Pathophysiology Review - part 6 docx

440 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review Quickie tests and treatments Tests for GERD include: ț Ambulatory pH monitoring to measure the frequency and duration of reflux episodes: performed by placing a tube through the nose and into the lower esophagus. The outer tube is connected to a monitor worn on the belt. Acid levels are usually measured for 24 hours. ț Barium swallow to show structural abnormalities and reflux of barium from stomach into esophagus. Performed by using x-rays after client swallows barium. ț Endoscopy (most common test used for diagnosis) to directly visualize tissue erythema, fragility, or erosion and detect esophageal cancer or Barrett’s esophagus (precancerous change in the lining of the esophagus). Performed using an endoscope (tube). ț Esophageal manometry to measure pressure of esophageal wave motility and identify LES pressure sufficiency. Performed by inserting water-filled catheter through the nose and into the esophagus. Pressures and peristalsis are measured as the catheter is withdrawn. Treatment of GERD aims to reduce reflux of gastric juices and abdominal pressure. Dietary management includes: ț Losing weight if obese. ț Eating a low-fat, high-protein diet to reduce acid production. ț Limiting or avoiding chocolate, fatty foods, and mints to ease LES pressure. ț Eating small frequent meals (4 to 6 a day) to help reduce abdominal pressure. ț Avoiding carbonated beverages, which can increase stomach pressure. ț Avoiding meals within 3 hours of going to bed to reduce reflux caused by larger meals. Table 12-12. (Continued) Signs and symptoms Why Pain Caused by acid irritation of the mucosal lining Usually occurs 30 minutes after meals or when lying down at night Hoarseness, throat clearing Acid irritation and backflow of gastric or sore throat contents (irritates the throat) Dysphagia (difficulty swallowing) Scarring from long-term exposure to acid irritation (scarring can cause narrowing in esophagus) Odynophagia (painful swallowing) From spasms in the esophagus caused by irritation of tissue Coughing Irritation of the phrenic nerve Source: Created by author from References #4, #6, and #7. Regurgitation when a person is lying down increases the risk of aspiration. An increased respiratory rate and crackles in the lung fields may indicate aspiration. GERD pain can be experienced as burning, or pain that radiates to the neck, throat, and face. CHAPTER 12 ✚ Gastrointestinal System 441 ț Avoiding spicy and high-acid foods, which can irritate the esophageal lining. ț Avoiding alcohol, especially late at night before bedtime. ț Increasing fluid intake to help wash gastric contents out of esophagus. Other changes include: ț Discontinuing of NSAIDs, as ordered by physician. ț Elevating head of the bed 6 to 12 inches or more to prevent reflux during sleep. ț Stopping smoking to improve pressure on LES. ț Avoiding constrictive clothing (tight clothes increase intra-abdominal pressure). Drug therapy includes: ț Proton-pump inhibitors—such as omeprazole (Prilosec), lansoprazole (Prevacid), esomeprazole (Nexium), and pantoprazole (Protonix)—to inhibit gastric acid formation. Proton-pump inhibitors are typically the most effective treatment for GERD. ț H 2 -receptor blockers—such as nizatidine (Axid), ranitidine (Zantac), and famotidine (Pepcid)—to inhibit gastric acid secretion. ț Antacids—such as aluminum magnesium combinations (Mylanta, Maalox)—to neutralize existing gastric acid. ț Mucosal barrier fortifiers—such as sucralfate (Carafate) to protect the mucosal barrier. Invasive treatments include: ț Endoscopic intervention to tighten the LES and prevent reflux. ț Surgical intervention to correct LES weakness. May be needed if client does not respond to medical management or problem is complicated by a hiatal hernia. Laparoscopic Nissen fundoplication (LNF) is the most common procedure. Some people choose to undergo surgery to prevent lifelong use of medication to treat GERD. What can harm my client? ț Long-term untreated GERD causes acidic burning of tissue, leading to esophagitis (erosion and ulceration of epithelium of esophagus). ț Stricture (narrowing of esophagus caused by scar tissue) can lead to swallowing difficulties. ț Barrett’s esophagus (a precancerous change in the tissue of the esophagus) can lead to esophageal cancer. If I were your teacher, I would test you on . . . ț Definition of GERD. ț Causes of GERD and rationales. ț Signs and symptoms of GERD and rationales. ț Pharmacology of drugs for GERD. ț Client education regarding pH and manometry studies. Cimetidine (Tagamet) can inhibit the elimination of other drugs, such as warfarin (Coumadin) and phenytoin (Dilantin), and is used less frequently than the other H 2 -receptor blockers. With Nissen, the condition tends to recur in some people so the focus is on identifying risk factors such as smoking, obesity, excessive alcohol intake, poor diet, etc., and making lifestyle changes to eliminate those contributing factors. 442 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review ț Client education regarding lifestyle changes to improve signs and symptoms. ț Signs and symptoms of more serious problems (bleeding, painful swallowing, weight loss, dysphagia) that require medical attention. ✚ Hiatal hernia What is it? A hiatal hernia (Fig. 12-3) occurs when part of the stomach protrudes through the esophageal hiatus (the opening in the diaphragm through which the esophagus passes through). There are two major types of hiatal hernias: ț Sliding: upper segment of the stomach including the esophageal-stomach junction slides through the opening in the diaphragm. ț Paraesophageal: upper segment of the stomach moves into the chest; the esophageal-stomach junction remains in normal position. Esophagus Hiatal hernia Diaphragm Hiatus Stomach What causes it and why Table 12-13 shows the causes of hiatal hernias and why these causes occur. Table 12-13 Causes Why Malformation Larger-than-normal esophageal hiatus that allows a portion of the stomach to enter the thorax Muscle weakness of the esophageal hiatus The weakening of this muscle allows a portion of the stomach to move into the thorax Esophageal shortening Caused by scarring of the tissue from gastric acids Obesity Causes increased pressure variations between thoracic and abdominal cavities, leading to stomach protrusion into the diaphragm Source: Created by author from References #7 and #8. Ǡ Figure 12-3. Hiatal hernia. A hiatal hernia occurs when the upper portion of the stomach slips through the hiatus (the hole between the abdominal cavity and the diaphragm) into the chest cavity. CHAPTER 12 ✚ Gastrointestinal System 443 Signs and symptoms and why Small hiatal hernias are usually asymptomatic (without symptoms). Signs and symptoms are usually related to reflux. Table 12-14 shows the signs and symptoms and rationales associated with hiatal hernias. Table 12-14 Signs and symptoms Why Feeling of fullness, smothering, Occurs more with paraesophageal hiatal or suffocation after meals hernia because part of the stomach is in the thorax. Eating distends the stomach and takes up more room, leading to a decreased ability of the lungs to expand Anemia Bleeding of the lining of the hernia may occur with both types of hernias, decreasing the red blood cell count Source: Created by author from References #5 and #6. Quickie tests and treatments Tests for hiatal hernias include: ț Fluoroscopy. ț X-ray studies. The tests may reveal a hiatal hernia. During the tests, the abdomen may need to be pressed to obtain a definitive diagnosis. Treatment includes dietary and medical management similar to that for GERD. Remind the client to SIT UP after eating to keep the stomach down. Surgical repair may be needed if symptoms persist after instituting dietary and medical management: ț Surgery is more common for large paraesophageal hernias. ț The most common technique is the laparoscopic Nissen fundoplication (LNF). What can harm my client? ț Strangulation (pinching of the hernia, causing it to loose blood supply) can develop. Strangulation leads to a rapid onset of excruciating pain, difficulty swallowing, and radiation of pain into the chest unrelieved by antacids. Immediate surgery is needed. ț Chronic reflux of GERD can lead to esophagitis and esophageal ulceration. If I were your teacher, I would test you on . . . ț Definition and types of hiatal hernias. ț Causes of hiatal hernia and rationales. ț Signs and symptoms of hiatal hernias and rationales. ț Signs and symptoms and management of hernia strangulation. ț Client education for symptom management. 7 444 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review ✚ Peptic ulcer disease (PUD) What is it? Peptic ulcer disease (PUD) is an erosion of the lining of the stomach, pylorus, duodenum, or esophagus caused by exposure to hydrochloric acid, pepsin, and Helicobacter pylori. H. pylori causes damage to the mucosa of the GI tract. Ulcers are named according to the area where they occur. Duodenal ulcers are more common than gastric ulcers. PUD is more common in the elderly and Caucasians. When you hear the term PUD, this is usually referring to either a stomach or duodenal ulcer (Figure 12-4). Normal Peptic ulcers What causes it and why Table 12-15 shows the causes of PUD and why these causes occur. Table 12-15 Causes Why Infection (H. pylori accounts for 90% H. pylori produces substances that damage the gastric mucosa, leading to of duodenal and 80% of gastric ulcers) irritation and inflammation Medications: Aspirin and NSAIDs irritate the lining of the stomach and duodenum and ț Aspirin expose it to acid and digestive enzymes, which can injure the epithelium ț Nonsteroidal antiinflammatory and lead to ulcer formation drugs (NSAIDs) Theophylline and caffeine stimulate acid production, which can damage ț Theophylline the lining of the GI tract and lead to ulceration ț Caffeine Prednisone also contributes to gastric irritation just like NSAIDs ț Prednisone (Continued) Ǡ Figure 12-4. Peptic ulcers. (From Saladin K. Anatomy and Physiology: The Unity of Form and Function. 4th ed. New York: McGraw-Hill; 2007.) Stress ulcers can be caused by severe illness and trauma (any kind of stress can cause hypersecretion of acid). Many clients in intensive care units are treated to prevent the development of these ulcers. Clients should not take NSAIDs and prednisone at the same time due to ↑ risk of GI irritation. CHAPTER 12 ✚ Gastrointestinal System 445 Signs and symptoms and why Gastric and duodenal ulcers have differentiating features. ț Gastric ulcers: common in women in labor; clients are malnourished in appearance; pain occurs 1 / 2 to 1 hour after meals; food doesn’t help but vomiting does; clients tend to vomit blood (hematemesis). ț Duodenal ulcers: common in executive type personalities (type A); clients are well nourished in appearance; pain occurs at night and 2 to 3 hours after meals; food helps; blood appears in stool (melena). Duodenal ulcers are the most common to rupture. Table 12-16 designates which symptoms go with each type of ulcer. If there is no designation, then the symptom is applicable to both types of ulcer. Table 12-15. (Continued) Causes Why Smoking Decreases gastric blood flow and delays ulcer healing; nicotine causes vasoconstriction Stress Increases acid production that can lead to erosions and ulcerations Source: Created by author from References #7 to #9. Table 12-16 Signs and symptoms Why Dyspepsia (indigestion) described as gnawing Stomach acid and digestive juices erode the lining of the stomach or burning in the left epigastric or upper Gastric: pain mainly in the left epigastric area abdominal area. May be described as sharp, Duodenal: pain mainly in the right epigastric area burning, gnawing. Some clients say they feel hungry Nausea, vomiting after eating, belching, GI tract is inflamed. These are other dyspeptic symptoms and bloating Ulcers can affect pyloric sphincter which could delay gastric emptying Weight loss Gastric ulcers: chronic nausea and vomiting can cause weight loss Pain 1 to 2 hours after eating Gastric ulcers: eating promotes motility of stomach and decreases acids and digestive enzymes on eroded areas After eating, an increase in acids and enzymes and a swelling of tissue leading to the small intestine make food passage difficult Burning or cramping pain in right epigastric Duodenal ulcers: caused by high acid concentrations or upper abdominal area Pain 2 to 4 hours after meals or during Duodenal ulcers: eating buffers stomach acids for first 2 hours. Pain the night returns when stomach is empty Weight gain Duodenal ulcers: increased food consumption decreases burning and cramping Relief from food, milk, antacids Duodenal ulcers: food, milk, and antacids buffer acids produced in the stomach Source: Created by author from References #7 to #9. Gastric—eating leads to pain. Duodenal—eating lessens pain. 446 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review Quickie tests and treatments Tests for PUD include: ț Urea breath test or (serum) to detect H. pylori. Carbon dioxide excreted in client’s breath is measured before and after client drinks carbon-enriched urea solution. ț Serum IgG antibody screening to detect H. pylori. Blood test identifies antibodies to H. pylori. ț Upper GI endoscopy with tissue biopsy and cytology for microscopic examination. Pyloritek is a biopsy urea test used to detect H. pylori per upper GI. ț Upper GI (barium swallow) to visualize changes in GI tract structure and function. (peptic ulcers). ț Esophagogastroduodenoscopy (EGD) to confirm presence of ulcers. Flexible tube (endoscopy) is inserted through the mouth and into the stomach and duodenum. A tissue sample is taken to test for H. pylori and gastric cancer. ț Serial stool specimens (stool for occult blood ϫ 3) to detect occult (hidden) blood. ț Gastric secretory studies (gastric acid secretion test and serum gastric level test). These will be elevated in some syndromes such as Zollinger–Ellison syndrome (a condition associated with high levels of gastric acid). ț Complete blood count to detect low hemoglobin level and hematocrit from bleeding. Treatments: ț Treatment itself decreases pain as mucosa starts to heal. ț A bland diet with no spicy or high-acid foods, which could cause irritation. ț Lifestyle changes includes avoiding irritants such as caffeine, tea, cola, alcohol, and smoking because these substances irritate the lining of the stomach or cause increased release of gastric acid. Coffee stimulates gastrin release and irritates the stomach. ț Meditation. ț Herbs and vitamins to increases healing. ț No bedtime snacks because it increases gastric secretions. ț No NSAIDs or salicylates (such as aspirin). Misoprostol (Cytotec) may be given to reduce the incidence of NSAID-induced ulcers. ț Decrease GI bleeding if applicable (may require surgery to do so). Drug therapy includes: ț Proton-pump inhibitors—such as omeprazole (Prilosec), lansoprazole (Prevacid), esomeprazole (Nexium), and pantoprazole (Protonix)—to inhibit gastric acid formation. ț H 2 -receptor blockers—such as nizatidine (Axid), ranitidine (Zantac), and famotidine (Pepcid)—to inhibit gastric acid secretion. ț Antacids—such as aluminum magnesium combinations (Mylanta, Maalox)—to neutralize existing gastric acid. CHAPTER 12 ✚ Gastrointestinal System 447 ț Mucosal barrier fortifiers—such as sucralfate (Carafate) to protect the mucosal barrier. Infection with Helicobacter pylori requires a 2-week course with three drugs. The most common combinations are bismuth subsalicylate (Pepto-Bismol) or a proton-pump inhibitor and metronidazole (Flagyl) and tetracycline (Achromycin) or clarithromycin (Biaxin) and amoxicillin (Amoxil). What can harm my client? Bleeding (hemorrhage) may appear as hematemesis (vomiting blood) or melena (blood in stool) and may be treated with: ț Endoscopy to achieve blood-clot formation (cauterizing the vessel, injec- tion of diluted epinephrine, laser therapy, or clipping of bleeding vessel). ț H 2 -receptor blockers or proton pump inhibitors to help heal the ulcer (for mild bleeding). ț Intravenous (IV) fluids and NPO (nothing by mouth) to allow healing. ț Saline lavage (instilling of saline through an NG tube with repeated withdrawal and insertion until the returns are light pink to clear). ț Surgery (for severe bleeding). Perforation (ulcers penetrating the wall of the GI tract) causes sudden, excruciating pain in shoulders that becomes more intense with position change or deep breathing, rebound tenderness (pain after the abdomen is pressed and released suddenly; means peritoneal inflammation), and fever. Treatment includes: ț Immediate replacement of fluids and electrolytes via IV route. ț Nasogastric suctioning (use of a tube inserted through the nose into the stomach and connected to low intermittent suction) to remove gastric contents and prevent further spillage. ț Suction turned too high will increase bleeding. ț Emergency surgery and IV antibiotics. Penetration (ulcer penetrates the stomach or duodenum and continues into adjacent organs), causes continuous pain at the involved site and is treated with: ț Drug therapy. ț Surgery (if drug therapy fails). Obstruction caused by edema (swelling) or scarring of tissue around an ulcer can decrease the passageway and cause a feeling of fullness, vomiting, regurgitation, and a loss of appetite. Treatment includes: ț Adequate ulcer treatment. ț Nasogastric suctioning (use of a tube inserted through the nose into the stomach and connected to low intermittent suction) until edema subsides. If I were your teacher, I would test you on . . . ț Definition of PUD. ț Differentiation of 2 types PUD. ț Causes of PUD and rationales. Barium studies should not be used if a perforation (tear in the lining) is suspected. Generally, abdominal x-rays are performed to check for free air (a sign of perforation) before these studies. Calcium carbonate (Tums) causes rebound acid secretion by triggering gastrin release, and thus is not recommended for ulcer disease. Flavored antacids should be avoided because the flavoring increases the emptying time of the stomach. You may not have had an ulcer before you started nursing school, but you may get one before it’s over! As many as 50% of upper GI bleeds result from peptic ulcers. 448 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review ț Signs and symptoms of PUD and rationales. ț The four types of drugs for stomach disorders. ț Triple-therapy medication options for treating H. pylori. ț Differentiating gastritis, gastric ulcer, and duodenal ulcer. ț Complications of PUD. ✚ Achalasia What is it? Achalasia is ineffective or absent peristalsis of the distal esophagus that affects movement of food into the stomach. In achalasia, the lower esophageal sphincter (LES) fails to relax or open with swallowing, causing a backup of food material, and the lower esophagus is narrowed above the stomach, leading to a gradual dilation of the esophagus in the upper chest. What causes it and why The underlying cause of achalasia is unknown. Table 12-17 shows the current theory on what causes achalasia and why this cause occurs. Table 12-17 Cause Why Denervation of muscle layers Immune (viral or autoimmune) damage of the esophagus occurs to nerves Source: Created by author from References #6 to #8. Signs and symptoms and why Table 12-18 shows the signs and symptoms of achalasia and associated rationales. Table 12-18 Signs and symptoms Why Difficulty swallowing solids and liquids Decreased esophageal contractions and tightening of LES (main symptom) Feeling of food sticking in the Tightening of LES makes it difficult for food to pass into the stomach lower esophagus Chest pain Common when swallowing because of accumulation of food in esophagus Weight loss Inability to maintain adequate nutritional intake because of difficulty passing nutrients Regurgitation of undigested food Food collects in enlarged esophagus, and as the passage of food becomes more difficult regurgitation can occur Contents are not acidic because food has not entered the stomach Typically occurs during sleep Can lead to aspiration of food into lungs Halitosis (foul mouth odor) Regurgitation of undigested food into the throat Source: Created by author from References #6 to #8. Define Time—Achalasia is a dis- order of the esophagus where the rhythmic contractions are sig- nificantly decreased and the lower esophageal sphincter fails to relax as it normally does. CHAPTER 12 ✚ Gastrointestinal System 449 Quickie tests and treatments Tests for achalasia include: ț Barium swallow (x-rays taken after drinking barium) to show an enlarged esophagus that narrows as it reaches the LES and decreased peristalsis. ț Esophagoscopy to visualize enlarged esophagus that is not due to obstruction. ț Biopsy (sample of tissue removed) to rule out cancer. ț Esophageal manometry to measure the pressure of esophageal wave motility. (Achalasia results in increased LES pressure with lack of sphincter relaxation during swallowing.) Treatment for achalasia includes: ț Having client eat slowly and chew food completely to aid passage through a narrowed LES. ț Having client drink fluids with meals to help prevent a feeling of food sticking to the throat. ț Explaining that warm food and liquids may be swallowed easier than cold ones. ț Elevating the head of the bed 6 to 12 inches to decrease reflux at night. ț Using medications such as nitrates, such as nitroglycerin; or calcium- channel blockers, such as nifedipine (Procardia); to help to relax the sphincter and make food passage easier. ț Using balloon dilation of the narrowed esophagus. ț Using a botulinum toxin (Botox) injection instead of balloon dilation; Botox is injected into the lower esophageal sphincter muscle to provide symptom relief. ț Using surgery (esophagomyotomy), cutting LES muscle fibers to decrease obstruction, if other treatments are unsuccessful. What can harm my client? ț Weight loss because of an inability to effectively swallow food and liquid. ț Malnutrition from inadequate nutritional intake. ț Esophageal rupture during balloon dilation, which is rare and requires surgical repair. ț Aspiration. If I were your teacher, I would test you on . . . ț Definition of achalasia. ț Causes of achalasia and rationales. ț Signs and symptoms of achalasia and rationales. ț Education on ways to increase nutritional intake. ț Client preparation for barium swallow 8 (nothing to eat after midnight before the test, removal of jewelry and metal before the test, x-rays taken in various positions after client drinks barium). Not only will eating before the test cause problems but clients should not smoke before the test either, because this increases gastric secretions and gastric motility. [...]... pass into the scrotal area or into the groin Intestine 460 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review Ǡ Figure 1 2-7 Femoral hernia The herniated intestine can cause a visible bulge Femoral hernia ǠFigure 1 2-8 Umbilical hernia Umbilical hernia What causes it and why Table 1 2-2 8 shows the causes of hernias and why these causes occur Table 1 2-2 8 Causes Why Congenital Weakness or incomplete closure... should avoid dairy products ț For celiac disease, the client should maintain a gluten-free diet ț For gallbladder disease and pancreatic insufficiency, the client should maintain a low-fat diet 451 452 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review ț Gastrectomy clients should maintain a high-protein and high-calorie diet and eat small, frequent meals Should also keep head of bed elevated Calcium... appendix (Fig 1 2-9 ) The appendix is a little sac on the intestine that can get filled with bowel contents, become inflamed, and possibly rupture Surgery for appendicitis is one of the most common abdominal surgeries The appendix is not an essential organ in the digestive process ǡ Figure 1 2-9 Appendicitis Large intestine Cecum Inflamed appendix 466 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review What... HURST ✚ Hurst Reviews: Pathophysiology Review ✚ Malabsorption disorders What are they? Malabsorption disorders are disorders in which nutrients are not digested or absorbed properly What causes them and why Table 1 2-1 9 shows the causes of malabsorption disorders and why these causes occur Table 1 2-1 9 Causes Why Bile salt deficiencies If the body is not producing enough bile salts, fats and fat-soluble vitamins... hernia Table 1 2-2 7 describes the four types of hernias Table 1 2-2 7 Hernia type Description Inguinal (Fig 1 2 -6 ) ț Protrusion of the spermatic cord (male) or round ligament (female) through the inguinal canal of the abdominal wall ț Can be direct (passes through weakness in the wall) or indirect (pushes into the inguinal canal) ț Most common type of hernia Femoral (Fig 1 2-7 ) ț Occurs in the upper part of thigh... Hooray for modern medicine!!! 468 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review ț Signs of perforation ț Preoperative nursing interventions ✚ Peritonitis What is it? Peritonitis is an acute inflammatory disorder of the peritoneum (lining of the abdominal cavity) What causes it and why Table 1 2-3 4 shows the causes of peritonitis and why these causes occur Table 1 2-3 4 Causes Why Rupture (perforation)... anusol to reduce swelling and pain associated with hemorrhoids 455 4 56 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review ț Compress pads of witch hazel (Tucks) to control symptoms ț Cleaning anal area by blotting, not wiping, with a moistened wipe (Sometimes baby wipes are used to reduce abrasion caused by toilet paper.) ț High-fiber diet and increased fluids to manage constipation (client needs... Created by author from References #7 and #8 Signs and symptoms and why Table 1 2-2 6 shows the signs and symptoms and rationales associated with dumping syndrome Table 1 2-2 6 Signs and symptoms Why Systemic (early dumping syndrome): ț Sweating (diaphoresis) ț Extreme fatigue and strong desire to lie down ț Palpitations ț Light-headedness and syncope ț Flushing Early dumping syndrome: these systemic signs... Exercise, stop smoking, decrease alcohol, eat a low-fat/high-fiber diet ț Routine colorectal screenings Clients needing colonoscopy will receive a liquid substance to drink prior to the test in order to evacuate the bowel of stool contents This allows for easy visualization of the inside of the colon 454 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review What can harm my client? ț Excessive rectal... common in whites of Jewish descent Source: Created by author from References #6 to #8 Signs and symptoms and why Table 1 2-3 9 shows the signs and symptoms and rationales associated with ulcerative colitis These signs and symptoms are intermittent; flare-ups can occur gradually or quickly Table 1 2-3 9 Signs and symptoms Why Left-quadrant abdominal pain (may be crampy) Multiple ulcerations, diffuse inflammation . maintain a gluten-free diet. ț For gallbladder disease and pancreatic insufficiency, the client should maintain a low-fat diet. 452 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review ț Gastrectomy. #7 to #9. Gastric—eating leads to pain. Duodenal—eating lessens pain. 4 46 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review Quickie tests and treatments Tests for PUD include: ț Urea breath. ulcers. 448 MARLENE HURST ✚ Hurst Reviews: Pathophysiology Review ț Signs and symptoms of PUD and rationales. ț The four types of drugs for stomach disorders. ț Triple-therapy medication options for