Ppt

1. UOG, CMHS, School of Nursing,
Department of Surgical Nursing
Seminar presentation on:
PUD & Gastric Ca
By: Alamirew Enyew
January 27 /2022
2/9/2024 1

2. Outlines
 Anatomy & physiology
overview
PUD:
 definitions & types
 Epidemiology
 Causes & pathophysiology
 Clinical features
 DDx
 Investigations &Rx
 Nursing mgt
 complications
Gastric ca
 Definition & types
 Epidemiology
 Risk factors
 Clinical features
 Staging
 Investigations &Rx
 Prevention
 Nursing process
2/9/2024 2

3. Learning objective
At the end of this presentation you will be able to:
 Define PUD and gastric ca
 Explain the epidemiology of PUD and gastric ca
 discus causes/risk factors &path-physiology of them
 List clinical features of PUD and gastric ca
 List DDx of PUD and gastric ca
 Identify the dx methods of PUD and gastric ca
 List nursing and medical mgt of PUD and gastric ca
 Complications PUD
2/9/2024 3

4. Anatomy of stomach
It is greatly expanded & most proximal abdominal
organ of GIT
It occupies part of the epigastrium, umbilical,& Lt.
hypochondrium
It is J-shaped &has two curvatures-lesser & greater
has 5 parts-cardia, fundus, body, pyloric part&
pylorus ( Fig:1)
2/9/2024 4

5. Fig 1: Anatomic regions of the stomach
2/9/2024 5

6. Layers of the stomach wall
1. Mucosa(epithelium,lamina
propria, &muscularis mucosa)
2. Submucosa
3. Muscularis (smooth muscle)
4. Serosa (fibrous membrane)
2/9/2024 6

7. Blood supply of stomach
Manipal manual of surgery
2/9/2024 7

8. Venous drainage
Venous drainage parallels the arterial supply
Left and right gastric veins drain into the portal vein
Right gastroepiploic drains into the superior
mesentric vein
Left gastroepiploic and short gastric artery drains
into the splenic vein
Manipal manual of surgery
2/9/2024 8

9. Nerve supply
Manipal manual of surgery
Innervation:
Parasympathetic via vagus
 Left-- anterior
 right-- posterior.
Sympathetic via celiac
plexus.
Intrinsic enteric neurons
2/9/2024 9

10. Lymphatic drainage
• Lymphatic drainage is into four zones:
Superior gastric
Suprapyloric
Pancreaticolienal
Inferior gastric/subpyloric
• All four drain into the celiac group of nodes and into
the thoracic duct.
2/9/2024 10

11. Function
 It stores & facilitates the digestion, absorption &
propulsed into SI.
Antrum & pylorus allowing entry of food to
duodenum & returning to proximal stomach until
it is appropriate for delivery into the duodenum.
Schwartz's Principles of Surgery 8th edition
2/9/2024 11

12. Gastric Cell Types, Location, and Function
Sabiston Textbook of Surgery, 18th ed.
2/9/2024 12

13. Manipal manual of surgery
2/9/2024 13

14. HCL
Physiologic control of acid secretion
2/9/2024 14

15. Mechanism of HCL secretion cont…
Bailey and Love's Short Practice of Surgery
2/9/2024 15

16. Functions of gastric acid
It plays a critical role in digestion of a meal.
Convert pepsinogen to pepsin used for hydrolysis of
proteins to polypeptide (pepsinogen HCL pepsin)
Elicits the release of secretin from the duodenum,
which results in pancreatic bicarbonate secretion.
Limit colonization of the upper GI tract with bacteria.
Sabiston Textbook of Surgery, 18th ed.
2/9/2024 16

17. Other gastric secretary products
 Gastric Juice: secreted by parietal, chief & mucus cells
 Intrinsic Factor: mucoprotein secreted by parietal cell
w/c essential for absorption of vit B12 in terminal ileum
 Pepsinogens: are proteolytic proenzymes secreted by the
glands of the gastroduodenal mucosa.
 Mucus & bicarbonate combine to neutralize gastric acid
at the gastric mucosal surface.
Sabiston Textbook of Surgery, 18th ed.
2/9/2024 17

18. Peptic ulcer disease (PUD)
 Are focal defects in the gastric or duodenal mucosa
which extend into the sub mucosa or deeper (muscle
to the peritoneum)
 It is acid peptic digestion of alimentary mucosa
 It may be gastric, duodenal, or esophageal ulcer
 Are more common in duodenum than stomach
Brunner and Suddarth’s textbook of medical-surgical nursing
12th edition , Sabiston Textbook of Surgery, 18th ed
2/9/2024 18

19. PUD cont…
 Common sites for PUD are:
 first part of the duodenum and
 lesser curve of the stomach.
 Also occur on stoma after gastric surgery, distal
esophagus, distal duodenum, jejunum and Meckel’s
diverticulum
Bailey and Love's Short Practice of Surgery
2/9/2024 19

20. Types of PUD
Based on site
 DU
 GU
 Combined(zollinger Ellision
syndrome)
 Esophageal
 Anastomotic
Based on duration
 Acute
 Chronic
Manipal manual of
surgery
2/9/2024 20

21. Site of PUD
2/9/2024 21

22. Types of gastric ulcers cont…
2/9/2024 22

23. Compression between GU &DU
Criteria Gastric ulcer Duodenal ulcer
Site Stomach duodenum
Common in age >50 years 30-60 years
Acid secretion Normal /hypo secretion Hyper secretion
weight loss Gain /normal
Duration of pain Immediately after meal
Rarely at night
2-4 hrs after meal &
usually night
Food Aggravate pain Relive pain
Vomiting and
bleeding
common rare
2/9/2024 23

24. Epidemiology of PUD
 PUD is a global problem with a lifetime risk 5% to 10%.
 DU are 4 times more common than GU and DU are more
common in men (Lanas A, Chan FKL. 2017)
 A recent SR & MA of 21 studies revealed that the
prevalence of PUD in the world in age range of 17–
82 years was 8.4%(Salari,N., Darvishi,N., Shohaimi,S. et
al., 2021.)
 Incidence rate of PUD in Nigeria was 6.7% and GU to DU
ratio was 1.4:1 (Ray-Offor E, Opusunju KA. 2020)
2/9/2024 24

25. Epidemiology cont…
 At UoGH, prevalence of PUD among dyspepsic patients
was 35% in which 72% were DU, 19% gastritis/doudenitis,
6% gastric mass & 4% pyloric obstruction (Assefa B,
Tadesse A, Abay Z. etal, 2021)
 A study done in TASH, ABO B/G distribution of PUD pts.
was 19.04% , 19.04% , 11.11% and 50.79% for B/G A, B,
AB, and O, respectively.
(Teshome Y, Mekonen W, Birhanu Y, Sisay T, 2019)
What could be the reason? b/g O More risk?
2/9/2024 25

26. Causes of PUD
 H. pylori infection,
 Ingestion of NSAIDs most common
 Increase acid & pepsin
 Food habits (spicy food, smoking and
alcohol, poor in vitamins)
2/9/2024 26

27. Causes cont…
 Psychogenic –Anxiety, worry (stimulation of vagus---
increase acid secretion)
 Genetic ( eg B/Group O more risk)
 Endocrinal
 (ZES)Tumor of pancreases with hypergastrinaemia
 Hyperparathyroidism (increase ca---increase parietal
cell----acid secretion)
Manipal manual of surgery
2/9/2024 27

28. Cause cont..
1. H. pylori infection
 90% of DU and 75% of GU are associated with H. pylori infection
 The mechanisms of H. pylori–induced GI injury
1.Production of toxic products to cause local tissue injury
2. Induction of a local mucosal immune response(cytokines.. )
3. Increased gastrin levels with a resultant increase in acid
secretion
Sabiston Textbook of Surgery, 18th ed
2/9/2024 28

29. Cause cont…
2. NSAID
 Common for GU by altering mucosal defense
 Ulcerations is proportional to the daily dosage
 In addition, complications increases with:
 age older than 60,
patients having a prior GI event, or
concurrent use of steroids or anticoagulants.
Sabiston Textbook of Surgery, 18th ed
2/9/2024 29

30. Path physiology of PUD
2/9/2024 30

31. 2/9/2024 31
Patho physiology of PUD cont…

32. History and P/E
 Burning stomach pain
 Feeling of fullness,
bloating or belching
 Intolerance to fatty
foods
 Nausea and vomiting
 Hematemesis
 Melena (black stool)
 Weight loss/gain
 Severe epigastric pain
 Epigastric tenderness on
palpation
2/9/2024 32

33. Differential diagnosis
 Gastritis
 GERD
 Gastric cancer
 Pancreatitis
 Biliary colic
 Cholecystitis
2/9/2024 33

34. Investigation of PUD
 Hx and P/E
 Esophagogastroduodenoscopy (EGD)-(gold standard)
 Ultrasonography-- (less sensitive)
 CT scanning
 Helicobacter pylori testing:
Serologic testing, Urea breath test, stool antigen test and
endoscopic biopsy for culture.
 CBC…
Bailey and Love's Short Practice of Surgery
2/9/2024 34

35. Treatment of peptic ulceration
1. Medical treatment:
 H2-receptor antagonists (eg Cimetidine)
 Proton pump inhibitor (Omeprazole)+
 Eradication therapy(Clarithromycin+Amoxacillin/Metronidazol)
2. Surgical Rx (vagotomy or partial gastrectomy)
 For DU: Billroth II gastrectomy (Gastrojejunostomy),
Vagotomy &drainage
 For GU: Billroth I gastrectomy (gastroduodenostomy )
Bailey and Love's Short Practice of Surgery
2/9/2024 35

36. DRUG REGIMENS FOR PEPTIC ULCER DISEASE
2/9/2024 36

37. Indication of surgery for PUD
 Fail to heal after 12 to 16 wks medical Rx
 Life-threatening hemorrhage,
 Perforation, or
Obstruction (GOO)
Brunner and Suddarth’s textbook of medical-
surgical nursing 12th edition
2/9/2024 37

38. Surgical Rx cont…
What is truncal vagotomy?
What are other types of vagotomy??
Brunner and Suddarth’s textbook of
medical-surgical nursing 12th edition
2/9/2024 38

39. Surgical management of PUD
2/9/2024 39

40. Manipal manual of surgery
summary of PUD treatment
2/9/2024 40

41. Nursing management
 Monitoring and managing potential complications
 Advice about:
 stress reduction, rest & D/c NSAIDs
 Improve hygiene to prevent infection
 Smoking cessation (how it prevent ?)
 Dietary modification(decrease consumption of meat
extracts, alcohol, coffee, milk and cream.. )
 Diet compatibility is an individual matter;
 eat foods that are tolerated
 avoid those that produce pain.
2/9/2024 41

42. Possible Nursing Dx for Pts. with PUD
 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 diet
 Deficient knowledge about prevention of
symptoms and management of the condition
2/9/2024 42

43. Planning and Goals
Relief of pain
Reduced anxiety
Maintenance of nutritional requirements
Improve knowledge about the management
and prevention of ulcer recurrence
 Absence of complications.
2/9/2024 43

44. Nursing Interventions
Relive pain
by prescribed medications, avoid aspirin, foods
and beverages that contain caffeine.
 Eat at regular intervals & relaxed setting
Reducing Anxiety
Give appropriate information regarding dx&Rx.
Interacts with pt. in a relaxed manner
 Encouraged pt. to participate in care
 provide emotional support
 Advise pt to comply with Rx & dietary
restrictions.
2/9/2024 44

45. Complications PUD
Upper GI bleeding
Gastric outlet obstruction/GOO
Perforation (most in DU) (Teshome H, Birega M,
Taddese M. 2020)
Penetration
Gastric cancer
Brunner and Suddarth’s 12th edition
2/9/2024 45

46. Complication of peptic ulcer surgery
Recurrent ulceration
Small stomach syndrome
 Bilious vomiting
 Early and late dumping (if vagotomy)
Diarrhoea and Steatorrhea
Malignant transformation
Bailey and Love's Short Practice of Surgery
2/9/2024 46

47. Brain storming with real case senario
A 60 yrs female admitted in UGCSH after she present with:
 Epigastric discomfort & burning sensation 3 months duration.
 But no Hx of vomiting, loss of appitite, Wt loss, diarrhea
 Had similar symptoms 2 yrs back & took different medications.
P/E:
 G/A---well looking, V/S stable
 HEENT---PC&NIS
 LGS----1x1cm palpable, non-tender mobile supraclavicular LN
 Abdomen---distended abdomen move with respiration
---tender epigastric area on palpation
2/9/2024 47

48. Investigations done:
1. Endoscopic insisional biopsy
 Gross----------multiple grey white matter tissue 1.5 cmx 4
 Microscopy---gastric surface epithelium with underlying
submucosal proliferation, no necrosis
2. OFT ( Cr-----0.5, Urea --29 , GOT---23, GPT----20)
3. Electrolyte---(K—3.83 , Na—136.9, Cl—105.6 )
4. Serum albumin---4.4
5. CBC (WBC—6.5, RBC---4.5, HCT---41.7, Plt ---305)
6. BG---B +ve
Discus 1. The Possible medical dx
2. Medical/surgical Rx 5 minute
3. Nursing dx and intervention
2/9/2024 48

49. Gastric neoplasm
Benign
 Rare
 Polyps
 Leiomyoma
Malignant
 >90%
 Adenocarcinoma (>95%)
 Lyhphoma(4%)
 Leiomyosarcoma(1%)
 Others
49
It is cells in the stomach grow out of control.
(GIST)
2/9/2024

50. Types of stomach adenocarcinomas:
Intestinal Diffused
Environmental Familial (Blood type A more)
Gastric atrophy, intestinal
metaplasia
Does not arise in gastritis
More common in men More Common women
Higher incidence with age Younger age group
Gland formation present Poorly differentiated, no gland
formation
Haematogenous spread Transmural extension &lymphatic
Better prognosis poor prognosis
Spread less slowly spread more quickly
More common less common
2/9/2024 50

51. Epidemiology
 Gastric ca was the 4th most common & the 2nd cause of
death of all malignancies worldwide (Jemal A, Bray F,
Center MM. etal 2011)
 The American Cancer Society estimated 26,560 cases of
stomach ca in 2021 (ACS, 2021)
 Gastric ca is the 15th most common ca in US, > 11,000
death/year & higher incidence in men ( American Cancer
Institute 2021)
2/9/2024 51

52. Epidemiology cont…
 Over 60% of the new gastric cancer cases are observed in
eastern Asia (most in Japan)
 Currently, there is gastric ca screening in Japan, and Korea
for >=50 & >=40 years respectively.
(Sekiguchi M. Oda I. Matsuda T. etal , 2022)
 In 2020, gastric ca was the 5th most common ca & the 4th
highest mortality rate ( table below) (Globocan, 2020)
 Study in Black lion hospital showed gastric ca was most
prevalent in male. Of 96 patients 68 were males(with ratio of
M:F 2.4:1) (Johnson, Olivier, Ersumo, T. Ali, A. 2000)
2/9/2024 52

53. Global trend of gastric ca
2/9/2024 53

54. Risk factors gastric ca
 Diet
 high in smoked, salted, or
pickled foods
 low in fruits & vegetables
(defi of antioxidants(Vit C.)
Lack of refrigeration
 Achlorhydria/decre acid
 Genetics( more B/G A)
 Smoking
Bailey and Love's Short Practice of Surgery
2/9/2024 54

55. Risk factors cont..
 Medical
Chronic
inflammation
 H. pylori infection
Subtotal gastrectomy
2nd PUD
 GU, Gastric atrophy& gastritis
 Adenomatous polyps
 Pernicious anemia
 Male gender
Bailey and Love's Short Practice of Surgery
2/9/2024 55

56. Pathophysiolgy of gastric ca
2/9/2024 56

57. Clinical features and P/E
 Features are obvious in advanced ca (muscular
mucosa & or serosa involvement +- L/node)
Early satiety, bloating, distension & vomiting
 Bleeding (lead IDA)
Dysphagia, epigastric fullness
2/9/2024 57

58. Clinical features and P/E
On P/E
 Palpable metastatic
L/nodes
 Palpable mass
 Epigastric tenderness
 Heart burn
 Loss of appetite
 Weight loss
 Feeling tired
 Vomiting blood
Bailey and Love's Short Practice
of Surgery
2/9/2024 58

59. Diagnosis/Investigations
 Imaging
US
CT scan (check metastasis)
 MRI
Endoscopy to take biopsy
Endoscopic ultrasound -stage
the tumor
 Biopsy
 Laboratory
CBC (to identify anemia)
Electrolyte
Liver function tests
Tumor markers
2/9/2024 59

60. Fig: Carcinoma stomach
large ulcerative lesion with
involvement of serosa
Fig: Endoscopy view
2/9/2024 60

61. Staging of gastric ca
2/9/2024 61

62. Staging of gastric ca
TNM Staging
2/9/2024 62

63. TNM Staging cont…
2/9/2024 63

64. TNM staging cont…
Manipal manual of surgery
AJCC Cancer staging manual 6th edition
Other staging methods:
Reading assignment
2/9/2024 64

65. Treatment
 Surgery (only curative option)
Endoscopic sub-mucosal dissection( ESD)
Gastrectomy (partial or total) (resection)
Radiation therapy
Chemotherapy
These treatments are generally combined.
What is the difference b/n
Neoadjuvant & adjuvant Therapy (2mi)
2/9/2024 65

66. Prevention gastric ca
Eating a healthy diet
 high in fruits and vegetables
 low in red meats, smoked, salted, pickled
foods
Maintain a healthy weight
Avoid smoking
2/9/2024 66

67. Possible nursing dx for gastric ca
 Anxiety related to the disease and anticipated Rx
 Imbalanced nutrition, less than body requirements,
related to early satiety or anorexia
 Pain related to tumor mass
 Anticipatory grieving related to the diagnosis of ca
 Deficient knowledge regarding self-care activities
2/9/2024 67

68. Planning and Goals
 Reduced anxiety
 Optimal nutrition
 Relief of pain
 Anticipated lifestyle changes
2/9/2024 68

69. Nursing Interventions
Reducing Anxiety
 Make relaxed atmosphere
 Encourages the family to
support the patient.
 Advises the pt about any
procedures & Rx
Promoting optimal nutrition
 Small, frequent nonirritating
foods
 high in calories, vit A & C &
Fe to repair tissue
 Vit B12 if total gastrectomy
 Note metabolic
abnormalities (Na, K,
glucose,BUN)
 Antiemetics if prescribed
2/9/2024 69

70. Nursing Interventions cont…
Relieving Pain
 Administers analgesic.
 Assesses frequency,
intensity &duration pain
 position changes,
imagery, distraction &
relaxation exercises
Providing psychosocial support
 Encourage to express fears,
concerns, and grief about dx.
 Answer the pt’s questions
honestly
 Encourage pt. to participate in
Rx decisions.
 Offers emotional support and
involve family
2/9/2024 70

71. Reference
Salari, N., Darvishi, N., Shohaimi, S. et al. The Global
Prevalence of Peptic Ulcer in the World: a Systematic
Review and Meta-analysis. Indian J Surg (2021).
Ray-Offor E, Opusunju KA. Current status of peptic ulcer
disease in Port Harcourt metropolis, Nigeria. African Health
Sciences. 2020 Oct 7;20(3):1446-51.
Assefa B, Tadesse A, Abay Z, Abebe A, Tesfaye T, Tadesse M,
Lakew AM. Prevalence of Peptic Ulcer Disease and
Associated Factors Among Dyspeptic Patients At Endoscopy
Unit, University of Gondar Hospital, Northwest Ethiopia.
Teshome Y, Mekonen W, Birhanu Y, Sisay T. The association
between ABO blood group distribution and peptic ulcer
disease: a cross-sectional study from Ethiopia. Journal of
blood medicine. 2019;10:193.
2/9/2024 71

72. Reference cont…
Bailey and Love's Short Practice of Surgery
Manipal manual of surgery
Sabiston Textbook of Surgery, 18th ed.
Brunner and Suddarth’s textbook of medical-surgical nursing 12th
edition
Schwartz's Principles of Surgery 8th edition
Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global
cancer statistics. CA Cancer J Clin. 2011;61(2):69–90.
2/9/2024 72

73. Reference cont…
Teshome H, Birega M, Taddese M. Perforated Peptic Ulcer
Disease in a Tertiary Hospital, Addis Ababa, Ethiopia:
Five Year Retrospective Study. Ethiop J Health Sci. 2020
May;30(3):363-370.
American Cancer Society. Key statistics about stomach
cancer. American Cancer Society. January 22, 2021;
Surveillance, Epidemiology, and End Results Program.
SEER Stat Fact Sheets: Stomach Cancer. National Cancer
Institute. Available
at http://seer.cancer.gov/statfacts/html/stomach.html
Sekiguchi M. Oda I. Matsuda T. etal epidemiological trends
and future perspectives of gastric cancer in Eastern Asia,
2022, Vol.103
2/9/2024 73

74. THANK YOU
2/9/2024 74