Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations of upper GI disorders
- Describe the diagnostics for and laboratory values monitored in the management of upper GI disorders
- Apply nursing concepts and plan associated nursing care for the patient with upper GI disorders
- Evaluate the efficacy of nursing care for a patient with upper GI disorders
- Describe the medical therapies that apply to the care of upper GI disorders
This section focuses on common disorders of the esophagus and stomach that can prevent proper digestion and absorption of nutrients, and how the nurse can effectively plan and implement care. Recall that masticated food from the mouth is formed into a bolus as it moves toward the pharynx in the back of the throat and then into the esophagus. Coordinated muscle movements in the esophagus, called peristalsis, move the food bolus into the stomach, where it is mixed with acidic gastric juices and further broken down into chyme through a chemical digestion process. As chyme is moved out of the stomach and into the duodenum of the small intestine, it is mixed with bile from the gallbladder and pancreatic enzymes from the pancreas for further digestion.
Barrett’s Esophagus
A condition called Barrett’s esophagus entails the cells lining the esophagus change, becoming more like intestinal cells. It is more common in men and usually is diagnosed around age 55 years (Spechler, 2022). The cells that develop on the esophagus can be precancerous and increase the patient’s chance of developing esophageal adenocarcinoma (Souza & Spechler, 2022).
Pathophysiology
Although the exact pathophysiology is unknown, researchers believe that damage to the squamous esophageal cells resulting from gastroesophageal reflux disease (GERD) causes the cells to undergo constant repair and wound healing. The continuous damage and wound healing causes progenitor cells (cells that can differentiate into a specific cell type) from the esophagogastric junction to travel to the esophagus to aid in wound healing and replace the squamous epithelial cells. Along with GERD, other risk factors for developing Barrett’s esophagus include central obesity, smoking, and family history.
Clinical Manifestations
Barrett’s esophagus is frequently asymptomatic, but patients tend to have other symptoms of GI conditions, such as frequent heartburn and acid regurgitation or reflux. In some cases, Barrett’s esophagus can cause ulceration and stricture, and patients may have the symptoms of dysphagia or odynophagia (painful swallowing).
Assessment, Diagnostics, and Laboratory Values
Assessment is primarily based on focused subjective data gathered by the nurse and provider. Although often there are no signs or symptoms of Barrett’s esophagus, it is often discovered when completing diagnostic testing for other more common GI issues, such as heartburn or reflux.
An upper endoscopy will confirm visual changes to the tissues in the esophagus. A biopsy of the tissues will ultimately confirm Barrett’s esophagus. Tissue changes that are 3 cm or longer are termed long-segment Barrett’s, and tissue changes that are 1 cm or shorter are termed short-segment Barrett’s (Spechler, 2022).
Nursing Care of the Patient with Barrett’s Esophagus
Patients in the hospital setting with Barrett’s esophagus have often had surgical intervention to remove parts of the esophagus. Nursing care consists of administration of prescribed medications such as antireflux agents to control reflux and monitoring for symptom improvement.
Recognizing Cues and Analyzing Cues
When providing care to a patient with Barrett’s esophagus, the nurse relies heavily on a focused subjective assessment, because there are often no physical signs or symptoms of disease. Subjective data may include a history of frequent GERD, heartburn, dysphagia, or odynophagia. The nurse inquires about the frequency, severity, and duration of symptoms, and if symptoms interrupt the patient’s sleep.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Foods that are spicy, fatty, acidic, or contain caffeine, carbonation, or alcohol can exacerbate symptoms of reflux and heartburn and trigger episodes of odynophagia or dysphagia. The nurse may ensure the patient receives prescribed proton pump inhibitors as ordered. A proton pump inhibitor (PPI) is a medication that binds to the hydrogen-potassium ATPase enzyme system of the parietal cell, thereby pumping hydrogen ions into the stomach. The nurse should provide patient education about food choices that help prevent acid reflux, such as whole grains, root vegetables, and green vegetables.
Evaluation of Nursing Care and Outcomes for the Patient with Barrett’s Esophagus
Symptom improvement and patient understanding of the importance of diet modification and medication adherence are the goals of treatment for Barrett’s esophagus. Reassessment of symptoms reported and monitoring of the patient’s food choices can determine areas that need further intervention. A patient who is still having symptoms, or not experiencing symptom improvement, may need additional medical or dietary intervention. It is important to collaborate with the interdisciplinary team when evaluating outcomes so treatment therapies can be modified to be more effective.
Medical Therapies and Related Care
Patients diagnosed with Barrett’s esophagus are prescribed a PPI, such as omeprazole or pantoprazole, to eliminate GERD symptoms and prevent further esophageal irritation. When reflux symptoms are not controlled by PPI therapy, antireflux surgery (fundoplication) may be performed. Diet modification is also important, and patients are encouraged to eat a low-acid, GERD-friendly diet.
Gastritis
Inflammation and redness of the lining of the stomach is called gastritis. The incidence of gastritis in the United States is 8 out of 1,000 people (Cleveland Clinic, 2023b). It may be acute or chronic, and erosive or nonerosive; once the underlying cause is treated, it usually resolves. A common complication of gastritis, peptic ulcer disease (PUD) is a defect in the lining of the stomach or duodenum and can occur when gastritis is left untreated. Approximately 10% of the U.S. population has had PUD at some time (Malik et al., 2023).
Pathophysiology
Acute gastritis is usually caused by an irritant, such as aspirin or NSAID use, heavy alcohol use, smoking, and certain infections. It can also be stress induced, caused by a decrease in bicarbonate concentration in the mucosal lining of the stomach. Chronic gastritis most commonly is caused by Helicobacter pylori infection (Figure 19.12) but can also be caused by autoimmune disease, Crohn’s disease, gastric surgery, and other infections, such as HIV. There is an increased risk for complications, including gastric cancer, peptic ulcers, and gastric bleeding or perforation, when gastritis is untreated (Azer et al., 2023).
Clinical Manifestations
Patients with acute gastritis may present with epigastric pain, nausea, vomiting, or a feeling of fullness in the upper abdomen after eating. In chronic gastritis, patients are usually asymptomatic.
Patients with PUD will most commonly present with epigastric pain after meals, with pain being more immediate in gastric ulcers, and 2 to 3 hours after eating in patients with duodenal ulcers. Other symptoms include heartburn, dyspepsia, chest discomfort, hematemesis (vomiting of blood), melena (black tarry stools), fatigue, and dyspnea
Assessment, Diagnostics, and Laboratory Values
Gastritis is difficult to diagnose based on symptoms alone. It is important to take a detailed medical and social history so proper diagnostic testing can be performed. Endoscopy with biopsy is the gold standard for diagnosing gastritis (Azer et al., 2023). H. pylori infection can be diagnosed through endoscopy and biopsy, or through a urease breath test. Other testing is focused on finding the underlying cause of the gastritis.
Link to Learning
Watch this video for an explanation and demonstration of the urea breath test for H. pylori infection.
An upper GI series, or barium swallow, can check for GERD, dysphagia, hiatal hernia, ulcers, tumors, or achalasia. Serological tests will evaluate for the presence of autoantibodies. Bloodwork will check for the presence of H. pylori infection and will also check for iron deficiency anemia that can be caused by blood loss in the GI tract. A stool sample may be evaluated to check for bacteria or the presence of blood.
Nursing Care of the Patient with Gastritis
Nursing care of the patient with gastritis focuses on symptom improvement and patient education. It is important to teach the patient the importance of avoiding any foods, drinks, or medications that irritate their stomach. Smoking cessation education is also important.
Recognizing Cues and Analyzing Cues
Subjective data for a patient with gastritis can include the patient’s report of presence of gastric pain, belching or hiccups, nausea or vomiting, blood in vomit or stool, or loss of appetite. Inquire about any history of smoking, alcohol use, regular NSAID or aspirin use, or high stress levels.
For PUD, life-threatening, or alarm symptoms that warrant immediate action are
- bleeding or anemia
- early satiety
- family history of GI cancers
- progressive dysphagia or odynophagia
- recurrent vomiting
- unexplained weight loss
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Signs of GI bleeding are a high priority to be addressed. Monitor the patient’s stool for the presence of blood in the stool; bloody stool may present as a fresh, bright red color (frank) or dark and tarry. Be sure to notify the provider immediately.
Evaluation of Nursing Care and Outcomes for the Patient with Gastritis
While providing care, the nurse will evaluate outcomes to see if goals have been achieved. Goal priorities are improvement of symptoms and patient education. Treatment of the underlying cause and prevention therapy ensure an excellent prognosis. The nurse will examine every intervention taken and the patient’s response. The nurse evaluates how often the patient experiences symptoms, including timing, severity, and what could have triggered them. When comparing the patient’s history of symptoms before care, the nurse can evaluate if the interventions provided are adequate or if modifications are needed.
Medical Therapies and Related Care
Treatment can be singular or a combination of antibiotics, PPIs, vitamin supplementation, immunomodulatory therapy (medications that change the body’s immune response), and dietary modifications (Azer et al, 2023). PPIs bind to the hydrogen-potassium ATPase enzyme system of the parietal cell, also referred to as the proton pump, because it pumps hydrogen ions into the stomach. PPIs inhibit the secretion of hydrochloric acid, and the antisecretory effect lasts longer than 24 hours (Table 19.5). Treatment is dependent on the underlying cause. Other treatments for gastritis include smoking and alcohol cessation, stress management, and discontinuation of anti-inflammatory medications.
| Medication | Indication | Nursing Considerations |
|---|---|---|
| Pantoprazole | GERD Zollinger-Ellison syndrome H. pylori infection |
Can interfere with the liver metabolism of other drugs IV pantoprazole can potentially exacerbate zinc deficiency. Long-term therapy can cause hypomagnesemia. |
| Raberprazole | GERD Peptic and esophageal ulcers Erosive esophagitis H. pylori infection Zollinger-Ellison syndrome |
May cause kidney damage Can interfere with the liver metabolism of other drugs Long-term therapy can cause hypomagnesemia. May cause vitamin B12 deficiency |
| Dexlanosoprazole | GERD Esophageal erosion (treatment and prevention) |
Can interfere with the liver metabolism of other drugs Long-term therapy can cause hypomagnesemia. |
| Esomeprazole | GERD Stomach and peptic ulcers Esophageal erosion Zollinger-Ellison syndrome |
May cause kidney damage May cause vitamin B12 deficiency Can interfere with the liver metabolism of other drugs Long-term therapy can cause hypomagnesemia. |
| Lansoprazole | GERD Esophageal erosion Zollinger-Ellison syndrome Duodenal and gastric ulcers (treatment and prevention) H. pylori infection (in combination with antibiotics) |
Can interfere with the liver metabolism of other drugs Long-term therapy can cause hypomagnesemia (Gillson, 2023). |
Gastric Cancer
Stomach cancer, or gastric cancer, is the fifth most frequently diagnosed cancer and the third leading cause of cancer deaths worldwide (Mukkamalla et al., 2023). Stomach cancers tend to develop slowly and often do not have symptoms until disease has progressed. Ethnicity variations are noted, with highest incidence in Hispanic Americans, Black Americans, and American Indians. Risk factors linked to stomach cancer include H. pylori infection; obesity; a diet high in salted foods or grilled or charcoaled meats; heavy alcohol use; and smoking (American Cancer Society, 2021).
Pathophysiology
Most stomach cancers begin at the cells that line the stomach and produce mucus. These cancers are called adenocarcinomas. There are two main types of adenocarcinomas: intestinal and diffuse. Intestinal cells are more clustered, more likely to have cell mutations, and more receptive to targeted therapy. Diffuse cells are more scattered and harder to see on the surface.
Clinical Manifestations
Because stomach cancer is slow growing, cancer in most patients who present with symptoms is usually at an advanced stage (Mukkamalla et al., 2023). Symptoms include nonspecific weight loss, dysphagia, persistent abdominal pain, anorexia, nausea, hematemesis, early satiety (fullness when eating), and indigestion.
Assessment and Diagnostics
Most patients with symptoms will present with advanced disease. A palpable abdominal mass may be found, indicating advanced disease. An upper endoscopy with biopsy is the most common way stomach cancer is diagnosed. A barium swallow study may also be done in certain circumstances. Other studies to rule out metastasis, or secondary malignant growths in other parts of the body, may include abdominal CT scans, x-ray, endoscopic ultrasound, and serum studies.
Interdisciplinary Management
The provider will give the patient treatment options. Potential treatments for stomach cancer may include surgery, chemotherapy, radiation therapy, targeted drug therapy, and immunotherapy. The nurse will coordinate care, complete ongoing assessments, provide patient education, and plan and evaluate nursing care.
Medical Therapies and Related Care
Surgery is the primary treatment for stomach cancer. Surgery may be performed via endoscopy, laparoscopy, or open surgery, depending on the stage and location of the cancer. The goal is to remove the tumor and all affected tissues and leave a surgical margin that is negative for cancer cells. Common surgical procedures performed in patients with stomach cancer are total gastrectomy, partial gastrectomy, esophagogastrectomy, lymph node dissection, gastrojejunostomy, gastrostomy tube insertion, and jejunostomy tube insertion. Systemic therapy, such as chemotherapy, chemoradiation, immunotherapy, or targeted therapy, may be initiated to kill any remaining cancer cells after surgical resection.