Upper GI Disorders Nursing 201 Daltrey Tyree ARNP, RN, MSN Pharmacology- UGI (Ch 46, 47)

Antacids (maalox, mylanta, gaviscon, riopan, amphojel, Tums)

Used in uncomplicated cases
Neutralizes HCL acid (short-term action; nighttime effectiveness is minimal)
Causes constipation (aluminum, calcium)
Causes diarrhea (magnesium)
**do not administer within 1-2 hours of other medications (interferes with absorption)

Histamine 2 Receptor Blockers (“Tidines”)

Tagamet (cimetidine), Pepcid (famitidine), Axid (nizatidine), Zantac (ranitidine).
Smoking ↓ effect
Block H2 receptors of parietal cells
Do not give at same time as antacids
If given IV push – push slowly - can cause hypotension, arrhythmias
Monitor tarry stools
Tagamet has ↑ s/e (confusion, dizziness, fatigue) and more drug to drug interactions
(need good renal fxn)

Proton Pump Inhibitors (“prazoles”) *****Most popular drug for Upper GI problems*****
Prevacid (lansoprazole), Prilosec (omeprazole), Protonix (pantoprazole), Aciphex (rabeprazole), Nexium
(exomeprazole)
Blocks final step of acid production
Do not Crush, Chew, Break
Monitor liver fxn
Used with abx for H. pylori
Rpt tarry stools

Pepsin Inhibitor
Carafate (sucralfate)
Covers ulcers (protection of mucosa)
Few s/e – constipation
Administer before meals and at bedtime
Reglan (metoclopramide)
Promotility (stimulates motility)
Extra Pyramidal Side Effects (speech, swallowing, balance, gait, twitching)

Anticholinergics Librax, Pro-Banthine, Belladonna (scopolamine)

Relieves spasms of GI tract
Monitor for urinary retention, constipation, dry mouth, vision changes

Antibiotics
Used for H. pylori

Antiemetics (phenothiazines)
Phenergan (promothazine), Compazine (prochlorperazine)
Block vomiting receptors
Always dilute phenergan (very irritating and painful)
s/e: sedation, ↓BP, agitation, dry mouth, retention, constipation
Monitor for Respiratory depression
Institute “fall precautions”
 Zofran (odansetron)
Given to chemo pts
Expensive
Serotonin blocker
Institute “fall precautions” (dizziness)

Emetics
Ipecac
Induces vomiting
Can cause aspiration; injury to esophagus
OTC – poison control

GI- Diagnostic Tests

Barium swallow
Radiopaque liquid
Aids in dx of GERD, ulcers, tumors, esoph. varices, patency of sphincter up to duodenum
NPO prior to procedure
↑ fluids after procedure
White; clay colored stools

Upper endoscopy (EGD)

Esophagus, stomach, gastric and duodenal mucosa
Biopsy
Monitor airway, O2 sats, mouthguard

24 Hour PH Monitoring
NG-like tube inserted
Pt wears 24 hrs for constant PH monitoring

Esophageal Manometry
Uncommon

Abdominal Series
X-ray

CT Scan
Oral contrast
IV contrast
Looks at anatomy

Capsule Endoscopy
New
Swallow a capsule that takes pictures

UGI Components
Mouth
Pharynx
Esophagus
Stomach
 Background A & P
1. Mouth (oral, buccal cavity)
Hard palate (covers bone)
Soft palate (covers muscle)
Lips
Cheeks
Tongue (mix food w/saliva (bolus); initiates swallowing; Amylase)
Teeth

2. Pharynx (passageway for food, fluids, air) Extends from base of skull to esophagus
Nasopharynx
oropharynx
laryngopharynx
***pharyngeal mucosa produces fluid to facilitate passage of food bolus as it is swallowed. Muscles of the
pharynx move food bolus to esophagus thru peritalysis***

3. Esophagus - From pharynx to stomach (thru thorax and diaphragm; ant. to spine; post to trachea)
Epiglottis (keeps food out of trachea, larynx)
Lower Esophageal Sphincter or cardiac sphincter (prevents reflux into esophagus from stomach)

4. Stomach (LUQ) *Can expand to hold 4L

cardiac (narrow part of esophagus)
fundus (nearest cardia)
body (main area)
pylorus (distal part of stomach) (pyloric sphincter controls emptying into duodenum)
**food mixes with gastric juices – Chyme)

Nutrients
Carbohydrates (converted to glucose for energy)
Proteins (complete–animal; incomplete-plants needed for building tissue, growth maintenance)
Fats (sat-animal; unsat-seeds, nuts, milk, egg yolks needed for membranes; *cell fuel)
Vitamins
Minerals

Stomach Secretions
Gastric juice produced by gastric glands
HCL acid produced by parietal cells
Intrinsic factor produced by parietal cells
Others- pepsinogen, histamine, endorphins, serotonin, somatostatin

Physical Assessment
6 Fs of distended abdomen (fat, fatal tumor, feces, fetus, fluid, flatus)
INSPECTION
*AUSCULTATION*
PERCUSSION
PALPATION (last to avoid problems)

Oral Cavity Problems

Disorders of Mouth
Cheilosis (painful lesions at corners of mouth; riboflavin, niacin deficiency)
Herpes Simplex 1 (cold sores on lips and mouth – can go south with oral sex)
Glossitis (beefy, red tongue – Folic acid deficiency)
Leukoplakia (white patches; precancerous. If on tongue – more apt to progress to malignancy)
 Candidiasis (white cheesy patches “thrush”. Immune deficiency; chemo pts)
Gingivitis (red gums that bleed easily)
Stomatitis (may see single or multiple ulcerations “canker sores”
Inflammation of oral mucosa;
Viral (Herpes) fungal (Candida), trauma, irritants
Tobacco, chemo drugs
Thin, fragile, rich blood supply

Premalignant Lesions
Leukoplakia (white, slightly raised circumscribed patches; 90% benign; 7% malignant after 8 yrs) Mechanical
causes, poorly fitted dentures, cheek nibbling, broken teeth. “Hairy” leukoplakia with HIV
Erythroplakia (red velvety lesions; higher level of malignancy) Most commonly found on floor of the mouth,
tongue, palate, and mandibular mucosa.

Malignant Tumors (oral cancer)

Squamous Cell Carcinoma – slow growth tumors; may be large before onset of symptoms
Basal Cell Carcinoma – on Lips; asymptomatic; primarily caused by sun exposure
Kaposi’s Sarcoma – AIDS; malignant lesion of blood vessels; painless purple nodule; hard palate
***Prevention = minimize sun and tanning bed exposure, tobacco cessation, and ↓ alcohol intake, HPV16***

Mouth Disorders- NANDA

Impaired oral mucus membranes
Imbalanced nutrition: < than body requirements
Deficient knowledge
Acute pain
Disturbed body image

Mouth Disorders- Interventions

Assess oral cavity frequently; document
Provide frequent mouth care; toothettes
Avoid irritants; tobacco, alcohol, spicy foods, rough foods
Assess food intake; high protein, ↑ calories
Provide assistive devices; straws, feeding syringes
Administer medications; topical anesthetics, antivirals, antifungals
***CAUTION: ANY UNDIAGNOSED ORAL LESION FOR MORE THAN ONE WEEK MUST BE EVALUATED FOR MALIGNANCY***

Oral Cancer
Primary Risk Factors
1. Smoking
2. Alcohol
3. Chewing tobacco
4. Possible: marijuana use, chemical exposure, viruses (HPV), sun exposure
***High mortality rates, appears on lips, tongue, floor of mouth. Squamous cell = most common. Early signs=unusual
lumps, thickening, pain, burning. Late signs=dysphagia, difficulty chewing, pain that radiates to the ear***

Oral Cancer Interventions (chart 56-3 pg 1236)

Eliminate causative agent (tobacco, alcohol)
Determination of malignancy (biopsy)
Determination of staging (MRI, CT – Mets to tongue, oropharynx, mandible, maxilla)
Assess cervical nodes (mets)
Tx: surgery (radical neck dissection), chemo, radiation or combo
***Death usually occurs if mets to lymph nodes***
Oral Cancer – NANDA
Risk for ineffective airway clearance r/t location, extent (positioning, TCDB, suctioning, O 2, monitor RR status,
monitor for aspiration risk)
Imbalanced nutrition; less than body requirements (daily wts, oral intake, dietary consult)
Impaired verbal communication (radical neck dissection – tracheostomy; can’t talk – need communication plan;
allow ample time to communicate. Work with speech therapist)
Disturbed body image (assess coping, provide emotional support)

ESOPHAGEAL PROBLEMS
GERD (GastroEsophageal Reflux Disease aka Acid Reflux)
Causes: Relaxation of LES (Lower esophageal sphincter)
Incompetent LES
↑ pressure in stomach

GERD Supporting Data (chart 57-1 pg 1244)

Heartburn (dyspepsia) after meals, when bending over or reclining
Regurgitation of sour taste in mouth
Difficulty (stricture/inflammation), pain when swallowing (dysphagia, odynophagia)
Atypical chest pain (rule out heart attack first)
Sore throat or hoarseness (chronic cough especially in children)
Belching (eructation), gas (flatulence), bloating after eating
Water brash (sensation of fluid in throat but no sour taste as with regurgitation)
***risk for aspiration****

GERD Complications
Esophageal strictures (narrowing)
Barretts esophagus (↑ risk of esophageal cancer due to changes in cells that line esophagus; ulcerations)
Superficial ulcers w/bleeding
Scarring
*****DX: 24 hr PH monitoring, Endoscopy*****

GERD NANDA
Pain
Imbalanced nutrition
Ineffective health maintenance
Deficient knowledge

GERD Interventions (Table 57-1, chart 57-2 pg 1244-45)

Lifestyle changes
Avoid triggers (caffeine, chocolate, peppermint, spicy foods, acidic foods, soda pop)
Do not eat 2-3 hrs before bedtime
Sit upright after eating (auscultate for crackles; aspiration)
Avoid tobacco, alcohol
↑ HOB
Maintain ideal body weight
Avoid tight clothing, bending (↓ intrabdominal pressure)
Teach diet modifications (low fat, high fiber diet, 4-6 small meals
Administer medications
Antacids (uncomplicated cases, minimal overnight effectiveness, do not give with other meds, diarrhea
(magnesium), constipation (calcium)
Histamine 2 blockers (tidiness, not given with antacids, IV rapid infusion= hypotension, arrhythmias, smoking ↓
effect, monitor for tarry stools)
 Proton pump inhibitors (prazoles, Do not crush, chew or break, given with abx for H. pylori, monitor liver fxn,
monitor for tarry stools)
Pro-motility agent (Reglan, Extra-pyramidal side effects – speech, gait, swallowing, twitching)

Surgery
Nissen fundoplication (R/F respiratory complications due to close proximity of incision to the lungs)

Hiatal Hernia (sliding (more common), rolling)

Diagnosis- same as GERD
Symptoms- similar to GERD
Treatment- similar to GERD
Nursing care- same as GERD
***complications include ↑ r/f infection(peritonitis), ↓ blood supply***

Achalasia
An Esophageal motility disorder in which the LES fails to relax properly with swallowing. Normal peristalsis of
the esophagus is replaced with abnormal contractions which cause discomfort. Over time, esophagus becomes
massively dilated which slows food passage. (Dx by barium swallow)

Esophageal Tumors
Etiology and Genetic Risk (most arise from epithelium, grow quickly and spread to lymph nodes)
Barrett’s esophagus
Dysphagia vs Odynophagia
Primary risk factors include tobacco, alcohol use, obesity and malnutrition

Esophageal CA Manifestations or Supporting Data (high mortality rate b/c dx usually late)
Dysphagia (Most common symptom)
Weight loss
Regurgitation
Chest pain
Anemia
GERD-like symptoms
Anorexia
Persistent cough
DX: barium swallow, endoscopy. CXR, CT, MRI identifies metastasis (often to liver)

Esophageal CA- NANDA

Imbalanced Nutrition: < body requirements r/t impaired swallowing
Anticipatory grieving r/t terminal prognosis
Risk ineffective airway clearance r/t impaired swallowing
Deficient knowledge
Risk for Aspiration r/t esophageal strictures; impaired swallowing
Acute/Chronic pain r/t pressure from tumor

Esophageal Cancer Interventions

Surgical resection (anastomosis of stomach to remaining esophagus)
Radiation (done prior to surgery)
Chemo (done prior to surgery)
May be palliative treatment (if advanced disease)
Provide post-op care (Respiratory care =priority. Shock, Pain, NG tube, prevent distention (fluid volume
overload), prevent aspiration, prevent infection, wound care, nutrition (j-tube feedings)
TX: is individual to each pt. Depends on stage, condition of pt and pt preference
Stomach Disorders
Gastritis (inflammation of the stomach lining)

Acute (thick red, with rugae) Chronic (patchy, diffuse inflammation)

Meds (ASA, NSAIDS, steroids) Autoimmune (antibody causes lack of intrinsic factor)
Alcohol H. pylori (gram (-) causes chronic infection of mucosa,
Caffeine ↑ risk for peptic ulcer disease)
Contaminated foods Aging
Corrosive substances
Radiation
Chemo
Erosive (stress induced – life threatening Curling’s ulcer with burn victims)
(Cushing’s ulcer with head injury)

Acute (Chart 58-2 pg 1267) Chronic

Rapid onset of epigastric pain Vague epigastric pain relieved by food
N/V N/V
Anorexia Anorexia
Gastric hemorrhage Intolerance of fatty. Spicy foods
Dyspepsia Pernicious anemia
Hematemesis

Gastritis NANDA
Deficient fluid volume
Imbalanced nutrition: < body requirements
Deficient knowledge

Gastritis- Interventions
Teach food safety (fully cooked meats, eggs; refrigerate food within 2 hrs)
Initially maintain NPO status with gradual reintroduction of fluids; clear liquids (for acute episode)
Avoid triggers
Meds (Proton pump inhibitors, H2 blockers, Flagyl, amoxicillin, Prilosec or Prevacid commonly used to treat H.
pylori (blood test, breath test)

Peptic Ulcer Disease

Duodenal (most common)
Gastric- increased risk gastric CA (common in smokers, NSAID use (ASA), family hx)
Esophageal
****peptic ulcer perforation is a surgical emergency. Pt may present in knee-chest (fetal) position****
****hypokalemia and metabolic alkalosis may result from vomiting****

Peptic Ulcer Disease

Duodenal Gastric
Most common Affects 55-70 yoa
Affects mostly males 30-55 years age Found on lesser curvature
Ulcer found near pylorus Associated with ↑ r/f gastric cancer
Wt loss Pain 30 minutes to 1 hr after eating
Pain after meals
High stress
PUD Manifestations or Supporting Data
Pain (radiates to the back; gnawing, burning, aching, hunger-like pain)
Heartburn
Regurgitation
***Elderly 1st symptom may be GI bleed (from blood thinner usage)***

PUD Complications
Hemorrhage(Most serious; hematemesis (coffee grounds), melena (black tarry; occult), weakness, fatigue, ↓HH)
Obstruction (edema of surrounding tissue; epigastric fullness, N/V, worsening ulcer s/s, electrolyte disturbances)
Perforation (pain radiates to shoulder, no bowel sounds, ↑HR, fever, diaphoresis, peritonitis *EMERGENCY*)

PUD Complication Interventions

Restore & maintain circulation (IVF, blood transfusion)
EGD control bleeding (laser cauterization)
NPO with NG tube (gastric decompression)
Meds (Antacids, IV H2 blockers (Protonix), IV abx with perforation)
Surgery (if bleeding is not controlled)
Nutrition therapy (directed toward neutralizing acid and reducing hypermotility)
Bland, nonirritating diet (during acute symptomatic phase)
Avoid bedtime snacks.
Avoid alcohol and tobacco.
Avoid Milk

Hypovolemia Management
Monitor VS, observe for fluid loss from bleeding and vomiting.
Monitor serum electrolytes
Insert two large-bore peripheral IV catheters to replace both fluids and blood lost.
Volume replacement should be started immediately (blood products)
Blood products may be ordered to expand volume and correct abnormalities in the CBC.
Orthostatic hypotension is common in patients with decreased fluid volume

NANDA PUD
Pain (stress reduction, meds, relaxation)
Sleep pattern disturbance
Imbalanced nutrition: < body requirements (limit foods after eating meals)
Deficient fluid volume
Deficient knowledge
Surgical Management
Preoperative care—insertion of a nasogastric tube.
Operative procedure: A simple gastroenterostomy permits neutralization of gastric acid.
Vagotomy eliminates the acid-secreting stimulus to gastric cells and decreases the response of parietal
cells.
Pyloroplasty facilitates emptying of stomach contents.

PUD Interventions
Assess pain
Administer meds (Reassess)
Teach stress reduction/relaxation techniques
Limit food intake after evening meal (or 3 hours prior to bedtime)
Assess diet/refer dietician (avoid irritants) (monitor N/V, anorexia)
Administer IVFs
Replace electrolytes (anemia)
Monitor labs
Zollinger-Ellison Syndrome
Characteristic ulcer pain is common
May have diarrhea & steatorrhea
Complications: bleeding & perforation; fluid & electrolyte imbalances

Gastric Cancer- Risk Factors (Most cancers of the stomach are adenocarcinomas; deposition in lymph nodes)
H. pylori (35%-89%)
Genetic predisposition
Chronic gastritis
Achlorhydria (absence of HCL)
Diet high in smoked foods & nitrates (Asians)

Gastric CA Manifestations or Supporting Data

Early Gastric Cancer Advanced Gastric Cancer
Indigestion N/V
Feeling of fullness (satiety) Iron deficiency anemia
Abdominal discomfort (relieved antacids) Enlarged lymph nodes
Epigastric, back, retrosternal pain Progressive wt loss
Obstructive symptoms
Palpable epigastric mass
Weakness, fatigue
Virchow’s, Blumer’s, Sister Mary Joseph nodes, Krukenergs

NANDA Gastric Cancer

Imbalanced nutrition: < body requirements
Acute pain
Risk for ineffective airway clearance
Anticipatory grieving
Deficient knowledge

Gastric Cancer
Surgery
Gastrectomy (total or partial removal of stomach)

Dumping Syndrome
Complication associated with gastric surgery
Occurs 5-30 minutes after eating:
1. nausea
2. possible vomiting
3. epigastric pain & cramping
4. borborygmi (loud gurgling, hyperactive bowel sounds)
5. diarrhea
***** Watch for vertigo, ↑HR, syncope, diaphoresis, pallor, palpitations, desire to lie down*****

Dumping Syndrome Interventions

Consume liquids & solids separate
Increase amount fat & protein (high calorie, high protein diet)
Reduce carbohydrates
Rest recumbent 30-60 minutes after eating
Meds (anticholinergics; antispasmotics)
Gastric CA- Interventions
Assess anemia
Administer chemo or radiation for mets
Consult dietician
Assess pain
Refer Hospice
Immediate post-op care

UGI- Pediatrics
Hypertrophic Pyloric Stenosis (first 2-5 wks of life; genetic predisposition)
DX: ultrasound, electrolyte imbalances (↓NA, ↓K, ↑BUN)
Surgical relief (pyloromyotomy)

Pyloric Stenosis Manifestations or Supporting Data

Projectile vomiting
Peristaltic waves
Olive sized mass in LUQ
Hungry, irritable, failure gain wt
Surgical correction

NANDA Pyloric Stenosis

Deficit fluid volume
Altered nutrition: less than body requirements
Sleep pattern disturbance
Altered family processes

Pyloric Stenosis- Interventions

Administer IVFs
Withhold oral feedings - NPO
Assess skin turgor (dehydration)
Assess fontanels (dehydration)
Monitor I/O (strict)
Assess mucous membranes (dehydration)
Monitor electrolytes
Obtain daily weights (fluid retention)
Maintain correct position
PREVENTION KEY