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Gastric ulcers are less common than duodenal ulcers; however,

patients with gastric ulcers have the highest mortality rate among

patients with peptic ulcer disease. Patients with gastric ulcers apparenrly have normal gastric acid secretion but have lowered defense mechanisms in the mucosal lining to protect against acid secretion.

Other highly causative factors for gastric ulcer include H. pylori infection and use of NSAlDs.32 However, high levels of physiologic and emotional stress cannot be ruled our as a contributing factOr in the

development of gastric ulcer formation.3'

Symptoms of a gastric ulcer may include abdominal pain during or

shortly after a meal, nausea with or without vomiting, or both. Management of gastric ulcers may consist of any or all of the following: modification or elimination of causative agents, antacids, and H.

pylori therapies (see Gastritis).J2·33

Duodenal Ulcer

Duodenal ulcers are more common than gastric ulcers and are defined as

a chronic circumscribed break in the mucosa that extends through the

muscularis mucosa layer and leaves a residual scar with healing. Duode-

GASTROINTFSrINAL SYSTEM

529

n.1 ulcers arc linked with gastric acid hypersecretion and genetic predisposition. JI Other risk factors for developing duodenal ulcers include tobacco lise, chronic renal failure, alcoholic cirrhosis, renal transplanration, hyperparathyroidism, and chronic obstructive pulmonary disease.

Clinical manifestations of duodenal ulcer disease may include

sharp, burning, or gnawing epigastric pain that may be relieved with

food or antacids. Abdominal pain can also occur at night. Managemenr of duodenal ulcers is similar to that of gastric ulcers.32,JJ

Zollinger-Ellison Syndrome

Zollinger-Ellison syndrome is a clinical triad that includes gastric acid

hypersecretion, recurrent peptic ulcerations, and a non-beta islet cell

tumor (gastrinoma) in the pancreas. Symptoms mimic peptic ulcer

disease, but consequences are more severe if left untreated. Patients

with Zollinger-Ellison syndrome may also present with diarrhea.

Management is primarily directed at surgical resection of the gasrrinoma, along with decreasing gastric acid hypersecretion.J2•36,37

Gastric Emptying Disorders

Abnormal gastric e�lprying is described as either decreased or increased

emptying. Decreased gastric emprying is also referred to as gastric

retelltioll and may result from or be associated with (1) pyloric stenosis

as a consequence of duodenal ulcers, (2) hyperglycemia, (3) diabetic

ketoacidosis, (4) electrolyte imbalance, (5) autonomic neuropathy,

(6) postoperative stasis, and (7) pernicious anemia. Pharmacologic

inrervenrion to promote gastric motility is indicated for patients with

decreased gastric emprying disorders.

Enhanced gastric emptying is associated with an interruption of

normal digestive sequencing that results from vagoromy, gastrectomy,

or gastric or duodenal ulcers. Gastric peristalsis, mixing, and grinding

are disturbed, resulting in rapid emprying of liquids, slow or

increased emptying of solids, and prolonged retention of indigestible

solids. With enhanced gastric emptying, blood glucose levels are subsequendy low and can result in signs and symptoms of anxiety, sweating, inrense hunger, dizziness, weakness, and palpitations. Nutritional and pharmacologic management are the usual treatment choices,J8

Gastric Cancer

The most common malignanr neoplasms found in the stomach are

adenocarcinomas, which arise from norma) or mucosal cells. Benign

tumors are rarely found but include leiomyomas and polyps. For a

more detailed discussion of gastric oncology, see Cancers in the Body

Systems in Chapter 5.

530

AClITE CARE HANDBOOK FOR PHYSICAL THERAPISTS

Intestinal Disorders

Appendicitis

Inflammation of the appendix of the large intestine can be classified as

simple, gangrenous, or perforated. Simple appendicitis involves an

inflamed but intact appendix. Gangrenous appendiciti is the presence

of focal or extensive necrosis accompanied by micro copic perforations. Perforated appendicitis is a gross disruprion of the appendix wall and can lead to serious complications if it is not managed

promptly]' The etiology of appendicitis includes a combination of

obstruction in the appendix lumen coupled with infection 'S

Signs and symptoms of appendicitis may include the following.l'·4o:

• Right lower quadrant, epigastric, or periumbilical abdominal

pain that fluctuates in intensity

• Abdominal tenderness in the right lower quadrant

• Vomiting with presence of anorexia

• Constipation and failure ro pass flatus

• Low-grade fever (no greater than 102°F or 39°C)

Management of appendicitis involves timely and accurate diagnosis of acute appendicitis to prevent perforation. Treatment choices include anti-infective agents or surgical appendecromy.''""''

Diverticular Disease

Diverticulosis is the presence of diverticula, which is an outpocketing,

or herniation, of rhe mucosa of the large colon through the muscle

layers of the intestinal wall. Diverticlliar disease occurs when the outpocketing becomes sympromatic. Diverticlliitis is the result of inflammation and localized peritonitis that occurs after the perforation of a single diverriculum.15,39,4o.42

Signs and symproms of diverticular disease include the following:

• Achy, left lower quadrant pain and tenderness (pain intensifies

with acLlte diverticulitis)

• Pain referred to low back region

• Urinary frequency

GASTROINTESllNAL SYSTEM

531

• Distended and tympanic abdomen

• Fever and elevated white blood cell count (acute diverticulitis)

• Constipation, bloody stools, or both

• Nausea, vomiting, anorexia

Management of diverticular disease includes any of the

followingJ•·•o •• J .•• :

• Dietary modifications (e.g., increased fiber)

• Insertion of nasogasrric tube in cases of severe nausea, vomiting,

abdominal distention, or any combination of these

• i.v. fluids

• Pain medications

• Ami-infective agents

• Surgical repair of herniation, resection (colectomy), or both

with possible colostomy construction. Video laparoscopic techniques are becoming a more favored surgical approach for these procedures.42

Hernia

Abdomillal Hernia

An abdominal hernia is an abnormal protrusion of bowel that is generally classified by the area where the protrusion occurs. These include the following areas: (I) epigastric, (2) inguinal, (3) femoral,

(4) ventral or incisional hernia, and (5) umbilical. Muscle weakening

from abdominal distention that occurs in obesity, surgery, or ascites

can lead to herniation through the muscle wall. Herniation may also

develop congenitally.J'·'5

Signs and symptoms of abdominal herniation include the

foliowingJ•·•5:

• Abdominal distention, nausea, and vomiting

• Observable bulge with position changes, coughing, or laughing

• Pain of increasing severity with fever, tachycardia, and abdominal rigidity (if the herniated bowel is strangulated)