GASTROINTESTINAL DISORDER

CASE: Gardner is a 56-year-old general contractor who is admitted to your telemetry unit directly from
his internist's office with a diagnosis of chest pain. On report, you are informed that he has an
intermittent 2-month history of chest tightness with substernal burning that radiates through to the
mid-back intermittently, in a stabbing fashion. Symptoms occur after a large meal; with heavy lifting at
the construction site; and in the middle of the night when he awakens from sleep with coughing,
shortness of breath, and a foul, bitter taste in his mouth.
Recently, he has developed nausea, without emesis, that is worse in the morning or after skipping
meals. He complains of “heartburn” three or four times a day. When this happens, he takes a couple of
Rolaids or Tums. He keeps a bottle at home, at the office, and in his truck.
Vital signs (VS) at his physician's office were 130/80 lying, 120/72 standing, 100, 20, 98.6° F, SpO2 92%
on room air. A 12-lead ECG showed normal sinus rhythm with a rare premature ventricular contraction
(PVC).

1. What are some common causes of chest pain?

2. What mnemonic can you use to help you better evaluate his pain?

3. What other history is important?

CASE STUDY PROGRESS: Gardner indicates that usually the chest pain is relieved with his antacids, but
this time they had no effect. A “GI cocktail” consisting of Mylanta and viscous lidocaine given at his
physician's office briefly helped decrease symptoms.

4. What tests can be done to determine the source of his problems?

CASE STUDY PROGRESS: Gardner has smoked one pack of cigarettes a day for the past 35 years, drinks
two or three beers on most nights, and has noticed a 20-pound weight gain over the past 10 years. He
feels “so tired and old now.” Gardner has dark circles under his eyes and complains of constant daytime
fatigue. His wife is even sleeping in another bedroom because he is snoring so loudly. He also reinjured
his lower back a month ago at work, lifting a pile of boards, so his physician prescribed ibuprofen
(Motrin) 800 mg bid or tid for 4 weeks.

5. Which factors in Gardner 's life are likely contributing to his chest pain and nausea? Explain how.

CASE STUDY PROGRESS: Gardner explains that 6 months ago his physician prescribed famotidine
(Pepcid) 20 mg PO at bedtime for heartburn, and that it helped a little, but that it never really “did the
job.” Now he keeps a bottle of Tums or Rolaids in his truck and at his bedside, in addition to the
ranitidine, “because I always seem to need them.”

6. Why do you think the famotidine did not help Gardner?

CASE STUDY PROGRESS: Gardner 's 12-lead ECG was normal, and the first set of cardiac enzymes was
normal. CBC showed WBC 6000/mm3, Hgb 15.0 g/dL, Hct 47%, platelets 220,000/mm3. Complete
metabolic panel (CMP) revealed Na 140 mEq/L, K 3.7 mEq/L, BUN 20 mg/dL, creatinine 1.0 mg/dL, lipase
20 units/L, amylase 18 units/L, PT 12.0 sec, INR 1.0.
The H. pylori antibody test came back as 20 units/mL. The chest x-ray showed no abnormalities. Room
air SpO2 is 94%, and breathing is unlabored. Suddenly, Gardner begins to complain of nausea; as you
hand him the emesis basin, he promptly vomits coffee-ground emesis with specks of bright red blood.
VS remains stable.

7. What concerns do you have about the coffee-ground emesis?

8. What is the significance of the H. pylori antibody test result?

CASE STUDY PROGRESS: You ask the charge nurse to contact the gastrointestinal (GI) consulting doctor
to explain the recent events while you stay with Gardner. The gastroenterologist gives several orders
and states he will be there in 45 minutes. The orders are as follows:

Physician's Orders:
o NPO status for emergent esophagogastroduodenoscopy (EGD)
o STAT CBC
o Oxygen by nasal cannula; titrate oxygen to maintain SpO2 over 92%
o Type and crossmatch (T&C) 2 units packed RBCs (PRBCs), and hold
o Start a pantoprazole (Protonix) drip at 8 mg/hr, preceded by an 80-mg bolus IV over 8 minutes.
o Insert a Salem Sump nasogastric tube (NGT) and start a gastric lavage with normal saline.
o Insert two large-bore IVs and start normal saline (NS) at 100 mL/hr.

9. List the previous orders in order of priority.

10. Explain the rationale for each of the preceding orders.

CASE STUDY PROGRESS: The gastroenterologist finds erosive esophagitis LA Class B, a moderately sized
hiatal hernia, diffuse erosive gastritis, and an ulcer in the antrum of the stomach that is oozing blood.
The duodenal bulb yielded a normal endoscopic appearance. During the EGD, the bleeding was stopped
with cautery. Biopsies were obtained of the gastric mucosa, and the biopsies are negative for H. pylori
bacteria; his bleeding ulcer is attributed to the NSAIDs (i.e., ibuprofen).
He is kept NPO until the next morning to allow good hemostasis of the cauterized site. Clear liquids are
allowed at breakfast. His hematocrit (Hct) dropped to 32%, but he remained asymptomatic from the
mild anemia; the drop was believed, in part, to reflect that he was dehydrated on admission, and the
decrease reflected the dilution of the blood from the IV fluids added. Thus, he did not receive a
transfusion of blood.
Gardner tolerated the liquid diet without any nausea and vomiting and is discharged to home the next
day with the following instructions:
o Advance diet slowly, as tolerated, to mechanical soft.
o Take pantoprazole 40 mg PO q AM on an empty stomach, at least 30 minutes before eating.
o Make follow-up appointment in 6 to 8 weeks with physician (give name and telephone number)
o Stop all aspirin and over the counter (OTC) or herbal pain relief medications (ibuprofen,
naproxen, etc)
o Stop or limit alcohol intake and smoking

11. Why does the patient need to take the pantoprazole first thing in the morning?

12. After discussing lifestyle modifications for controlling acid reflux with Gardner, which statement by
Gardner indicates a further need for teaching?
a. “I will try to stop smoking.”
b. “I will wait thirty minutes before lying down or sitting in my recliner after meals.”
c. “I will avoid fatty foods, caffeine, and chocolate.”
d. “I will avoid eating two to three hours before my bedtime.”