PATHOPHYSIOLOGY OF GASTRIC OUTLET OBSTRUCTION

Predisposing factors: Non-modifiable: Old age (68 years old) Modifiable: Diet (small serving/ meals) Stress Helicobacter pylori infection Smoking NSAID use Colonoscopy: Nonspecific Colitis; Internal Hemorrhoids Grade 1 UGIE: Diffuse Erosive Gastritis; Hiatal Hernia; Gastroduodenal Reflux Chest PA: Senile Pulmonary Emphysematous changes. Atherosclerotic aorta. Senile Osteoporosis Abdomen Supine Upright There are non-dilated bowel loops with no air fluid level. There is no demonstrable free peritoneal air. The hepatic shadow appears prominent with displacement. of the hepatic flexure inferiorly. No unusual paravertebral density. There is spurring along the margins of the visualized vertebral bodies. There is generalized decrease in osseous density. There is slight rightward deviation of the lumbar spine. The rest of the structures are unremarkable. Obstruction persists for 5-7 days despite intense medical therapy, operation should be considered. (vagotomy and antrectomy with gastroduodenal drainage or truncal vagotomy with drainage; balloon dilation) Precipitating factor: Excess gastric acid production

Acid-peptic injury to the gastroduodenal mucosal barrier Acute ulcer Inflammation and edema and/or muscular spasm epigastric pain

Succession splash, epigastric tenderness abdominal distension, hypoactive bowel sounds

Lumen obstruction Tympanic mass in epigastric area

Inc. WBC, segmenters, lymphocytes

Nausea, vomiting, LBM, fullness relieve by emesis, early satiety, weight lost, lost of appetite, fatigue

Progressive gastric dilation Malnutrition (protein) Stomach loses contractility Inc. BUN, crea Anemia, dec. S. albumin Loss of fluid, hydrogen, chloride

Intestinal bacterial overgrowth

Accumulation of undigested food

DHN, metabolic, hypokalemic alkalosis TPN (Kombiven ) Severe DHN (kidneys compensate by retaining Na+) Ensure patent line, regulate rate Dec. Na+

Medical therapy is effective in preparing patients for surgery but not proved successful on eliminating need for surgery

Risk for aspiration PNA Monitor CBC, signs of bleeding, albumin, edema, skin turgor

PNA, recurrent or persistent bleeding, ulceration, perforation, or obstruction

postgastrectomy syndromes, such as dumping, alkaline gastritis, and afferent loop syndrome

Stomach decompression, maintain optimum nutritional status

Death

K+ is initially exchanged, but as DHN progresses and K+ stores become depleted, H+ is exchanged for Na+ in the renal tubules

Encourage COMPLIANCE monitor of weight loss Correct the volume, electrolyte, acidbase disturbances Administer Normal Saline FC place (if renal function is adequate) may give K+ Continuous nasogastric suction Decompression of the stomach (placement of large bore NGT) Parenteral administration of H2receptor antagonist/ PPI meds Monitor VS, UO, electrolytes, signs of infection, dehydration Keep patient comfortable in bed Health teachings: avoids acidic drinks

Meds: Omeprazole 40 mg 1 cap BID Moseger 1 tab OD @ HS Ciprofloxacin 500 mg 1 tab BID Colchicine 0.5 mg 1 tab BID Prednisone 1 tab OD x 5 days Mucosta 100 mg 1 tab TID Conzace 1 cap OD Stat/prn meds: Metoclopramide 1 amp prn for comiting Tx: Ensure 3 scoops / 150cc water BID

Recovery

Starvation

Hypoproteinemia and potential Vit, K deficiency

Monitor nutritional status (TPN) and coagulation factors

Anemia

BT, parenteral iron Leads to

LEGEND:

If metabolic alkalosis (blood pH >7.6) either 0.01 N HCl or ammonium chloride solution may be given IV

Inc. clotting time; dec. RCB, hemohlobin, hematocrit Bold letters

Does not lead to S/sx manifested by the patient Laboratory results/ diagnostic findings Nursing Intervention Medical intervention