surgical
resectability of the tumor before surgery is scheduled.
Medical management
• A diagnostic laparoscopy may be the initial surgical approach to evaluate the
gastric tumor, obtain tissue for pathologic diagnosis and detect metastasis.
The patient with a tumor that is deemed resectable undergoes an open
surgical procedure to resect the tumor and appropriate lymph nodes. A total
gastrectomy may be performed for a resectable cancer in the midportion of
the body of the stomach.
Assessment
• The nurse obtain a dietary history from the patient, focusing on recent
nutritional intake and status. After the interview, the nurse performs a
complete physical examination, carefully assesses the patient’s abdomen for
tenderness or masses and palpates and percusses the abdomen to detect
ascites.
Nursing diagnosis
• Anxiety related to the disease and anticipated treatment
• Imbalanced nutrition: less than body requirements related to safety or anorexia
• Acute pain related to tumor mass
• Grieving related to diagnosis of cancer
• Deficient knowledge regarding of 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 intervention
• A relaxed, nonthreatening atmosphere is provided so the patient can express fears,
concerns and possibly anger about the diagnosis and prognosis.
Promoting optimal nutrition
• The nurse encourages the patient to eat small, frequent portions of nonirritating foods
to decrease gastric irritation. Food supplement should be high calories as well as
vitamins A and C and iron to enhance tissue repair.

Relieve pain
• The nurse administer analgesics agents as prescribed. A continuous IV infusion of an
opoid or a PCA pump set to infuse an opoid may be necessary to mitigate
postoperative pain.
Providing psychosocial support
• The nurse helps the patient express fears, concerns and grief about the
diagnosis. The nurse answers the patient’s question honestly and encourage
the patient participate in treatment decisions. Some patients mourn the loss
of a body pain and perceived their surgery as a type of multilation.
Gastric surgery
• Performed on patients with peptic ulcer who have life threatening
hemorrhage, obstruction, perforation or penetration or whose condition
does not respond medication. It also may be indicated for patients with
gastric cancer or trauma.
Nursing management
• Before surgery, the nurse assess the patients and family knowledge of
preoperative and postoperative surgical routines and the rationale for surgery.
After surgery the nurse assess the patient for complications secondary to the
surgical intervention, such as hemorrhage, infection, abdominal distention,
atelectasis or impaired nutritional status.
Clinical manifestation

• Tumors of the small intestine often present insidiously with vague, non
specific symptoms. Most benign tumors are discovered incidentally on an x-
ray study, during surgery or at autopsy. When the patient is symptomatic,
benign tumors often present with intermittent pain.
Assessment and diagnostic findings
• A CBC may reveal low hemoglobin levels and hematocrit that are consistent
with anemia if the patient has an occult source of GI bleeding. The bilirubin
may also be elevated if tumor mass has caused biliary obstruction. CEA
levels may also be elevated, consistent with a malignant mass.
Management
• Benign tumors of the small intestine include adenomas, lipomas ,
hemangiomas and hamartomas these tumors may be treated endoscopically
by excision or electro cautery if the patient is symptomatic.. The most
common primary malignant tumor of the small intestine is adenocarcinoma;
the second and third portions of duodenum are most often involved.