1. Med/Surg II, Part 3 of 4Digestion Disorders Malignant Oral and Laryngeal Tumors

2. Pre-Malignant Mouth Lesions • Leukoplakia: pre-malignant lesion, especially on tongue or lips; thickened, white, permanently attached patches, slightly raised, sharp edges • Erythroplakia: pre-malignant lesion more likely to progress to malignancy than leukoplakia; red, velvety lesion found in floor of mouth, tongue, palate, mandible mucosa

3. Squamous Cell Mouth Carcinoma • Risk Factors • Increased age • Tobacco (chewing or smoking) • Treatment • Early detection is most important • Local excision will be done if possible for biopsy and possible cure.

4. Diagnosis of Laryngeal Cancer • Direct laryngoscopy • CT scan of the head and neck with contrast • MRI of head and neck with contrast • PET scan: • Biopsies • Endoscopic biopsy • Fine needle aspiration (FNA) biopsy

5. Total Laryngectomy, Preoperative Care • Discuss the informed consent • Explain that the procedure will likely be many hours • Intensive care unit for airway protection - may be on a ventilator. • Alternate forms of communication • Prepare the patient for a feeding tube • Explain pain control methods: PCA machine. Have the patient practice with one if possible. • Tracheostomy will probably be performed - explain this to the patient.

6. Postoperative Care Airway Maintenance Flap and reconstructive tissue care Hemorrhage Wound breakdown Pain management Nutrition Speech rehabilitation

7. Discharge TeachingStoma Care • Avoid swimming, care with showering or shaving to protect stoma opening • Lean slightly forward, cover stoma when coughing or sneezing • Wear a stoma guard • Clean the stoma with mild soap & water. Lubricate with non-oil-based ointment prn • Increase humidity in airway with saline spray, humidifier in room • Wear a Med-Alert bracelet & carry emergency care card

8. Communication • Verify the patient knows how to use his selected communication method • Keep backup communication options available • Card that explains the patient’s situation in an emergency: http://www.larynxlink.com/

9. Resources • Smoking cessation support • Speech therapy • Dietician • Laryngectomy support group • Alcoholics Anonymous if needed

10. Psychosocial Preparation • A visit from a fellow laryngectomee • Importance of returning to a normal lifestyle as much as possible • Expect changes in smell & taste as well as communication • Prepare for mucus with handkerchiefs, tissues or gauze

11. Esophageal Problems Gastroesophageal Reflux Disease (GERD) Esophageal Cancer

12. Clinical Manifestations of GERD • Pyrosis • Dyspepsia - may mimic symptoms of a myocardial infarction • Regurgitation of food particles or fluid – sour or bitter taste in mouth – high risk aspiration • Dysphagia • Hypersalivation

13. Collaborative Management: Diet • Limit or eliminate chocolate, fat, mints, carbonated drinks • Limit spicy and acidic foods when symptomatic • Eat 4-6 small meals per day • Avoid evening snacks, no food 3 hours before sleeping

14. Lifestyle Changes • Elevate head of bed at least 6 inches to avoid reflux when sleeping • Sleep in left lateral decubitus position • Smoking and alcohol exacerbate reflux • Weight reduction will decrease intra-abdominal pressure • Avoid any activity that increases abdominal pressure

15. Medication • Antacids for occasional episodes raise gastric pH: Gaviscon, Maalox, Mylanta one hour before and 2-3 hours after a meal • Histamine receptor antagonists reduce acid secretion: ranitidine (Zantac), famotidine (Pepcid) • Proton pump inhibitors are the main treatment for GERD: omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), esomeprazole (Nexium)

16. Esophageal Cancer • Risk Factors: Chronic irritation: smoking, alcohol ingestion, GERD • Manifestations: progressive and persistent dysphagia (most common), sense of mass in throat, painful swallowing (odynophagia), substernal pain or fullness, regurgitation with foul breath and hiccups and weight loss

17. Diagnosis • Barium swallow with fluoroscopy • Esophagogastroduodenoscopy (EGD) with biopsies (definitive diagnosis) Image Source: National Cancer Society, Public Domain, http://visualsonline.cancer.gov/

18. Esophageal ReconstructionPostoperative Nursing Care • Highest priority • Stress deep breathing • Incentive spirometer • Early ambulation • Semi-fowler’s position in bed

19. Cardiovascular • Monitor closely for: • Hypotension from hypovolemia • Pulmonary edema from fluid overload • Chest tube management if present

20. Wound management • Multiple incisions and drains • Support incision when moving to prevent dehiscence • Infection from incision leak • Watch for fever, increased fluid from drains, signs of local inflammation, tachycardia

21. Nasogastric tube • Placed intraoperatively to decompress suture area • Do not irrigate or reposition. • Drainage bloody early, green-yellow after 24 hours

22. Nutrition • Jejunal tube placed intraoperatively • Start tube feeding after 24 hours, increase slowly • When taking oral nutrition, start with liquids and advance slowly to accommodate decreased stomach capacity • Teach: always eat in upright position – to protect against reflux • Eat 6-8 small meals per day • No liquids with meals to prevent diarrhea (dumping syndrome)

23. Stomach Disorders Peptic Ulcer Disease (PUD) Gastric Carcinoma

24. Peptic Ulcer Disease (PUD) • Risk Factors • Acute gastritis caused by: • Helicobacter pylori, a gram-negative bacterium • Medication side effect: Nonsteroidal anti-inflammatory drugs, alcohol, cytotoxic agents, caffeine, corticosteroids

25. Prevention • Avoid excess alcohol • Use caution with inflammatory medications • Avoid excess caffeine • Stop smoking

26. Manifestations • Epigastric pain • Anorexia, nausea or vomiting • Hematemesis • Dyspepsia • Intolerance of fatty and spicy foods

27. Collaborative Treatment • Teach: Stress reduction, avoid alcohol and tobacco • Diet: • Limit any foods or spices that cause symptoms • Avoid bedtime snacks (stimulate acid secretion)

28. Drugs • H. pylori: Treat with 2 antibiotics + bismuth compound (Pepto-Bismol) or proton pump inhibitor • Antacids 2 hours after meals to buffer acid secretions. • H2- receptor blockers to prevent acid secretions

29. Drugs(continued) • Mucosal barrier, sucralfate (Carafate) • Antisecretory agents • Prostaglandin analogues such as misoprostol (Cytotec) to decrease acid secretion and increase mucosal resistance

30. Manage Complications • Bleeding: Watch for coffee ground vomitus; black, tarry stools (melena) as well as bright red blood • Monitor hemoglobin, hematocrit, coagulation studies • Monitor vital signs for shock

31. Manage Complications • Nasogastric lavage: • NOTE: use 0.9% saline NOT tap water

32. Hypovolemia from Bleeding • Isotonic crystalloids (0.9% saline, Ringer’s lactate), blood products, electrolytes as indicated • Watch! for metabolic alkalosis due to acid loss from vomiting.

33. Assist physician with EGD • Patient preparation: • Large-bore IV catheter for conscious sedation • Blood products if needed • NPO for at least 6 hours, informed consent • Post-procedure: monitor vital signs, oxygen

34. Surgical Management • Vagotomy • Pyloroplasty • Billroth I (gastroduodenostomy) • Billroth II (gastrojejunostomy) Image Source: www.healcentral.rog, Royal College of Surgeons of Ireland, Creative Commons http://www.healcentral.org/healapp/searchResults?searchtype=simple&display=25&keywords=vagotomy&page=1

35. Postoperative Management: • Nasogastric Tube: Attach securely to maintain position – do not change position without surgeon’s order • Monitor drainage for color, volume of drainage • NOTE: report more than scant bloody drainage or minimal drainage; do not irrigate.

36. Dumping Syndrome • Early manifestations: vertigo, tachycardia, syncope, sweating, pallor, palpitations. • Late (90 minutes to 3 hours after eating): excessive insulin release causes dizziness, palpitations, diaphoresis, confusion.

37. Management: Dumping Syndrome • Eat small amounts • Eliminate liquids at meals • High-protein, high-fat, low-carbohydrate diet • Powdered pectin may prevent symptoms • Octreotide (Sandostatin) prescribed in severe cases to inhibit hormones that cause symptoms

38. Alkaline Reflux Gastropathy • Bile reflux in patients whose pylorus is bypassed or removed (Billroth procedures) • Symptoms of early satiety, abdominal discomfort, vomiting.

39. Delayed Gastric Emptying • Often present after gastric surgery, usually resolves within one week. • Continued nasogastric suction relieves symptoms until resolved.

40. Afferent Loop Syndrome • If duodenal loop is partially obstructed after a Billroth II, pancreatic and biliary secretions fill the loop, distending it. • Monitor for abdominal bloating, pain 20-60 minutes after eating followed by nausea and vomiting. Surgical correction is necessary.

41. Nutrition • Decreased absorption of calcium and vitamin D. • At risk for pernicious anemia. • Give vitamin B12 injection • May need folic or iron replacement.

42. Gastric Carcinoma:Risk Factors • H. pylori infection, untreated • Pernicious anemia • Gastric polyps • Achlorhydria • Chronic atrophic gastritis • Cigarette smoking, alcohol consumption are controversial

43. Manifestations • Early: • Indigestion • Abdominal discomfort, feeling of fullness • Epigastric, back, or retrosternal pain • Late: • Nausea and vomiting • Obstructive symptoms, enlarged lymph nodes • Iron deficiency anemia • Palpable epigastric mass • Enlarged lymph nodes • Progressive weight loss

44. Surgical Management • Subtotal or total gastrectomy: stomach, or portion, is removed and duodenum, or remainder of stomach, is sutured to esophagus

45. Postoperative Care • Decompress wound: maintain patency and suction from NG tube to keep pressure off sutures and prevent anastomosis leakage • Notify surgeon if reposition or irrigation needed.

46. Postoperative Care(continued) • Assess color, amount, odor of NG drainage: notify surgeon of any changes • Color should change from dark red to green-yellow over the first 2-3 days

47. Postoperative Care(continued) • Replace fluids and electrolytes intravenously: • At risk for dehydration, • Imbalances of sodium, potassium, chloride • Metabolic alkalosis.

48. Postoperative Care(continued) • Anti-ulcer and antibiotic therapy: prevention of stress ulcers and prophylaxis against any gastric contamination of the abdominal cavity.

49. Postoperative Care(continued) • Monitor abdomen: listen for bowel sounds, watch for distention – may be third spacing, obstruction or infection. • Encourage ambulation to stimulate peristalsis.

50. Nutrition • Total parenteral nutrition (TPN) • Enteral feeding postoperatively • Oral feedings: prevent regurgitation from overeating or eating too quickly. • Watch for dumping syndrome. • Treat anemia, vitamin B12, and folate deficiency. • Teach: recurrence of cancer is common – need regular follow-up.