Nutrition: Gastric

• 
  Holding tank for food
  
• Food is exposed to stomach acids and digestive effects of pepsin
  
• Saturates food with gastric juices
  
• Excretes HCL (hydrochloric acid)
  
• Ph 2.0
  
• Absorbs H20, alcohol, sugars, salt, electrolytes & some drugs

• 
  Caused by gastric acid flowing upward into the esophagus
• Incompetent lower esophageal sphincter
  
• Acid becomes an irritant destroying esophageal lining

• Heartburn
• •Most common symptom
• •Burning chest pain behind breast bone
• •Moves upward toward throat
• •Worse after eating, lying down or bending down

• – Relaxed lower esophageal sphincter (LES)
• – Being overweight
• – Overeating
• – Caffeine / alcohol (increases amount of HCA)
• – Smoking
• – Gastritis
• – Ulcer disease
• – Stress
• – Nonsteroidal antiinflammatory drugs (NSAID’s) (over use of)
• • Aspirin & Ibuprofen
• – Certain foods
• • Citrus
• • Peppermint
• • Chocolate
• • Fatty & Spicy food

• – Ingestion of barium followed by x-rays
• > shows how well the sphincter is closing

• – Endoscope used
• – Direct visualization of stomach and stomach wall
• – Can perform biopsy
• – Oral anesthetic (spray in mouth to decrease gag reflex)
• – Observe for return of “Gag Reflex” (can not eat or drink anything until the gag reflex has returned

• – Determines the strength of the muscles in the esophagus
• – Small nasal tube

• – Small nasal tube
• – Rest above LES
• – Last 12-24 hours

check to see the presents of acid over a period of time

– Mild acid placed in the esophagus

creating mild signs of GERD

• - Places capsule next to LES
• - Detaches after 24 - 48 hours
• - Then download the results

• 
  Diet and lifestyle changes
  
• Medications
  
• Quit smoking
  
• Observe food intake and food types
  
• Eat smaller portions
  
• Avoid overeating
  
• Watch alcohol consumption
• Do not lie down or go to bed right after eating
  
• Decrease fluid intake
  
• Lie on LEFT side, elevate HOB 30°
  
• Lose excess weight
  
• SURGICAL CORRECTION
• – Nissen Fundoplication
  NON-SURGICAL CORRECTION
• –Stretta Procedure

• –Age, overall health and medical history
• –Extent of condition
• –Tolerance to specific meds, procedures & therapies
• –Expectation for the course of the condition
• –Patient opinion or preference

- must rule out MI before treating the heartburn

• –Done on the LES
• –Use of Radiofrequency (radio waves)
• –Tiny cuts leading to scar tissue
• > which can help close/narrow the esophagal sphincter and relieve some of the symptoms
• 

• Excessive use of these leads to an ion imbalance
• • Sodium bicarbonate
• • Calcium carbonate
• • Aluminum hydroxide
• • Magnesium hydroxide
• –Neutralize stomach acid
• –OTC
• –Tablet or liquid forms
• – Fast pain relief

• • Zantac (ranitidine)
• • Pepcid (famotidine)
• • Tagment (cimetidine)
• • Axid (nizatidine)
• - OTC or by prescription
• - Blocks histamine (in the stomach which produces acid)
• - Reduces acid and pain
• - Do not promote healing

• • Prevacid (lansoprazole)
• • Aciphex (rabeprazole)
• • Prilocec (omeprazole)
• • Protonix (pantoprazole)
• • Nexium (esomeprazole)
• - Blocks the enzyme in the stomach that produces acid
• - Promotes healing of the stomach and esophagus

• • Reglan (metoclopramide)
• - Assists the stomach to empty more rapidly
• - May help tighten the LES
• - Prescription

• • Bentyl, Dibent (dicyclomine)
• • Levsin, Cystospaz (hyoscyamine)
• - Relaxes smooth muscles of intestine
• - Works to decrease digestion
• - Prescription
• - Makes the food move faster through the system

• - Prescription only
• • Carafate (sucralfate)
• • Cytotec (misoprostol)
• - OTC
• • Pepto-Bismol (bismuth subsalicylate) [black,tarry stool]
• - Protects lining of stomach & intestine
• - Does not decrease the amount of acid
• - Used to prevent ulcer formation
• - Must give an hour before meals and at bedtime

• ESOPHAGITIS
  (inflammation of esophagus)
• ESOPHAGEAL STRICTURE
  (food can no enter the stomach -projective vomit)
• BARRETT’S ESOPHAGUS (changes the epithelium and is precancerous, can not return to normal)
• – Considered Precancerous
  
• HIATAL HERNIA

• 
  Altered nutrition
  
• Pain (acute versus chronic)
  
• Altered sleep pattern
• 
  Knowledge deficit
• 
  Risk for fluid volume imbalance
  
• Risk for impaired swallowing

• – Foods
• –Smoking cessation
• –Stress avoidance
• –Medications and side effects
• – Importance of following medical regime
• –S&S to report to physician
• –Possible pre and post operative care

• Type 1 –SLIDING: Stomach moves back and forth through hiatus of the diaphragm
• Type 2 –PARAESHOPHAGEAL or ROLLING: greater curvature of the stomach move above diaphragm forming a pocket
• > Food may accumulate in the pocket and cause bacterial changes and physical changes
• 

• – unknown
• – Weakening of diaphragm muscles
• – Increased intra-abdomimal pressure
• – Increased age
• – Trauma
• – Poor nutrition
• – Forced recumbent positioning (if they have had a C₁ or C₂ fracture were they must lay on back)
• – Congenital
• – Obesity

• – May be asymptomatic
• – Heartburn
• – Nocturnal heartburn
• – Dysphagia
• – Mimics gallbladder disease

• – Large meals
• – Alcohol
• – Smoking
• - no tight clothes or tight belts

• – GERD (primary problem)
• – Hemorrhage (by ulcer formation)
• – Esophageal stenosis
• – Ulceration
• – Strangulation
• – Regurgitation with aspiration

– EGD and Barium Swallow

• •Lifestyle Modifications
• •Medications

• •Nissen Fundoplication
• 

• Erosion of the GI mucosa from the action of HCL and pepsin
• 
  Includes gastric & duodenal ulcers

• Erosion
  
• Acute Ulcer
  
• Perforated Ulcer (eats through all the layers of the stomach wall)

• •80-90% OF ALL ULCERS
• •Bacterium infection
• •Weakens the stomach’s protective mucus

• Lifestyle
  Overactive acid & pepsin secretion
  
• Smoking
  
• Caffeine
  
• Alcohol
  
• Vagal nerve stimulation
  
• Stress
  
• Physical stress
• – “Stress Ulcers”
  (every pt prone)
• NSAIDs
  
• Corticosteroids

• May be asymptomatic until serious complications occur.
• – Heartburn
• – Gnawing / burning pain
• – Acid, bitter, slimy taste in mouth
• – Belching / indigestion
• – Nausea / vomiting [presence of blood means need for HCP]
• – Weight loss & poor appetite
• – Feeling tired and weak

• ALL ARE EMERGENCIES!
• - Most common
• - Black, tarry stools (MELENA)
• - Occult blood [in the beginning]
• - Emesis (coffee ground or fresh)
• - Have blood in the stomach (possibility of multiple bleeding sites [can loose LOTS OF BLOOD])

• ALL ARE EMERGENCIES!
  
• - Most lethal complication
• - Requires surgery
• - Causes peritonitis
• - S&S onset sudden and dramatic
• • Sudden, severe upper abdominal pain
• • Abdomen muscles contract - rigid & “board-like”
• • Respirations shallow & rapid
• • Absent bowel sounds
• • Tachycardiac

They need to open and wash the abdomen (may take some time to completly clean all the organs)

• ALL ARE EMERGENCIES!
  
• – Narrowing of pylorus
• • Scar tissue
• • Pylorospasm
• • Edema / Inflammation
• – Vomiting projectile (nothing getting to the stomach [smells really bad])
• – Contains food particles
• – Offensive odor

Immeadiate NG tube to decompress the stomach

• –Endoscopy: direct visualization (done 1st) [NPO]
• –H. pylori testing:
• sputum, urine, blood, tissue, breath
• • Urea breath shows active infection
• –Occult blood

• – Bland diet & 6 small meals per day
• – Protein neutralizes but stimulates gastric secretions
• – Adequate physical / emotional rest
• – Stop ASA & NSAID’s (not always possible)
• – Strict adherence to prescribed meds
• – Antibiotic therapy for H. pylori
• • May use two or more antibiotics [long term]

• • Slurry (mix it up)
• • Give on empty stomach 1 hour before meals and bedtime.

• • Promotes healing
• • Partially effective against H. pylori
• • May blacken stools

• • For pts. taking ASA or NSAIDs who can not stop taking them
• • Prevents gastric ulcers induced by the above

• –20% of ulcer patients
• – Indications:
• • Obstruction
• • Perforation
• • Hemorrhage
• • Ulcers unresponsive to treatment
• • Multiple ulcer sites
• • Possible malignancy

• is an operation in which the pylorus is removed and the distal stomach is connected directly to the duodenum
• 

• is an operation in which the greater curvature of the stomach is connected to the first part of the jejunum in a side-to-side manner.
• The surgical procedure is called gastrojejunostomy
• – For gastric outlet obstruction
• – Food bypasses the obstruction
• 

• –Truncal (total)
• –Cut all or part of the Vagus Nerve
• –Selective
• –Reduces acid
• –↓ gastric motility
• –Often combined with Billroth I & II
• 

• –Surgical enlargement
• –Aids gastric emptying
• –Can do balloon angioplasty
• 

• – Biggest issue
• – Result of large portion of stomach and pyloric sphincter removal
  
• – The food enters the small intestines before it can be properly digested/broken down
• – Do not drink liquids with meal

• – Form of dumping syndrome
• – Large bolus of carbohydrates dumps into small intestine resulting in ↓BS
  (Increased carb diet will cause the pancrease to release insulin causing the blood sugar to drop)

– Related to surgery on pyloric sphincter

• NPO status
  (after midnight)
• The procedure itself
  
• C & DB, IS use, incisional splinting
  
• IV therapy (supplement IV therapy)
• 
  NG tube
  (placed by OR sutured to the nose [DO NOT TOUCH])
• Pain relief
  
• Answering all patient questions

• Promote comfort
  
• Promote effective airway management and gas exchange
  Monitor I & O
• – NG drainage: amount, color, odor
• – Bright red in beginning (normal), then coffeeground
• – Becomes yellow-green after 36-48 hours
• –DO NOT IRRIGATE OR REPOSITION
• Abdominal dressingdrainage, bleeding, odor
  
• ALWAYS AT RISK FOR ULCER REDEVELOPMENT
  
• Adequate rest, nutrition with avoidance of stressors
• EMPHASIZE avoidance of meds not prescribed by MD, alcohol and smoking

can migrate to the esophogus, duedoneum, or may mirgrate throught the stomach wall and spread to other organs and to distal lymph nodes

• – Twice as often in men (depends on diet)
• • Especially from lower socioeconomic class in urban areas
• – More often occurrence over age 55
• – Higher in African Americans than Caucasians
• – Highest incidence in Japan, South America, Eastern Europe and part of the Middle East.

• UNKNOWN
  
• DIET
• – High in nitrates, salt and spiced foods
  
• FOOD PREPARATION– Preserved by salt-curing, smoking, pickling or drying
  
• PREPARATION ENVIROMENT– Poor drinking water or lack of refrigeration

• – Hx of GI cancer
• – Type A blood has higher incidence
  

– Pernicious anemia, chronic gastritis, intestinal polyps, GERD

• - Obesity
• - H. Pylori
• - Smoking
• - Occupational (rubber plants and coal mines)

• Gastritis
  
• Nitrites
  
• Poor nutrition
• 
  Poor sanitation
• 
  H. Pylori

• Abdominal pain
  Stool guiac +, GI bleeding
  
• Bloating after meals, indigestion, heartburn
  
• Diarrhea or constipation
  
• Fatigue, weak
  
• Anorexia, nausea, vomiting
  
• Weight loss

• –Fecal occult blood
• –Complete blood count
• –Upper GI series
• –Endoscopic gastroscopy (EGD)
• •Permits biopsy
• –CT scan +/or PET scan (assessing to see if metestasis)

• –Total Gastrectomy (Esophojejunostomy)
• • Stomach completely removed
• • Anastomosis of lower esophagus to the jejunum
• –Lymph node involvement
• –Followed by Chemo & Radiation

• Compliance of prescribed dietary & drug regimes
  
• Keep appointments for chemo &/or radiation
  
• Referral to home care (TPN, nurse needs to hang)
• 
  Long term follow-up stressed