Care of Patient with

GERD & Peptic Ulcer

63-273

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 GERD: Background
 Gastroesophageal reflux is a normal physiologic
phenomenon in most people, particularly after a
meal.

 Gastroesophageal reflux disease (GERD) occurs

when the amount of gastric juice that refluxes
into the esophagus exceeds the normal limit

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Causes of GERD

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 GERD: Symptoms
 Typical symptoms:
 Heartburn (Pyrosis):
 Most common
 Felt as a retrosternal sensation of burning or discomfort
 Occurs usually after eating or when lying down or bending over.
 Often relieved with milk or water

 Regurgitation:
 Effortless return of gastric and/or esophageal contents into the
pharynx.
 It can induce respiratory complications if gastric contents spill into
the tracheobronchial tree.
 Atypical symptoms
 Cough, dyspnea, hoarseness, and chestpain
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 Diagnosis
 Role out other potential causes for the
heartburn:
 Cardiac
 Peptic ulcer

 Esophagitis

 Esophageal Endoscopy:
 The gold standard as a definitive diagnosis

 Barium swallow
 Not as definitive in mild cases
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 Collaborative Care
 Lifestyle modifications

 Nutritional therapy
 Decrease high-fat foods, avoid milk products at night, and
avoid late snacking or meals

 Drug Therapy

 Surgical therapy

 Endoscopic therapy

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 GERD: Complications
 Arerelated to HCl effect on the
esophageal mucosa
 Esophagitis
 Can complicate to esophageal ulceration

 Barrett’s
esophagus (esophageal
metaplasia)
 Pre-cancerous lesion
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 Nursing Management
 Avoid factors that cause reflux
 Stop smoking
 Avoid acid or acid producing foods

 Elevate HOB ~30°

 Do not lie down 2 to 3 hours after eating

 Patient teaching (see Table 40-10 in textbook)

 Drug therapy
 Evaluate effectiveness
 Observe for side effects
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 Peptic ulcer
 Erosion or excavation of mucosal wall of the esophagus,
stomach, pylorus, duodenum
 (most common). “Autodigestion”
 Requires acid environment to develop
 Mucosal defenses impaired; cannot protect from effects of
acid/pepsin
 Result from infection with H. pylori or Zollinger-Ellison
syndrome
 Risk factors:
 Alcohol, smoking, and stress, medications

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 Three types of peptic ulcer
 Gastric
 Duodenal
 Stress

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 Gastric ulcer
 Most common in the lesser curvature of stomach near
the pylorus
 Mucus and bicarb. generally protect mucosal barrier
from acid
 H. pylori plays a role
 Break in gastric mucosal barrier allows HCl to damage
epithelium via “back diffusion”
 Bile reflux from duodenum may break integrity
 Decreased blood flow

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 Duodenal ulcer

 Results from excessive acid

 Associated with protein-rich meals, Ca++, and vagal
stimulation)

 Rapid emptying of food from stomach large acid

load in duodenum

 H. pylori infection plays key role in development

 produces substances that damage the mucosa, and
contributes to higher acid concentrations

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 Stress ulcer
 Occurs after acute medical crisis, surgery, or trauma

 Proximal portion of stomach and duodenum are most

common sites

 Ischemia and elevated HCl contribute to evolution of

erosions  ulcerations

 May progress to hemorrhage

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 Duodenal versus Gastric ulcers
Gastric
Normal/hypo-secretion of
gastric acid
Pain 1-2 hrs pc meals
Food aggravates pain
Vomiting common
More likely to hemorrhage –
manifests as hematemesis
Duodenal
Hyper-secretion
Pain 2-4 hrs pc meals
Food may relieve pain
Vomiting not common
Less likely to hemorrhage, but if
occurs, likely to manifest as
melena
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 Diagnostic tests
 Esphagogastroduodenoscopy
 Fiberoptic endoscope allows
direct visualization of
esophagus, stomach and
duodenum

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 Diagnostic tests: Upper GI series
 Patients ingests barium, a thick,
white, milkshake-like liquid, then
multiple X-rays. Can detect structural
disorders

 After the exam, provide plenty of

liquids for 24 to 48 hours.

 The barium may make the stool white

for several days.

 If constipation occurs, the doctor

may recommend a mild laxative.

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 Complications of ulcers:
Hemorrhage
 Manifested by:
 Orthostatic hypotension,  BP, HR, cool, clammy skin
overt bleeding

 Hematemesis (bloody vomit) – bright red or coffee

ground (more likely with gastric ulcer)

 Melena (bloody or tarry [black] stool) – more likely with

duodenal ulcer

  Hgb,  Hct

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 Remember: Management during
Haemorrhage includes

 Monitor S/S
 Determine rate amount of blood loss (Hct/hct),
 NGT
 Replace blood, fluid and electrolyte loss
 saline lavage via NGT
 NGT to low intermittent suction
 Prevents distension

 Assess amount/rate of bleeding,

 Medications, oxygen, possible surgery
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 Complications: Perforation
 GI contents empty into peritoneal cavity
 Manifested by:
 Sudden, sharp mid-epigastric pain which can shortly spread
to all abdomen
 Rigid, tender, board-like abdomen
 Patient assumes the fetal position to reduce tension on
muscles

 Can lead to shock

 It is a surgical emergency

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 Remember: Management during perforation
includes
 NGT to prevent additional spillage of GI contents in
peritoneum

 Replace blood, fluid, electrolytes

 Antibiotics

 I & O, NPO

 SURGERY: Urgent

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 Complications: Pyloric obstruction
 Caused by inflammation or edema of the
pylorus

 Stomach cannot empty  abdominal bloating,

N&V

 Persistent vomiting  Hypokalemia and

metabolic alkalosis

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 Medical Management of ulcers
 Conservative therapy:
 Rest: Both physical and
emotional
 Dietary modifications
 Elimination of smoking
 Long term follow up
care
 Pharmaceutical:
 Antibiotics
 To eradicate H. Pylori infections
 Recurrence of ulcer is 75-90% as high
with infection
 Antiacids
 Initial drugs of choice
 Histmaine H2 receptor antagonists
 Histamine is the final intracellular
activator of HCL secretion
 Anticholinergic:
 Stop the cholinergic stimulation of HCl
secretion and slow gastric motility
 Not commonly used, if used need to be
used with caution in pts with Glaucoma
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Surgical Management of ulcerations
 Gastroduodenostomy
(Billroth I)
 Removal of the lower
portion of stomach and
small portion of
duodenum and connects
remaining of stomach to
duodenum

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 Surgical Management of ulcerations
 Gastojejunostomy
 Removes lower stomach and
small portion of duodenum.
 Reconnects stomach to jejunum.
 Subtotal gastrectomy
 - removal distal third of
stomach, reconnecting to
duodenum or jejunum
 Total gastrectomy
 removal of stomach; connects
esophagus to jejunum
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 Dumping syndrome
 A complication of gastric surgery
 S&S
 vertigo, sweating, palpitations, syncope, pallor, tachycardia

 occurs after eating

 D/t rapid emptying of hypertonic stomach contents into small intestine
 fluid shifts into gut abd. distention and cramps and S/S of  plasma
volume.
 Later get rapid elevation of blood glucose followed by insulin secretion
and hypoglycemia

 Management
 Small frequent meals
  fat,  protein,  CHO meals
 liquid between (not with) meals
 Lie down after meals

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 Nursing diagnoses
 Pain r/t mucosal injury

 Anxiety

 Knowledge deficit

 Risk for fluid volum deficit r/t hemorrhage or

vomiting

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 Intervention: Pain
 Medications
 Give antacids after meals and at bedtime to decrease
gastric acidity; buffers the acid.

 Give H2 receptor antagonists as prescribed to decrease acid

secretion

 Diet therapy
 Effectiveness controversial
 Avoid caffeinated beverages
 Exclude foods that cause discomfort
 Provide frequent, small, bland meals
 Avoid smoking, alcohol

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Intervention: Anxiety & Knowledge
deficit
 Anxiety
 Provide emotional support
 Teach and provide relaxation techniques
 Identify and manage sources of stress

 Knowledge deficit
 Teach re diet, medications,
 Teach the risks associated with continued smoking
 Teach S/S of complications

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