GASTRODUODENAL

DISORDERS

SUAZO, TRISHA MAE S.

3BSN-A
Gastrointestinal Bleeding
GI bleeding is not just a gastroduodenal disorder but may occur anywhere along the alimentary
tract. Bleeding is a symptom of an upper or lower GI disorder. It may be obvious in emesis or
stool, or it may be occult (hidden).
Pathophysiology and Etiology
1. Trauma anywhere along the GI tract.
2. Erosions or ulcers.
3. Rupture of an enlarged vein such as a varicosity (esophageal or gastric varices).
4. Inflammation, such as esophagitis (caused by acid or bile), gastritis, inflammatory bowel
disease (chronic ulcerative colitis, Crohn’s disease), and bacterial infection.
5. Alcohol and drugs (aspirin-containing compounds, NSAIDs, anticoagulants,
corticosteroids).
6. Diverticular disease.
7. Cancers.
8. Vascular lesions or disorders, such as bowel ischemia, aortoenteric fistula, arteriovenous
malformations.
9. Mallory-Weiss tear.
10. Anal disorders, such as hemorrhoids or fissures.
Clinical Manifestations
Characteristics of Blood
1. Bright red: vomited from high in esophagus (hematemesis); passed from rectum or distal
colon (coating stool).
2. Dark red: higher up in colon and small intestine; mixed with stool.
3. Shades of black (“coffee ground”): vomited from esophagus, stomach, and duodenum.
4. Tarry stool (melena): occurs in patient who accumulates excessive blood in the stomach.
Signs and Symptoms of Bleeding
1. Massive bleeding.
a. Acute, bright red hematemesis or large amount of melena with clots in the stool.
b. Rapid pulse, drop in BP, hypovolemia, and shock.

2. Subacute bleeding.
a. Intermittent melena or coffee-ground emesis.
b. Hypotension.
c. Weakness, dizziness.
3. Chronic bleeding.
a. Intermittent appearance of blood.
b. Increased weakness, paleness, or shortness of breath.
c. Occult blood.
 d. Iron-deficiency anemia.
Diagnostic Evaluation
1. It is not difficult to diagnose bleeding, but it may be difficult to locate the source of
bleeding.
2. History: change in bowel pattern, presence of pain or tenderness, recent intake of food
and what kind (eg, red beets), alcohol consumption, drugs (eg, aspirin or steroids).
3. Complete blood count (CBC) (hemoglobin, hematocrit, platelets) and coagulation studies
(partial thromboplastin time, prothrombin time with international normalized ratio) may
show abnormalities.
4. Endoscopy: identifies source of bleeding, determines risk of re-bleeding, and provides
endoscopic therapy, if needed.
5. Imaging may detect etiology of bleeding.
6. Test of stool for occult blood.
Management
Based on Etiology
1. If aspirin or NSAIDs are the cause, discontinue medication and treat bleeding.
2. If ulcer is the cause, assess medications, dietary and lifestyle modifications, and for
Helicobacter pylori.
3. Therapeutic endoscopic procedure (cautery, injection).
4. Surgery may be indicated for cancers, inflammatory diseases, and vascular disorders.
Emergency Intervention
1. Patient remains on NPO status.
2. IV lines and oxygen therapy initiated.
3. If life-threatening bleeding occurs, treat shock, administer blood replacement, intra-
arterial vasopressin or embolization.
4. Surgical therapy, if indicated.
Nasogastric Intubation
1. An NG tube should be in place for most patients with acute or upper GI bleeding.
2. If the aspirate continues to be bloody after 2 to 3 L of tap water lavage, the patient may
have an active bleed requiring more emergent intervention or endoscopic therapy.
Other Measures
1. Electrocoagulation using a heater probe.
2. Injection of sclerosant or epinephrine.
3. Endoscopy used in conjunction with management measures as well as in diagnostic
evaluation.
4. Pharmacotherapy depends on cause; can include histamine blockers—as either
continuous IV (preferred) or bolus infusion to block the acid-secreting action of
 histamine—or IV pantoprozole (Protonix). Intra-arterial vasopressin can be used to slow
or stop active bleeding from diverticulum or vascular ectasia.
5. Surgery is indicated when more conservative measures fail.
Complications
1. Hemorrhage.
2. Shock.
3. Death.
Nursing Assessment
1. Obtain history regarding:
a. Change in bowel patterns or hemorrhoids.
b. Change in color of stools (dark black, red, or streaked with blood).
c. Alcohol consumption.
d. Medications, such as aspirin, NSAIDs, antibiotics, anticoagulants, corticosteroids.
e. Hematemesis.
f. Other medical conditions.
2. Evaluate for presence of abdominal pain or tenderness.
3. Monitor vital signs and laboratory tests for changes that indicate bleeding (hemoglobin,
hematocrit, platelet count, coagulation studies).
4. Test for occult blood, if indicated.
Nursing Diagnoses
 Deficient Fluid Volume related to blood loss.
 Imbalanced Nutrition: Less Than Body Requirements related to nausea, vomiting,
diarrhea.
Nursing Interventions
Attaining Normal Fluid Volume
1. Maintain NG tube and NPO status to rest GI tract and evaluate bleeding.
2. Monitor intake and output, as ordered, to evaluate fluid status.
3. Monitor vital signs, as ordered.
4. Observe for changes indicating shock, such as tachycardia, hypotension, increased
respirations, decreased urine output, change in mental status.
5. Administer IV fluids and blood products, as ordered, to maintain volume.
Attaining Balanced Nutritional Status
1. Weigh daily to monitor caloric status.
2. Administer IV fluids, TPN, if ordered, to promote hydration and nutrition while on oral
restrictions.
3. Begin liquids when patient is no longer NPO. Advance diet as tolerated. Diet should be
high-calorie, high-protein. Small, frequent feedings may be indicated.
 4. Offer snacks; high-protein supplements.
Patient Education and Health Maintenance
1. Discuss the cause and treatment of GI bleeding with patient.
2. Instruct patient regarding signs and symptoms of GI bleeding: melena, emesis that is
bright red or “coffee ground” color, rectal bleeding, weakness, fatigue, shortness of
breath.
3. Instruct patient on how to test stool or emesis for occult blood, if applicable.
Evaluation: Expected Outcomes
 Intake and output equal, vital signs stable.
 Tolerates small feedings, weight stable.

Peptic Ulcer Disease

Peptic ulcer disease refers to ulcerations in the mucosa of
the lower esophagus, stomach, or duodenum
Pathophysiology and Etiology
1. Etiology of peptic ulcer disease is multifactorial.
a. H. pylori infection—present in most patients
with peptic ulcer disease.
b. NSAID-induced injury—presents as a
chemical gastropathy.
c. Acid secretory abnormalities (especially in
duodenal ulcers).
d. Zollinger-Ellison syndrome (hypersecretory
syndrome) should be considered in refractory ulcers.
2. Risk factors may include drugs (NSAIDs, prolonged high dose corticosteroids), family
history, Zollinger-Ellison syndrome, cigarettes, stress, O blood type, and lower
socioeconomic status.
3. Studies are inconclusive in determining an association between ulcer formation and diet
or the intake of alcohol and caffeine.
Clinical Manifestations
1. Gnawing or burning epigastric pain occurring 1½ to 3 hours after a meal.
2. Nocturnal epigastric, abdominal pain or burning; may awaken patient at night, usually
around midnight to 3 am.
3. Epigastric tenderness on examination.
4. Early satiety, anorexia, weight loss, heartburn, belching (may indicate reflux disease).
5. Dizziness, syncope, hematemesis, or melena (may indicate hemorrhage).
6. Anemia.
Diagnostic Evaluation
1. Upper GI endoscopy with possible tissue biopsy and cytology.
a. PyloriTek, a biopsy urea test, is up to >97% specific and >96% sensitive for
detection of H. pylori.
b. Point of service test with results within 1 hour.
2. Upper GI radiographic examination (barium study).
3. Serial stool specimens to detect occult blood.
4. Gastric secretory studies (gastric acid secretion test and serum gastric level test)—
elevated in Zollinger-Ellison syndrome.
5. Serology to test for H. pylori antibodies or stool test to assess for H. pylori antigen.
6. C-urea breath test to detect H. pylori.
Management
General Measures
1. Eliminate use of NSAIDs or other causative drugs.
2. Eliminate cigarette smoking (impairs healing).
3. Well-balanced diet with meals at regular intervals. Avoid dietary irritants.
Drug Therapy
Multiple drug regimens are used to treat H. pylori, usually involving triple therapy with two
antibiotics and a proton-pump inhibitor for 10 to 14 days to eradicate the bacteria.
Surgery
1. Surgical interventions may be indicated for hemorrhage, obstruction, perforation, and
acid reduction. Surgery may also be indicated with ulcer disease of long duration or
severity or difficulty with medical regimenbcompliance.
2. Gastroduodenostomy (Billroth I).
a. Partial gastrectomy with removal of antrum and pylorus of stomach.
b. The gastric stump is anastomosed with the duodenum.
3. Gastrojejunostomy (Billroth II).
a. Partial gastrectomy with removal of antrum and pylorus of stomach.
b. The gastric stump is anastomosed with the jejunum.
4. Antrectomy.
a. Gastric resection includes a small cuff of duodenum, the pylorus, and the antrum
(lower half of stomach).
b. The duodenal stump is closed and the jejunum is anastomosed to the stomach.
5. Total gastrectomy.
a. Also called an esophagojejunostomy.
b. Removal of the stomach with attachment of the esophagus to the jejunum or
duodenum.
6. Pyloroplasty.
 a. 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.
b. Often, a vagotomy is performed at the same time.
7. Vagotomy.
a. The surgical division of the vagus nerve to eliminate the impulses that stimulate
HCL secretion.
b. 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.
c. Traditionally performed by laparotomy, the vagotomy procedure can also be done
using a laparoscope.
Complications
1. GI hemorrhage.
2. Ulcer perforation.
3. Gastric outlet obstruction.
Nursing Assessment
1. Determine location, character, radiation of pain, factors aggravating or relieving pain, how
long it lasts, when it occurs.
2. Ask about eating patterns, regularity, types of food, eating circumstances.
3. Ask about medications (especially aspirin, steroids, or anti-inflammatory drugs).
4. Inquire about a history of illnesses, including previous GI bleeds.
5. Obtain psychosocial history.
6. Perform physical assessment with documentation of positive abdominal findings.
7. 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
1. Monitor intake and output continuously to determine fluid volume status.
2. Monitor stools for blood and emesis.
3. Monitor hemoglobin and hematocrit and electrolytes.
4. Administer prescribed IV fluids and blood replacement, as prescribed.
5. Insert NG tube as prescribed, and monitor the tube drainage for signs of visible and
occult blood.
6. Administer medications through the NG tube to neutralize acidity, as prescribed.
7. Prepare the patient for saline lavage, as ordered.
8. Observe the patient for an increase in pulse and a decrease in BP (signs of shock).
9. Prepare the patient for diagnostic procedure or surgery to determine or stop the source of
bleeding.
Achieving Pain Relief
1. Administer prescribed medication.
2. Provide small, frequent meals to prevent gastric distention if not NPO.
3. Advise the patient about the irritating effects of certain drugs and foods.
Decreasing Diarrhea
1. Monitor the patient’s elimination patterns to determine effects of medications.
2. Monitor vital signs and watch for signs of hypovolemia.
3. Administer antidiarrheal medication as prescribed.
4. 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
1. Eliminate foods that cause pain or distress; otherwise, the diet is usually not restricted.
2. Provide small, frequent meals that neutralize gastric secretions and may be better
tolerated.
3. Provide high-calorie, high-protein diet with nutritional supplements, as ordered.
4. Administer parenteral nutrition, as ordered, if bleeding is prolonged and patient is
malnourished.
Educating the Patient about the Treatment Regimen
1. Explain all tests and procedures to increase knowledge and cooperation and minimize
anxiety.
2. Review the health care provider’s recommendations for diet, activity, medication, and
treatment. Allow time for questions and clarify any misunderstandings.
3. Give the patient a chart listing medications, dosages, times of administration, and desired
effects to promote compliance.
Patient Education and Health Maintenance
1. Teach the patient the signs and symptoms of bleeding and when to notify the health care
provider.
2. Promote healthy lifestyle changes to include adequate nutrition, cessation of smoking,
decreased alcohol consumption, stress reduction strategies.
3. Explain the purpose, dosage, and adverse effects of each medication prescribed.
Evaluation: Expected Outcomes
 Vital signs stable; fluid volume maintained.
 Pain free.
 No more than two to three loose stools per day.
 Eats small, frequent meals each day; reports no loss of weight.
 Describes peptic ulcer disease, its treatment, and complications; complies with treatment
regimen.
Gastric Cancer
Malignant tumor of the stomach.
Pathophysiology and Etiology
1. Risk factors include:
a. Chronic atrophic gastritis with intestinal metaplasia.
b. Pernicious anemia or having had gastric resections (more than 15 years).
c. Adenomatous polyps.
2. Related factors:
a. More common in men and African Americans.
b. Incidence increases with age.
Clinical Manifestations
Early Manifestations
Typically, patient presents with same symptoms as gastric ulcer; later, on evaluation, the lesion
is found to be malignant.
1. Progressive loss of appetite.
2. Noticeable change in or appearance of GI symptoms—gastric fullness (early satiety),
dyspepsia lasting longer than 4 weeks.
3. Blood (usually occult) in the stools.
4. Vomiting.
a. May indicate pyloric obstruction or cardiac–orifice obstruction.
b. Occasionally, vomiting has a coffee-ground appearance because of slow leaks of
blood from ulceration of the cancer.
Later Manifestations
1. Pain, usually induced by eating and relieved by vomiting.
2. Weight loss, loss of strength, anemia, metastasis (usually to liver), hemorrhage, obstruction.
3. Abdominal or epigastric mass.
Diagnostic Evaluation
1. History—weight loss and fatigue over several months.
2. Upper GI radiography and endoscopy—afford visualization and provide means for
obtaining tissue samples for histologic and cytologic review.
3. Imaging, such as bone or liver scan—may determine extent of disease.
Management
1. The only successful treatment of gastric cancer is surgical removal.
1. Gastric resection is surgical removal of part of the stomach.
2. If tumor has spread beyond the area that can be excised surgically, cure is not possible.
a. Palliative surgery, such as subtotal gastrectomy with or without
gastroenterostomy, may be performed to maintain continuity of the GI tract.
b. Surgery may be combined with chemotherapy to provide palliation and prolong
life.
Complications
1. If surgery is performed, possible risk of hemorrhage or infection.
2. Dumping syndrome following gastrectomy.
3. Metastasis and death.
Nursing Assessment
1. Assess for anorexia, weight loss, GI symptoms (gastric fullness, dyspepsia, vomiting).
2. Evaluate for pain, noting characteristics/location.
3. Check stool for occult blood.
4. Monitor CBC to assess for anemia.
Nursing Diagnoses
 Pain related to disease process or surgery.
 Risk for Injury, shock and other complications related to surgery and impaired gastric
tissue function.
 Imbalanced Nutrition: Less Than Body Requirements related to malignancy and
treatment.
Nursing Interventions
Promoting Comfort and Wound Healing
1. Turning, coughing, deep-breathing every 2 hours to prevent vascular and pulmonary
complications and promote comfort.
2. Institute NG suction, if ordered, to remove fluids and gas in the stomach and prevent
painful distention.
3. Administer parenteral antibiotics, as ordered, to prevent infection.
4. Administer analgesics, as ordered.
Preventing Shock and Other Complications
1. Shock and hemorrhage.
a. Monitor changes in BP, pulse, and respiration.
b. Observe the patient for evidence of changes in mental status, pallor, clammy skin,
dizziness.
c. Check the dressings and suction canister frequently for evidence of bleeding.
d. Administer IV infusions and blood replacement, as prescribed.
2. Cardiopulmonary complications.
a. Encourage the patient to cough and take deep breaths to promote ventilatory
exchange and enhance circulation.
b. Assist the patient to turn and move, thereby mobilizing secretions.
c. Promote ambulation, as prescribed, to increase respiratory exchange.
3. Thrombosis and embolism.
a. Initiate a plan of self-care activities to promote circulation.
b. Encourage early ambulation to stimulate circulation.
c. Prevent venous stasis by use of elastic stockings, if indicated.
d. Check for tight dressings or binder that might restrict circulation.
4. Dumping syndrome—a complex reaction that may occur because of excessively rapid
emptying of gastric contents. Manifestations include nausea, weakness, perspiration,
palpitation, some syncope, and possibly diarrhea. Instruct the patient as follows:
a. Eat small, frequent meals rather than three large meals.
b. Suggest a diet high in protein and fat and low in carbohydrates, and avoid meals
high in sugars, milk, chocolate, salt.
c. Reduce fluids with meals, but take them between meals.
d. Take anticholinergic medication before meals (if prescribed) to lessen GI activity.
e. Relax when eating; eat slowly and regularly.
f. Take a rest after meals.
5. Phytobezoar formation (formation of gastric concretion composed of vegetable matter)
can be seen with partial gastrectomy and vagotomy. After a gastric resection, the
remaining gastric tissue is not able to disintegrate and digest fibrous foods. This
 undigested fiber congeals to form masses that become coated by mucus secretions of the
stomach.
a. Avoid fibrous foods, such as citrus fruits (skins and seeds), because they tend to form
phytobezoars.
b. Stress the importance of adequate chewing.
Attaining Adequate Nutritional Status
1. Administer parenteral nutrition, if ordered.
2. Follow prescribed diet progressions.
a. Give fluids by mouth when audible bowel signs are present.
b. Increase fluids according to the patient’s tolerance.
c. Offer a diet with vitamin supplements when the patient’s condition permits.
d. Avoid high-carbohydrate foods, such as milk, which may trigger dumping
syndrome.
e. Offer diet, as prescribed—usually high in protein and calories to promote wound
healing.
Patient Education and Health Maintenance
1. Emphasize the importance of coping with stressful situations. Provide information about
support groups.
2. Review nutritional requirements with the patient.
3. Stress the importance of I.M. vitamin B12 supplements after gastrectomy to prevent
surgically induced pernicious anemia.
4. Encourage follow-up visits with the health care provider.
5. Recommend annual blood studies and medical checkups for any evidence of pernicious
anemia or other problems.
6. Instruct on measures to prevent dumping syndrome.
Evaluation: Expected Outcomes
 States pain decreased to 2 or 3 on 0-to-10 scale.
 Vital signs stable; no evidence of complications.
 Tolerating small, frequent meals.