Upper GI Problems

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On the lips or anywhere in the mouth-- tongue, floor of mouth, buccal mucosa, hard and soft palate, pharyngeal walls, and tonsils.

Where can cancer of the mouth occur?

60 years

Average age onset of cancer of the mouth?

Men (Affects all ethnic groups.)

Cancer of the mouth more common in men or women?

Squamous Cell Carcinoma

Most common oral malignant tumor

Lower lip in men. (other common sites: under tongue, labial, buccal mucosa)

Most malignant tumors of the mouth occur where?

Carcinoma of the lip (b/c lip lesions are more apparent)

Most favorable prognosis of any of the oral tumors.

Carcinoma of the oral cavity

Predisposing factors of ____: Overexposure to ultraviolent radiation, irritation from pipe smoking, tobacco use, chronic alcohol use, poor dental care, and increasing age.

Oral Cancer

Leukoplakia, erythroplakia, ulcerations, sore spot, rough area (felt with tongue). Later s/s--dysphagia, pain, difficulty chewing and speaking.

Leukoplakia

White patch or "smoker's patch" on mucosa of mouth or tongue-- becomes hard and leathery. Result of chronic irritation, esp from smoking. (Precancerous lesion--7% become malignant)

Erythroplasia

Red velvet patch on floor of the mouth or tongue, palate, and mucosa. (Precancerous lesion--90% become malignant).

Cancer of the lip

Usually appears as a painless ulcer of the lip.

Ulcer or area of thickening

First sign of carcinoma of the tongue

Proximal (may experience limitation of movement of the tongue)

Cancerous lesions are most likely to develop on which part of the tongue?

Later s/s of CA

Increased salivation, slurred speech, dysphagia, toothache, earache (May be asymptomatic)

Biopsy

Best definitive diagnostic measure for oral cancer.

Surgery (esp for removing central core of tumor)

Most effective tx for oral cancer.

Radical neck dissection (removes lesion, regional lymph nodes, deep cervical lymph nodes, and lymphatic channels)

Cancers of the oral cavity mets early to the cervical lymph nodes, so a ___ is commonly performed.

Chemo and radiation are used together

When lesions are more advanced, what is done?

Chemo

When sx and radiation fail OR initial therapy for small tumors

Pallative tx

Best management when the prognosis is poor, cancer is inoperable, or pt decides against surgery.

treat the s/s & make pt more comfortable

Pallative tx aims to...

Frequent suctioning and GT tube may be placed

When swallowing becomes difficult for the pt...

See MD!!

Danger S/S: Unexplained pain or soreness in mouth, unusual bleeding from oral cavity, dysphagia, swelling or lump in neck, ulcer that does not heal in 7-10 day.

GERD

Reflux of gastric contents into the lower esophagus

Predisposing factors of GERD

Hiatal hernia, incompetent lower esophageal spinchter (LES), decreased gastric emptying

Heartburn

Burning, tight sensation felt beneath the lower sternum and spreads upward.

When it occurs >1/wk, becomes more severe, and occurs at night and awakes person

When should heartburn be reported to MD?

Barium swallow and endoscopy

Diagnostic studies for GERD

Antacids

Drugs therapy for GERD

Health promotions behaviors for GERD

Sleep with HOB raised or 2-3 pillows, decrease gasy and high fat foods, no milk products at nights, and avoid late night snacking or meals, stop smoking, avoid acid-containing foods, do not lie down 2-3 hrs after eating.

Regurgitation

Common with GERD-- hot, bitter, or sour tasting liquid coming into mouth or throat.

GERD

Heartburn, regurgitation (common). May report--wheezing, coughing, dyspnea, hoarseness, sore throat, lump in throat, choking.

Hiatal hernia

Herniation of a portion of the stomach into the esophagus thru an opening or hiatus, in the diaphragm.

Older adults, women

Hernias are more common in who?

Sliding hernia

Most common type of hernia (90%)-- the junction of the stomach and esophagus is above the hiatus of the diaphragm, and a part of the stomach slides thr the hiatal opening in the diaphragm. (Reflux)

TC=supine AC=standing upright

Slides into throacic cavity in ___ position. Back into ab cavity= ___.

Rolling hernia

Gastroesophageal junction remains in the normal position, but the fudus and greater curvature of the stomach roll through the esophageal hiatus and into the thorax BESIDE the esophagus.

Factors for sliding hernia

Obesity, pregnancy, ascites, tumors, tight corsets, intense physical exertion, heavy lifting, increased age. (reflux)

Sliding hiatal hernia

Heartburn, regurgitation, chest pain, dysphagia, belching

Rolling hiatal hernia

Feeling of fullness after eating, breathlessness after eating, feeling of suffocation, worsening of conditions in recumbent (lying) position.

barium swallow

Diagnostic study for hernia

Tx for Hiatal hernia

Administer anacids and antisecretory agents, elimination of constricting garmants, avoidance of heavy lifting, elimination of alcohol and smoking, elevation of HOB, weight lose. Operative=Nissen (reinforces LES)

Post op care for hiatal hernia repair

TCDB, NG tube--peristalsis returns, fluids given initially. Solids gradually. Normal diet w/i 6 wks. Chew thoroughly and avoid gas forming foods.

Esophageal CA

Predisposing factors: cig smoking, excessive alcohol intake (2 most important) chronic trauma, poor oral hygience, spicy foods, exposure to asbestos and metal, low intake of frest fruits and veggies

Esophageal CA

Usually located in middle or lower portions of the esophagus. Malignant tumor usually appears as an ulcerated lesion. Tumor may penetrate the muscular layer and even extend outside the wall of the esophagus.

Esophageal CA

Onset of sx usually late in relation to tumor. Progressive dysphagia--first with meat, then soft foods, then liquids. Feeling of food stuck in throat, regurg, hoarseness. Pain (late) in substernal, epigastric, and back areas and increases with swallowing. Weight loss (>20).

Barium swallow and biospy

Diagnostic studies for esophageal CA

Liver, lung

Common mets sites for esophageal CA

Early lymphatic spread and late development of sx

Why does esophageal CA have a poor prognosis?

Surgical removal and radiation

Tx with best results for esophageal CA

High protein, high cal diet

What type of diet should a post-op pt c esophageal CA be on?

Diverticula

Saclike outpouchings of one or more layers of the esophagus.

Diverticula

Dysphagia, regurg, tasting sour food, foul odor.

Malnutrition, aspiration, perforation

Complications of diverticula

If nutrition becomes disrupted

Surgical tx for diverticula if...

Barium swallow, EGD

Diagnostic tests for diverticula

Esophageal strictures

Most common cause--strong acids or alkalines injested, reflux, peptic strictures. Can also be caused by trauma--throat lacerations or gunshot wounds. Develop over long period of time. Can be dilated periodically with balloon dilation technique.

Achalasia

LES fails to relax with swallowing and normal peristalsis is replaced with abnormal contractions (spasms).

Achalasia

Dysphagia, substernal chest pain during or after meal, regurg of sour tasting foods, weight loss, halitosis.

Achalasia

Tx: dilation (balloon periodically and metal stents), surgery (esophagomyotomy), drugs--Procardia to reduce LES pressure. Semi-soft bland diet, eat slowly, and drink fluids with meals. Sleep with HOB elevated.

Gastritis

Inflammation of the gastric mucosa (acute or chronic & diffuse or localized)-- Occurs as a result of a breakdown in the normal gastric mucosal barrier

Causes of Gastritis

Corticosteroids and NSAIDS--increase HCl acid secretion. ASA and digitalis--directly irritate gastric mucosa. Chronic alcohol abuse, excessive ingestion of ASA.

type A (fundal) & type B (antral)

Types of gastritis

Type A Gastritis--seen in pts with pernicious anemia

Type __ Gastritis: autoimmune d/o; seen in pts with?

Type B

Type __ Gastrits: common prob in adults and H pylori is found.

Gastritis

S/S: anorexia, n/v, epigastric tenderness, feeling of fullness, and hemorrhage (most common c alchol abuse; may be only sx)

Sx are non-specific

Why is the diagnosis of gastritis frequently delayed or missed?

Find the cause and avoid!! Follow prescribed diet and med regimen. May be put on bed rest, NPO, and IV fluids

Tx for gastritis

Bland diet with 6 feedings/day and antacids after meal.

Diet for gastritis pt

Peptic ulcers

EROSION of the GI mucosa (acute or chronice & gastric or duodenal)

Acute ulcer

SUPERFICIAL erosion with minimal inflammation--short duration and resolves quickly.

Chronic ulcer

LONG duration, ERODING thru the muscular wall with formation of fibrous tissue. Present for many months or intermittently throughout life.

Any part of the stomach. Most common--lesser curvature

Where do gastric ulcers occur?

ibuprofen, ASA, cortiocosteriods (Predinisone)

Meds that can cause ulcers (GIVE WITH FOOD!!!)

Duodenal ulcers--found first 1-2 cm of duodenum

80% of all peptic ulcers. Found where?

Duodenal ulcer

Very common for patient with gastric ulcers to have no pain or other sx. What type of ulcer has BURNING OR CRAMP LIKE pain often in the midepigastrium region beneath xiphoid process.

Gastric ulcer

Ulcer that has burning or gaseous pain

On empty stomach OR after ingestion of foods

When does pain with peptic ulcers occur?

Duodenal ulcer

Pain occurs 2-4 hrs after meals. Relieved by antacids and sometimes foods that neutralize and dilute HCl acid.

duodenal ulcer

Occur continuously for a few weeks or months and then disappear for a time, only to recur some months later.

1. Hemorrhage 2. Peforation 3. Gastric outlet obstruction

Major complications of peptic ulcers

Hemorrhage

Most common complication of peptic ulcers. Develops from erosion of granulation tissue found at base of ulcer during healing or from erosion of ulcer thru a major bv.

Duodenal ulcers

Account for greater percentage of upper GI bleed

Perforation

Most lethal complication of peptic ulcers

Gastric ulcer

Mortality rates associated with perforation are higher c ___ ulcer.

Gastric outlet obstruction

Long hx of ulcer pain. Pain progresses (generalized to upper ab area) and becomes worse toward the end of the day. Relief is obtained by belching or self-induced vomitting (projectile). Odor is offensive due to food particles that were ingested hrs or even days ago. Pt=anorectic aeb weight loss, c/o thirst and bad taste in mouth, constipation, swelling in upper ab, loud peristalsis.

Fiber optic endoscopy

Diagnostic test for peptic ulcers

3-9 weeks (Pain often disappears 3-6 days, but healing is much slower.) **important to comply with therapy and continue with follow up care for at least one year.

Complete healing of peptic ulcers may take how long?

Xray and endoscopic exam

Healing ulcer should be assessed by?

pt teaching with peptic ulcer disease

Avoid foods that cause epigastric distress--black pepper, spicy and acidic foods. Small frequent meals. Avoid cigs--delay healing and promote ulcer development. Reduce alcohol intake. Take ALL meds--antacids and antisecretory meds.

Peptic ulcer disease: Criteria for Surgery

Intractability--failure of ulcer to heal or recurrence of ulcer after therapy. Hx of hemorrhage or inc bleeding during tx. Multiple ulcer sites. Existence of malignant tumor.

1. dumping syndrome 2. postprandial hypoglycemia 3. bile reflux gastritis

Postop complications from peptic ulcer surgery

Dumping syndrome

Urge to deficate--onset occurs at end of meal within 15-30 minutes after eating. Weakness, sweating, dizziness, cramps.

Postprandial hypoglycemia--relieved by sugared fluids

Uncontrollable gastric emptying of a bolus of fluid high in carbs into the small intestine-->hypoglycemia-->Weakness, mental confusion, palpitations, tachy, anxiety. What relieves this?

Postprandial hypoglycemia

Weakness, mental confusion, palpitations, tachy, anxiety.

Bile reflux gastritis-- temp relieved by vomitting & questran before/after meals

Continuous epigastric distress that INCREASES after meals.

Stomach CA

Declining CA. More prevalent with MEN in LOWER socioeconomic class, living in URBAN areas. ADVANCED stage when diagnosed.

Stomach CA

Etiology: Diet of smoked, highly salted, and spiced foods (bacon, ham). Genetics, pernicious anemia (can't absorb), atrophic gastritis, and benign gastric polyps.

Spread to adjacent organs

Stomach CA-->Malignant tumors are present for a long time and what before any sx occur?

Stomach CA

Nervous tension, anxiety, vague intermittent abdominal distress--epigastric fullness and early satiety after meals, weight loss, constipation, pale, weak, fatigue, dizzy, SOB (extreme). Pain RELIEVED BY BELCHING.

Diagnostic tests--Stomach CA

Liver enzymes, stool exam, analysis of blood/stool/gastric secretions, CEA, Upper GI, xray.

CEA (elevated=malignancy. could be elevated c smokers and benign lesions.)

Diagnostic tool for CA of GI tract.

Irregular edges and more elevated than benign

On an xray with a pt c stomach CA what does the ulcer look like?

Stomach CA

Surgery--remove as much of stomach as possible (only definiative means of achieving a cure). Radiation/chemo.

Until peristalsis returns

After stomach CA surgery, the NG tube remains in place til when?

decrease degree of gastric acidity

Aim of tx for stomach CA pt

Origin--venous, capillary, or arterial.

The severity of a GI bleed depends on what?

Bright red blood (indicated blood has not been in contact with stomach's acid secretions)

What color is bleeding from an arterial source?

Coffee ground

Reveals that blood has been in the stomach for some time--changed by contact with gastric secretions.

Slow bleed from upper GI source

Melena (black, tarry stools) indicates

Darker the stool

The longer the passage of blood thru the intestines = ?

Causes of GI Bleed

Chronic esophagitis, bleeding from a tear of the mucosa, esophageal varices, peptic ulcers, and ulcers can penetrate into arteries. Drug-induced (ASA, ibuprofen, corticosteriods). Systemic diseases (leukemia, blood dyscrasias).

GI bleed (vomit and stools should be tested for occult blood.)

Diagnostic tests for ? = Blood work, CBC, BUN elevated, serum electrolytes, blood glucose, PT time, liver enzymes, ABGs, type and cross-match of blood.

2- one for fluids and the other for blood replacement

How many IV lines should a patient with a GI bleed have?

Isotonic crystalloid (RL)

In a GI bleed best to begin with what IV solution?

Whole blood, PRBCs, fresh frozen plasma

Used for replacement of lost volume in massive hemorrhage.

BP, Rate and character of pulse, peripheral perfusion (cap refill), neck vein distention, s/s of shock.

Immediate physical exam on GI bleed pt includes?

:(

Ulcer disease, drug or alcohol abuse, and liver and resp diseases can all result in GI bleed!!

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