This document provides an overview of gastrointestinal disorders, including disorders of the mouth and esophagus. It discusses stomatitis, describing the causes, signs and symptoms, and treatments. It also discusses oral cancer, describing risk factors, signs and symptoms, and treatments like surgery, radiation, and chemotherapy. Finally, it discusses salivary gland disorders, describing different types like obstructions, infections, cysts, and tumors, and providing details on specific disorders like sialolithiasis, sialadenitis, and malignant tumors.

1. Gastrointestinal Disorders
Unit-I
Subject: AHN I
Awal Sher Khan & Sohaib Ali Shah
Faculty of Nursing Sciences
Khyber Medical University
1

2. Learning Objectives
By the end of the session learners will be able to:
1. Review the anatomy and physiology of gastrointestinal
system (GIT)
2. Discuss the causes, pathophysiology and manifestation of the
following GIT disorders
3. Discuss the diagnostic, medical and surgical management of
the below mentioned disorders
4. Apply nursing process including assessment, planning,
implementation and evaluation of care provided to the clients
with GIT disorders
5. Develop a teaching plan for a client experiencing disorders of
the GIT
2

3. A & P of Gastrointestinal Tract
3

4. Disorders of mouth and esophagus
• Stomatitis
• Oral cancer/tumor
• Salivary gland disorders
• Gastro esophageal reflux disorder
• Hiatal hernia
• Achalasia
• Diverticula
• Esophageal cancer/tumor
4

5. Disorders of mouth and esophagus
Stomatitis
Inflammation of the mucous membrane of the mouth.
It may be due to local lesion in the mouth, infection,
nutritional deficiency, chemotherapy, immune
suppression or a feature of a systemic disease.
OR
Stomatitis is inflammation of the mucosal tissue of
the mouth (inner cheeks, tongue, lips, throat and
gums etc.).
5

6. Sign and symptoms
•swelling,
•pain,
•ulcerations,
• excessive salivation,
•halitosis, (bad breath)
•sore mouth
•In ability to chewing
•bleeding
•Bad smell
6

7. Causes of stomatitis
•Infection:
• Viruses: measles, primary herpes simplex.
• Bacteria: streptococcus, diphtheria.
• Fungus: Candida albicans .
•Eruption stomatitis: associated with eruption of teeth.
•Traumatic: cheek biters.
•Local reactions: due to sensitivity to contact
substances from foods.
•Immunological impairment: in leukemias.
•Drugs and poisons
•Chemotherapy
•Radiation therapy
7

8. Investigations
•Oral swab culture
•Physical examination
• Learning Objectives
8

9. Types of Stomatitis:
There are two main types of stomatitis
•Herpes simplex Stomatitis/cold sore
•Aphthous Stomatitis
9

10. Cont….
•Herpes simplex Stomatitis
• Herpes simplex Stomatitis (cold sore/fever blister):
• It is an externally common viral infection that produces
characteristic blisters commonly called cold sore or fever
blister.
• It is caused by herpes simplex virus type I (HSV-1)
predisposing factors of upper respiratory infections,
excessive exposure to sunlight, food allergies, emotional
stress and onset of menstruation.
• The virus is harbored in a dormant (inactive) state by cells in
the sensory nerve ganglia.
• Reactivation of the virus can occur with emotional stress,
fever, exposure to cold or ultraviolet rays.
10

11. 11
Cold Sore

12. Cont…
• The lesions appear more common on the mucous
membranous border junction of the lips in the form of small
vesicles, which then erupt and form painful shallow ulcers.
• Vesicle formation may be single or clustered.
• Painful vesicles and ulceration of mouth, lips or edge of
nose; may have prodromal itching or burning, fever, malaise,
lymphadenopathy may occur.
• Prodromal: relating to or denoting the period between the
appearance of initial symptoms and the full development of a
rash or fever.
• Lymphadenopathy: A disease affecting the lymph nodes
12

13. /Pathophysiology of HSS
• Etiology: HSV I (less commonly HSV II)
Transmission:
• via mucous membranes or open skin
• Kissing
• Fomites (e.g. shared towels, utensils)
• Incubation: 2-20 days after contact.
• Shedding: 48-60 hour duration (not longer than 96 hours)
13

14. Aphthous Stomatitis
• Aphthous Stomatitis (cancer sore) it is recurrent and chronic form of
infection secondary to systemic disease, trauma, stress or unknown
causes. The cause remains unknown, an autoimmune base is
suspected. Self-limited, they usually resolve within a few weeks, but
they may recur in the same or a different location.
• It produces well-circumscribed ulcers on the soft tissues of the mouth,
including lips, tongue, insides of the cheeks, pharynx and soft palate.
• Ulcers of the mouth and lips causing extreme pain, ulcers surrounded
by erythematous base.
• Painful small ulceration on oral mucosa heals in 1 to 3 weeks.
14

15. Risk Factors
•Aging
•Nutritional deficiency
•Poor oral hygiene
•Smoking
•Alcohol
•Specific chemotherapeutic agents
•Bone marrow transplantation
•Radiotherapy
15

16. 16

17. Pathophysiology
•Characterized by damage to the epithelium of the
oropharyngeal cavity .
•Rapidly dividing basal cells of the oral mucosa are
among the body cells vulnerable to damage by
chemotherapy and radiation therapies.
17

18. Treatment
•pain relief,
• removal of causative factor,
•oral hygiene with saline, Gentian violet, glycerin
•Broad spectrum antibiotic in sever case
•Anti fungal drugs i.e. Nystatin, Daktarin
• soft bland diet
•IV infusion in sever case
18

19. Nursing diagnosis
•Pain related to lesion of mouth.
•Alteration in nutrition less than body requirement
related to ulceration in the mouth and chewing
problem.
•Alter sleep pattern related to pain secondary to
stomatitis.
•Difficulty in talking (dysphasia) related to blisters
and sores on the tongue.
19

20. Nursing Intervention
• Check for oral burning, pain, or change in tolerance to
temperature.
• Do oral examination noting evidence of lesions within the
mouth and tongue.
• Administer the respective medication.
• Give analgesic to relieve from pain.
• Advice soft food and avoid spicy food.
• Do oral hygiene with soothing solution.
• Administer topical medication e.g. nylstate and bonjela to
relieve from pain to enhance sleep.
20

21. Oral cancer
Oral cancer is a subtype of head and neck
cancer, is any cancerous tissue growth
located in the oral cavity.
21

22. Signs and symptoms
•lesion, lump, or ulcer that do not resolve in 14 days
located:
•On the tongue, lip, or other mouth areas
•Usually small
•Most often pale colored, be dark or discolored
•Early sign may be a white patch (leukoplakia) or a
red patch (erythroplakia) on the soft tissues of the
mouth
•Usually painless initially
•May develop a burning sensation or pain when the
tumor is advanced
22

23. Cont…
•Additional symptoms that may be associated with
this disease:
•Tongue problems
•Swallowing difficulty
•Mouth sores
•Pain and paresthesia are late symptoms.
•Feeling of something caught in the throat
•Difficulty or pain with chewing or swallowing
•Swelling in jaw
•Voice changes
•Pain in ear
23

24. Oral Cancer
•Occurs most often in people over age 40
Symptoms
•Sore that does not heal
•Lump on lip or mouth
•White or red patch on gum, tongue, or buccal
mucosa
•Unusual bleeding, numbness, or pain
24

25. 25
Squamous Cell Carcinoma (SCC)

26. Risk factors
• Uncommon (5% of all cancers) but has high rate of morbidity,
mortality
• Highest among males over age 40
• Risk factors include
• smoking and
• using oral tobacco,
• drinking alcohol,
• marijuana use,
• occupational exposure to chemicals,
• viruses (human papilloma virus)
• History of leukoplakia
• Erythroplakia
26

27. Pathophysiology
a. Squamous cell carcinomas
b. Begin as painless oral ulceration or lesion with irregular, ill-
defined borders
c. Lesions start in mucosa and may advance to involve tongue,
oropharynx, mandible, maxilla
d. Non-healing lesions should be evaluated for malignancy
after one week of treatment
27

28. Investigation
a. Elimination of causative agents
b. Determination of malignancy with biopsy
c. Determine staging with CT scans and MRI
28

29. Treatment
1. Surgery and/or
2. Radiation
• Treatment usually involves surgery or radiation or both
• Chemotherapy primarily used as an adjunctive procedure in
advanced cases
• Advanced lesions < 30% 5-year survival rate
• 9 - 25% of patients develop additional mouth or throat cancer
3. Chemotherapy
• Several drugs currently being used include:
• Paclitaxel (Taxol, Bristol)
• Methotrexate
• Bleomycin
• Cisplatin
• 5-Fluorouracil
29

30. Nursing Diagnosis
• Pain related to oral lesion or treatment
• Imbalanced nutrition less than body requirements, related to
inability to ingest adequate nutrients secondary to oral
condition.
• Risk for infection related to disease or treatment
• Alter sleep pattern related to pain secondary to stomatitis.
• Impaired verbal communication related to treatment
30

31. Nursing Intervention
•Pain management
•Oral hygiene
•Preparation for surgery or radiation
•Nutritional management
•Post operative care and dressing
•Symptomatic treatment.
•Administration of chemotherapy
•Monitoring of client response to any treatment
•Emotional support to client and family
•Care of symptom associated with treatment
31

32. Cont….
Health promotion:
Teach risk of oral cancer associated with all tobacco use and
excessive alcohol use
Need to seek medical attention for all non-healing oral lesions
(may be discovered by dentists); early precancerous oral
lesions are very treatable
Work out for following possible Nursing Diagnoses
1. Risk for ineffective airway clearance
2. Imbalanced Nutrition: Less than body requirements
3. Impaired Verbal Communication: establishment of specific
communication plan and method should be done prior to any
surgery
4. Disturbed Body Image
32

33. Salivary Glands disorder
• The salivary glands make saliva and release it into the mouth.
There are three pairs of relatively large, major salivary glands:
• Parotid glands: Located in the upper part of each cheek, close
to the ear. The duct of each parotid gland empties onto the
inside of the cheek, near the molars of the upper jaw.
• Submandibular glands: Under the jaw. They have ducts that
empty behind the lower front teeth.
• Sublingual glands: Beneath the tongue. They have ducts that
empty onto the floor of the mouth.
oIn addition to these major glands other minor salivary glands are
scattered throughout the mouth and throat.
33

34. Cont….
34

35. Classification of Salivary Glands disorder
1-Obstructions: this could be by calculi or cystic
type (stone, mucocele, ranula)
2-Infections: viral (Mumps), bacterial (acute &
chronic Sialadenitis)
3-Degenerative changes: Sjogren syndrome,
radiation.
4-Functional disorders.
5- Neoplasms.
35

36. Investigations for salivary glands
1- Sialometery: measures the amount of saliva
production in a certain time.
2- Sialochemistry: measures the composition of
saliva.
3- Sialography: by introducing the iodine containing
contrast media through the opening of the duct.
4- Sonography: Ultrasonic patterns when dealing
with minor salivary glands.
5- Cytology: by aspiration.
6- Biopsy.
36

37. Cont….
Some of the most common salivary gland disorders
include:
Sialolithiasis
Sialadenitis
Viral infections
Cysts
Benign tumors
Malignant tumors
Sjogren's syndrome
Sialadenosis
37

38. Sialolithiasis
Sialolithiasis (salivary gland stones) Tiny, calcium-rich stones
sometimes form inside the salivary glands. 70-90% of stones
occur in the submandibular gland due to long twisted path of the
duct & thick secretion of the gland. about 6% in parotid gland &
2% in sublingual gland & minor S.G.
• Etiology: The exact cause of these stones is unknown. Some
stones may be related to:
• Dehydration, which thickens the saliva.
• Decreased food intake, which lowers the demand for saliva.
• Medications that decrease saliva production, including
certain antihistamines, anti-hypertensive drugs and
psychiatric medications.
• Deposition of ca++ salt around a nidus of debris within the
duct lumen
38

39. Cont….
• Some stones sit inside the gland without causing any symptoms.
In other cases, a stone blocks the gland's duct, either partially or
completely. When this happens, the gland typically is painful
and swollen, and saliva flow is partially or completely blocked.
This can be followed by an infection called sialadenitis.
• Signs & Symptoms The most common symptom are dry
mouth and a painful lump, usually in the floor of the mouth.
Pain may worsen during eating.
• Treatments
• Gentle probing: If the stone is located near the end of the duct,
the doctor may be able to press it out gently.
• Therapeutic sialdenoscopy
• Surgery: If stone are in deeper part
• Shock wave treatment
39

40. 40

41. Sialadenitis
Sialadenitis: (infection of a salivary gland)
Sialadenitis is a painful infection. It is more common
among elderly adults with salivary gland stones.
Sialadenitis also can occur in infants during the first
few weeks of life.
•Etiology It is usually caused by bacteria.
•Sign and symptoms: Symptoms may include:
oA tender, painful lump in the cheek or under the
chin.
oIn severe cases, fever, chills and general weakness.
41

42. Cont….
Treatment
Treatment includes:
•Drinking fluids or receiving fluids intravenously
•Antibiotics
•Warm compresses on the infected gland
•Encouraging saliva flow by chewing gums,
sugarless candies or by drinking orange juice.
•If these methods do not cure the infection,
surgery can be done to drain the gland.
42

43. Viral infections
Viral infections: Systemic (whole-body) viral
infections sometimes settle in the salivary glands. This
causes facial swelling, pain and difficulty in eating.
The most common example is mumps.
•Etiology These infections are caused by viruses.
• Sign and symptoms The first symptoms often
include:
•Fever and poor appetite
•Headache,
•Muscle aches
•Joint pain and malaise.
43

44. Cont….
•Treatment: These infections almost always go away
on their own. Treatment focuses on relieving
symptoms through:
•Rest
•Drinking fluids to prevent dehydration
•Taking acetaminophen (Tylenol) to relieve pain and
fever
44

45. Cysts
Cysts: (tiny fluid-filled sacs)
Babies sometimes are born with cysts in the parotid gland
because of problems related to ear development before birth.
Later in life, other types of cysts can form in the major or minor
salivary glands.
• Etiology They may result from traumatic injuries, infections, or
salivary gland stones or tumors.
• Sign and symptoms: A cyst causes a painless lump. It
sometimes grows large enough to interfere with eating.
• Treatment : A small cyst may drain on its own without
treatment. Larger cysts can be removed using traditional surgery
or laser surgery.
45

46. Benign tumors
Benign tumors: (noncancerous tumors)
Most salivary gland tumors occur in the parotid gland. The
majority are benign. The most common type of benign parotid
tumor usually appears as a slow-growing, painless lump at the
back of the jaw, just below the earlobe.
• Etiology Risk factors include radiation exposure and possibly
smoking.
• Sign and symptoms A slow-growing lump is the most
common symptom. The lump is sometimes painful. This lump
may be found in the cheek, under the chin, on the tongue or on
the roof of the mouth.
• Treatment Non cancerous tumors usually are removed
surgically. In some cases, radiation treatments are given after
surgery to prevent the tumor from returning.
46

47. Malignant tumors
• Malignant tumors: (cancerous tumors)
Salivary gland cancers are rare. They can be more or less
aggressive.
• Etiology The only known risk factors for salivary gland
cancers are Sjogren's syndrome and exposure to radiation.
Smoking also may play some role.
• Sign and symptoms A slow-growing lump is the most
common symptom. The lump is sometimes painful. This lump
may be found in the cheek, under the chin, on the tongue or on
the roof of the mouth.
• Treatment Smaller, early stage, low-grade tumors often can be
treated with surgery alone. However, larger, high-grade tumors
usually require radiation following surgery. Tumors that cannot
be operated are treated with radiation or chemotherapy.
47

48. Sjogren's syndrome
• Sjogren's syndrome Sjogren's syndrome is a chronic
autoimmune disorder. The body's immune defenses attack the
salivary glands, the lacrimal glands (glands that produce tears),
and occasionally the skin's sweat and oil glands.
• Classification:
Primary: xerostomia + xerophthalmia
Secondary: xerostomia + xerophthalmia + C.T. disease usually
rheumatoid arthritis.
• Etiology Over activity of the immune system.
• Sign and symptoms The main features of Sjogren's syndrome
are swelling of the salivary glands, dry eyes and a dry mouth.
• Immune system attacks parts of your own body by mistake.
In Sjogren's syndrome, it attacks the glands that make tears
and saliva. This causes a dry mouth and dry eyes.
48

49. Cont….
Treatment
•The main symptom related to the salivary glands is a
dry mouth. Options include:
•Medication to stimulate more saliva secretion, such as
pilocarpine (Salagen) and cevimeline (Evoxac).
•Sugarless gum and candy to stimulate saliva
production.
•Avoiding medications that can make dry mouth worse.
•Avoid smoking.
•Good oral hygiene is must. People with Sjogren's have
teeth and gum problems because of low saliva
secretion.
49

50. Sialadenosis
Sialadenosis (nonspecific salivary gland enlargement)
Sometimes, the salivary glands become enlarged without
evidence of infection, inflammation or tumor. This nonspecific
enlargement is called sialadenosis. It most often affects the
parotid gland.
• Etiology Its cause remains unknown.
• Sign and symptoms This condition typically causes painless
swelling of the parotid glands on both sides of the face.
• Treatment: Treatment is aimed at correcting any underlying
medical problem. Once the medical problem improves, the
salivary glands should shrink to normal size.
50

51. Medical Diagnosis
• Medical history.
• Smoking history.
• Current medications.
• Blood tests.
• X-rays.
• Magnetic resonance imaging (MRI).
• Computed tomography (CT) scans.
• Sialography.
• Salivary gland biopsy.
• Salivary function test.
51

52. Complications
• Abscess of salivary gland.
• Infection returns.
• Spread of infection.
• Facial nerve injury (Sialorrhea).
• Hematoma.
• Deformity.
• Dry mouth (xerostomia).
• Mumps.
52

53. Prevention
• We can lower our risk of viral infections of the salivary glands.
To do so, get immunized against mumps and influenza.
• There are no specific guidelines to protect against other types of
salivary gland disorders. However, it is helpful to:
• Avoid smoking.
• Eat a healthy diet.
• Drink six to eight glasses of water daily to avoid dehydration.
• Practice good oral hygiene, with regular tooth brushing and
flossing.
53

54. Nursing Diagnosis
• Low secretion of saliva related to stone in the salivary gland.
• Dry mouth related to blockage of saliva.
• Pain related to tumor & inflammation in the mouth.
• Difficulty in eating related to painful lump in the mouth.
• Poor appetite related to disease.
• Fever related to infection of salivary gland.
54

55. Nursing Interventions
• Give medication to stimulate more saliva secretion, such as
pilocarpine (Salagen) and cevimeline (Evoxac).
• Give sugarless gum and candy to stimulate saliva production.
• Avoiding medications that can make dry mouth worse.
• Provide analgesic to relief pain.
• Administer tube feeding.
• Give acetaminophen (Tylenol) to relieve fever.
• Cold sponging to relieve from fever.
55

56. Gastroesophageal Reflux Disease (GERD)
• Gastroesophageal reflux is the backward flow of gastric
content into the esophagus.
• People with asthma are at higher risk of developing GERD.
Asthma flare-ups can cause the lower esophageal sphincter to
relax, allowing stomach contents to flow back, or reflux, into
the esophagus.
• GERD common, affecting 15 – 20% of adults
• 10% persons experience daily heartburn and indigestion
56

57. Pathophysiology
• When you eat, food passes from the throat to the stomach
through the esophagus. A ring of muscle fibers in the lower
esophagus prevents swallowed food from moving back up.
These muscle fibers are called the lower esophageal sphincter
(LES).
• When this ring of muscle does not close all the way, stomach
contents can leak back into the esophagus. This is called
reflux or gastroesophageal reflux. Reflux may cause
symptoms. Harsh stomach acids can also damage the lining
of the esophagus.
• Gastroesophageal reflux results from transient relaxation or
incompetence of lower esophageal sphincter, or increased
pressure within stomach
57

58. Factors contributing to gastroesophageal reflux
• Increased gastric volume (post meals)
• Position pushing gastric contents close to gastroesophageal
juncture (such as bending or lying down)
• Increased gastric pressure (obesity or tight clothing)
• Hiatal hernia
58

59. Cont..
• Normally the peristalsis in esophagus and bicarbonate in
salivary secretions neutralize any gastric juices (acidic) that
contact the esophagus; during sleep and with
gastroesophageal reflux esophageal mucosa is damaged and
inflamed; prolonged exposure causes ulceration, friable
mucosa, and bleeding; untreated there is scarring and
stricture.
Manifestations
• Heartburn after meals, while bending over, or recumbent and
worse at night
• May have regurgitation of sour materials in mouth, pain with
swallowing
• Chest pain
• Nausea
• Bloating, gas and belching
• Sensation of lump in throat 59

60. 60

61. Cont..
Complications
• Esophageal strictures, which can progress to dysphagia
• Barrett’s esophagus: changes in cells lining esophagus with
increased risk for esophageal cancer diagnosis
• Esophagitis
Diagnostic tests
• Barium swallow (evaluation of esophagus, stomach, small
intestine)
• Upper GI endoscopy: direct visualization; biopsies may be
done
• 24-hour ambulatory pH monitoring (gold standard of GERD)
• Esophageal motility studies/ Esophageal manometry, which
measure pressures of esophageal sphincter and peristalsis
61

62. Cont..
Treatment
• Life style changes
• Diet modifications
• Medications
62

63. Cont..
Medications
• Antacids: for mild to moderate symptoms, e.g. Mucain,
Tricel, Mylanta, Gaviscon
• H2-receptor blockers: decrease acid production; given BID
or more often, e.g. cimetidine, ranitidine, famotidine,
nizatidine
• Proton-pump inhibitors: reduce gastric secretions, promote
healing of esophageal erosion and relieve symptoms, e.g.
omeprazole (risek); lansoprazole (Prevacid) initially for 8
weeks; or 3 to 6 months
• Promotility agent: enhances esophageal clearance and
gastric emptying, e.g. metoclopramide (reglan)
63

64. Cont..
Surgery
• Surgery indicated for persons not improved by diet and life
style changes
• Laparoscopic procedures to tighten lower esophageal
sphincter
• Open surgical procedure: Nissen fundoplication
64

65. Cont..
Dietary and Lifestyle Management
• Elimination of acid foods (tomatoes, spicy, citrus foods,
coffee)
• Avoiding food which relax esophageal sphincter or delay
gastric emptying (fatty foods, chocolate, peppermint, alcohol)
• Maintain ideal body weight
• Eat small meals and stay upright 2 hours post eating; no
eating 3 hours prior to going to bed
• Elevate head of the bed 6 – 8 inches to decrease reflux
• No smoking
• Avoiding bending and wear loose fitting clothing
• Limit meal size and avoid heavy evening meal
65

66. Nursing Diagnosis
• Imbalanced nutrition: less than body requirements related to
inability to intake enough food because of reflux.
• Acute pain related to irritated esophageal mucosa.
• Imbalanced nutrition: more than body requirements related
to eating to try to assuage pain.
• Impaired tissue integrity related to esophageal exposure to
gastric acid.
• Nausea related to irritation of gastric mucosa secondary to
Gastroesophageal Reflux Disease (GERD)
66

67. 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
• Drug therapy
• Evaluate effectiveness
• Observe for side effects
67

68. Hiatal Hernia
• Hiatal hernia also known as diaphragmatic hernia a
condition in which a portion of the stomach or the lower part
of the esophagus protrudes upward into the thoracic cavity
through a defect in the wall of the diaphragm.
68

69. Cont..
Causes:
• Loss of muscle strength and tone
• Factors that cause increased intra-abdominal pressure (such
as obesity or multiple pregnancies)
• Congenital defects
• Trauma
69

70. Cont..
Manifestations
• Often no signs and symptoms unless there is reflux of
stomach acid
• Indigestion, belching,
• substernal or epigastric pain
• feelings of pressure after eating
• Regurgitation of a hot, sour liquid coming into the throat or
mouth
• Nighttime coughing that may awaken the patient
70

71. Cont..
Pathophysiology:
• A defect in the wall of the diaphragm where the esophagus
passes through Protrusion of part of the stomach or the lower
part of the esophagus up into the thoracic cavity
• Herniated portion often slides back beneath the diaphragm
71

72. Cont..
72

73. Cont..
Diagnostic procedure:
• History & P.E
• UGI series or barium swallow
• X-ray, CT or MRI
• Endoscopy
73

74. Cont..
Medical management:
• Weight reduction
• Avoidance of tight-fitting clothes around the abdomen
• Administration of antacids, H2-receptor antagonists, or
proton pump inhibitors
• Elevating the head of the bed 6 to 8 inches
• Instructing the patient not to eat within 3 hours of going to
bed
• Limiting intake of alcohol, chocolate, caffeine, and fatty
food, and avoiding smoking
• Surgical correction of the hernia if bleeding or discomfort
cannot be controlled.
• Anchoring the lower esophageal sphincter by wrapping a
portion of the stomach around it to anchor it in place 74

75. 75

76. Cont..
Nursing management:
• Encouraging weight reduction if necessary
• Reminding the patient to stay upright for 2 hours after eating
and not to eat 3 hours before bedtime
• Advising against lifting or moving heavy items
• Using a wedge pillow to elevate the upper body if the head of
the bed cannot be raised
• Encouraging the patient to take prescribed H2-receptor
antagonists or proton pump inhibitors at bedtime to prevent
reflux and damage from acid entering the esophagus
• Advising the patient to avoid foods that cause bloating,
which increases abdominal pressure and may push the
stomach upward through the diaphragmatic defect.
76

77. Cont..
Nursing Diagnosis for Hiatal Hernia
• Risk for aspiration related to reflux of gastric contents and
impaired esophageal sphincter function.
• Acute pain related to esophageal inflammation and irritation
caused by reflux of gastric contents.
• Imbalanced nutrition: less than body requirements related to
decreased oral intake and fear of eating due to pain and
discomfort.
• Anxiety related to symptoms and potential complications of
GERD and hiatal hernia.
• Risk for ineffective coping related to chronic illness and
lifestyle changes required for disease management.
77

78. Cont..
Nursing Diagnosis for Hiatal Hernia
• Ineffective self-health management related to lack of
knowledge about disease process and treatment options.
• Risk for impaired gas exchange related to decreased lung
expansion due to upward displacement of the diaphragm in
hiatal hernia.
• Risk for injury related to potential complications of hiatal
hernia such as bleeding or obstruction.
• Disturbed sleep pattern related to nighttime symptoms of
GERD and hiatal hernia.
• Impaired swallowing related to esophageal inflammation and
obstruction caused by hiatal hernia.
78

79. Achalasia
• Achalasia is absent or ineffective peristalsis of the distal
esophagus, accompanied by failure of the esophageal
sphincter to relax in response to swallowing. Narrowing of
the esophagus just above the stomach results in a gradually
increasing dilation of the esophagus in the upper chest.
79

80. Cont..
Causes:
• Idiopathic (unknown cause) in most cases
• degeneration of the nerves in the esophagus
• Dysfunction of (LES)
• Inflammation of the esophageal muscles
• Viral infections
• Autoimmune disorders
• Hereditary factors
• Environmental factors such as exposure to chemicals or
radiation
80

81. Cont..
Clinical Manifestations:
• difficulty in swallowing both liquids and solids
• sensation of food sticking in the lower portion of the
esophagus
• regurgitation, either spontaneously or intentionally
• chest pain and heartburn (pyrosis).
81

82. Cont..
Diagnostic procedure:
• X-ray studies
• Barium swallow
• computed tomography (CT)
• endoscopy may be used for diagnosis;
• however, the diagnosis is confirmed by manometry, a process
in which the esophageal pressure is measured by a radiologist
or gastroenterologist.
82

83. Cont..
Medical and Surgical management:
• The patient should be instructed to eat slowly and to drink
fluids with meals.
• As a temporary measure, calcium channel blockers and
nitrates have been used to decrease esophageal pressure and
improve swallowing.
• Injection of botulinum toxin (Botox) to quadrants of the
esophagus via endoscopy has been helpful because it inhibits
the contraction of smooth muscle. Periodic injections are
required to maintain remission.
• If these methods are unsuccessful, pneumatic (forceful)
dilation or surgical separation of the muscle fibers may be
recommended (Heller myotomy)
83

84. Cont..
Nursing Diagnosis:
• Impaired Swallowing related to esophageal dysfunction and
dysphagia manifested by difficulty swallowing solid and
liquid foods, regurgitation, and chest pain.
• Risk for Aspiration related to decreased lower esophageal
sphincter (LES) function and difficulty swallowing
manifested by coughing, choking, and respiratory distress.
• Imbalanced Nutrition: Less than Body Requirements related
to inadequate oral intake due to difficulty swallowing
manifested by weight loss, poor oral intake, and malnutrition.
• Anxiety related to fear of choking or complications related to
the disease process manifested by restlessness, nervousness,
and apprehension.
84

85. Cont..
Nursing Diagnosis:
• Ineffective Coping related to chronic illness and its impact on
daily activities manifested by poor self-care, social isolation,
and decreased quality of life.
• Risk for Injury related to fatigue, weakness, or impaired
mobility manifested by falls, accidents, and decreased ability
to perform activities of daily living.
85

86. Cont..
Nursing Intervention:
• Nutrition management: ensure adequate nutrition and
hydration, such as providing small, frequent meals and
thickening liquids if needed.
• Medication administration: Nurses may administer
medications that help relax the LES.
• Positioning: Positioning the patient in an upright position
during and after meals can help reduce the risk of aspiration
and improve digestion.
• Patient education: about the disease process, the importance
of adhering to treatment plans, and warning signs of
complications such as weight loss or recurrent chest pain.
86

87. Cont..
Nursing Intervention:
• Emotional support: Patients with achalasia may experience
anxiety or depression due to their symptoms or difficulty
swallowing. Nurses can provide emotional support, assess for
any psychosocial issues, and refer the patient to appropriate
resources such as counseling or support groups.
• Monitoring for complications: Nurses should monitor for
complications such as aspiration pneumonia, weight loss, or
chest pain, and report any changes in the patient's condition
to the healthcare team.
87

88. Diverticulum
• Diverticulum is an outpouching of mucosa and submucosa
through a weak portion of the musculature in the esophagus.
• Zenker's diverticulum is the most common type, occurring in
the upper area of the esophagus in people over 60.
• Other types include midesophageal, epiphrenic, and
intramural diverticula.
88

89. Cont..
Causes:
• Improper functioning of the lower esophageal sphincter or
motor disorders of the esophagus.
• Age-related changes in the esophagus.
89

90. Cont..
Clinical Manifestations:
• Difficulty swallowing, fullness in the neck, belching,
regurgitation of undigested food, and gurgling noises after
eating.
• Undigested food regurgitation when in a recumbent position.
• Halitosis and sour taste in the mouth.
90

91. Cont..
Diagnostic procedure:
• Barium swallow to determine the exact nature and location of
a diverticulum.
• Manometric studies to rule out a motor disorder.
• Esophagoscopy is usually contraindicated due to the danger
of perforation of the diverticulum.
91

92. Cont..
Medical Management:
• Management of symptoms such as dysphagia and chest pain.
• Intramural diverticula usually regress after the esophageal
stricture is dilated.
Surgical Management:
• Surgery is indicated if symptoms are troublesome and
becoming worse.
92

93. Cont..
Nursing Diagnosis:
• Impaired Swallowing related to pharyngoesophageal pulsion
diverticulum as evidenced by difficulty swallowing, regurgitation
of undigested food, and gurgling noises after eating.
• Imbalanced Nutrition: Less Than Body Requirements related to
pharyngoesophageal pulsion diverticulum as evidenced by weight
loss, anorexia, and inadequate dietary intake.
• Risk for Aspiration related to pharyngoesophageal pulsion
diverticulum as evidenced by difficulty swallowing, regurgitation
of undigested food, and coughing.
• Anxiety related to surgical intervention for diverticulum as
evidenced by verbalization of fears, restlessness, and increased
heart rate.
• Risk for Infection related to surgical intervention for diverticulum
as evidenced by surgical wound site drainage, fever, and elevated
white blood cell count. 93

94. Cont..
Nursing Management:
• Diet: Patients with diverticulum should be advised to
consume a high-fiber diet to prevent constipation and reduce
the pressure on the diverticulum. Additionally, patients may
need to avoid certain foods that can irritate the diverticulum,
such as seeds, nuts, and popcorn.
• Medications: Patients may need to take medications to
manage symptoms such as pain, reflux, and constipation.
Nurses should ensure that patients understand the correct
dosage and potential side effects of these medications.
94

95. Cont..
Nursing Management:
• Post-operative care: For patients who undergo surgery to
remove a diverticulum, nurses should closely monitor the
surgical incision for signs of infection or leakage. Patients
may also require a nasogastric tube and may need assistance
with maintaining proper nutrition and hydration during the
post-operative period.
• Education: Nurses should educate patients on the
importance of following a high-fiber diet, staying well
hydrated, and avoiding activities that can increase intra-
abdominal pressure (such as heavy lifting or straining during
bowel movements). Patients should also be advised to seek
medical attention if they experience worsening symptoms or
develop complications such as fever or severe abdominal
pain.
95

96. Esophageal cancer/tumor
• Cancer of the esophagus, also known as esophageal cancer, is
a malignant tumor that develops in the tissues of the
esophagus.
• Esophageal cancer typically arises from the inner lining of
the esophagus and can spread to nearby tissues and organs if
not diagnosed and treated at an early stage.
• There are two main types of esophageal cancer:
Adenocarcinoma: Begins in glandular cells that lines the
esophagus which produce and release mucus. It usually form
in the lower part of esophagus near stomach and often caused
by Barrett’s esophagus.
Squamous cell carcinoma: Found in upper and middle
section of esophagus and risk factor is smoking and alcohol
ingestion.
96

97. 97

98. Cont..
Causes
• Smoking.
• Heavy alcohol consumption.
• Chronic heartburn or acid reflux.
• Gastroesophageal reflux disease (GERD)
• Barrett's esophagus, a condition that sometimes develops in
people with GERD.
• Achalasia, a rare disorder of muscles in the lower esophagus.
98

99. Cont..
Manifestations
• Progressive dysphagia (difficulty swallowing)
• Hoarseness
• Regurgitation of foods
• Foul breath
• Persistent cough
• Dysphagia initially with solids, then with soft foods, and
eventually even with liquids
• Late occurrence of pain (substernal, epigastric, or back) with
swallowing
• Weight loss
99

100. Cont..
Diagnostic Procedures
• Barium swallow with fluoroscopy may reveal a narrowed
esophagus.
• Definitive diagnosis is made through
esophagogastroduodenoscopy (EGD)
• Biopsy
• Biomarker testing
• Cytosponge is a new diagnostic test being introduced by
NHS Scotland to identify important oesophageal conditions
such as Barrett's oesophagus
100

101. Cont..
Medical Management:
1. Endoscopic ablative therapy (photodynamic therapy,
radiotherapy ablation, endoscopic mucosal resection)
2. Radiofrequency ablation burns away abnormal cells using
radiofrequency energy.
3. Photodynamic therapy uses medication to make damaged
cells sensitive to light, which is then used to destroy them.
4. Endoscopic mucosal resection involves injecting a saline
solution under the lining of abnormal tissue to facilitate its
removal.
5. Palliative care for advanced stage cancer may include
external beam radiation, chemotherapy, esophageal dilation,
electrocoagulation, photodynamic therapy, and the insertion
of expanding metal stents to relieve severe dysphagia.
101

102. Cont..
Surgical Management:
• Esophagectomy (removal of sections of the esophagus) with
reconstruction using part of the stomach is occasionally
performed but carries multiple potential complications.
102

103. Cont..
Nursing Diagnosis:
• Risk for Infection related to impaired swallowing and
compromised immune system as evidenced by presence of fever,
increased white blood cell count, signs of respiratory infection
(e.g., cough, chest congestion).
• Deficient Knowledge about the disease process, treatment options,
and self-care measures as evidenced by patient or family member’s
express confusion or lack of understanding about the disease,
treatment options, or self-care instructions.
• Disturbed Body Image related to changes in physical appearance
and functional abilities as evidenced by expressions of
dissatisfaction or discomfort with changes in body image, social
withdrawal, low selfesteem.
• Risk for Aspiration related to impaired swallowing and reflux as
evidenced by coughing, choking, history of aspiration pneumonia,
dyspnea.
103

104. Cont..
Nursing Diagnosis:
• Impaired Swallowing related to tumor obstruction and/or radiation
therapy as evidenced by difficulty swallowing (dysphagia),
coughing or choking during eating or drinking, regurgitation,
weight loss.
• Imbalanced Nutrition: Less Than Body Requirements related to
dysphagia and treatment-related side effects as evidenced by
weight loss, decreased oral intake, malnutrition, fatigue, altered
taste sensation.
• Anxiety related to diagnosis, treatment, and prognosis as
evidenced by restlessness, increased heart rate, nervousness,
difficulty sleeping, verbal expressions of worry or fear.
• Acute Pain related to esophageal inflammation, tumor invasion, or
surgical interventions as evidenced by sharp or burning pain in the
chest or upper abdomen, pain with swallowing or eating, pain at
the surgical site.
104

105. Cont..
Nursing Interventions:
• The intervention focuses on improving the patient's
nutritional and physical condition before surgery, radiation
therapy, or chemotherapy.
• A high-calorie and high-protein diet, in liquid or soft form, is
provided to promote weight gain if the patient can consume
adequate food orally.
• If oral intake is not possible, parenteral (intravenous) or
enteral (tube feeding) nutrition is initiated.
• The patient's nutritional status is monitored throughout the
treatment process.
• The patient is informed about the postoperative equipment
that will be used, such as closed chest drainage, nasogastric
suction, parenteral fluid therapy, and gastric intubation.
105

106. Cont..
Nursing Interventions:
• After recovering from anesthesia, the patient is placed in a
low Fowler's position and later in a Fowler's position to
prevent reflux of gastric secretions.
• Close observation is maintained for regurgitation, dyspnea,
and the possibility of aspiration pneumonia.
• The patient's temperature is monitored to detect any elevation
that may indicate aspiration or fluid seepage into the
mediastinum.
• If jejunal grafting has been performed, the nurse checks the
graft viability hourly for at least the first 12 hours.
106

107. Gastritis
Awal Sher Khan
Lecturer
INS-KMU

108. Objectives:
• At the end of this lecture the students will
be able to:
• Define Gastritis and types of Gastritis.
• Elaborate etiology of Gastritis
• Explain Pathophysiology of Gastritis
• Sign and symptoms of Gastritis.
• Discuss diagnosis , and medical
management of Gastritis
• Apply Nursing Process to the patients
suffering from Gastitis

109. Gastritis:
• Definition;
• Gastritis is an inflammation, irritation or
erosion of the stomach mucosa.
• Gastritis is a condition that inflames
stomach lining (the mucosa), causing belly
pain, indigestion (dyspepsia), bloating and
nausea.
• Gastritis can come on suddenly (acute) or
gradually (chronic).

110. Cont'd
• Gastritis is a general term for a group of
conditions with one thing in common:
inflammation of the lining of the stomach
• In some cases, gastritis can lead to ulcers
and an increased risk of stomach cancer.
• Pangastritis; Inflammation of the whole
stomach is called Pangastritis
• Antral gastritis ;Inflammation of a part of
stomach.

114. Types of Gastritis
• Gastritis can broadly be divided into acute
gastritis and chronic gastritis.
• Acute gastritis Acute gastritis is a
sudden inflammation of the lining of the
stomach.
•Acute gastritis can be divided in to;
1.Acute superficial gastritis
2.Erosive gastritis
3.Acute gastric ulceration

115. Cont'd
• Chronic gastritis; inflammation of the
lining of the stomach that occurs
gradually and persists for a prolonged
time.
• Chronic gastritis can divided into:
1.TypeA chronic gastritis (autoimmune
gastritis)
2.Type B chronic gastritis (chronic antral
gastritis)

118. Etiology of Gastritis
• Bacterial infections(.Hpylori): A bacteria that lives in
the mucous lining of the stomach; without treatment,
the infection can lead to ulcers, and in some people,
stomach cancer.
• Autoimmune Gastritis
• Bile reflux: A backflow of bile into the stomach from the
bile tract (that connects to the liver and gallbladder)
• Regular use of pain relievers (NSAID)
• Bile reflux disease
• Stress
• Alcohol addiction
• Cocaine
• Radiation and chemotherapy

120. Pathophysiology;
• The gastric mucosa is protected from high
acidity in stomach by mucous secretion.
• Mucosal damage occur through;
• Hypersecretion of acid
• Reduction of mucus production
• Generalized inflammation results

121. Pathophysiology;

122. Sign & Symptoms
• Abdominal pain and burning, often in the
upper center of the abdomen called the
epigastric area
• Bloating
• Weight loss
• Belching
• Indigestion
• Anorexia
• Nausea with or without vomiting
• Hiccups

123. Cont'd
• Severe gastritis can lead to life-threatening
symptoms including:
• Severe chest pain
• Feeling faint or short of breath
• Severe abdominal pain
• Sudden onset of bloody stools (blood may
be red, black or tarry in texture)
• Vomiting blood or black material
(resembling coffee grounds)

126. Diagnosis of Gastritis;
• Gastritis is diagnosed on the basis of medical
history and physical examinations of the
patient and the following tests:
• Test for H pylori
• Blood test
• Stool test
• Upper gastrointestinal X ray
• Upper gastrointestinal endoscopy .An
endoscope, a thin tube containing a tiny
camera, is inserted through your mouth and
down into your stomach to look at the
stomach lining.

129. Medical treatment of Gastritis
• T
aking antacids and other drugs (such as
proton pump inhibitors or H-2 blockers) to
reduce stomach acid
• Avoiding hot and spicy foods
• For gastritis caused by H. pylori infection,
your doctor will prescribe a regimen of
several antibiotics plus an acid blocking
drug (used for heartburn)

130. Cont'd
• If the gastritis is caused by pernicious
anemia, B12 vitamin shots will be given.
• Eliminating irritating foods from your diet
such as lactose from dairy or gluten from
wheat
• Once the underlying problem disappears,
the gastritis usually does, too.

134. Nursing diagnosis for Gastritis
• 1.Fluid And Electrolyte Imbalances related
to inadequate intake, vomiting.
• 2.Imbalanced Nutrition Less Than Body
Requirements related to inadequate intake,
anorexia.
• 3. Impaired sense of comfort: acute pain
related to gastric mucosal inflammation.
• 4. Activity Intolerance related to physical
weakness.
• 5. Knowledge deficit related to lack of
information.

135. Nursing Interventions
• If thepatient is vomiting, give antiemetics.
• Administer I.V. fluids as ordered to maintain
fluid and electrolyte imbalance.
• When the patient can tolerate oral feedings,
provide a bland diet that takes into account
his food preference. Restart feedings slowly.
• Offer smaller, more frequent servings to
reduce the amount of irritating gastric
secretions.
• Help patient identify specific foods that cause
gastric upset and eliminate them from his
diet.

136. Cont'd
• Administer antacids and other prescribed
medications as ordered.
• If pain or nausea interferes with the patient’s
appetite, administer pain medications or
antiemetics about 1 hour before meals.
• Monitor the patient’s fluid intake and output
and electrolyte levels.
• Assess the patient for presence of bowel
sounds.
• Monitor the patient’s response to antacids
and other prescribed medications.

138. Nursing process
• 1,Nursing Assessment for Gastritis
• During the gathering health history, the
nurse asked about the signs and
symptoms in patients.
• Does the patient have heartburn, can not
eat, nausea or vomiting?
• Does the patient have symptoms occur at
any time, before or after meals?

139. Cont'd
• Does the patient have symptoms
associated with anxiety, stress, allergies,
eating or drinking too much, or eating too
fast? how the symptoms disappear?
• Is there a history of previous gastric or
stomach surgery?
• Historical diet plus a new type of diet
eaten for 72 hours, would help.

140. Cont'd
• Full history is essential in helping nurses
to identify whether excess dietary known,
associated with current symptoms,
whether others in the same patient has
symptoms, whether the patient vomited
blood, and if the elements are known to
have ingested causes.

141. Nursing Diagnosis
• Based on all the data assessment, nursing
diagnosis is the major include the
following:
• Anxiety related to treatment.
• Imbalanced Nutrition, Less Than Body
Requirements related to inadequate
nutrient input

142. Cont'd
• Risk for Fluid Volume Deficit related to
insufficient fluid intake and excessive fluid
loss due to vomiting.
• Knowledge Deficit r/t unfamiliarity with the
disease process
• Acute Pain related to gastric mucosal
irritation.

143. Nursinh Care Plans for Gastritis
• Imbalanced Nutrition: less than body
requirements r/t insufficient
absorption of nutrients
• Expected Outcome:
The patient can absorb an adequate
amount of nutrients
• Assessment and Intervention.Obtain
the patient’s weight and other body
measurements .

144. Cont'd
• Admission weight serves as a baseline
metric and helps guide.
• Obtain information about the patient’s
eating habits(Some food items can
exacerbate the symptoms of gastritis.
Acidic or citrus food items may worsen
symptoms. )
• Place the patient NPO (nothing by mouth)
in case of vomiting.

145. Cont'd
• Discourage the patient from consuming
spicy foods, caffeine, and alcohol.
• Anticipate total parenteral nutrition (TPN).
• Consult a dietitian if indicated.
The patient might need an addition of
supplements to compensate for insufficient
nutrient intake.
• Encourage small, frequent meals rather
than three full meals.

146. Cont'd
• 2 Risk for Fluid Volume Deficit: Risk
factors: Vomiting; Decreased intake
• Expected Outcome: The patient will have
a stable fluid volume as evidenced by
normal blood pressure, at least 30ml
hourly urine output, and elastic skin turgor.
• Assess for signs of dehydration.
• Vital signs, especially blood pressure,
urine output, and skin turgor.

147. Cont'd
• Monitor how many times the patient vomits
and note the amount of emesis each time.
• Frequent vomiting causes fluid loss and
can lead to dehydration.
• Monitor the patient’s BP and HR.
• Monitor electrolytes closely.
• Frequent vomiting can cause a loss of
electrolytes, especially potassium.

148. Cont'd
• Monitor urine output hourly and note the
color.
• Provide oral care frequently.
• Often patients are unable to eat or drink,
which can leave the mouth dry.
• Administer antiemetics as prescribed.
• Antiemetics will reduce the feeling of
nausea and vomiting and, therefore, the
risk of insufficient fluid volume.

149. Cont'd
• 3.Knowledge Deficit r/t
unfamiliarity with the disease
process
• Expected Outcome: The patient will
verbalize information about the causes,
treatment, and prevention of gastritis
• Assessment and Interventions:
• Assess the patient’s knowledge about
gastritis.

150. Cont'd
• This information provides a baseline for
further educational content. The patient
might not be aware of the disease.
• Teach about appropriate eating intervals
and the types of food in case of a flare-up
• Teach the patient not to take additional
medication over the counter.

155. By the end of the session learners will be able to:
 Review the anatomy and physiology of
gastrointestinal system (GIT)
 Define Peptic Ulcer disease.
 Discuss the causes, pathophysiology and
manifestation of Peptic Ulcer disease.
 Discuss the diagnostic and medical and surgical
management of Peptic Ulcer disease.
 Apply nursing management for patient with Peptic
Ulcer disease.
 5. Develop a teaching plan for a client experiencing
Peptic Ulcer disease.

157.  An Ulcer is …
 Erosion in the lining of the stomach or
the first part of the small intestine, an area
called the duodenum.
Ulcers damage the mucosa of the
alimentary tract, which extends through the
muscularis mucosa into the sub mucosa
or deeper.

158.  A peptic ulcer is an excavation that forms in
the mucosal wall of the stomach, in the
pylorus, in the duodenum, or in the
esophagus.
 The erosion of a circumscribed area may
extend as deep as the muscle layers or
through the muscle to the peritoneum.
 A peptic ulcer may be referred to as a
gastric, duodenal, or esophageal ulcer,
depending on its location.

159.  Gastric ulcer. Gastric ulcer tend to occur in
the lesser curvature of the stomach, near the
pylorus.
 Duodenal ulcer. Peptic ulcers are more
likely to occur in the duodenum than in the
stomach.
 Esophageal ulcer. Esophageal ulcer occur
as a result of the backward flow of HCl from
the stomach into the esophagus

160. Ulcers that form in the stomach are called gastric
ulcers; in the duodenum, they are called duodenal
ulcers. Both types are referred to as peptic ulcers.

162.  The gastroduodenal mucosal integrity is
determined by protective (defensive) &
damaging (aggressive) factors.

164. • Bicarbonate
• Mucus layer
• Prostaglandins
• Mucosal blood flow
• Epithelial renewal
Defensive
• Helicobacter pylori
• NSAIDs
• Pepsins
• Bile acids
• Smoking and alcohol
Aggressive
Mucosal damage  erosions & ulcerations

165.  Erosion. The erosion is caused by the increased
concentration or activity of acid-pepsin or by
decreased resistance of the mucosa.
 Damage. A damaged mucosa cannot secrete
enough mucus to act as a barrier against HCl.
 Acid secretion. Patients with duodenal ulcers
secrete more acid than normal, while patients with
gastric ulcers tend to secrete normal or decreased
levels of acid.
 Decreased resistance. Damage to the gastro
duodenal mucosa results in decreased resistance
to bacteria and thus infection from the H. pylori
bacteria may occur.

166. • In the past it was believed lifestyle factors, such as
stress and diet caused ulcers. Later, researchers
determined that stomach acids -- hydrochloric acid
and pepsin -- contributed to ulcer formation.
• Today, research shows that most ulcers (80 percent
of gastric ulcers and 90 percent of duodenal ulcers)
develop as a result of infection with a bacterium
called Helicobacter pylori (H. pylori).
• It is believed that, although all three of these factors
-- lifestyle, acid and pepsin, and H. pylori -- play a
role in ulcer development, H. pylori is considered to
be the primary cause.

168.  Factors for the development of peptic ulcers
include:
 Helicobacter pylori
Research shows that most ulcers develop as a
result of infection with bacterium called
Helicobacter pylori (H. pylori). The bacterium
produces substances that weaken the
stomach's protective mucus and make it more
susceptible to the damaging effects of acid and
pepsin, as well as produce more acid.

169.  Smoking:
Studies show smoking increases the chances of
getting an ulcer, slows the healing process of
existing ulcers, and contributes to ulcer
recurrence.
 Caffeine:
Caffeine seems to stimulate acid secretion in
the stomach, which can aggravate the pain of
an existing ulcer. However, the stimulation of
stomach acid cannot be attributed solely to
caffeine

170. • Acid and pepsin
It is believed that the stomach's inability to defend
itself against the powerful digestive fluids,
hydrochloric acid and pepsin, contributes to ulcer
formation.
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
These drugs (such as aspirin, ibuprofen, and
naproxen sodium) make the stomach vulnerable to
the harmful effects of acid and pepsin. They are
present in many non-prescription medications used
to treat fever, headaches, and minor aches and
pains.

171.  The following are the most common symptoms
for ulcers, however, each individual may
experience symptoms differently.
 Belching
 Nausea
 Vomiting
 Poor appetite
 Loss of weight
 Feeling tired and weak

172. Symptoms of ulcer may last for a few days, weeks,
months, and may disappear only to reappear, often
without an identifiable cause.
 Pain. As a rule, the patient with an ulcer
complains of dull, gnawing pain or a burning
sensation in the midepigastrium or the back that
is relieved by eating.
 Pyrosis. Pyrosis (heartburn) is a burning
sensation in the stomach and esophagus that
moves up to the mouth.

173.  Vomiting. Vomiting results
from obstruction of the pyloric orifice, caused
by either muscular spasm of the pylorus or
mechanical obstruction from scarring.
 Constipation and diarrhea. Constipation or
diarrhea may occur, probably as a result of diet
and medications.
 Bleeding. 15% of patients may present with GI
bleeding as evidenced by the passage
of melena (tarry stools).

174.  Bleeding.
 Perforation.
 Narrowing and
obstruction.

175.  Esophagogastroduodenoscopy. Confirms the
presence of an ulcer and allows cytologic studies and
biopsy to rule out H. pylori or cancer.
 Physical examination. A physical examination may
reveal pain, epigastric tenderness, or abdominal
distention.
 Barium study. A barium study of the upper GI tract may
show an ulcer.
 Endoscopy. Endoscopy is the preferred diagnostic
procedure because it allows direct visualization of
inflammatory changes, ulcers, and lesions.
 Occult blood. Stools may be tested periodically until
they are negative for occult blood.

176.  Helicobacter pylori. Research has documented
that peptic ulcers result from infection with the
gram-negative bacteria H. pylori, which may be
acquired through ingestion of food and water. H.
pylori damage the mucous coating that protects the
stomach and duodenum.
 Salicylates and NSAIDs. Encourages ulcer
formation by inhibiting the secretion of
prostaglandins.
 Various illnesses. Pancreatitis, hepatic disease,
Crohn’s disease, gastritis, and Zollinger-Ellison
syndrome are also known causes.

177.  Excess HCl. Excessive secretion of HCl in the
stomach may contribute to the formation of
peptic ulcers.
 Irritants. Ingestion of milk and caffeinated
beverages and alcohol also increase HCl
secretion. These contribute by accelerating
gastric emptying time and promoting mucosal
breakdown.
 Blood type. Gastric ulcers tend to strike people
with type A blood while duodenal ulcers tend to
afflict people with type O blood.

178.  Lifestyle changes: In the past, physicians
advised people with ulcers to avoid spicy,
fatty, or acidic foods.
 Smoking: Smoking has been shown to
delay ulcer healing and has been linked to
ulcer recurrence; therefore, people with
ulcers should not smoke.

179.  Medications:
Physicians treat stomach and duodenal ulcers
with several types of medications, including:
 H2-blockers to reduce the amount of acid the
stomach produces by blocking histamine, a
powerful stimulant of acid secretion. E.g.
Cimetidine, Ranitidine, and Famotidine.
 Proton pump inhibitors to more completely
block stomach acid production by stopping the
stomach's acid pump -- the final step of acid
secretion. E.g. Omeprazol.

180. • Mucosal protective agents to shield the
stomach's mucous lining from the damage of
acid, but do not inhibit the release of acid. E.g.
Bismuth, Sucralfate
• When treating H. pylori, these medications are
often used in combination with antibiotics.
• Antibiotics: The discovery of the link between
ulcers and H. pylori resulted in a probable new
treatment option -- antibiotics for patients with
H. pylori.

181. H. pylori Therapy:
• Triple therapy:
Proton pump inhibitor
Clarithromycin
Amoxicillin.

182.  At present, surgery is performed to treat
ulcers. Types of surgery include:
 Vagotomy
 Pyloroplasty
 Antrectomy

183.  Vagotomy: a surgical operation in which one
or more branches of the vagus nerve are cut,
typically to reduce the rate of gastric
secretion (e.g. in treating peptic ulcers).

184.  Pyloroplasty is surgery to widen the
opening in the lower part of the stomach
(pylorus) so that stomach contents can
empty into the small intestine (duodenum).
The pylorus is a thick, muscular area. When
it thickens, food cannot pass through.

185.  Surgical removal of the walls of an antrum,
especially the antrum of the stomach.

186.  Hemorrhage. Hemorrhage, the most common
complication, occurs in 10% to 20% of patients with
peptic ulcers in the form of hematemesis or melena.
 Perforation and penetration. Perforation is the erosion
of the ulcer through the gastric serosa into the peritoneal
cavity without warning, while penetration is the erosion of
the ulcer through the gastric serosa into adjacent
structures.
 Pyloric obstruction. Pyloric obstruction occurs when the
area distal to the pyloric sphincter becomes scarred and
stenosed from spasm or edema or from scar tissue that
forms when an ulcer alternately heals and breaks down.

187.  Pharmacologic therapy. Currently, the most
commonly used therapy for peptic ulcers is a
combination of antibiotics, proton pump
inhibitors, and bismuth salts that suppress or
eradicate the infection.
 Stress reduction and rest. Reducing
environmental stress requires physical and
psychological modifications on the patient’s part
as well as the aid and cooperation of family
members and significant others.

188.  Smoking cessation. Studies have shown that
smoking decreases the secretion of bicarbonate
from the pancreas into the duodenum, resulting
in increased acidity of the duodenum.
 Dietary modification. Avoiding extremes of the
temperature of food and beverages and
overstimulation from consumption of meat
extracts, alcohol, coffee, and other caffeinated
beverages, and diets rich in cream and milk
should be implemented.

190.  Assessment for a description of pain.
 Assessment of relief measures to relieve the
pain.
 Assessment of the characteristics of the
vomitus.
 Assessment of the patient’s usual food
intake and food habits.

191.  Acute pain related to the effect of gastric
acid secretion on damaged tissue.
 Anxiety related to an acute illness.
 Imbalanced nutrition related to changes in
the diet.
 Deficient knowledge about prevention of
symptoms and management of the condition.

192.  Relief of pain.
 Reduced anxiety.
 Maintenance of nutritional requirements.
 Knowledge about the management and
prevention of ulcer recurrence.
 Absence of complications.

193.  Administer prescribed medications.
 Avoid aspirin, which is an anticoagulant, and foods
and beverages that contain acid-enhancing
caffeine (colas, tea, coffee, chocolate), along with
decaffeinated coffee.
 Encourage patient to eat regularly spaced meals
in a relaxed atmosphere; obtain regular weights
and encourage dietary modifications.
 Encourage relaxation techniques

194.  Assess what patient wants to know about the
disease, and evaluate level of anxiety;
encourage patient to express fears openly and
without criticism.
 Explain diagnostic tests and administering
medications on schedule.
 Interact in a relaxing manner, help in identifying
stressors, and explain effective coping
techniques and relaxation methods.
 Encourage family to participate in care, and
give emotional support.

195.  Assess for faintness or dizziness and nausea, before or with
bleeding; test stool for occult or gross blood; monitor vital signs
frequently (tachycardia, hypotension, and tachypnea).
 Insert an indwelling urinary catheter and monitor intake and
output; insert and maintain an IV line for infusing fluid and
blood.
 Monitor laboratory values (hemoglobin and hematocrit).
 Insert and maintain a nasogastric tube and monitor drainage;
provide lavage as ordered.
 Monitor oxygen saturation and administering oxygen therapy.
 Place the patient in the recumbent position with the
legs elevated to prevent hypotension, or place the patient
on the left side to prevent aspiration from vomiting.

196.  Note and report symptoms of penetration
(back and epigastric pain not relieved by
medications that were effective in the past).
 Note and report symptoms of perforation
(sudden abdominal pain, referred pain to
shoulders, vomiting and collapse, extremely
tender and rigid abdomen, hypotension and
tachycardia, or other signs of shock).

197.  Assist the patient in understanding the condition and
factors that help or aggravate it.
 Teach patient about prescribed medications, including
name, dosage, frequency, and possible side effects. Also
identify medications such as aspirin that patient should
avoid.
 Instruct patient about particular foods that will upset
the gastric mucosa, such as coffee, tea, colas, and
alcohol, which have acid-producing potential.
 Encourage patient to eat regular meals in a relaxed
setting and to avoid overeating.
 Explain that smoking may interfere with ulcer healing; refer
patient to programs to assist with smoking cessation.

198.  Alert patient to signs and symptoms of
complications to be reported. These
complications include hemorrhage (cool skin,
confusion, increased heart rate, labored
breathing, and blood in the stool), penetration
and perforation (severe abdominal pain, rigid
and tender abdomen, vomiting, elevated
temperature, and increased heart rate),
and pyloric obstruction (nausea, vomiting,
distended abdomen, and abdominal pain).

199.  Relief of pain.
 Reduced anxiety.
 Maintained nutritional requirements.
 Knowledge about the management and
prevention of ulcer recurrence.
 Absence of complications.

200.  https://nurseslabs.com/peptic-ulcer-disease/

201. Gastric Carcinoma
Subject: AHN I
Sohaib Ali Shah
Faculty of Nursing Sciences
Khyber Medical University
201

202. Gastric Cancer
• The incidence of stomach cancer in the United States has
been decreasing, but it still causes a significant number of
deaths annually.
• More common in individuals over 40 years of age
• Men have a higher incidence of gastric cancer than women.
• The incidence of gastric cancer is higher in Japan, where
mass screening programs have been implemented for early
detection.
• The prognosis for gastric cancer is generally poor, as most
patients are diagnosed with metastases already present.
202

203. 203

204. Causes
• Chronic stomach inflammation
• Barrett's esophagus
• Pernicious anemia
• Achlorhydria
• Gastric ulcers
• H. pylori infection
• Genetics
• Food preservatives such as nitrates
• Diet high in smoked, highly salted, or spiced foods
204

205. Manifestations
•Early symptoms, such as pain relieved with antacids,
can resemble those of benign ulcers.
•Progressive disease may manifest with symptoms such
as:
anorexia (loss of appetite)
dyspepsia (indigestion)
weight loss
abdominal pain
Constipation
Anemia
nausea and vomiting 205

206. Pathophysiology
206

207. Diagnostic Procedure
• Physical examination: Usually not helpful as most gastric
tumors are not palpable.
• Ascites: Apparent if the cancer cells have metastasized to the
liver.
• Endoscopy
• Barium x-ray examination
• Computed tomography (CT) scan
• Bone scan
• Liver scan
• Complete x-ray examination of the GI tract
207

208. Medical & Surgical Management
• Surgical removal: The only successful treatment for gastric
carcinoma is the removal of the tumor. Cure is possible if the
tumor is localized to the stomach and can be completely
excised.
• Palliative surgery: If the tumor has spread beyond resectable
areas, palliative surgery may be performed to alleviate
symptoms caused by obstruction or dysphagia.
• Subtotal gastrectomy
• Total gastrectomy
• Chemotherapy
• Pre-surgical chemotherapy
• Radiation therapy
• Tumor marker assessment
• Learning Objectives
208

209. 209

210. Nursing Diagnosis
• Imbalanced Nutrition: Less Than Body Requirements
related to anorexia, altered taste sensation, and effects of
cancer treatment.
• Acute Pain related to tumor growth, invasion, or surgery.
• Anxiety related to the diagnosis of gastric cancer, fear of
treatment, or uncertainty about the future.
• Risk for Infection related to impaired immune function
secondary to cancer and/or treatment.
• Risk for Imbalanced Fluid Volume related to vomiting,
anorexia, and inadequate intake.
• Disturbed Body Image related to changes in physical
appearance due to cancer and treatment.
• Fatigue related to the disease process, anemia, or cancer
treatments.
210

211. Nursing Interventions
Reduce Anxiety:
• Provide a relaxed, non-threatening atmosphere for the
patient to express fears, concerns, and anger
• Encourage family support and positive coping measures
• Advise patient about procedures and treatments
• Suggest talking to a support person (e.g., spiritual advisor)
Promote Optimal Nutrition:
• Encourage small, frequent portions of non-irritating foods
• Provide high-calorie food supplements with vitamins A and
C and iron
• Monitor intake, output, and daily weight
• Assess for signs of dehydration and metabolic abnormalities
• Administer antiemetics as prescribed
211

212. Nursing Interventions
Relieve Pain:
• Administer analgesics as prescribed
• Assess the effectiveness of pain management
• Suggest non-pharmacologic pain relief methods
Provide Psychosocial Support:
• Help the patient express fears, concerns, and grief
• Answer patient's questions honestly and encourage
participation in treatment decisions
• Recognize mood swings and defense mechanisms
• Reassure patients and family members that emotional
responses are normal
212

213. Cont..
• Offer emotional support and involve family members and
significant others
• Make the services of healthcare professionals available if
needed
• Project an empathetic attitude and spend time with the
patient
213