Current therapies for peptic ulcer disease are aimed at neutralization of gastric acid, inhibition of gastric acid (H2 antagonists and proton pump inhibitors), and promotion of mucosal protection. Growth of the mucosa itself, strengthening the gastrointestinal (GI) sphincters, and changing the rate of stomach emptying are not goals of the usual pharmacologic treatments for peptic ulcers.
Increasing the rate of gastric emptying
Promoting hypertrophy of the gastric mucosa
Increasing muscle tone of the cardiac sphincter
Inhibiting gastric acid production
Zollinger-Ellison syndrome is a rare condition caused by gastrin-secreting tumors that are most commonly found in the small intestine or pancreas. Gastric acid secretions reach levels that ulceration becomes inevitable. Excessive belching and burping following meals are associated with GERD. Continuous vomiting lasting many days at a time may be associated with a neurological event or may be drug related (e.g., chemotherapy).
Pain located near the midline close to the xiphoid process
Excessive belching and burping following meals
Burning, gnawing pain when the stomach is empty
Continuous vomiting lasting many days at a time
Diagnosis of gastric cancer is accomplished by a variety of techniques, including barium x-ray studies, endoscopic studies with biopsy, and cytologic studies (Pap smear) of gastric secretions. Echocardiography is used primarily for suspected or known heart diseases.
Papanicolaou smear of gastric secretions
Barium swallow study
Endoscopic exam with biopsy
A hallmark of irritable bowel syndrome is abdominal pain that is relieved by defecation and associated with a change in consistency or frequency of stools. Irritable bowel disease is characterized by persistent or recurrent symptoms of abdominal pain, altered bowel function, and varying complaints of flatulence, bloating, nausea and anorexia, constipation or diarrhea, and anxiety or depression. Abdominal pain usually is intermittent, is described as cramping in the lower abdomen, and does not usually occur at night or interfere with sleep. Inflammatory bowel disease is characterized by blood in stool. Peptic ulceration pain occurs when the stomach is empty.
Pain is relieved by defecation.
Pain is described as “cramping” in the lower abdomen.
Pain is worse after and between meals.
Pain is most severe at night.
Belching makes the pains go away.
Inflammatory bowel diseases produce inflammation of the bowel, with a lack of confirming evidence of a proven causative agent, have a pattern of familial occurrence, and can be accompanied by systemic manifestations. A number of systemic manifestations have been identified: osteoarthritis affecting the spine, sacroiliac joints, large joints of the arms and legs; inflammatory conditions of the eye; skin lesions, especially erythema nodosum; stomatitis; and autoimmune anemia, hypercoagulability of blood (rather than thrombocytopenia), and sclerosing cholangitis. With irritable (rather than inflammatory) bowel syndrome, a history of lactose intolerance should be considered because intolerance to lactose and other sugars may be a precipitating factor in some persons.
Crohn disease is a recurrent, granulomatous type of inflammatory response with formation of multiple sharply demarcated, granulomatous lesions that are surrounded by normal-appearing mucosal tissue. There usually is a relative sparing of the smooth muscle layers of the bowel, with marked submucosal layer inflammatory and fibrotic changes. Complications of Crohn disease include fistula formation, abdominal abscess formation, and intestinal obstruction. Fistulas are tube-like passages that form connections between different sites in the gastrointestinal tract. They also may develop between other sites, including the bladder, vagina, urethra, and skin (hence, the urine will smell like feces). Characteristics of ulcerative colitis (rather than Crohn disease) are crypts of Lieberkühn lesions in the base of the mucosal layer, formation of pinpoint mucosal hemorrhages, and development of crypt abscesses that become necrotic.
Inability to control diarrhea
Urine that has the look and smell of feces
Necrotic abscesses from twisting of the bowel
Tender right upper quadrant pain upon deep palpation
Unlike Crohn disease, which can affect various sites in the gastrointestinal tract, ulcerative colitis is confined to the rectum and colon. Ulcerative colitis typically presents as a relapsing disorder marked by attacks of diarrhea. The diarrhea may persist for days, weeks, or months and then subside, only to recur after an asymptomatic interval of several months to years or even decades. Because ulcerative colitis affects the mucosal layer of the bowel, the stools typically contain blood and mucus. Nutritional deficiencies are common in Crohn disease because of diarrhea, steatorrhea (fatty stools), and other malabsorption problems. Crohn disease causes granulomatous changes, often referred to as skip lesions because they are interspersed between what appear to be normal segments of the bowel. External hemorrhoids and prolapsed colon are not associated with ulcerative colitis.
Stool containing blood (hematochezia)
C. difficile colitis is associated with antibiotic therapy; C. difficile is noninvasive, and development of C. difficile colitis requires disruption of normal intestinal flora. Peptic ulcers, hyperbilirubinemia, and Crohn disease are not common risk factors for the development of C. difficile colitis.
A 55-year-old man who takes proton pump inhibitors for the treatment of peptic ulcers
A 79-year-old hospitalized client who is being treated with broad-spectrum antibiotics
A premature neonate who has developed hyperbilirubinemia and is receiving phototherapy
A 30-year-old client who has a history of Crohn disease and has been admitted to a hospital to treat a recent flare-up
Diverticulitis is a complication of diverticulosis in which there is inflammation and gross or microscopic perforation of the diverticulum with possible abscess formation and without bleeding. One of the most common complaints of diverticulitis is pain in the lower left quadrant, accompanied by nausea and vomiting. Appendicitis has an abrupt onset of general pain referred to the epigastric or periumbilical area. The large-volume form of diarrhea usually is a painless, watery type without blood or pus in the stools. Acute abdominal distention is associated with acute bowel obstruction or peritonitis.
Increased abdominal distention
Lower left quadrant pain
Frequent rectal bleeding
Increased fiber is important in both the prevention and treatment of diverticular disease. Overuse of laxatives is not linked to diverticular disease, and heartburn and indigestion are not specific signs of the problem. An organic diet and the use of dietary supplements are not key treatments.
“I suppose I should try to eat a bit more fiber in my diet.”
“I've always struggled with heartburn and indigestion, and I guess I shouldn't have ignored those warning signs.”
“From now on, I'm going to stick to an organic diet and start taking more supplements.”
“I think this might have happened because I've used enemas and laxatives too much.”
Appendicitis is thought to be related to intraluminal obstruction with a fecalith or to twisting. Osmotic and bacterial changes are not thought to induce appendicitis, and the intestinal mucosa does not slough off either before or during episodes of appendicitis.
Increased osmolality of intestinal contents
Elimination of normal intestinal flora
Sloughing of the intestinal mucosa
Obstruction of the intestinal lumen
Inflammatory diarrhea may be caused by invasion of intestinal cells, whereas noninflammatory diarrhea normally results from the disruption of the normal absorption or secretory process. The volume of diarrhea is typically smaller and bloody. Electrolyte imbalances may accompany either type.
Larger volume of diarrhea
Infection of intestinal cells
Absence of blood in the stool
Drugs such as narcotics, anticholinergic agents, calcium channel blockers, diuretics, calcium (antacids and supplements), iron supplements, and aluminum antacids tend to cause constipation. Propylthiouracil is indicated for hyperthyroidism. Hypothyroidism can be associated with constipation.
Diuretics for his heart failure
Propylthiouracil for his hyperthyroidism
Calcium channel blockers for his hypertension
Antacids for his heartburn
Major inciting causes of mechanical bowel obstruction include external hernia (i.e., inguinal, femoral, or umbilical) and postoperative adhesions. The major symptoms of acute intestinal obstruction are pain, absolute constipation, abdominal distention, and vomiting. With mechanical obstruction, the pain is severe and colicky, in contrast with the continuous pain and silent abdomen of paralytic ileus. Paralytic (adynamic) obstruction accompanies inflammatory conditions of the abdomen, occurs early in the course of peritonitis, and can result from chemical irritation caused by bile, bacterial toxins, electrolyte imbalances as in hypokalemia, and vascular insufficiency. The major effects (rather than causes) of both types of intestinal obstruction are abdominal distention and loss of fluids and electrolytes. The most common direct causes of peritonitis include ruptured appendix.
Sluggish to absent bowel sounds
Continuous abdominal pain
Nausea and vomiting
Increase in abdominal distention
Paralytic ileus is a significant complication of abdominal surgery. The problem is not associated with the use of antidiarrheal medications, obesity, or irritable bowel syndrome.
A client who is first day postoperative following gallbladder surgery
An obese client who refuses to ambulate because he complains of shortness of breath
A client whose acute diarrhea has necessitated the use of antidiarrheal medications
A client with a long-standing diagnosis of irritable bowel syndrome
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