GERD

• Gastritis


  Inflammation of the stomach mucosa
• Gastritis

  • More often in older adults; males
  • Disruption of the mucosal barrier that normally protects the stomach tissue from digestive juices
• Causes of acute gastritis

  • Infections Bacterial (H Pylori) or Viruses (CMV)
  • Alcohol
  • Smoking
  • Medications (NSAIDS, iron, chemotherapy)
  • GERD
  • Others
  • Acute Illness
• Chronic gastritis


  May not be able to absorb vitamin B 12= pernicious anemia
• Diagnosis of gastritis

  • Endoscopy with biopsy
  • Assess for H Pylori (Urease breath test)
• Acute gastritis medical management

  1. Mucosa generally able to repair self

  2. May require IV fluids- replacement

  3. May require NG tube

  4. Antacids

  5. H- 2 Blockers: Famotidine (Pepcid)

  6. Proton Pump Inhibitors: (Omeprazole- Prilosec); Lansoprazole (Prevacid)
• H2 blockers and proton pump Inhibitors


  Lower the production of acid
• Chronic gastritis management


  1. Promote rest

  2. Modify diet

  3. Instruct to avoid alcohol and NSAIDS

  4. Initiating meds (H2 blocker/proton pump inhibitor)
• Nursing management - promote optimal nutrition for acute gastritis

  1. Encourage no foods or fluids by mouth at onset

  2. After symptoms subside Ice chips, then clear liquids, then solids. (with diet orders)

  3. Discourage caffeine

  4. Discourage alcohol

  5. Discourage smoking

  6. Eat a fiber-rich diet

  7. Foods containing flavonoids like apples, celery, cranberries (including cranberry juice), onions, garlic may stop growth of H pylori (if applicable)

  8. Avoid high-fat foods which increase inflammation in the stomach lining
• Monitoring for hemorrhagic gastritis

  • Hematemesis
  • Tachycardia
  • Hypotension
  • Assess stools for frank or occult blood (Melena, hematochezia)
• Gastritis - relief of pain


  1. Instruct to avoid irritating foods and beverages

  2. Instruct on correct use of medications
• Peptic ulcer disease


  • Gastric
  • Duodenal- more common
  • Esophageal
• Causes of peptic ulcers

  • Most result from Gram Negative Bacteria H. Pylori- may be acquired through infection of food and water
  • Person to person transmission close contact and exposure to emesis
  • Most infected people do not develop ulcers
  • Use of NSAIDs - major factor in risk
  • Excessive secretion of HCL may contribute- increased secretion may be associated with stress
  • Smoking and alcohol may increase risk
• Increased risk of peptic ulcers

  • Patients with COPD and chronic kidney disease
  • Zollinger-Ellison Syndrome (ZES)
• Pathophysiology of peptic ulcers

  • Most ulcers are in the mucosa because the tissue can't withstand the acid and pepsin
  • Caused by increase in concentration/activity of acid-pepsin or decreased resistance of the mucosa
  • Damage of mucosal layer prevents barrier of protection
  • NSAIDS
  • People with duodenal ulcers have increased levels of acid while people with gastric ulcers tend to secrete normal or lower than normal levels
  • Damage to the mucosal layer allows bacteria- H Pylori to cause infection
  • ZES: suspected when patient has several peptic ulcers or ulcer resistant to treatment
  • Stress ulcer: Acute ulcer occurring during physiologically stressful events
• Clinical manifestations of gastric/duodenal ulcers

  • No sx - perforation and hemorrhage in 20-30% of ulcers
  • Midepigastric burning or gnawing pain. Gastric ulcer (pain immediately after eating)
  • Duodenal (pain 2-3 hours post eating)
  • Patients with duodenal more often awaken during the night
  • Duodenal ulcer patients more often have pain relief with eating or taking antacids
  • Other nonspecific sx: heartburn (pyrosis), vomiting, constipation, diarrhea, and bleeding
• Diagnostic findings for peptic ulcers

  • Endoscopy (EGD- Esophagogastroduodenoscopy)
  • Serum test for antibodies against H pylori antigen, stool antigen test, urea breath test (tests to see if urea breaks up if swallowed)
  • Bleeding ulcer? : CBC, stools for occult blood until negative
• Medical management of peptic ulcers


  1. After treatment, recurrence may develop

  2. Goals: Eradicate H pylori if present and manage gastric acidity

  3. Medication, lifestyle changes, and surgical intervention
• Medications for H pylori

  • 10-14 day combination of 2 antibiotics, proton pump inhibitors, and sometimes bismuth salts (pepto bismol)
  • Antibiotic: Metronidazole (Flagyl) or Amoxicillin (Amoxil) + Clarithromycin (Biaxin)
  • 2 other potential antibiotics: Flagyl and Tetracycline
• Proton pump inhibitors


  Decrease acid production
• Proton pump inhibitors


  • Lansoprazole (Prevacid)
  • Omeprazole (Prilosec)
  • Rabeprazole (Aciphex)
• Lansoprazole (Prevacid)


  • Proton pump inhibitor
  • Side effects/Adverse reactions: Diarrhea, stomach pain, nausea, constipation, headache
  • Other side effects: With prolonged/increased doses- bone fractures, low magnesium levels
  • Instructions: Do not chew or crush delayed release; Take before a meal
• Omeprazole (Prilosec)


  • Proton pump inhibitor
  • Delayed release capsule- take 1 hour before a meal (anywhere from 1-3 times a day)
  • Extended release- do not crush
  • More common side effects: constipation, gas, nausea, vomiting, headache
  • Those on high doses or on for long periods are at higher risk of fracture
• Aciphex


  • Proton pump inhibitor
  • More common side effects: pain, sore throat, gas, infection, and constipation. Could have diarrhea- may be caused by C-diff
  • Low magnesium levels and fractures may occur with longer term medication
• H2 blockers


  • Cimetidine (Tagamet)
  • Famotidine
  • Nizatidine
• H2 blockers


  • Side effects: Headache, diarrhea, constipation, nausea, vomiting, abdominal pain, low white blood cell count, gynecomastia
  • Confusion may occur in the elderly
• Instructions for H2 blockers and proton pump inhibitors


  1. Patients need to take medication as timed and until complete

  2. Avoid use of NSAIDS
• Prophylactic medication for physiological trauma/stress

  IV H2 blockers and cytoprotective agents (misopropistol, sucralfate)
• Cytoprotective agents

  • Misopropistol (Cytotec)
  • Sucralfate (carafate)
• Sucralfate (Carafate)


  • Forms a protective layer in the stomach mucosa including over the open ulcer
  • Give one hour before meals and at bedtime
  • If antacids are also given, they should be administered 30 minutes before carafate
• Lifestyle changes for ulcers

  1. Quit smoking

  2. Avoid extremes in temperature of food and drink

  3. Avoid coffee and alcoholic beverages

  4. Avoid caffeinated beverages

  5. Neutralize acid by eating three meals a day

  6. Eat food individual is able to tolerate
• Nursing assessment/recognizing cues for ulcers

  1. Have patient describe the pain, strategies that help

  2. Hx of vomiting?

  3. Hx of smoking, alcohol?

  4. Use of NSAIDS

  5. Family hx of ulcer disease

  6. Monitor for s/s hemorrhage: vital signs (?)

  7. Monitor lab- stool for occult blood, CBC

  8. Assess for tenderness
• Nursing problems for ulcers

  • Acute pain
  • Anxiety
  • Imbalanced nutrition
  • Potential complications: Hemorrhage, Perforation, Penetration, Gastric outlet obstruction
• Nursing interventions for ulcers

  1. Monitor pain

  2. Reduce anxiety

  3. Maintaining optimal nutritional status

  4. Monitor and managing complications
• Nursing management of hemorrhage from ulcers

  1. Hemorrhage- gastritis and hemorrhage from peptic ulcer are the most common causes of upper GI tract bleeding

  2. Bright red or coffee ground vomit

  3. Tarry stools

  4. Management depends on how bad the hemorrhage

  5. Monitor CBC/HCT, test the stool for occult blood

  6. Vital signs

  7. Recording I&O

  8. IV fluids, blood transfusion
• Perforation and penetration of ulcers

  • Perforation is erosion of ulcer through into peritoneal cavity
  • Penetration is erosion into the adjacent structures (pancreas, biliary tract)
  • Requires immediate surgery
  • Symptoms of penetration: include back and epigastric pain not relieved by medications that have been effective for patient
  • s/s of perforation: Sudden, severe upper abdominal pain (persisting and increasing in intensity); pain may be referred to shoulders- especially right shoulder; vomiting, collapse, extremely tender and rigid (boardlike) abdomen, hypotension and tachycardia, indicating shock
• GERD


  • Gastro-esophageal Reflux Disease
  • Excessive reflux may occur due to an incompetent lower esophageal sphincter, pyloric stenosis, hiatal hernia or a motility disorder
  • Sx Mimic heart attack
• Diagnostic findings for GERD

  • Endoscopy (EGD) or barium swallow
• Barium swallow for GERD


  NPO from midnight
• Management of GERD

  1. Teach to avoid situations that decrease lower esophageal sphincter and cause esophageal irritation

  2. Foods: Avoid eating or drinking 2 hours before bedtime

  3. Maintain normal body weight

  4. Elevate head of bed