abd dx and tx plans nurs 623 essays

abd dx and tx plans nurs 623 essays

abd dx and tx plans nurs 623 essays

Acute Gastroenteritis

Acute infection causing inflammation of the stomach and intestinal lining resulting in vomiting, diarrhea, and fever. Infection is by fecal-oral route or respiratory route. Pathogens invade the intestinal mucosa, resulting in a decreased area available for fluid absorption.

Viruses (most common), bacteria, and parasites are responsible.

• Rotavirus most common in age <1 but found in adults too. The other 3 most common pathogens in adults are: norovirus, enteric adenovirus, and astrovirus.
• Bacterial infections are less common, but usually more severe.
• Campylobacter jejuni most common in children
• Salmonella most common cause of food borne illness in US
• Other common pathogens: shigella, Escherichia coli, Yersinia enterocolitica, clostridium difficile
• Parasitic
• Giardia Iamblia most common parasitic agent in US
• Cryptosporidium
• abd dx and tx plans nurs 623 essays

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Risk factors

Improper handwashing and food preparation, daycare center attendance, recent use of antibiotics or hospitalization (C. difficile common), lack of sanitation, immunocompromised status, recent travel to developing countries

Assessment findings

Hyperactive bowel sounds, diarrhea (3 or more loose stools in 24 hours), blood in stool, white cells in stool (common with salmonella, shigella, and campylobacter), nausea and vomiting usually precede diarrhea, anorexia, fever, tenesmus (strong urge to defecate caused by and anal sphincter spasm), and fecal incontinence with C. difficile, abdominal cramps, dehydration (poor skin turgor, dry mucus membranes, flattened or sunken fontanels, tachycardia, tachypnea, oliguria), lethargy, pale skin color

Differential diagnosis

Viral, bacterial, parasitic, inflammatory bowel disease, medication/food intolerances, appendicitis, IBS, fecal impaction

Diagnostic studies

• Usually none unless symptoms are severe and last > 48 hours,
• stool for WBC: rare scattered leukocytes are normal; may suggest crohn’s disease, ulcerative colitis, ischemic colitis, shigella, salmonella, campylobacter
• stool cultures: shigella, salmonella, campylobacter, E. coli most commonly identified
• blood or mucus present in stool
• stool for ova and parasites
• urinalysis, culture, and sensitivity
• abd dx and tx plans nurs 623 essays
• in infants and elderly consider assessment for dehydration: BUN, specific gravity, electrolytes

Prevention

Hygiene, avoidance of risk factors, Shigella: culture all symptomatic contacts and treat those with positive stool cultures; report to local health department

Nonpharmacological management

• Correct dehydration, orally if possible
• Mild dehydration (3-5% volume loss): 50 mL/kg or 5 teaspoons per pound over 4 hours
• Moderate dehydration (6-9% volume loss): 100 mL/kg or 10 teaspoons/pound over 4 hours
• Rehydrating with soft drinks, gelatin, and apple juice is not advisable due to the high carbs, low electrolyte composition; commercially prepared rehydration products help avoid this problem Pedialyte, CeraLyte, Infalyte
• Age appropriate diet ASAP
• Reintroduce solid foods within 24 hours of onset of diarrhea
• BRAT diet no longer recommended because it provides inadequate protein, fat, and calories
• May develop temporary lactose intolerance and post infectious irritable bowel syndrome (IBS)
• Monitor oral intake, urine output, and bowel movements, count wet diapers

Pharmacologic Management

Use of antidiarrheal agents is discouraged; the offending agent must be excreted.

1. aureus- antibiotics not recommended

Salmonella- antibiotics not recommended because it prolongs carrier state y slowing excretion or organisms, treatment recommended (Bactrim or ciprofloxacin for patients with valvular heart disease, immunocompromised states.

Shigella- Bactrim BID for 3-5 days; if acquired outside US ciprofloxacin for 10 days

1. coli- Bactrim Bid for 3 days, may use ciprofloxacin in adults

Campylobacter- erythromycin QID for 5 days or cipro BID for 7 days

Giardia (Protozoa)- Metronidazole 250 mg TID for 5-7 days

1. Difficile- Metronidazole 500 mg 3-4 times daily for 10-14 days for mild to moderate; vancomycin 125 mg every 6 hours for 10-14 days for first episode; fecal transplant for resistance/recurrence. Questran for diarrhea

Antiemetic

Promethazine adult 12.5-25 mg every 4-6 hours prn; children 2 years or older 0.5 mg/kg at 4-6 hr intervals max 25 mg

• May cause fatal respiratory depression in children. Do not use in children under 2
• Pregnancy category C
• Cautious use in dehydrated patient
• Cautious use in sleep apnea, asthma, lower respiratory disorders, glaucoma, GI or urinary obstruction
• Potentiates CNS depression
• If given IM, must be a deep IM injection

Selective 5-HT3 receptor antagonist

Ondansetron adult 8 mg q 8 hours; children 4-11 years 4 mg q 4 hours

• For prevention of nausea/vomiting
• Not recommended for children under 4 years of age
• N/V associated with chemotherapy

Pregnancy/Lactation Considerations

Antibiotics indicated when there is a bacterial pathogen identified, refer if there is dehydration, intractable symptoms, or bloody diarrhea

Consultation/referral

Parenteral rehydration for intractable symptoms, neurologic symptoms, severe abdominal pain

Follow-up

Telephone contact within 24 hours, 3 days

abd dx and tx plans nurs 623 essays

Expected course

Both viral and bacterial gastroenteritis is usually self-limiting and resolves without medication in 5 days unless patient is at age extremes or immunocompromised, Salmonella and C. difficile infections: diarrhea may continue for up to 2 weeks

Possible complications

Cardiovascular from dehydration and acidosis, colonic perforation/septicemia, carrier state abd dx and tx plans nurs 623 essays.

Appendicitis

Inflammation of the veriform appendix, which is a projection from the apex of the cecum. Obstruction of the appendix secondary to stool, inflammation, stricture, foreign body, or neoplasm. The obstructed lumen prevents drainage. The resultant increased pressure decreases mucosal blood flow, and the appendix becomes hypoxic. Most common between ages 5-50 years, males>females.

Risk Factors

Family history, abdominal neoplasm

Assessment findings

Abdominal pain, usually severe and initially throughout the abdomen, or periumbilical area, later becomes localized to the right lower quadrant (RLQ). Anorexia, abdominal pain, nausea, and vomiting are most common symptoms (in this order). Constipation and diarrhea occur after the pain. Maximum abdominal tenderness and rigidity occurs over the right rectus muscle (McBurney’s point). Psoas sign: pain with right thigh extension. Obturator sign: pain with internal rotation of flexed right thigh. abd dx and tx plans nurs 623 essays. Fever, usually 99-101F (37.2-38.3 C). Patients frequently flex the right lower extremity when supine to relieve muscle tension. May have urinary frequency, urgency, and dysuria. Decreased bowel sounds. Elderly may present with weakness, anorexia, tachycardia, and abdominal distention.

A rectal exam should be performed on all patients with suspected appendicitis. Retrocecal appendix presents with tenderness on rectal exam.

A pelvic exam on all females with lower abdominal pain to rule out PID, adnexal mass, ectopic pregnancy, or uterine pathology.

Differential diagnosis

Mittelschmerz, ruptured etopic pregnancy, PID, gastroenteritis, gastric ulcer, duodenal ulcer, cholecystitis, urinary tract infection, Inflammatory bowel disease, recurrent abdominal pain, renal calculi

Diverticulitis, ileitis, inflammatory bowel disease and some GYN disorders can present with right sided abdominal pain.

Diagnostic studies

• Urinalysis: may be positive for RBC and leukocytes
• CBC: elevated WBC count indicates possible perforation
• Urine pregnancy test: negative
• KUB: may show gas filled appendix
• CT scan: diagnostic test of choice in adults
• Ultrasound is imaging study of choice in children
• abd dx and tx plans nurs 623 essays

Nonpharmacologic management

• Keep NPO
• Instruct to refrain from using laxative, enemas, or from applying heat to abdomen
• Prompt surgery is the treatment of choice: appendectomy

Pharmacological management

Preoperative antibiotics may be prescribed by surgeon (ex cefoxitin)

Consultant/referral

Prompt surgical referral

Follow-up

Routine postoperative assessment: 2 weeks, 6 weeks. May require postoperative antibiotics if perforation has occurred

Expected course

Quick recovery usually follows surgery. Activity should be restricted for 2-6 weeks

Possible complications

Ruptured appendix (often manifested by cessation of pain), abscess, peritonitis

abd dx and tx plans nurs 623 essays

Cholecystitis

Inflammation of the gallbladder usually associated with gallstone disease; can be acute or chronic. Gallstone obstructs the gallbladder-cystic duct junction; results in inflammation (90-95%) and acute pain. In a smaller number of cases, gallbladder inflammation occurs without stone formation. Obstruction of common bile duct can cause jaundice, light colored stools, and biliary colic. Obstruction of pancreatic duct can produce pancreatitis, pain over the abdomen, nausea and vomiting. Gallbladder sludge. Incidence increases with age and BMI; most common in ages 50-70 years females>males (2:1), very common in Native Americans.

Risk Factors

Pregnancy, rapid weight loss, obesity, gallstones, surgery or trauma, sickle cell anemia, parenteral alimentation over prolonged period.

Assessment findings

Patients are usually ill appearing, febrile, and tachycardic, murphy’s sign: inspiratory arrest with deep palpation of right upper quadrant (RUQ) (classic sign), RUQ pain, may be unremitting, with or without rebound pain, may radiate to right shoulder or subscapular area. Nausea and vomiting/anorexia. Attack follows meal (especially high fat) by 1-6 hours. Low grade fever, palpable RUQ mass. abd dx and tx plans nurs 623 essays.

A patient with acute cholecystitis usually lies very still because peritoneal inflammation is present and worsens with movement.

Differential diagnosis

PUD, cardiac disease, pancreatitis, hepatitis, bowel obstruction, appendicitis

Fatty food intolerance that produces pain, belching, a few minutes after eating is NOT typical of gallbladder disease.

Diagnostic studies

• Ultrasound is most sensitive and specific to test to diagnose cholecystitis
• Ultrasound demonstrates presence of gallstones, thickening of wall of gallbladder (4-5 mm), fluid, and enlargement.
• HIDA scan helpful if ultrasound is negative but patient is suspected of having cholecystitis (positive scan demonstrates gallbladder disease if the gallbladder is unable to be visualized due to cystic duct obstruction)
• Magnetic Resonance Cholangiopancreatography (MRCP, type of MRI that provides detailed images of hepatobiliary and pancreatic systems)
• Endoscopic retrograde Cholangiopancreatography (ERCP) used to see biliary and pancreatic ducts to detect common bile stones. Usually this is performed after a MRCP for choledocholithiasis.

A HIDA scan cholescintigraphy is indicated if the diagnosis of gallbladder disease is still considered and the ultrasound is negative. abd dx and tx plans nurs 623 essays.

Prevention

Avoid risk factors, during parenteral feedings, administer cholestyramine (Questran) daily.

Nonpharmacological management

• Severe attacks: nothing by mouth
• Mild attacks: avoid fatty meals
• Nasogastric tube for persistent nausea or abdominal distention
• Laparoscopic or open cholecystectomy within 72 hours of diagnosis

Pharmacological management

Endogenous bile acids

Bile acid (Actigall) adults: 8-10 mg/kg per day in 2-3 divided doses; prevention 300 mg twice daily

• Pregnancy category B
• Not for calcified, radio-opaque or radiolucent bile pigment stones
• Obtain sonogram at 6 and 12 months
• After complete dissolution, repeat sonogram in 1-3 months then discontinue
• Used to prevent gallstone formation in patients undergoing rapid weight loss
• Measure liver enzymes at 1 and 3 months, then q 6 months while taking

Bile acid (Urso forte) adults: 13-15 mg/kg per day in 2-4 divided doses

• Pregnancy category B
• Take with food
• Reduced absorption with bile acid sequestrants and aluminum containing antacids
• Not for calcified, radio-opaque or radiolucent bile pigment stones
• Obtain sonogram at 6 and 12 months
• After complete dissolution repeat sonogram in 1-3 months then discontinue
• Used to prevent gallstone formation in patients undergoing rapid weight loss
• Measure liver enzymes at 1 and 3 months, then q 6 months while taking
• abd dx and tx plans nurs 623 essays

Antiemetic

Promethazine adult 12.5-25 mg every 4-6 hours prn; children 2 years or older 0.5 mg/kg at 4-6 hr intervals max 25 mg

• May cause fatal respiratory depression in children. Do not use in children under 2
• Pregnancy category C
• Cautious use in dehydrated patient
• Cautious use in sleep apnea, asthma, lower respiratory disorders, glaucoma, GI or urinary obstruction
• Potentiates CNS depression
• If given IM, must be a deep IM injection

Selective 5-HT3 receptor antagonist

Ondansetron adult 8 mg q 8 hours; children 4-11 years 4 mg q 4 hours

• For prevention of nausea/vomiting
• Not recommended for children under 4 years of age
• N/V associated with chemotherapy

Consultation/referral

Outpatient if mild symptoms, surgeon if biliary colic >6 hr, toxic appearing, or intractable pain.

Follow-up

Throughout postoperative period

Expected course

Stones may recur in bile ducts after cholecystectomy

Possible complications

Empyema of the gallbladder: bacterial invasion of the gallbladder. Emphysematous cholecystitis: infection with a gas-forming bacterium. Perforation: requires aggressive fluid replacement, antibiotics and emergency surgical exploration. Cholecystenteric fistula: gallbladder perforates into duodenum or colon; should be treated as a bowel obstruction with fluid replacement, nasogastric suction, and surgical exploration.

Inflammatory bowel disease

Inflammatory bowel diseases are chronic disorders of the GI tract distinguished by the recurrent inflammatory involvement of the intestinal segments. Teo main types are Crohns disease and ulcerative colitis.

Crohn’s disease

Chronic, slowly progressive transmural inflammation of the gastrointestinal tract, small intestine (most common), and/or large intestine, often involving the terminal ileum; disease ranges from mild to refractory in severity. Typically, several locations of the intestines with sections in between are unaffected. Idiopathic. Females>males, % have family history, Caucasians>African-Americans or Asians, peak age at onset is 15-25 years, then smaller peak at 55-65 years. Three to six-fold increased incidence in Ashkenazi Jewish population.

Risk factors

Family history, cigarette smoking

Assessment findings

Diarrhea (including nocturnal), fever, abdominal pain and tenderness, ulcers of the intestine or mouth, fatigue, weight loss, abdominal mass, fistulas, intestinal obstruction (uncommon), hematochezia, megacolon, extracolonic disease: uveitis, arthritis, dermatitis, sclerosing cholangitis (<10%), joint swelling, hepatosplenomegaly, bone age in children usually delayed by 2 years

The hallmark of Crohns disease are fatigue, abdominal pain, and prolonged diarrhea with or without bleeding, weight loss, and fever.

Differential diagnosis

Ulcerative colitis, NSAID adverse effects, enteritis, intestinal pathogenic bacteria, malignancy, IBS, appendicitis, PUD, renal colic, celiac sprue, diverticulitis

Diagnostic studies

• Colonoscopy with biopsy: submucosal inflammation with pseudopolyps, edema, and strictures; biopsy often reveals granulomatous inflammation
• Flexible sigmoidoscopy
• CT scan or CT enterography
• MRI or MRI enterography
• Antiglycan antibody: elevated in 75% of cases
• Barium X-rays
• Capsule endoscopy if suspicious of diagnosis despite other tests being negative
• Sedimentation rate: elevated
• CBC: anemia
• Albumin: below normal if severe disease
• Electrolytes: imbalances
• B12, folate: deficient
• Stool for leukocytes, culture and sensitivity, C. difficile, ova and parasites to rule out other causes for symptoms
• Fecal occult blood test

Nonpharmacologic management

Maintain nutrition and weight:

• May be helpful to decrease fat and increase fiber to treat diarrhea; fiber can be a trigger as well
• Low lactose diet for small intestine involvement
• Avoid caffeine, alcohol, nuts, seeds

Sitz baths helpful if perirectal disease present

Drainage of perirectal abscess if present

Manage extracolonic manifestations

Refer to crohns and colitis foundation of America for information and support www.ccfa.org

Surgery when indicated

• Abscess
• Intestinal obstruction
• Ostomy placement

Pharmacologic management

• Mesalamine (asacol, pentasa, rowasa) or sulfasalazine (Azulfidine, salazopyrin) is used for maintenance and is taken daily
• Antibiotics (if perirectal involvement): metronidazole (flagyl) reduces bacteria, granuloma formation
• Corticosteroids short-term for moderate to severe disease or budesonide x 8 weeks
• Immunosuppressant such as Imuran or mercaptopurine methotrexate for severe, progressive disease
• Biologics such as humira or remicade alone or in conjunction with Imuran
• Folate supplement while taking sulfasalazine, which inhibits folate absorption
• Antispasmotics and antidiarrheals may be helpful

Pregnancy/lactation considerations

Pregnancy not contraindicates, long term sulfasalazine therapy is associates with reversible sterility in males

Consultation/referral

Gastroenterologist

Follow-up

• Frequency dependent on severity
• Monitor weight, symptoms, CBC, sedimentation rate, Vitamin B12, folate levels
• Changes in weight, increase in severity of symptoms, and colonoscopy findings are helpful in determining need to increase or decrease medications
• Endoscopy indicated if symptoms change
• Annual liver function tests

Expected course

Chronic illness with recurrences and exacerbations. Surgery usually needed every 4-7 years for the average patient. Full activities and normal, but often shortened life can be expected.

Possible complications

Fistulae, colon perforation, toxic megacolon, adenocarcinoma, malnutrition, bowel obstruction, ulcers, anal fissure

  

Diverticulitis

Diverticula, outpouchings that can occur along the wall of the large intestine, become infected, with resultant inflammation. Aerobic and anaerobic bacteria invade diverticula. Chronic, low grade inflammation contributes to recurrence of diverticulitis. Diverticulosis, the presence of diverticula, is common; especially in Western cultures where low fiber diets predominate and incidence increases with age. 2,200-3,000/100,000 in US.

Risk factors

Low fiber diet, low residue diet, diverticulosis, age >50, smoking, NSAID/Aspirin use

Assessment findings

Abdominal pain (due to tension in the wall of the colon), typically left lower quadrant, with or without palpable mass. Rebound tenderness, board like rigidity, anorexia, nausea and vomiting, diarrhea, constipation, bloating, gas, abdominal distention, fever, chills abd dx and tx plans nurs 623 essays.

Differential diagnosis

Gynecologic disorders, urologic disorders, appendicitis, ulcerative colitis, lactose intolerance, Crohns disease, IBS, colon cancer, infective colitis, ischemic colitis

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Diagnostic studies

• Abdominal computed tomography (CT) scan, with or without contrast, is least expensive and provides the most information about presence, location, and extent of inflammation but cannot detect presence of bleeding. Not indicated if recurrent disease with good response to treatment
• Barium enema used to diagnosis diverticulosis
• CBC: leukocytosis
• Sed rate elevated
• Colonoscopy/ flexible sigmoidoscopy to rule out malignancy, ulcerative colitis, or ischemic colitis

Colonoscopy and flexible sigmoidoscopy are usually contraindicated during acute diverticular episode. Generally, a colonoscopy is performed about 6 weeks after the acute episode to allow the colon to heal before insufflating the colon.

Prevention

High fiber diet (but not proven)

Many patients have been advised to avoid seeds, nuts, corn because they could become lodged in a diverticula and produce diverticulitis. Most colorectal surgeons do not believe that these should be avoided but some patients swear they are triggers. abd dx and tx plans nurs 623 essays.

Nonpharmacologic management

• Bowel rest and relaxation
• NPO during acute episode, advance to clear liquids in small volume at frequent intervals for 3 days, low residue diet 5-7 days, then slowly advance to high fiber diet
• Surgery may be indicated if patient experiences frequent recurrences
• Recommend high fiber diet

Pharmacologic management

Ciprofloxacin and metronidazole given in combination for outpatient treatment

IV antibiotics given for severe symptoms/infection

Anti-infectives

Ciprofloxacin 500 mg bid for 7-14 days

• Pregnancy category C
• Quinolones are associated with increased risk of tendon rupture in all ages
• Cipro XR is only indicated for UTI. Use ciprofloxacin for diverticulitis
• Dosage adjustment needed for renal impairment
• Quinolones should not be used for pediatric patients
• Drug interactions with theophylline, methylxanthines, glyburide, NSAIDS and others

Metronidazole adult: 500 mg q 6-8 hr for 7-14 days max: 4g/24 hr; 750 mg tid for 7-10 days

• Pregnancy category B
• Alcohol should be avoided while taking metronidazole and for at least 3 days after last dose
• Potentiates the anticoagulant effect of warfarin and other anticoagulants
• Dosage adjustment for renal impairment
• abd dx and tx plans nurs 623 essays

Consultation/referral

Gastroenterologist if moderate or severe symptoms exist

Indications for surgical consult

• Severe, repeated, or extensive disease
• Carcinoma suspected
• Abdominal drainage

Expected course

Symptoms completely resolve in 1-2 weeks, greater than 2/3 of patients fully recover without recurrence, and colon resection is almost always curative

Possible complications

Perforation, abscess formation, sepsis, enteroenteric or enterovesical fistula, peritonitis, bowel obstruction

Non-alcoholic fatty liver disease

A diagnosis of NAFLD can be made when other causes of liver disease have been excluded by either imaging or biopsy.

Thought to be related to “two hits theory”. First occurs due to insulin resistance and altered lipid metabolism resulting in fatty acids infiltrating the liver. Proinflammatory cytokines (tumor necrosis factor [TNF]-alpha and interleukin-6) and endotoxins are released causing oxidative stress and inflammation, and later steatohepatitis. Poor dietary choices (high cholesterol foods, sugary foods, especially fructose) can worsen the process. Inflammation causes more liver injury, which can result in fibrosis, and later cirrhosis and/or hepatocellular carcinoma. Three genes were discovered that have polymorphisms which contribute to the development of nonalcoholic steatohepatitis (NASH). In western countries, NAFLD is the most common liver disorder. 20% of the population is affected worldwide. 25% of Americans are affected. The most common form of liver disease for pediatric patients (3-11% od children) abd dx and tx plans nurs 623 essays.

Risk factors

Insulin resistance, metabolic syndrome, obesity, type 2 DM, CVD, HTN, dyslipidemia, particularly high triglycerides and/or low-density lipoprotein levels, male gender, older age, Hispanic ethnicity, genetic disposition

Assessment findings

Penetration of fat into liver cells (hepatic steatosis) that may result in inflammation and/or fibrosis of the liver. It can progress to cirrhosis. Disease is divided into nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH). NASH is differentiated from NAFL because it is associated with significant hepatic inflammation.

• Most are asymptomatic
• Mild abdominal pain, particularly RUQ
• Nausea
• Fatigue
• Dorsocervical lipohypertrophy
• Elevated liver enzymes (particularly ALT> AST)
• Jaundice
• Pruritis
• Hepatomegaly

Assessment should include a thorough review of onset of symptoms and social history (alcohol consumption, illicit drug use, history of blood transfusions, and sexual history).

Differential diagnosis

Alcohol fatty liver disease, viral hepatitis, starvation, drug related liver injury, pregnancy, autoimmune hepatitis, iron overload

Diagnostic studies

• Ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI): all can identify hepatic steatosis
• Transient elastography: used to determine degree of liver fibrosis
• Gold standard for diagnosis is liver biopsy and should be considered for patients who have elevated liver enzymes
• Laboratory studies
• No biomarker currently available for diagnosis
• Liver function test (LFTs): may be elevated
• Ferritin and uric acid levels: may be elevated
• Laboratory studies to exclude other liver diseases
• Total protein
• Alanine transaminase (ALT)
• Aspartate transaminase (AST)
• Alkaline phosphatase
• Albumin
• Total and direct bilirubin
• Viral hepatitis serologies (Hepatitis A IgG/IgM, Hepatitis B surface antigen Hepatitis B surface antibody, hepatitis B core antibody, hepatitis C antibody)
• Ferritin
• Total iron (plasma)
• Iron binding capacity
• Fasting glucose
• Hemoglobin A1C
• Lipid panel, including low-density lipoprotein cholesterol
• Prothrombin time
• Autoimmune markers (serum gammaglobulin level, antinuclear antibody, antismooth muscle antibody, and anti-liver/kidney microsomal antibody-1).

Prevention

Adequate treatment of other comorbidities (diabetes, obesity, hyperlipidemia, hypertension). Good, balanced nutrition (avoidance of high sugary and fatty foods). Hepatitis A and B vaccinations. A high rate of fatal cardiovascular events occur in patients who have NAFL.

Nonpharmacologic management

• Mainstay of treatment is lifestyle changes, including diet modifications and increasing physical activity
• Avoid alcohol consumption
• Dietary changes, including decreasing calorie intake, low fat/low cholesterol diet and avoiding trans fats and high fructose corn syrup
• Exercise (moderate physical exercise 3-4 times per week)
• >3% weight loss has been shown to reduce hepatic steatosis
• Support groups have been proven helpful to make necessary lifestyle changes
• Psychosocial therapy is available to help with weight loss
• abd dx and tx plans nurs 623 essays

Pharmacologic management

There are no current medications FDA approved for the treatment of NASH

Consultation/referral

• If steatohepatitis is found on liver biopsy, referral to a gastroenterologist/hepatologist is recommended
• If cirrhosis is found on liver biopsy, consider referral to a hepatologist, preferably a transplant center

Follow-up

Close follow-up ad management of other comorbidities is suggested. Weight management and physical activity should be logged and discussed at every follow up visit.

Expected course

Most common cause of death in this patient group is related to cardiovascular related events. Patients with NASH have a higher risk of liver related mortality.

Possible complications

Hepatocellular carcinoma, cirrhosis

abd dx and tx plans nurs 623 essays

Gastroesophageal reflux (GER) Gastroesophageal Reflux Disease (GERD)

Gastroesophageal reflux (GER): movement of gastrointestinal contents up the esophagus or larynx facilitated by decreased lower esophageal sphincter (LES) tone. Some reflux is physiologic

Gastroesophageal reflux disease (GERD): gastric contents reflux into the esophagus or oropharynx and symptoms occur. abd dx and tx plans nurs 623 essays.

Affects up to a third of Americans at some time in their lives. Affects 81% of patients 60 years or older, common in pregnant patients. Recurrent vomiting occurs. Small minority of infants develop GERD. ER: common in pediatrics. GERD: little is known about prevalence in children and adolescents.

Risk factors

Factors which may reduce LES tone

• Alcohol
• Anticholinergic medications
• Calcium channel blockers
• Chocolate, peppermint
• Fatty, spicy, and citrus foods
• Hormones: estrogen, progesterone, glucagon, secretin
• Obesity
• Pregnancy
• Meperidine
• Nicotine
• Theophylline

Childhood GERD predisposes GERD in adolescence and adulthood

Risk factors for GERD during childhood:

• Neurologic disorder (cerebral palsy)
• Congenital malformation (esophageal atresia or trachea-esophageal fistula)
• Severe chronic pulmonary disease (cystic fibrosis)

Aging

Zenker’s diverticulum

Irritation of esophageal mucosa by

• NSAIDS
• Tetracycline
• Quinidine
• Caffeine

Increased gastric acid secretion: acidic foods

Delay in gastric emptying: fatty foods

Zollinger-Ellison syndrome

Obesity

Diabetes mellitus, diabetic gastroparesis

Assessment findings

• Pyrosis (heartburn) is cardinal symptom, burning beneath sternum, typically postpradial and nocturnal
• Regurgitation, (“sour, hot”): 60%
• Chest pain: 33% send for cardiac workup
• Dysphagia (present in longstanding heartburn): 15-20%
• Esophageal pain referred to neck, mid back, and upper abdomen
• Chronic cough, PND, clearing throat (common to have and all three)
• Chronic sore throat/hoarseness
• Erosion of teeth by acid
• Ulceration: hematemesis, fatigue, anemia
• Barrett’s esophagitis (small number of patients): replacement of the squamous epithelium of the esophagus by columnar epithelium, which may be further complicated by adenocarcinoma in 1-5% of cases
• abd dx and tx plans nurs 623 essays

Infants

• Recurring vomiting
• Poor weight gain or weight loss
• Irritability or excessive crying
• Disturbed sleep
• Dysphagia or refusal to eat
• Arching of back during feeding
• Respiratory problems/stridor
• Apnea
• Apparent life threatening events (ALTE)

Child or adolescent

• Recurrent vomiting or regurgitation
• Heartburn or chest pain
• Hoarseness

Bilious vomiting and hematemesis are RED flags in children

Differential diagnosis

Cardiac disease, esophageal spasm or infection, cholelithiasis, PUD, lower respiratory infection: bronchitis, pneumonia, asthma, pulmonary edema

In infants and children consider gastrointestinal obstruction, gastrointestinal disorders, infectious disease, neurologic disorders, metabolic or endocrine disorders, renal conditions, toxic conditions, cardiac problems : chronic heart failure

Diagnostic studies

• Patient with one episode of heartburn that responds well to nonpharmacologic and acid suppressant therapy may require no further investigation
• Endoscopy necessary for patients with GERD symptoms who have not responded to empirical trial of PPI therapy
• Endoscopy with biopsy necessary at presentation for patients with esophageal GERD syndrome with troublesome dysphagia
• Manometry: motility test to determine LES and esophageal function
• Ambulatory esophageal pH testing to detect pathologic reflux
• Endoscopy to observe effects of esophagitis and obtain biopsy for histology
• 50% of symptomatic patients have NERD (nonerosive reflux disease)
• Infants and children
• History and physical sufficient to reliability diagnose GER, recognize complications, and initiate management in most infants with vomiting, older children with regurgitation and heartburn
• Upper GI to evaluate presence of anatomic abnormalities
• Esophageal pH monitoring: acid reflux
• Endoscopy and biopsy assess presence and severity of esophagitis, strictures, and Barrett’s esophagus; exclude other disorders
• Empiric medical therapy for a trial period to determine if GER is causing specific symptoms

Nonpharmacologic management

Education: physical causes of GERD, common aggravating and ameliorating factors, and lifestyle changes to control GERD:

• Avoid recumbence until 2 hours after meals
• Elevate head of bed, including entire chest
• Reduce size of meals and amount of fat, acid, spices, caffeine, and sweets
• Smoking cessation
• Reduce alcohol consumption
• Lose weight if indicated
• Avoid stooping, bending after meals and tight fitting garments

Surgical interventions, crural tightening or fundoplication, reserved for patient with stricture, hemorrhage, barrett’s esophagitis, chronic aspiration or intractable symptoms

Infants

• Milk thickening: reduces number of episodes of vomiting
• Supine position to sleep to reduce risk of sudden infant death syndrome (SIDS)
• Diet changes: hypoallergenic formula

Child or adolescent:

• Position left side with head of bed elevated
• Lifestyle changes
• Avoid caffeine, chocolate, spicy foods
• Avoid cigarette smoke and alcohol use
• Weight control: obesity associated with GER
• abd dx and tx plans nurs 623 essays

Pharmacologic management

Antacids

Calcium carbonate (tums) adult: chew 2-4 tabs as symptoms occur max 15 tabs/24 hrs

• Pregnancy category C
• Do not use maximum dosage for more than 2 weeks
• FDA not evaluated and approved this OTC for reflux
• Produces rapid relief of heartburn symptoms
• Use with caution in patients with CHF, renal failure, edema, and cirrhosis
• Blocks absorption of digoxin, tetracyclines, benzodiazepines, iron, and others

H2 antagonists

Cimetidine (Tagamet)adults and children >16 years old initial: 800 mg bid for 12 weeks; alternative 400 mg qid for 12 weeks; max 12 weeks; adult max 1600 mg/day

Children 20-40 mg/kg/day q 6 hr; infants 10-20 mg/kg/day q 6-12 hr; neonates 5-10 mg/kg/day q 8-12 hr

• Pregnancy category B
• Cimetidine associated with many 3A4 drug interactions
• Long term therapy may be associated with B12 deficiency
• May take several days for relief to occur
• Allow one hour between H2 blocker and antacid consumption
• Dose adjustment needed for renal and hepatic impairment
• Give with food

Ranitidine (zantac) adults: 150-300 mg bid max g in hypersecretory conditions

Children >1 month-16 years old 5-10 mg/kg/day in divided doses BID or TID

• Pregnancy category B
• Efferdose is 25 mg. dissolve in 5 mL water. Do not chew, swallow whole or dissolve on the tongue
• Contains phenylalanine
• Potential drug interactions with procainamide, warfarin, glipizide, and others
• Dose adjustment needed for renal and hepatic impairment
• No dosage adjustment needed for geriatric patients

Famotidine (Pepcid) adult: with symptoms of GERD 20 mg bid for up to 6 weeks; treatment of esophagitis due to GERD: 20-40 mg bid for up to 12 weeks

Children < 3 months: 0.5 mg/kg/day divided once daily; 3-12 months 1 mg/kg/day divided BID; 1-6 years 1-2 mg/kg/day divided BID

• Pregnancy category B 20 mg twice daily was superior to 40 mg bedtime for improvement of symptoms
• No drug interactions have been identified
• No dosage adjustment needed for geriatric patients
• Dose adjustment needed for renal and hepatic impairment

Proton Pump Inhibitors

Pantoprazole (protonix) adult 40 mg daily for up to 8 weeks non erosive esophagitis 20 mg daily for 4-8 weeks

Children 5 years old and older 15-<40 kg: 20 mg daily for up to 8 weeks; 5 years and older> 40 kg: 40 mg daily for up to 8 weeks abd dx and tx plans nurs 623 essays

• Pregnancy category B
• Lactation: probably safe
• Possible interactions with antiretroviral therapy, diazepam, warfarin, phenytoin, and others
• No dosage adjustment necessary for elderly

Omeprazole (Prilosec) adult: 20 mg for up to 4 weeks if esophagitis GERD: 20 mg daily ofr 4-8 weeks

Children 1-16 years > 20 kg: 20 mg once daily; 10-20 kg: 10 mg once daily; 5-10 kg: 5 mg once daily

• Pregnancy category C
• Lactation: probably safe
• Possible interactions with antiretroviral therapy, diazepam, warfarin, phenytoin, and others
• No dosage adjustment necessary for elderly or renal impairment
• Dosage adjustment needed for hepatic impairment

Consultation/referral

Cardiologist: severe chest pain, radiating pain

Gastroenterologist:

• Dysphagia
• Unexplained weight loss
• Vomiting
• GI bleeding
• Anemia
• Palpable abdominal mass
• Recurrent or refractory symptoms
• Long history of alcohol and/or nicotine abuse
• Regular NSAID use

Infants/children: pediatric gastroenterologist

• Uncomplicated GER: if symptoms worsen or do not improve by 18-24 months
• Recurrent vomiting and poor weight may require medical therapy, hospital observation, and/or endoscopy with biopsy
• Infant with feeding refusal
• Child over 2 years with recurrent vomiting or regurgitation
• Child with dysphagia
• Unresolved chronic heartburn or chest pain in older child or adolescent

Follow-up

CBC, screen for B12 deficiency and high risk of osteopenia after long term PPI use, and Barrett’s esophagitis: endoscopy and biopsy every 1 to 2 years.

Possible complications

Erosion and ulceration, stricture, barrett’s esophagitis, high-grade dysplasia, esophageal adenocarcinoma, aspiration pneumonia,

Co-existing conditions in children with GERD: esophagitis, dysphagia, odynophagia, asthma, recurrent pneumonia, upper airway syndrome, anemia, hematemesis abd dx and tx plans nurs 623 essays