Upper GI Disorders Nursing 201 Daltrey Tyree ARNP, RN, MSN

Pharmacology- UGI (Ch 46, 47)

Antacids (maalox, mylanta, gaviscon, riopan, amphojel, Tums)

Used in uncomplicated cases
Neutralizes HCL acid (short-term action; nighttime effectiveness is minimal)
Causes constipation (aluminum, calcium)
Causes diarrhea (magnesium)
**do not administer within 1-2 hours of other medications (interferes with
absorption)
Histamine 2 Receptor Blockers (Tidines)
Tagamet (cimetidine), Pepcid (famitidine), Axid (nizatidine), Zantac (ranitidine).
Smoking effect
Block H2 receptors of parietal cells
Do not give at same time as antacids
If given IV push push slowly - can cause hypotension, arrhythmias
Monitor tarry stools
Tagamet has s/e (confusion, dizziness, fatigue) and more drug to drug interactions
(need good renal fxn)
Proton Pump Inhibitors (prazoles) *****Most popular drug for Upper GI problems*****
Prevacid (lansoprazole), Prilosec (omeprazole), Protonix (pantoprazole), Aciphex
(rabeprazole), Nexium (exomeprazole)
Blocks final step of acid production
Do not Crush, Chew, Break
Monitor liver fxn
Used with abx for H. pylori
Rpt tarry stools
Pepsin Inhibitor
Carafate (sucralfate)
Covers ulcers (protection of mucosa)
Few s/e constipation
Administer before meals and at bedtime
Reglan (metoclopramide)
Promotility (stimulates motility)
Extra Pyramidal Side Effects (speech, swallowing, balance, gait, twitching)
Anticholinergics Librax, Pro-Banthine, Belladonna (scopolamine)
Relieves spasms of GI tract
Monitor for urinary retention, constipation, dry mouth, vision changes
Antibiotics
Used for H. pylori
Antiemetics (phenothiazines)
Phenergan (promothazine), Compazine (prochlorperazine)
Block vomiting receptors
Always dilute phenergan (very irritating and painful)
s/e: sedation, BP, agitation, dry mouth, retention, constipation
Monitor for Respiratory depression
Institute fall precautions
Zofran (odansetron)
Given to chemo pts

Expensive
Serotonin blocker
Institute fall precautions (dizziness)
Emetics
Ipecac
Induces vomiting
Can cause aspiration; injury to esophagus
OTC poison control
GI- Diagnostic Tests
Barium swallow
Radiopaque liquid
Aids in dx of GERD, ulcers, tumors, esoph. varices, patency of sphincter up to
duodenum
NPO prior to procedure
fluids after procedure
White; clay colored stools
Upper endoscopy (EGD)
Esophagus, stomach, gastric and duodenal mucosa
Biopsy
Monitor airway, O2 sats, mouthguard
24 Hour PH Monitoring
NG-like tube inserted
Pt wears 24 hrs for constant PH monitoring
Esophageal Manometry
Uncommon
Abdominal Series
X-ray
CT Scan
Oral contrast
IV contrast
Looks at anatomy
Capsule Endoscopy
New
Swallow a capsule that takes pictures
UGI Components
Mouth
Pharynx
Esophagus
Stomach

Background A & P
1. Mouth (oral, buccal cavity)
Hard palate (covers bone)
Soft palate (covers muscle)

Lips
Cheeks
Tongue (mix food w/saliva (bolus); initiates swallowing; Amylase)
Teeth
2. Pharynx (passageway for food, fluids, air) Extends from base of skull to esophagus
Nasopharynx
oropharynx
laryngopharynx
***pharyngeal mucosa produces fluid to facilitate passage of food bolus as it is swallowed.
Muscles of the
pharynx move food bolus to esophagus thru peritalysis***
3. Esophagus - From pharynx to stomach (thru thorax and diaphragm; ant. to spine; post to
trachea)
Epiglottis (keeps food out of trachea, larynx)
Lower Esophageal Sphincter or cardiac sphincter (prevents reflux into esophagus from
stomach)
4. Stomach (LUQ) *Can expand to hold 4L
cardiac (narrow part of esophagus)
fundus (nearest cardia)
body (main area)
pylorus (distal part of stomach) (pyloric sphincter controls emptying into duodenum)
**food mixes with gastric juices Chyme)
Nutrients
Carbohydrates (converted to glucose for energy)
Proteins (completeanimal; incomplete-plants needed for building tissue, growth
maintenance)
Fats (sat-animal; unsat-seeds, nuts, milk, egg yolks needed for membranes; *cell fuel)
Vitamins
Minerals
Stomach Secretions
Gastric juice produced by gastric glands
HCL acid produced by parietal cells
Intrinsic factor produced by parietal cells
Others- pepsinogen, histamine, endorphins, serotonin, somatostatin
Physical Assessment
6 Fs of distended abdomen (fat, fatal tumor, feces, fetus, fluid, flatus)
INSPECTION
*AUSCULTATION*
PERCUSSION
PALPATION (last to avoid problems)
Oral Cavity Problems
Disorders of Mouth
Cheilosis (painful lesions at corners of mouth; riboflavin, niacin deficiency)
Herpes Simplex 1 (cold sores on lips and mouth can go south with oral sex)
Glossitis (beefy, red tongue Folic acid deficiency)
Leukoplakia (white patches; precancerous. If on tongue more apt to progress to
malignancy)
Candidiasis (white cheesy patches thrush. Immune deficiency; chemo pts)
Gingivitis (red gums that bleed easily)
Stomatitis (may see single or multiple ulcerations canker sores

Inflammation of oral mucosa;

Viral (Herpes) fungal (Candida), trauma, irritants
Tobacco, chemo drugs
Thin, fragile, rich blood supply
Premalignant Lesions
Leukoplakia (white, slightly raised circumscribed patches; 90% benign; 7% malignant
after 8 yrs) Mechanical
causes, poorly fitted dentures, cheek nibbling, broken teeth.
Hairy leukoplakia with HIV
Erythroplakia (red velvety lesions; higher level of malignancy) Most commonly found on
floor of the mouth,
tongue, palate, and mandibular mucosa.
Malignant Tumors (oral cancer)
Squamous Cell Carcinoma slow growth tumors; may be large before onset of symptoms
Basal Cell Carcinoma on Lips; asymptomatic; primarily caused by sun exposure
Kaposis Sarcoma AIDS; malignant lesion of blood vessels; painless purple nodule; hard
palate
***Prevention = minimize sun and tanning bed exposure, tobacco cessation, and alcohol
intake, HPV16***
Mouth Disorders- NANDA
Impaired oral mucus membranes
Imbalanced nutrition: < than body requirements
Deficient knowledge
Acute pain
Disturbed body image
Mouth Disorders- Interventions
Assess oral cavity frequently; document
Provide frequent mouth care; toothettes
Avoid irritants; tobacco, alcohol, spicy foods, rough foods
Assess food intake; high protein, calories
Provide assistive devices; straws, feeding syringes
Administer medications; topical anesthetics, antivirals, antifungals
***CAUTION: ANY UNDIAGNOSED ORAL LESION FOR MORE THAN ONE WEEK MUST BE EVALUATED FOR
MALIGNANCY***

Oral Cancer
Primary Risk Factors
1. Smoking
2. Alcohol
3. Chewing tobacco
4. Possible: marijuana use, chemical exposure, viruses (HPV), sun exposure
***High mortality rates, appears on lips, tongue, floor of mouth. Squamous cell = most common.
Early signs=unusual lumps, thickening, pain, burning. Late signs=dysphagia, difficulty chewing,
pain that radiates to the ear***
Oral Cancer Interventions (chart 56-3 pg 1236)
Eliminate causative agent (tobacco, alcohol)
Determination of malignancy (biopsy)
Determination of staging (MRI, CT Mets to tongue, oropharynx, mandible, maxilla)
Assess cervical nodes (mets)
Tx: surgery (radical neck dissection), chemo, radiation or combo
***Death usually occurs if mets to lymph nodes***
Oral Cancer NANDA

Risk for ineffective airway clearance r/t location, extent (positioning, TCDB, suctioning, O 2,
monitor RR status,
monitor for aspiration
risk)
Imbalanced nutrition; less than body requirements (daily wts, oral intake, dietary consult)
Impaired verbal communication (radical neck dissection tracheostomy; cant talk need
communication plan;
allow ample time to communicate.
Work with speech therapist)
Disturbed body image (assess coping, provide emotional support)
ESOPHAGEAL PROBLEMS
GERD (GastroEsophageal Reflux Disease aka Acid Reflux)
Causes: Relaxation of LES (Lower esophageal sphincter)
Incompetent LES
pressure in stomach
GERD Supporting Data (chart 57-1 pg 1244)
Heartburn (dyspepsia) after meals, when bending over or reclining
Regurgitation of sour taste in mouth
Difficulty (stricture/inflammation), pain when swallowing (dysphagia, odynophagia)
Atypical chest pain (rule out heart attack first)
Sore throat or hoarseness (chronic cough especially in children)
Belching (eructation), gas (flatulence), bloating after eating
Water brash (sensation of fluid in throat but no sour taste as with regurgitation)
***risk for aspiration****
GERD Complications
Esophageal strictures (narrowing)
Barretts esophagus ( risk of esophageal cancer due to changes in cells that line
esophagus; ulcerations)
Superficial ulcers w/bleeding
Scarring
*****DX: 24 hr PH monitoring, Endoscopy*****
GERD NANDA
Pain
Imbalanced nutrition
Ineffective health maintenance
Deficient knowledge
GERD Interventions (Table 57-1, chart 57-2 pg 1244-45)
Lifestyle changes
Avoid triggers (caffeine, chocolate, peppermint, spicy foods, acidic foods, soda pop)
Do not eat 2-3 hrs before bedtime
Sit upright after eating (auscultate for crackles; aspiration)
Avoid tobacco, alcohol
HOB
Maintain ideal body weight
Avoid tight clothing, bending ( intrabdominal pressure)
Teach diet modifications (low fat, high fiber diet, 4-6 small meals
Administer medications
Antacids (uncomplicated cases, minimal overnight effectiveness, do not give with other
meds, diarrhea
(magnesium), constipation (calcium)
Histamine 2 blockers (tidiness, not given with antacids, IV rapid infusion= hypotension,
arrhythmias, smoking
effect, monitor for tarry stools)
Proton pump inhibitors (prazoles, Do not crush, chew or break, given with abx for H. pylori,
monitor liver fxn,
monitor for tarry stools)

Pro-motility agent (Reglan, Extra-pyramidal side effects speech, gait, swallowing,

twitching)
Surgery
Nissen fundoplication (R/F respiratory complications due to close proximity of incision to
the lungs)
Hiatal Hernia (sliding (more common), rolling)
Diagnosis- same as GERD
Symptoms- similar to GERD
Treatment- similar to GERD
Nursing care- same as GERD
***complications include r/f infection(peritonitis), blood supply***
Achalasia
An Esophageal motility disorder in which the LES fails to relax properly with swallowing.
Normal peristalsis of the esophagus is replaced with abnormal contractions which cause
discomfort. Over time, esophagus becomes
massively dilated which slows food passage.
(Dx by barium swallow)
Esophageal Tumors
Etiology and Genetic Risk (most arise from epithelium, grow quickly and spread to lymph
nodes)
Barretts esophagus
Dysphagia vs Odynophagia
Primary risk factors include tobacco, alcohol use, obesity and malnutrition
Esophageal CA Manifestations or Supporting Data (high mortality rate b/c dx usually late)
Dysphagia (Most common symptom)
Weight loss
Regurgitation
Chest pain
Anemia
GERD-like symptoms
Anorexia
Persistent cough
DX: barium swallow, endoscopy. CXR, CT, MRI identifies metastasis (often to liver)
Esophageal CA- NANDA
Imbalanced Nutrition: < body requirements r/t impaired swallowing
Anticipatory grieving r/t terminal prognosis
Risk ineffective airway clearance r/t impaired swallowing
Deficient knowledge
Risk for Aspiration r/t esophageal strictures; impaired swallowing
Acute/Chronic pain r/t pressure from tumor
Esophageal Cancer Interventions
Surgical resection (anastomosis of stomach to remaining esophagus)
Radiation (done prior to surgery)
Chemo (done prior to surgery)
May be palliative treatment (if advanced disease)
Provide post-op care (Respiratory care =priority. Shock, Pain, NG tube, prevent distention
(fluid volume
overload), prevent aspiration, prevent infection, wound care, nutrition (j-tube
feedings)
TX: is individual to each pt. Depends on stage, condition of pt and pt preference

Stomach Disorders
Gastritis (inflammation of the stomach lining)
Acute (thick red, with rugae)
Chronic (patchy, diffuse
inflammation)
Meds (ASA, NSAIDS, steroids)
Autoimmune (antibody causes lack of
intrinsic factor)
Alcohol
H. pylori (gram (-) causes chronic
infection of mucosa,
Caffeine

risk for peptic ulcer disease)

Contaminated foods
Aging
Corrosive substances
Radiation
Chemo
Erosive (stress induced life threatening Curlings ulcer with burn victims)
(Cushings ulcer with head injury)
Acute
(Chart 58-2 pg 1267)
Rapid onset of epigastric pain
N/V
Anorexia
Gastric hemorrhage
Dyspepsia
Hematemesis

Chronic
Vague epigastric pain relieved by food
N/V
Anorexia
Intolerance of fatty. Spicy foods
Pernicious anemia

Gastritis NANDA
Deficient fluid volume
Imbalanced nutrition: < body requirements
Deficient knowledge
Gastritis- Interventions
Teach food safety (fully cooked meats, eggs; refrigerate food within 2 hrs)
Initially maintain NPO status with gradual reintroduction of fluids; clear liquids (for acute
episode)
Avoid triggers
Meds (Proton pump inhibitors, H2 blockers, Flagyl, amoxicillin, Prilosec or Prevacid
commonly used to treat H. pylori (blood test, breath test)
Peptic Ulcer Disease
Duodenal (most common)
Gastric- increased risk gastric CA (common in smokers, NSAID use (ASA), family hx)
Esophageal
****peptic ulcer perforation is a surgical emergency. Pt may present in knee-chest (fetal)
position****
****hypokalemia and metabolic alkalosis may result from vomiting****
Peptic Ulcer Disease
Duodenal
Most common
Affects mostly males 30-55 years age
Ulcer found near pylorus
Wt loss
Pain after meals
High stress

Gastric
Affects 55-70 yoa
Found on lesser curvature
Associated with r/f gastric cancer
Pain 30 minutes to 1 hr after eating

PUD Manifestations or Supporting Data

Pain (radiates to the back; gnawing, burning, aching, hunger-like pain)
Heartburn
Regurgitation
***Elderly 1st symptom may be GI bleed (from blood thinner usage)***
PUD Complications
Hemorrhage(Most serious; hematemesis (coffee grounds), melena (black tarry; occult),
weakness, fatigue, HH)
Obstruction (edema of surrounding tissue; epigastric fullness, N/V, worsening ulcer s/s,
electrolyte disturbances)
Perforation (pain radiates to shoulder, no bowel sounds, HR, fever, diaphoresis,
peritonitis *EMERGENCY*)
PUD Complication Interventions
Restore & maintain circulation (IVF, blood transfusion)
EGD control bleeding (laser cauterization)
NPO with NG tube (gastric decompression)
Meds (Antacids, IV H2 blockers (Protonix), IV abx with perforation)
Surgery (if bleeding is not controlled)
Nutrition therapy (directed toward neutralizing acid and reducing hypermotility)
Bland, nonirritating diet (during acute symptomatic phase)
Avoid bedtime snacks.
Avoid alcohol and tobacco.
Avoid Milk
Hypovolemia Management
Monitor VS, observe for fluid loss from bleeding and vomiting.
Monitor serum electrolytes
Insert two large-bore peripheral IV catheters to replace both fluids and blood lost.
Volume replacement should be started immediately (blood products)
Blood products may be ordered to expand volume and correct abnormalities in the CBC.
Orthostatic hypotension is common in patients with decreased fluid volume
NANDA PUD
Pain (stress reduction, meds, relaxation)
Sleep pattern disturbance
Imbalanced nutrition: < body requirements (limit foods after eating meals)
Deficient fluid volume
Deficient knowledge
Surgical Management
Preoperative careinsertion of a nasogastric tube.
Operative procedure: A simple gastroenterostomy permits neutralization of gastric
acid.
Vagotomy eliminates the acid-secreting stimulus to gastric cells and decreases the
response of parietal
cells.
Pyloroplasty facilitates emptying of stomach contents.
PUD Interventions
Assess pain
Administer meds (Reassess)
Teach stress reduction/relaxation techniques
Limit food intake after evening meal (or 3 hours prior to bedtime)

Assess diet/refer dietician (avoid irritants) (monitor N/V, anorexia)

Administer IVFs
Replace electrolytes (anemia)
Monitor labs
Zollinger-Ellison Syndrome
Characteristic ulcer pain is common
May have diarrhea & steatorrhea
Complications: bleeding & perforation; fluid & electrolyte imbalances
Gastric Cancer- Risk Factors (Most cancers of the stomach are adenocarcinomas; deposition
in lymph nodes)
H. pylori (35%-89%)
Genetic predisposition
Chronic gastritis
Achlorhydria (absence of HCL)
Diet high in smoked foods & nitrates (Asians)
Gastric CA Manifestations or Supporting Data
Early Gastric Cancer
Advanced Gastric Cancer
Indigestion
N/V
Feeling of fullness (satiety)
Iron deficiency anemia
Abdominal discomfort (relieved antacids)
Enlarged lymph nodes
Epigastric, back, retrosternal pain
Progressive wt loss
Obstructive symptoms
Palpable epigastric mass
Weakness, fatigue
Virchows, Blumers, Sister Mary Joseph nodes,
Krukenergs
NANDA Gastric Cancer
Imbalanced nutrition: < body requirements
Acute pain
Risk for ineffective airway clearance
Anticipatory grieving
Deficient knowledge
Gastric Cancer
Surgery
Gastrectomy (total or partial removal of stomach)
Dumping Syndrome
Complication associated with gastric surgery
Occurs 5-30 minutes after eating:
1. nausea
2. possible vomiting
3. epigastric pain & cramping
4. borborygmi (loud gurgling, hyperactive bowel sounds)
5. diarrhea
***** Watch for vertigo, HR, syncope, diaphoresis, pallor, palpitations, desire to lie
down*****
Dumping Syndrome Interventions
Consume liquids & solids separate
Increase amount fat & protein (high calorie, high protein diet)
Reduce carbohydrates
Rest recumbent 30-60 minutes after eating

Meds (anticholinergics; antispasmotics)

Gastric CA- Interventions

Assess anemia
Administer chemo or radiation for mets
Consult dietician
Assess pain
Refer Hospice
Immediate post-op care
UGI- Pediatrics
Hypertrophic Pyloric Stenosis (first 2-5 wks of life; genetic predisposition)
DX: ultrasound, electrolyte imbalances (NA, K, BUN)
Surgical relief (pyloromyotomy)
Pyloric Stenosis Manifestations or Supporting Data
Projectile vomiting
Peristaltic waves
Olive sized mass in LUQ
Hungry, irritable, failure gain wt
Surgical correction
NANDA Pyloric Stenosis
Deficit fluid volume
Altered nutrition: less than body requirements
Sleep pattern disturbance
Altered family processes
Pyloric Stenosis- Interventions
Administer IVFs
Withhold oral feedings - NPO
Assess skin turgor (dehydration)
Assess fontanels (dehydration)
Monitor I/O (strict)
Assess mucous membranes (dehydration)
Monitor electrolytes
Obtain daily weights (fluid retention)
Maintain correct position
PREVENTION KEY

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