Episode 10, Class 10: Upper GI

Moving down into the stomach we're going to talk about gastritis, which theitis tells you there's inflammation, gastro stomach, so the stomach is inflamed and it's caused by a breakdown of the mucosa of the stomach which normally protects the stomach tissue from hydrochloric acid and pepsin, those are the erosive agents. There's tissue edema, so edema always leads to redness, there's capillaries closer to the surface, the capillaries can burst, plasma leaks, there could be hemorrhage possibly. So once it's acute it is usually related to something that somebody's eaten or ingested, so contaminated food or spicy food, something that's going to be irritating, alcohol, aspirin and scents, also bio reflux can cause it in reation. So they're going to have abdominal discomfort, anorexia nausea vomiting, headache possibly and hiccuping, so that's a chronic flare up, when they have, I mean an acute flare up, when they have it though, they've got chronic gastritis, that's often longer term, it's going to be related to ulcers or H by lory dietary factors, so habitual things that they're eating or drinking, medications that they're taking, alcohol smoking and reflux. So the signs there, anorexia nausea vomiting, belching, heartburn, after eating something, they'll have a sour taste in the mouth and that's from the acid that's coming up when they burp or if they regurgitate a little bit, and then they may have a vitamin B12 deficiency and think about what's going on there. So the stomach lining is inflamed and angry and unhappy, and so what's in the stomach that we need in transic factor to escort B12 to the small intestine for absorption, and so they're going to have a vitamin B12 deficiency because whatever they're taking in, they're not able to absorb because the stomach is unhappy and doesn't give up the intrinsic factor. So there's an actual picture there, and then a cartoon picture that shows the damaged mucosa, and look at the layers of the stomach. So at the bottom we've got the serosa, the muscularis, the submucosa, and the mucosa. So the mucosa is the innermost lining in the stomach, so the inside of the stomach, and the cells secrete mucous, which provides a protective barrier to protect the lower levels from the acid. So we've got the hydrochloric acid and pepsin that are constantly eating away at the mucous, but the bridal cells should be continually making more mucous to protect it, but when there's a gastritis or ulcers or any kind of situation like that, where it's just not in balance correctly, then that's when there's going to be damage to the underlying tissues. So when assessing the patient, we want to ask them some questions about what they are eating and drinking and medications they're taking. So NSAID use, how much alcohol do they drink? Other medications, Digitalis is one that leads to gastrointest, the dronates, remember the osteoporosis drugs, where they have to sit up for 30 minutes because those cause gastrointest or esophageitis, if they don't do that, they have to drink them with a full glass of water, also corticosteroids, somantide coagulants, and then also women that are older than 60, and anyone with a history of an ulcer, we want to ask about that, those may be predisposing factors. So how are we going to find out if they have gastritis? We're going to do some diagnostic studies and remember we're always going to go from least invasive to most invasive, so the easiest thing to do first, and that's just a breath test. So a breath balloon test tests for the presence of CO2 before and after drinking a lemon soda or taking a urea pill, and so they breathe into a balloon and then they test it for its contents, and then they have them drink the soda or take this pill, and then breathe into it again and they test the difference. So this is a test, not only for gastritis, but also for hpylori, because if they have hpylori it breaks down urea and lets off CO2. So hpylori helicopter pylori is one of the leading causes of gastritis, and that's a bacteria that's present in about 50% of the world's population, but it's not a problem in 50% of the people that's not always a problem. And how we know that that causes gastritis is because there was an Australian doctor and professor called Barry Marshall, and I believe it was in the 70s or 80s, and he surmised that hpylori was the cause of gastritis because he kept seeing it come up again and again in patients when he did biopsies. And so you can't conduct medical tests where you're giving somebody something that you know or you strongly suspect is going to cause a problem, so he drank it himself. So he mixed up some hpylori and drank it and then took repeated images of his stomach by doing endoscopies, and he shortly developed gastritis because of the hpylori. So he had a theory, he proved it, and he won the Nobel Prize. So that's how we know that hpylori causes gastritis. So we're going to do an endoscopic examination with biopsy, and that's where they'll take a tissue. That would be the more invasive test, so they're going to stick an endoscope down you. So that requires some level of sedation, and it's invasive, they're going inside your stomach. And that's how they'll take the tissue, and then they'll test it for hpylori to see if that's the cause of it, if they can't find anything else. Very often it's somebody eats Mexican food every day or really spicy food all the time. So something that's going to cause frequent irritation can be the cause, but if not, then they're going to look a little bit further. So they're also going to do labs. They want to rule in or rule out anemia, and what would cause them to have anemia? Remember, we just talked about the intrinsic factor, B12 anemia. So if the stomach is unhappy, then we're going to have anemia. Then they're going to look at the white blood cells to rule in or rule out a bacterial infection. And how would we know it's bacterial? What do Beyonce say? To the left and left? So if there's a shift to the left to the bacterial infection, and if it is bacterial, then what do we want to test for hpylori? That's the most common bacterial cause of gastritis. We're going to check for a cult blood. And how do we do that? They'll be looking at those stools that we do in the guiax stool test, and then ask them if they are vomiting blood, if they see any blood in their vomit or in their stool, they want to know about that. So how do we manage gastritis? If it's acute, well, they really just need to stop doing whatever it is they're doing that's causing the problem as they determine it. So we're framed from alcohol and the triggering foods until symptom subside. It may be due to drinking a strong acid or alkali treatment to neutralize the acid. If that's the case, then they need to avoid amettics and lavage, which is rinsing out the stomach because that's a danger of perforating and damaging the esophagus. And then supportive therapy, so that would include nutritional therapy and then just literal supportive hand-holding therapy, helping them manage the crisis and medications for the pain. And then if it's chronic, they're going to need to modify their diet long term, promote rest, reduce stress and avoid alcohol and insides. And then pharmacologic therapy will get to that in a minute. So in both, we want to discourage caffeinated beverages, alcohol, cigarette smoking, cigarettes, increased GI motility, and they also increase gastric acid secretion. And so somebody may need referrals for alcohol or smoking cessation programs. And then promoting fluid balance, monitor eyes and nose. It's going to be important, want to look for signs of dehydration, electrolyte abnormalities and hemorrhage. So we'll want to take a look at labs as well because if they have gastritis, they could be bleeding and it could anytime go to a large level of bleeding. So if that's likely, if hemorrhages likely, we're going to want to do frequent vital signs and think about what vitals would look like if they're bleeding, blood pressure is going to be low, heart rate is going to be high. And then if we have vomit, we're going to want to test that for blood because sometimes you can't see it, but it's there. Drug therapy, we want to reduce the irritation on the mucosa. So part of that is providing symptomatic relief, and so we'll give them things that's going to relieve the pain, but then also decreasing the acid, so the H2s and the PPI's. If we found that they are positive for H. Pylori, we're going to do a series of antibiotics. And then if they have pernicious anemia, they're going to get cyanocobalamin supplements. So H. Pylori treatment. It is a tricky little devil when it becomes resistant, so they use more than one antibiotic. So the first thing they'll try is double drug therapy, and that is bifimus salt and one antibiotic. Chlorothermiasins listed here as an example, but it could be others. Bifimus salt is peptobizmal. [BLANK_AUDIO] triple drug therapy is a PPI or pepto and two antibiotics such as a moxicillin and chlorothromycin. And then if that doesn't work, quadruple drug therapy, bismisols, PPI and two antibiotics. And these are different ones here, mentioned tetracycline and metronide dissolved. So those are the methods for treating H-pilory. Next is Peptic Ulcer Disease. And this is a break in the mucosa lining and it can be anywhere along the GI tract in the esophagus, the stomach or the doggone, most commonly in the doggone. And again, there's another picture of the layers. And so with the first layer, again, the mucosa on the top, there's erosion. So there's just a little divot in it, but then that erosion goes deeper. It goes into the sub-mucosa and touches into the muscularis that becomes an acute ulcer as it goes deeper still into the muscularis. So the muscle tissue of the stomach, that's a chronic ulcer, and it goes deep and leads to scarring. So remember that the stomach has the layers and the innermost layers designed to protect the lower layers. And the erosive agents again are hydrochloric acid and pepsin. So any part is vulnerable. I have a picture here of the GI tract. And this is just something to refer back to to think about what is absorbed where. Because as we start talking about the different surgeries that we're going to cover, if some of that GI tract is missing, you need to know that those certain things are not going to be absorbed anymore because it's simply not there. So just refer back to this as we get into the different surgeries when you're talking in your study groups. Realize that little absorption actually occurs in the stomach, mostly just alcohol and water. So what causes ulcers? Peptic ulcer disease develops in the mucosal layers in a acidic environment. And it's influenced how one responds to that. It's going to be influenced by their diet, their genetics, and the environment. So not everybody's going to be susceptible. Not everyone's going to get ulcers when they have these things in their life. But some risk factors, fats, alcohols, caffeine, stress, and smoking. So alcohol, coffee, and stress stimulate acid secretion. And we know that, right? You feel stressed. There's that mind-body connection there. You start feeling stressed and you feel your stomach kind of squirting out the juices and churning up. So stress stimulates acid secretion. Smoking and stress and depression delay healing. Other things that cause it, things that destroy the mucosal barrier. H. Pylori talked about. So that produces urease. And it mediates inflammation making mucosa more vulnerable. Aspirin and NSAIDs. Aspirin, or also in those ASA, what does that stand for? C. D. Salicylic acid. So it's an acid. So it increases the acid in the stomach and that damages the mucosa. If you think about it, it doesn't have an exactly this way, but think about. You take an aspirin and you swallow it down in it and you don't drink a lot of water and it just sits there under stomach. And as it dissolves, it's acid and it's just kind of going to burn a little hole right there in the stomach. Not exactly what's happening, but that gives you a visual. So aspirin and NSAIDs both inhibit prostaglandins and it leads to an abnormal level of permeability in the submucosa. So it allows the stomach acid to get deeper. Corticosteroids, we know a lot of bad things that they do and one of them is they give you immune suppression. They decrease the rate of mucosal cell renewal. So your mucous cells are not replicating as quickly, so there's going to be less mucous cells available. And that decreases the protective effect of the mucous. Lipid soluble cytotoxic drugs, those might pass through just right through the mucous destroy it. And then vagal nerve stimulation that's, let's talk about with stress, your emotions, now leads to an increase in hydrochloric acid. So peptic ulcer, clinical manifestations, commonly there's no pain or any other symptoms because there's not a lot of sensory pain fibers in the stomach. You don't normally feel pain in your stomach or feel anything in your stomach, right? Like you don't feel when you swallow food, you don't generally feel it, "Hey, your stomach." So if there's pain, if it's a gastric ulcer, it's going to be high in the epigastrum. And it usually is one to two hours after meals, food aggravates it, and vomiting relieves it. And there's often blood in the vomit. The pain is described as burning or gaseous. And then if it's a duodenolcer, which again is more common, that pain is usually described as a dull or gnawing pain. And it's going to be in the mid-epigastric region beneath the zyphoid process, so a little bit lower. And there may be back pain if it's on the posterior aspect of the stomach or of the abdomen. So with duodenolcer, food alleviates it. Food makes it feel better, and they're going to have blood in the stool. So I want you to just pause and think about what these people are going to look like for a minute. So a gastric ulcer person, if food aggravates it, how are they going to look? They're going to be skinny. They're not going to want to eat because they do eat, it hurts, and then they vomit. So they're not absorbing nutrients. So they're going to be malnourished. And then a duodenolcer person, think about them. Food makes them feel better. So they're going to be eating a lot. And then when the stomach gets empty, two to four hours after the meal, that's when they start hurting again. What do they do? They go and eat some more. And they may be doing that all through the day and night. And so obviously then they're going to be heavier. They're going to be well nourished or overweight or obese. So just to give you a hint of what their people are going to look like. So there's major complications with peptic ulcer disease and includes hemorrhage, perforation, penetration, and pyloric or gastric outlet obstruction. All of these are an emergency. We'll talk more about them in a minute. So with hemorrhage is the most common, it occurs more commonly in the duodenolcers more than the gastric ulcers. Perforation is most lethal. So that's where it perforates into the peritoneal cavity. This also occurs more commonly in duodenol than gastric ulcers, but the gastric ones are more fatal. And if you think about that it makes sense because there's a lot of acid in the stomach and so that perforates all that acid goes out into the bowel cavity and starts destroying things. Older patients tend to get gastric ulcers also more commonly. And so what do they have? Comorbidities. They've got a lot of other stuff. And so that's going to contribute to a higher mortality rate. So that's why gastric ulcers can be more lethal. Small perforations can happen regularly and they're able to just kind of seal themselves, the body seals them up with fiber. And then when it's a major perforation they're going to feel severe abdominal pain and it's going to be dramatic sudden and it's going to spread throughout the abdomen. It may refer to the shoulder and that's one of those weird things. There's a common nerve root that goes to the abdomen and the shoulder. So sometimes abdominal pain refers to the shoulder, different, certain kinds of abdominal pain. You won't be hearing bowel sounds because things aren't moving through the bowel. It's all been released into the perforation of the cavity. And the pain may spread if they're lying on their back, if they're lying down in bed, they're going to say that it's spreading out through their back. So they're going to feel like this burning in their back and that's because the acid is settling down into their back. A gastric outlet obstruction can be related to just the dima of the stomach due to the gastritis, but also inflammation. Pylorus spasm is where the pyloric sphincter is just spasming because it's angry and unhappy. There can be scar tissue that builds up from the gastritis and the ulcers and then we know that scar tissue becomes hypertrophic. And so that's going to be larger and so that can help form an obstruction. They're going to have pain and it's going to get worse later in the day as the stomach fills and dilates. So things are not getting through or they're having trouble getting through. So the stomach's going to become full and they're not going to get relief until they belt or vomit. And then projectile vomiting is sometimes common. With penetration, that is a perforation that penetrates into another organ. And so with that, they're going to have similar symptoms of abdominal pain, maybe to the shoulder, vomiting, collapse, tender board like abdomen. Whenever you see those words, tender board like abdomen, that means that there's bleeding in the abdomen. There's leakage in the abdomen so it's filling up, it's getting firm and hard. And that's dangerous because well number one, that can lead to shock. And then number two, it can lead to parotonitis. And if you look at the picture, you'll see why because there's a bunch of stool contents that just kind of exploded into the abdomen. And so a lot of bacteria in there and it can very quickly lead to acute parotonitis within a few hours. So that patient's gonna need immediate surgery. They're gonna need to go in there and clean all that out, hose it out with an antibiotic-infused solution and keep rinsing it until it's clear, find the hole, sew it back up, and then eventually close them up. If they have any of these things, we're going to want to put an NG tube in. Because the more we can suck stuff out, the less it's going to be in the abdominal cavity and I'm causing damage. So by lower obstruction, an NG tube is going to relieve the symptoms of the stomach getting all full and bloating and with a penetration or perforation or penetration, an NG tube is going to suck the stuff out before it can cause much damage in the peritoneal cavity. So with that, you're pulling fluid out of the body. So do you think guys in hose are important? Yes, very much so. You can be pulling a lot, very much out, like leader after leader. That suction thing can keep filling up. So we need to be replacing that fluid. You can expect signs of shock, so you need to be very careful about assessing for that. And fluid replacement is going to be a big priority with them because they're losing so much of it. And it's not in the vascular space where it needs to be, so they're not oxygenating. And so you're going to see all the symptoms of lack of oxygen. So we'll look for that. So Peptic ulcer disease drug therapy. H2s, PPIs, we've talked about those antibiotics to treat what? Hpylori, primarily, and then of course if they perforate, then antibiotics to treat the impending infection from that. Maybe antacids, but of course those are going to be weak and not do a whole lot compared to the other ones. Anticholinergic, those are going to block the vagal stimulation, which will decrease the acid buildup. Those are rarely used. And then the last one is cytoprotective therapy. And this is a new one for us. So there's two drugs in this class, misoprostol and sucrophate. So these are similar. First one, misoprostol or cytotek. This is one that people may take if they have to take insides. So they shouldn't take insides if they have an ulcer, right? But they have to because other stuff doesn't work or they have allergies or whatever. So if they're taking insides, they need to take cytotek to protect their stomach lining. And that's what it does. So it secretes by carbonate, which is a base. So that neutralizes acid and also cytoprotective mucus. So it helps repair or replace rather the mucus inside the stomach. This should be given with meals. And the way you can remember that is miso, like miso soup. So that's food. Take this with food. It can cause abdominal pain and diarrhea and it should not be used if someone is pregnant or think they may be. And that is because it is one of the ingredients in the morning after pill. And given alone at high doses, it can be used to induce abortion. So we wouldn't want to give that to anybody who's pregnant. Sucrophate or carophate is the other one. And this one is a little bit different. You need to be taken on an empty stomach and it creates a protective barrier. So if you've ever seen the commercials for like peptobizmal or something, they show the cartoon stomach and they take the medication and then it coats it and it makes it all nice and pink and happy. That's kind of like what this does. So it creates a protective barrier. It just covers the inside of the stomach. So that's why we need to take it on an empty stomach. It may cause constipation and it also interacts with a lot of other medications. So it should be taken alone on an empty stomach literally with no other medications. So separate that out by two hours when giving carophate. Aside from the medications, there are a couple of procedures that they can do to help with ulcers and the first one is a vagotomy. And that's where they sever the vagus nerve branch that goes into the stomach. So that eliminates vagal stimulation which decreases acid, which then will decrease the burning that's going to occur on the ulcers. Another one will be a pyloriplasty and that is a surgical enlargement of the pyloric sphincter. And that's going to help with the gastric emptying and prevent the gastric envelope obstruction. So if they have a lot of ulcers and scarring in that area in the distal part of the stomach, they might want to do that. So they might want to open that up because food's getting caught in the stomach and then that's what leads to the the vomiting because the food gets trapped and can't get out. So all of these things that we talked about can lead to gastric cancer. So any kind of chronic irritation I've said before leads to cancer. So they're the gastritis, the ulcers, oversaw creation of acid, any of those things are going to cause irritation to the stomach and then that just invites cancer in. So gastric cancer accounts for about 10,000 deaths annually. There are 26,000 cases a year and 63% of them are men. So there's an increased incidence in men and native, Hispanic and African-Americans. Respectors are diet, chronic inflammation of the stomach. So all the things that we've talked about including H. Pylory, smoking ulcers, a previous sub-total gastrectomy. So that means they've taken out part of the stomach and left some of it behind, but it's maybe overacidified. And then just genetics, nothing you can do about that. Manifestations, they have pain often relieved by antacids, dyspepsia, early satiety, which means that they get full. They feel satiated or satisfied early. And that's probably because there's a tumor growing in there that's taking up space in the stomach that also leads to weight loss because they're not absorbing, well, they're not eating much because they feel full early. But then the tumor is also preferentially feeding off of what they're eating. And so the tumor's getting bigger while they're losing weight. Abdominal pain because the tumor's pressing on nerves in that area, loss of decrease in appetite. We can understand that. Not as you have vomiting. Oftentimes the diagnosis is late. And so for treatment, it depends on when it was found. If it's early, they may be able to remove the tumor easily. There may be a partial gastrectomy or a gastrectomy, which would be taken out the whole stomach, or it may end up just being palliative care if the tumor is unresectable, meaning it's just twisted around all kinds of different areas, or the cancer has metastasized. So let's, I'm going into the different surgeries for this. First one is a bilroth one gastro-duodenostomy. So this is a partial gastrectomy where they remove the distal two-thirds of the stomach, and they amass the most that gastric stump that remains to the duodenum. So very simple. They're just taking out the distal third of the stomach, two-thirds rather, and then they just attach it to the duodenum that remains. The sphincter's going to be gone there, so that can lead to a problem. They may do some kind of like a kind of a purse string suture there where it kind of creates an artificial opening enclosure, but there's always going to be some passage of things through the stomach too soon, and we'll talk about that in a few minutes. Next is the bilroth two gastro-duodenostomy. So with this one it's a little bit different. They've removed the distal two-thirds, so that's the same thing, but this time they've been asked to most the stomach to the jejunum. And if you look at the picture you see they've left there's a tail there of the duodenum, and that is so you can see the big yellow thing is the pancreas, and that's so that the pancreas can inject its juices, its digestive juices that we need. It's enzymes into the duodenum, and then through peristalsis they flow back up and join the stuff that's coming out of the stomach, and then the things will get further digested from there. So that's important because we need to have that. In the previous one, the bilroth one, that wasn't even mentioned because we didn't affect that part of the anatomy. We just hooked the stomach right up to the duodenum right where it was, just passed these fincter. And then the more drastic one is the total gastrectomy. So this is removing the entire stomach, attaching the esophagus to the jejunum or the duodenum. So, understand there's no stomach now, there's no storage facility, so think about what their diets can need to be. It's going to be more a lot of liquids or pureed or thick soups, things like that, because you can't just choose something a few times and swallow it and expect the stomach to break it down because it's not there anymore. So a diet is going to be different at this point. And we'll get more into that later. Again, they've got the duodenum stump with the pancreas, again, just so we can get the digestive enzymes that we need in there. So with all of these gastric surgeries and later bariatric surgeries, which we'll touch upon in a bit in a little bit, dumping syndrome is the biggest risk factor. And that's caused by the rapid passage of food into the jejunum. So again, there's no stomach for it to hang out in or no duodenum for it to go through to partially absorb. And so this hypertonic mass is flowing into the jejunum. So fluid is drawn into the jejunum because of the hypertonicity of the intestinal contents. And so, you know, the body's always trying to equalize concentration. So it's hypertonic. Fluid rushes in, that's a rush of fluid we don't really need in the bowel. And then vasomotor and GI symptoms results also reactive hypoglycemia. So their sugar is going to bottom out after this happens. Basically what happens is it's called dumping syndrome for a reason. They basically just dump out everything that they've just taken in. It just falls right out. But it's not just that. There's also So, systemic symptoms, so they're gonna have a fast heart rate or palpitations, sweating, nausea, vomiting or diarrhea, cramping, dizziness, it's all, it's all thing, it's not comfortable. So they have to be taught how to eat, and the biggest thing is they're gonna have small frequent meals. And foods that particularly trigger it are sugar salt and milk, so carbohydrates, and then salty things, and milk. They need to eat a high protein diet with high fat because we want them, there's stomach has been sick, right, with cancer, so we want them to put on some weight, but low carbs, so we don't want carbs because carbs are gonna cause dumping syndrome. So the biggest thing is high protein, high fat, and quality foods too. You can't just say you're having ice cream every day for all your meals, so we need to get them all their nutrients, and so good quality, real fruits and vegetables, not frozen or canned, whole grains, good foods. They should avoid fluids with meals though, because if they have a stomach, if it's just been a partial gastric to me, the stomach is smaller, and they don't want to fill it up with fluids, so they want to be able to fill it up with nutrients. And they should lie down after meals. Now, this may seem counter-intuitive because with the other things like hyalurnea and gourd, we talked about always sitting up with meals, right, don't lie down. Well, we're using gravity to our advantage here, so in both cases, we're using gravity. In those cases, we're using gravity to keep the stomach down, and keep the food down, keep the acid out of the throat. In this case, we're trying to keep the food from moving too fast and just dumping out. So as they lie down, it allows the food to move more slowly through the digestive tract, which enhances the ability to absorb things. So hopefully, they'll absorb more of the nutrients that they've just taken in. Post-operative care is going to be similar to any abdominal surgery, so they may have done laparoscopically, they may have a few incisions, they may have one big one, they may need an abdominal binder for comfort, they need to get up a walk as soon as they can, but not after eating as we just said, accurate eyes and nose, always important. After surgery, they are likely to come up to you with an NG tube, and that's used to decompress the stomach because it's still putting out acid more so because of the stress response. And so we want to keep it empty because we want to decrease pressure on the new suture line. And we don't ever want to irrigate that tube, nor would you want to be the one to put in the tube. We don't have an NG tube, and they start complaining of reporting and stuff, and you might think, well, maybe an NG tube would help, don't be the one to put that down there, because you don't want to put it into a new surgery, a new stomach-fresh incision, you could easily go right through it, and then you'd be in big trouble, so don't mess with that. The head of bed should be in foulish position, and that's going to decrease pressure on the suture line, so allow the stomach to be flexed, the abdomen to be bent up a little bit, so that it's soft, so the belly's soft. Assess bowel sounds, and they should be in PO until they have bowel sounds, until the doctor orders, until they're passing gas, until they have the NG tube out, so basically they're going to be in PO for a little while. So this is different from the ortho surgeries where they can eat dinner that night. These guys are not going to be eating for a while. When they do start out taking something in, it's going to be liquids, and that's going to be a very slow progression. So maybe liquids for a full day, and then maybe full liquids for another day, and then slowly progressing upwards, so it's going to take a long time for them to get to a normal diet. If they don't have a stomach, they will never get to back to a normal diet. So you have to be fully aware of what your patient has done, and then also fully aware of what the orders are, and know what makes sense, because if you have somebody who's had a total gas trick to me, and then you see, you know, the doctor orders a regular diet, well, obviously you need to know the question that, and that is something that could happen, because they just click boxes and may have, you know, clicked the wrong box or not, and thinking or been on the phone or who knows what. So always know what would make sense as an order or what would not, and question those that don't. So we're going to be keeping a close eye on the vitals and labs, because we're looking for possible hemorrhage, and we know where our vitals would look like if that happened, and obviously the labs. We also want to look for infection as it gets a few days out, and pernicious anemia. Why would they be at risk for that? Because we've just taken out part or all of their stomachs, so they don't have the intrinsic factor to absorb the B12, they're not making blood cells, they're going to have anemia. So a lot of things to assess your patient for when they've had a gastric surgery. The next thing with an NG2, the drainage out of there, is going to be bright red, probably at first there's going to be some blood, and that's to be expected, but keep a close eye on it, because it should darken up within the first 24 hours. If it continues to remain red, it's just sucking red for, you know, well, we wouldn't let it go day after day, but within, I would say 12 to 24 hours, it should be darkening up and not bloody anymore. Within 36 to 48 hours, it should change to yellow to green, which is basic, what you would see in the stomach, that's what you would normally see an NG2 drainage is green. So we're going to do, careful eyes and nose, so we want to make sure of the amount that's coming out, and odor, if you notice any odor, any unusual color or consistency in it, and you want to note that out. Okay, the next thing is obesity and bariatric surgeries. Obesity is classified as a body mass index above 30, and 66% of all adults are overweight or obese in the US, and more than one third are obese. So that's an epidemic problem, and it's happening more and more at younger ages, too. There's obesity and children in juvenile diabetes, that diabetes have not really been a problem until the last about 20 years. Obesity-related mortality rates are high, and they increase with every five points of BMI that you get above 25. So 25 is overweight, 30 is obese, and so the higher that BMI is obviously the more somebody is at risk for various complications, and there are lots of them. Additionally, psychological issues, low self esteem, body image, depression, and just overall diminished quality of life. People get arthritis, makes it harder to walk around, their knees break down, hypertension, you know, they get dizzy going upstairs, there's a lot of impacts on their life. So bariatric surgery is used to treat morbid obesity, and it is the only treatment found if had successful and lasting impact for sustained weight loss. There's some important exclusions in the book as to who will not be getting this, but they do have to meet certain criteria. So generally, that to be 18 years or older, there have been some exceptions where they'll do it on younger teenagers. The BMI has to be greater than 40 or greater than 35 with one or more obesity-related complications, and if your BMI is greater than 35, you definitely are going to have more than one obesity-related complications, so that's not hard to come by. I believe that is going to vary state by state. So just if you happen to work in bariatrics, you want to know what your regulations are where you're at. Patient has to understand the risks and benefits, and also understand the lifestyle changes that are going to have to take place. So this is not a quick fix, it's a whole lifestyle change, they're going to have to change everything about how they eat, and they're going to have to exercise, so they really need to understand what it's going to take to make this happen for them. They also have to be obese for over five years and try and fail to lose the weight. And then psychological stability, they just need to know that, basically, this is not a quick fix. They can't be doing this for just some kind of a quick vanity purpose or something. So there should be good counseling before somebody gets approved for bariatric surgery. I think it's better these days than it used to be, but for a while they were just doing lap bands to everybody, anybody that wanted them, and people didn't really have the counseling. They weren't ready for it, they didn't know what it was going to take, and it led to a lot of really poor outcomes. So there's three broad categories of bariatric surgery, restrictive malabsorption and a combination of the two. Then they are pretty much exactly what they sound like. So restrictive surgery reduces the size of the stomach to 30 ml or less. If you make the okay sign with your hand, that's about 30 ml. It's about the size of a egg. So that is the size of your stomach now. So think about how quickly it's going to be that you're going to feel full. The trick is to stop eating when you feel full, and that is sometimes not what people are used to doing. So that's again, is where the lifestyle changes come into play. There is normal stomach digestion and intestinal absorption. of the food. So there's a decreased risk of anemia and cyanobalamin deficiency weight loss is going to be slower, which is better. Rapid weight loss tends to lead to some different complications we'll talk about later. So the two types of restrictive, we have vertical banded or staples, you might hear if somebody got their stomach stapled, that's what that is, or circumgastric banding, which is the lap band. So with the lap band goes around the top of the stomach and just kind of crimps it off and makes it smaller. And with the vertical banded, the same thing they do kind of a crimp around it and then they staple off the rest of it. And with that there's their pouch is going to be only 15 to 30 ml. So again very, very tiny gastric banding, it can vary. This is 10 to 15 ml, it could even be a little bit bigger than that, but I mean that is tiny, that is like one bite. The thing with the lap band is that there's the self-sealing reservoir that'll go somewhere else in your abdomen to where it's under the skin, but they can access it with a needle and they can inflate it and what that does is it inflates the cuff that's going around the top of the stomach and it can make it tighter or they can take out some of the fluid and make it looser and that controls the size of the pouch. And that can help with the speed at which they're losing the weight. A combination of restrictive and malabsorptive is the Biliopancreatic diversion or BPD. This one removes about 3/4 of the stomach, so that reduces food intake and decreases acid output. The remaining part of the stomach is connected to the lower portion of the small intestine. So the patient's going to lose weight because not much is absorbed, it just passes to the colon. There's an increased risk of coliophiasis with this, gallstones, ulcers, intestinal irritability, and frequent liquid bowel movements. With coli, lathiasis happens in about one and twelve people hush, settle down. Coliophiasis, one and twelve people with rapid weight loss and we don't know why. So the nutrients pass basically just kind of pass through quickly without being digested. They, the BPD with the wadinal switch, which is a variety of this one. This one they leave a larger part of the stomach intact and that helps prevent dumping syndrome. Which is good because we talked about the complications with that. Another one is the rune y. So this has low complication rates, it has really good tolerance, it's the gold standard for sustained weight loss. It's one of the oldest procedures done, it's tried and true. It's good stuff. So the stomach size here is decreased. There's a little pouch that is anastomose to the jijunum and that pouch is about 20 to 30 ml. So again very tiny, very tiny. There's a chart that has the four main types there. The gastric sleeve is another one and this one is where they just kind of make the stomach into a tube. So they remove the larger portion of the stomach, the greater curvature, which helps maintain the pyloric sphincter. So all of the main components are still intact. The cardiac sphincter and the pyloric sphincter are intact. They just take away the bulk of the stomach and so it's just a sleeve, it's just a tube that food goes through. And then it has normal digestion down the rest of the line. So make sure that you talk about these, look at these with your group, bariatric-surgery-sourced.com is a good resource for that. Currently I believe the sleeve is the most common in 2019 but that can change at any time. So look at that website or do some googling to find out more information. So post.care starts pre-op of course with planning and teaching. We're going to tell them they need to do early abulation using the incentive sprometer. They will have an NG tube so warn them of that. That's going to be uncomfortable. Make sure you don't pull on it. Wound care. We're not going to probably talk about that pre-op too much because you know that's something for later but it is something we want to teach them at discharge. The diet is going to be very slowly advanced with all these bariatric surgeries. So clear liquids when they have bowel sounds, when the NG tube has been removed, when they're passing gas, and when the doctor says so. Then it's going to be progressed very slowly to full liquids, then pureed foods, then soups. So full liquids and pureed for about six weeks. And then they're going to progress to high protein, low carb, low fat, low fiber, six small meals, and fluids should not exceed a thousand milliliters a day and are not to be taken with meals. So a lot of changes there. This is not probably how these people are eating. And so this really needs to be stressed to them and they need to have classes and counseling before having these procedures done or it's not going to work. And low carbs is listed there because carbs cause what? Dumping syndrome. So nursing care, I've said it a few times for your operative care evaluation and counseling. So we really want to make sure that these people know what they're in for. Post-op care is going to be similar to a gastrectomy or a gastroprosection. The risk of complications is greater because of their morbid obesity. So that complicates things a lot. I mean, these are people that may be 4, 5, 600 pounds. So they are at high risk of not only infection, slower healing, clots. So there's a lot of issues we have to think about. Their post-operative diet, once they get progressed to a regular diet, six small meals, 600 to 800 calories a day. That is not much. Psychosocial interventions to modify their eating behaviors. So it would be really great if they could change their dietary habits before surgery, so you can start getting into that habit and they can show that they can do it. And some doctors will make that a prerequisite, which I think is a good idea, just to make sure that they can stick to that and that they lose some doctors will even have to make sure that they lose a certain amount of pounds before they'll do the surgery. If you've ever watched my 600 pound life or something like that, you may have seen some of those things in action. So follow-up care. They'll need to get regular check-ups and blood work and make sure that they're safely losing the weight and that they're getting good nutrition, because they still need to be eating good stuff. So, and that's an important thing. The stuff that they are eating needs to be good quality food. They can't just be filling up on Doritos. Possible complications. There are, unfortunately, a lot of them. So anemia, let's think about why. They've lost a portion of their stomach. So again, intrinsic factor would be 12, that whole thing. Vitamin deficiencies be 12 and other things that are not being absorbed because things are moving through faster or the part that was absorbing them has been removed. Peptic ulcer formation can happen. Sometimes there's over-secretion of acid, and now the stomach is small, so that concentration of acid is high. Dumping syndrome, of course, we've talked about small bowel obstruction. This can occur because there's not, well, the stomach churns and twists and breaks down things. So if you swallow a piece that's too big that you shouldn't have swallowed that big, the stomach kind of further breaks it down. In these cases the stomach may not do that because now the stomach is tiny and it doesn't have time for that. So bowel obstruction can occur because of that. Diaria psychiatric problems. Sometimes people can lose the weight and still have that same self-image that they had before, so that's going to require some counseling. And then cololyphysus, like I said, I think it's about one in 12 and they don't really know why. I just call stones tend to be more active than people that have had weight loss surgeries. Next thing is cosmetic surgeries. So the ideal candidates for this have achieved weight reduction and they have excess skin folds or fat. So again, if you've seen these shows, you've probably seen this happen. They have lost all the weight, but then the skin just kind of hangs on them and they might look okay with enclosed, but then they take them off and it's just you know folds and folds. And so they need to get a lipectomy and that's where they're going to take out the cut off the skin and the fat, surgical removal of folds of skin and adipose tissue. Lifestyle changes are necessary with any of these surgeries because obesity can come back. Fat cells can continue to grow if we don't stick with our diets. And then liposuction is another type of surgery. This is not so much done for dramatic weight loss. This is done when you've lost you know most of your weight, but you still have some pockets of some fat. They'll suck that out. It sounds like a nice little minor procedure, but it's actually pretty brutal. They take a hollow cannula. It goes under the skin and they're instilling saline into it to kind of lubricate and keep it. moving around there and then they are just jabbing it in there in between your muscle and your fat, your fascia and sucking out the fat and blood. It is very painful, there's a lot of bruising and then they have to work pressure garments for a while afterwards. So with bariatric care, it takes a lot of planning ahead. So think about the patient that you're going to be getting, you're going to need to prepare for that so you need an extra large bed, an extra large BP cuff, walker, bedside commode, all of these things need to be considered, we need to get the wider ones. If you're going to be giving any IM shots, you're going to need longer needles, they're going to need higher, they're going to be at a higher risk of clots, so they're probably going to have SCDs and medication, anti-quagulants. They're going to probably be shallow breathing, they're going to have a hard time breathing, they might have a CPAP, they might need oxygen all the time, they most definitely will right after surgery but they may need oxygen longer than another person. We still want to get them up, ambulating as soon as possible, make them use the IS, all of that stuff. Also when they've just had the bariatric surgery, they're still morbidly obese, they have less skin folds, we need to have some powder or extra towels or washcloths to kind of keep in there as they're laying in the bed as they're immobile because those folds yeast can grow in there, so we want to kind of keep them padded and keep them dry so that it doesn't get moist. There are a lot of things to consider and that is it for upper GI.