Chapter 37

Management of Patients With

Gastric and Duodenal Disorders

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Gastritis
• Inflammation of the stomach
• A common GI problem
• Acute: rapid onset of symptoms usually caused by
dietary indiscretion. Other causes include medications,
alcohol, bile reflux, and radiation therapy. Ingestion of
strong acid or alkali may cause serious complications.
• Chronic: prolonged inflammation due to benign or
malignant ulcers of the stomach or by Helicobacter
pylori. May also be associated with some autoimmune
diseases, dietary factors, medications, alcohol, smoking,
or chronic reflux of pancreatic secretions or bile.

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Erosive Gastritis

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Manifestations of Gastritis
• Acute: abdominal discomfort, headache, lassitude,
nausea, vomiting, hiccuping.
• Chronic: epigastric discomfort, anorexia, heartburn after
eating, belching, sour taste in the mouth, nausea and
vomiting, intolerance of some foods. May have vitamin
deficiency due to malabsorption of B12.
• May be associated with achlorhydria, hypochlorhydria, or
hyperchloryhydria.
• Diagnosis is usually by UGI X-ray or endoscopy and
biopsy.

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Medical Management of Gastritis
• Acute
– Refrain form alcohol and food until symptoms subside
– If due to strong acid or alkali treatment to neutralize the
agent, avoid emetics and lavage due to danger of
perforation and damage to esophagus
– Supportive therapy
• Chronic
– Modify diet, promote rest, reduce stress, avoid alcohol and
NSAIDs
– Pharmacologic therapy (See Table 37-1)

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Peptic Ulcer
• Erosion of a mucous membrane forms an excavation in
the stomach, pylorus, duodenum, or esophagus
• Associated with infection of H. pylori
• Risk factors include excessive secretion of stomach acid,
dietary factors, chronic use of NSAIDs, alcohol, smoking,
and familial tendency.
• Manifestations include a dull gnawing pain or burning in
the mid-epigastrium; heartburn and vomiting may occur
• Treatment includes medications, lifestyle changes, and
occasionally surgery (See Tables 37-1 and 37-3)

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Deep Peptic Ulcer

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Surgical Procedures for Peptic Ulcers

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Question
Is the following statement True or False?

The most common site for peptic ulcer formation is the

pylorus.

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Answer
False

The most common site for peptic ulcer formation is not the
pylorus. The most common site for peptic ulcer formation
is the duodenum.

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Nursing Process: The Care of the Patient
with Gastritis—Assessment
• History including presenting signs and symptoms
• Dietary history and dietary associations with symptoms
• 72 hour diet; diary may be helpful
• Abdominal assessment

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Nursing Process: The Care of the Patient
with Gastritis—Diagnoses
• Anxiety
• Imbalanced nutrition
• Risk for fluid volume imbalance
• Deficient knowledge
• Acute pain

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Nursing Process: The Care of the Patient
with Gastritis—Planning
• Major goals may include reduced anxiety, avoidance of
irritating foods, adequate intake of nutrients,
maintenance of fluid balance, increased awareness of
dietary management, and relief of pain.

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Interventions
• Reduce anxiety; use calm approach and explain all
procedures and treatments.
• Promote optimal nutrition; for acute gastritis, the patient
should take no food or fluids by mouth. Introduce clear
liquids and solid foods as prescribed. Evaluate and report
symptoms. Discourage caffeinated beverages, alcohol,
cigarette smoking. Refer for alcohol counseling and
smoking cessation.
• Promote fluid balance; monitor I&O, for signs of
dehydration, electrolyte imbalance, and hemorrhage.
• Measures to relieve pain: diet and medications.
• See Chart 37-1.

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Nursing Process: The Care of the Patient
with Peptic Ulcer—Assessment
• Assess pain and methods used to relieve pain
• Dietary intake and 72 hour diet diary
• Lifestyle and habits such as cigarette and alcohol use
• Medications; include use of NSAIDs
• Sign and symptoms of anemia or bleeding
• Abdominal assessment

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Nursing Process: The Care of the Patient
with Peptic Ulcer—Diagnoses
• Acute pain
• Anxiety
• Imbalanced nutrition
• Deficient knowledge

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Collaborative Problems/Potential
Complications
• Hemorrhage
• Perforation
• Penetration
• Pyloric obstruction (gastric outlet obstruction)

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Nursing Process: The Care of the Patient
with Peptic Ulcer—Planning
• Major goals for the patient may include relief of pain,
reduced anxiety, maintenance of nutritional
requirements, knowledge about the management and
prevention of ulcer recurrence, and absence of
complications.

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Anxiety
• Assess anxiety
• Calm manner
• Explain all procedures and treatments
• Help identify stressors
• Explain various coping and relaxation methods such as
biofeedback, hypnosis, and behavior modification

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Patient Teaching
• Medication teaching
• Dietary restrictions
• Lifestyle changes
• See Chart 37-2

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Question
What is the best time to teach a client to take proton pump
inhibitors?
A. 30 minutes before a meal
B. With a meal
C. Immediately after the meal
D. One to three hours after the meal

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Answer
A

The best time for a client to take a proton pump inhibitor is

before a meal. It is a delayed-release medication that is
to be swallowed whole and taken before a meal.

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Management of Potential Complications
• Management of hemorrhage
– Assess for evidence of bleeding, hematemesis or melena,
and symptoms of shock/impending shock and anemia.
– Treatment includes IV fluids, NG, and saline or water
lavage; oxygen, treatment of potential shock including
monitoring of VS and UO; may require endoscopic
coagulation or surgical intervention.
• Pyloric obstruction
– Symptoms include nausea and vomiting, constipation,
epigastric fullness, anorexia, and (later) weight loss.
– Insert NG tube to decompress the stomach, provide IV
fluids and electrolytes. Balloon dilation or surgery may be
required.
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Management of Potential Complications
• Management of perforation or penetration
– Signs include severe upper abdominal pain that may
be referred to the shoulder, vomiting and collapse,
tender board-like abdomen, and symptoms of
shock/impending shock.
– Patient requires immediate surgery.

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Bariatric Surgery
• Morbid obesity: persons more than two times IBW, BMI
exceeds 30 kg/m2, or more than 100 pounds greater
than IBW. High risk for health complications.
• Surgery is preformed only after nonsurgical methods
have failed.
• Selection factors include body weight, patient history,
and failure to lose weight using other means, absence of
endocrine disorders, and psychological stability
See Chart 37-3

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Surgical Procedures for Morbid Obesity—
Roux-en-Y Gastric Bypass

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Surgical Procedures for Morbid Obesity—
Gastric Banding

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Surgical Procedures for Morbid Obesity—
Vertical-banded Gastroplasty

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Surgical Procedures for Morbid Obesity—
Biliopancreatic Diversion with Duodenal
Switch

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Nursing Care of the Patient Undergoing
Bariatric Surgery
• Preoperative care; evaluation and counseling
• Postoperative care is similar to gastric resection but the
patient is at greater risk for complications due to obesity
• Postoperative diet: six small feedings totaling 600-800
calories per day (see Chart 37-4)
• Patients require psychosocial interventions to modify
their eating behaviors.
• Follow-up care
• Education regarding long-term effects

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Question
Is the following statement True or False?

The average weight loss after bariatric surgery is 60% of

previous body weight.

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Answer
True

The average weight loss after bariatric surgery is 60% of

previous body weight.

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Gastric Cancer
• Incidence is deceasing, but accounts for 12,000 deaths in U.S.
annually.
• Increased incidence in men, Native Americans, Hispanic
Americans, and African Americans, typically ages 40-70.
• Risk factors include diet, chronic inflammation of the stomach,
H. pylori infection, pernicious anemia, smoking, achlorhydria,
gastric ulcers, previous subtotal gastrectomy, and genetics.
• Manifestations include pain relieved by antacids, dyspepsia,
early satiety, weight loss, abdominal pain, loss or decrease in
appetite, bloating after meals, nausea, and vomiting. Diagnosis
of the disease is often late.
• Treatment is surgical removal of the tumor if possible, and
palliative care if the tumor is unresectable or metastasized.

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Nursing Process: The Care of the Patient
with Gastric Cancer—Assessment
• Dietary history and nutritional status
• Risk factors and smoking and alcohol history
• Social support, individual and family coping
• Resources
• Physical assessment including assessment of the
abdomen

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Nursing Process: The Care of the Patient
with Gastric Cancer—Diagnoses
• Anxiety
• Imbalanced nutrition
• Pain
• Anticipatory grieving
• Deficient knowledge

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Nursing Process: The Care of the Patient
with Gastric Cancer—Planning
• Major goals include reduced anxiety, optimal nutrition,
relief of pain, adjustment to the diagnosis, and
anticipated lifestyle changes.

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Anxiety
• Provide a relaxed, nonthreatening atmosphere.
• Allow patient to express fears and concerns.
• Provide support and encourage family support.
• Promote positive coping measures.
• Explain treatments and procedures.
• Referral to support persons such as social worker or
clergy.

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Promote Optimal Nutrition
• Encourage small, frequent meals of non-irritating foods.
• Provide foods high in calories and vitamins A and C and
iron.
• Provide diet and teaching for potential dumping
syndrome after gastric resection.
• Six small feedings low in carbohydrates and sugar, with
fluids between, not with, meals.
• Assessment includes I&O, daily weights, assessment for
signs of dehydration, and nutritional status.

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Other Interventions
• Pain
– Administer analgesic as prescribed
– Nonpharmacologic pain relief measures
• Psychosocial support
– Allow patient to express fears concern and grief
– Allow patient to participate in decisions
– Include family members and significant others
– Referral/involvement of other support persons as
needed.
• Patient teaching (see Chart 37-5)

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Nursing Process: The Care of the Patient
with Gastric Surgery—Assessment
• Patient and family knowledge
• Nutritional status
• Abdominal assessment
• Postoperatively assess for potential complications

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Nursing Process: The Care of the Patient
with Gastric Surgery—Diagnoses
• Anxiety
• Pain
• Deficient knowledge
• Imbalanced nutrition

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Collaborative Problems/Potential
Complications
• Hemorrhage
• Dietary deficiencies
• Bile reflux
• Dumping syndrome

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Nursing Process: The Care of the Patient
with Gastric Surgery—Planning
• Major goals include reduced anxiety, increased
knowledge, optimal nutrition, management of
complications that can interfere with nutrition, relief of
pain, avoidance of hemorrhage and steatorrhea, and
enhanced self-care skills at home.

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Interventions
• Provide interventions to reduce anxiety
• Pain
– Administer analgesics as prescribed so patient may
perform pulmonary care, leg exercises, and
ambulation activities
– Position in Fowler’s position
– Maintain function of NG tube
• Patient teaching (see Chart 37-6)
• Individualized nutritional care and support

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Care and Prevention of Complications
• Gastric retention
– May require reinstatement of NPO and Ng suction.
Use low-pressure suction
• Bile reflux
– Agents that bind with bile acid: cholestyramine
• Malabsorption of vitamins and minerals
– Supplementation of iron and other nutrients
– Parenteral administration of vitamin B12 due to lack
of intrinsic factor

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Care and Prevention of Complications
• Dumping syndrome
– Due to rapid passage of food into the jejunum and
drawing of fluid into the jejunum due to hypertonic
intestinal contents.
– Causes vasomotor and GI symptoms with reactive
hypoglycemia
– Avoid fluid with meals
– Avoid high carbohydrate/sugar intake
• Steatorrhea
– Reduce fat intake and administer loperamide

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Dietary Self-Management
• To delay stomach emptying and dumping syndrome
assume low Fowler’s position after meals; lie down for
20-30 minutes.
• Take antispasmodics as prescribed.
• Avoid fluid with meals.
• Meals should contain more dry items than liquid items.
• Eat fat as tolerated, but keep carbohydrate intake low,
and avoid concentrated carbohydrates.
• Eat small, frequent meals.
• Take dietary supplements as prescribed; vitamins,
medium-chain triglycerides, and B12 injections.

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