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COLLEGE OF NURSING
MALAYBALAY CITY,
BUKIDNON
CASE STUDY:
PYLORIC STENOSIS
SUBMITTED TO:
GIOVANNI JAN N. SANCHEZ RN, MAN
SUMBITTED BY:
CABATIC, MARIA ANGELICA G.
APRIL 2020
Table of Contents
Table of Contents i
I. Introduction 1
IX. Pathophysiology 39
X. Medical/Surgical Management 40
XI. Laboratory
41
i
I. INTRODUCTION
pediatrics and the medical care of children specifically from infancy to teenage years.
This is an important field for the health of the children is distinct from adults due to
mitigate health problems before they occur. Pediatric nurses not only work directly
with children and their families but they also serve as policy advocates for major
According to the Centers for Disease Control and Prevention (CDC), every 4.5
minutes, a baby is born with a birth defect in the United States. That means nearly
120,000 babies are affected by birth defects each year. Birth defects may affect how
the body looks, works, or both and it can vary from mild to severe. Depending on the
severity of the defect and what body part is affected, the expected lifespan of a person
with a birth defect may or may not be affected. One of this type of birth defect is most
is the most common cause of intestinal obstruction in infancy. IHPS occurs secondary
between the stomach and small bowel (duodenum) becomes narrower. Basically, for
babies with pyloric stenosis, the valve is too large and does not allow food to pass
through and therefore it becomes trapped in the stomach. It tends to occur most
frequently in first-born White male infants. The cause is unknown, but multifactorial
1
According to Epidemiological Features of Infantile Hypertrophic Pyloric
2007(2011), The incidence rate of IHPS varies from 0.17 to 4.4 per 1000 live births
among different populations around the world. In the study Prevalence of infantile
per 1000 live births), Vietnamese (0.44 per 1000 live births), Asian Indians (0.59 per
1000 live births) and Filipinos (0.43 per 1000 live births) when compared to white
populations.
The higher risk of pyloric stenosis in boys than girls is the earliest noted and
series published before 1951, among 2506 cases, 82.8% were male—a male to female
(M:F) ratio of 4.8:1. In the 5 largest series published since 1995, there were 8160
cases of which 81.5% were male. Four of these series were from the United States,
but very similar findings have been reported from Canada, Australia, Denmark,
Sweden, and England. It appears that a 4- to 5-fold higher risk of this disease in boys
has been characteristic of the disease for many years and in all countries in which it is
common.
2
II. Purpose of the Study
General Objectives:
At the end of the study, the learners will be able to obtain knowledge about the
Pyloric stenosis which is also known as Infantile Hypertrophic Pyloric Stenosis
(IHPS) as well as right approach and develop positive attitude in rendering care
towards patient having the condition.
Specific Objectives:
At the end of effective reading and comprehension of the study, the learners will
be able to:
3
III. Data Base and History
I. BIOGRAPHIC DATA
Name of patient: X
Date of Birth: 02-25-2020 Sex: M Age: 4 weeks old
Address: 8090 Sherman St. Lenoir, NC 28645
Religion: Catholic Civil Status: Single
Nationality: Caucasian Occupation: N/A Income: N/A
Type of Health Insurance: Informant: Relationship to client:
National Health Insurance Mrs. B Mother
4
AL LERGIES ☐ Yes ☒ No
MEDICATIONS TAKEN: NONE
BLOOD TRANSFUSION ☐ Yes ☒ No
5
Patient X is the first child and therefore has no siblings. The mother of the
patient was said to have the same condition during infancy but has already recovered
and is now completely healthy while the father has hypertension and diabetes. The
Patient’s mother has two siblings and she is the youngest, her eldest brother is
diseased due to cancer while the other sibling is completely healthy. The grandfather
on the mother side is diseased due to stroke and the grandmother has goiter. On the
other hand, the father of the patient has only one sibling and is suffering from
diabetes. Both the grandparents on the father’s side is alive but the mother has
diabetes while the grandfather is completely healthy.
VI. GENOGRAM
Legend:
- Female
- Male
- Diseased
- Stroke
- Goiter
- Cancer
- Hypertension
- Diabetes
- Pyloric Stenosis
- Recovered from
pyloric stenosis
6
HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN
The patient’s guardian verbalized that to keep her child (the patient) healthy she
ensures that her child gets the right immunization and vaccinations on time and
follow the doctor’s order for her child for no further complications. Washes her
hands before handling her baby, ensures correct handling of her infant to avoid any
accidents, learned how to properly swaddle the baby and making sure that the baby
in his diaper is comfortable, clean and safe to prevent any skin rashes or infection
and to prevent any development of urinary tract infection. Also the mother bathes
the baby on schedule to prevent any drying of skin, proper umbilical cord care,
feeding the baby on time and burping afterwards and ensures that the infant gets
enough rest throughout the day and night.
NUTRITION/METABOLIC PATTERN
The mother says that she switched to bottle feeding three days after birth due to
anxiety about her baby not liking her breastmilk. Her formula-fed newborn takes 2-
3 ounces (60-90 mL) of formula per feeding and eats every three to four hours per
day. So far, the patient isn’t allergic to his milk but the mother is starting to have
second thoughts due to the patient’s frequent vomiting.
ELIMINATION PATTERN
The patient defecates once every two days, usually brown in color and small in
amount. Usually cries whenever defecating and patient usually voids that could fill
up one or two wet diapers a day since his third week.
ACTIVITY/EXERCISE PATTERN
Sleeps a lot during the day and parents lets the baby cry making sure that his cry
is not due to medical reasons to help stretch the baby’s muscles.
COGNITIVE/PERPETUAL
Actively uses their perceptual systems to acquire information from their
surroundings. Can discriminate mother from other women by the smell and by the
sound of their voice. Responds to tactile stimulation. Olfaction and taste are well
developed and affected by maternal diet.
SLEEP-REST PATTERN
In the first few days, the average newborn sleeps between 16-18 hours a day
(Iglowstein et al 2002). By four weeks, newborn sleep averages about 14 hours but
the range is considerable. Some four-week-old babies sleep as little as 9 out of 24
hours while others sleep for 19 hours a day (Iglowstein et al 2002).
ROLE/RELATIONSHIP PATTERN, SELF CONCEPT
Since the patient is an infant, he is in the first stage of Erickson’s Psychosocial
Stage which is Trust vs mistrust. Infants are dependent on their caregivers, so
caregivers who are responsive and sensitive to their infant’s needs help their baby
7
develop a sense of trust. Enjoys watching face of primary caregiver, needs play and
time in prone position.
SELF-PERCEPTION/SELF-CONCEPT PATTERN
In Jean Piaget’s cognitive development, the patient is still in the sensorimotor
stage where infants acquire knowledge through sensory experiences and
manipulating objects. A child’s entire experience at the earliest period of this stage
occurs through basic reflexes, senses and motor responses.
STRESS AND COPING PATTERNS
The patient is still a month old, he only uses his cries as a relief of stress or sign
of any discomfort.
VALUE AND BELIEF PATTERN
The patient’s mother verbalized that their religion is Roman Catholic. She said
they believe in one God only and do not believe in other things but only on what is
in the Bible. They go to church every Sunday and is a firm believer of Jesus Christ.
SEXUALITY-REPRODUCTIVE STAGE
In Sigmund Freud’s psychosexual stage of development, the patient is still i oral
stage wherein the libido is centered in the baby’s mouth. He gets much satisfaction
form putting all sorts of things in his mouth to satisfy libido and thus it demands.
Which at this stage in life are oral or mouth oriented such as, sucking, biting and
breastfeeding.
RECREATION, HOBBIES, AND PETS
The patient’s parents spare time to play with the child in order for the patient to
feel love and affection. Also, the patient’s family does not own any pets.
PERSONAL HABITS
Sleeping in about fourteen hours a day is the only habit that is developed by the
infant patient.
OCCUPATIONAL HEALTH PATTERNS
Their family is not exposed to any hazards at work because they all work at the
office.
SOCIO-ECONOMIC STATUS
His mother works at a private company as an engineer and has a monthly salary
of 7 thousand dollars per month and his husband also works at a private company
as an dentist which he earns 14 thousand dollars per month. The mother verbalized
that their earnings is enough to provide for their everyday needs.
ENVIRONMENTAL HEALTH PATTERN
They live in a Subdivision and are not exposed to any hazards at home. Their
house far from the road and is not dusty. Their house is well ventilated and with
proper lighting and is full of trees and plants but is organized.
SOCIAL PATTERN
Since the patient is still a four-week-old infant, he expresses his feelings with
8
alert, widened eyes and a rounded mouth. The bond grows between parents and
their baby during this stage.
A. DIGESTIVE/METABOLIC/NUTRITION
Objective Subjective
General Appearance: Usual Diet: Diet as Tolerated
☐ Alert/responsive ☒ Apathetic No. of meals per day: 5x a day
☐ Cachexia ☐ Abd’l Distention No. of fluid drink each day: 12 to 24
☐ Mass ☐ Tenderness/pain ounces a day
Alcohol and Beverages: milk
Skin: ☒ Dry ☐ Warm ☐ Cold Use of Tabaco: none
Loss of Appetite:
☐ Moist
☐ Anorexia ☐ Bulimia
Edema: None
Body weight:
☐ Pitting ☐ Non-pitting Grade:
N/A ☐ Previous 3.8kg ☐ Current 3.5kg
9
☐ Cleft Palate ☐ Cleft Lip ☐ Ulcers Abdominal Pain: none
☐ Lesions: none ☐ LUQ ☐ RUQ ☐ LLQ ☐ RLQ
B. RESPIRATORY SYSTEM
Objective Subjective
Breath Sounds: Previous/Recent Illnesses:
10
☐ Diminished/Absent ☐ Stridor ☐ Bronchitis ☐ Emphysema ☐
☐ Rales/Crackles ☐ Rhonchi/Wheezing Asthma
☐ None (atelectasis) ☒ ☐ Bronchiectasis ☐ Pneumonia
Bronchovesicular ☐ Hydrothorax ☐ Pneumothorax
Others: ☐ Hemothorax ☐ CHF ☐ Chest
Trauma ☐ Lung Cancer
Resonance:
☒ Resonant (specify) Nose and Sinuses:
☐ Hypo (specify) ☐ Epistaxis
☐ Obstruction_______(specify)
Retractions: N/A
Smoking:
LOC: ☐ Alert ☒ Lethargic
☐ Yes For how long: __________
☐ Obtunded ☐ Stupor ☐ Comatose
☒ No
Tube/Drainage: none
☐ CTT ☐ Oral Airway Nutrition:
☐ Endotracheal Tube ☐ Ventilator ☐ Anorexia ☐ fatigue ☐ cachexia
☒ weight loss
Cough: ☐ Productive ☐ Non-
productive ☐ Weak ☐ Forceful Comments:
Sputum: none
☐ Mucoid ☐ Bloody ☐ Rusty ☐
Frothy
☐ Thick Tenacious Color:
____________
11
Excursion: ☐ Normal ☐ Decrease
C. CARDIOVASCULAR/CIRCULATORY SYSTEM
Objective Subjective
Temperature: 38.5°C Previous/Recent Illness: Pneumonia
☐ CVA ☐ CHF ☐ MI ☐
Blood Pressure: 50/40mmhg Thrombophlebitis
Pulses Rate: 170bpm ☐ Family History of HPN ☐ Renal
Failure
Heart Rhythm: ☐ Bleeding Disorder
☐ Tachycardia
☐ Bradycardia Do you experience any of the
☐ Arrhythmia/ Dysrhythmia following?
☐ Chest pain ☐ Arm pain
Jugular Veins Distention: ☐ Leg pain ☐ Joint and Back
☐ Positive ☐ Negative ☐ Dyspnea ☐ Orthopnea
☐ Cough ☐ Numbness and
Nail bed Color: ☒ Pink ☐ Blue Tingling
☐ Pale ☐ Light headedness ☐ Fatigue and
weakness
Capillary Refill: Normal - less than 2 ☐ Palpitations
sec
Exercises: none
Edema: none
Frequency: N/A
☐ Pitting ☐ Non-Pitting Duration: N/A
Location: N/A
Problem experience with usual
Varicosities: activity and exercise: none
☐ Yes ☒ No
Location: none Factors Affecting Activity
Intolerance:
12
Calf Tenderness (Homan’s Sign): none
Right ☐ Positive ☒ Negative
Left ☐ Positive ☒
Negative
D. INTEGUMENTARY SYSTEM
Objective Subjective
Skin: Skin history and Disorders: None
☒ Dry ☐ Intact ☒ Warm ☐ Cold
☐ moist
Turgor: decreased
Edema: none
☐ Pitting ☐Non-pitting Grade: -_
Region: N/A
13
☐ Patchy hair loss
Distribution: Even
Nails:
☐ Dirty ☐ Pallor ☐ Cyanosis
☐ Clubbing ☐ Paronychia
☐ Onycholysis
E. ELIMINATION
Objective Subjective
Mobility and Dexterity: Previous/Recent Surgery/Illness:
☒ Ambulatory ☐ Non-ambulatory Pneumonia
☐ Bedridden ☐ with assistive device
History of pain and discomfort: None
Tubes/Drainage/Stoma: none Diet: Hypoallergenic
☐ Colostomy ☐ Ileostomy ☐
Elimination Habits: 2-3x a
NGT
day___________
☐ Catheter (specify): N/A
Number Flatulence Passed:
Abdomen: _________
☐ Soft ☒ Firm (normal is 13-21x/day)
☐ Distended ☐ Non-distended
Bowel:
Bowel Sounds: (5 – 20 sounds/min) ☐ Loose bowel movement ___x/day
☐ Normoactive ☐ Hypoactive ☒ Constipation ☐ Impaction
☒ Hyperactive ☐ Absent ☐ Fecal Incontinence
☐ Retention/distention ☐ Black/tarry
Measurement:
Intake: 12 – 24 ounces a day stool ☐ Fresh blood ☒ Mucus
Urine Output:
Edema: none Urine:
☐ Pitting ☐ Non-pitting Grade: - ☐ Dysuria ☐ Urgency ☐ Polyuria
_____ ☐ Oliguria ☐ Nocturia ☐ Dribbling
☐ Incontinence ☐ Hematuria
Occult blood: ☐ Positive ☒ ☐ Retention ☐ Voiding freely
Negative ☐ Neurologic Impairment ☒ Residual
14
☐ Not tested urine (> 100ml)
Anus:
☐ Mass ☐ Hemorrhoids ☐ Polyps Describe CFACO. Describe comfort
and/or gene-bleeding, and/or
☐ Abscesses ☐ Inflammations ☐
discharge.
Fissures
>Voids less than normal due to
☐ Smooth Rectal walks ☐ Strong dehydration
Sphincter
☐ Rectal Prolapse ☐ Excoriations Medication taken that interferes with
☐ Lesions (specify) _____ normal elimination
☐ Ulcers (specify) _____ ☐ Laxatives ☐ Cathartics
☒ Not Assessed _____ ☐ others
F. MUSCULOSKELETAL SYSTEM
Objective Subjective
Mobility: Do you experience any of the
☒ Ambulatory ☐ Non-Ambulatory following?
☐ Bedridden ☐ Cast/mold ☐ Lumbar pain ☐ Thoracic Pain
☐ Traction (specify) – N/A ☐ Cervical Pain ☐ Joint pain
☐ Assistive devices (specify) - N/A
Gait:
☐ Propulsive Gait ☐ Scissors Gait
☐ Spastic Gait (Hemiplegic)
☐ Waddling Gait
☐ Steppage Gait ☐ Foot drop
☐ Amputated Limb ☒ Normal
☐ Others ______________________
Posture: Normal
15
☐ Lordosis ☐ Kyphosis
☐ Scoliosis ☐Corrective Device
(specify) __________
Muscle Strength:
RATE: 5/5 Classification: Normal
Strength
Explanation: muscle is functioning
normally and is able to maintain its
position even when maximum resistance
is applied.
☐ Atrophy ☐ Spasm ☐
Impaired ROM
☐ Joint swelling
☐Contractures/Deformities
☐ Tingling/Numbness ☐ Pressure
Ulcers
☐ Hyper-atrophy
☐ Bathing - ☐ Toileting -
☐ Bed Mobility - ☐ Dressing -
☐ Grooming - ☐ Feeding -
16
G. COGNITIVE AND PERCEPTUAL/ NEUROLOGIC
Objective Subjective
LOC: Check the Following Risk Factors:
☐ Alert ☒ Lethargic ☐ Comatose normal
☐ Unresponsive ☐ Obtunded ☐ ☐ Older Adulthood ☒ Male
Stupor ☐ Hx Stroke or TIA ☐ Hypertension
☐ Decorticate ☐ Decerebrate ☐ Smoking ☐ Hx CVD
☐ Sleep apnea ☐ High level of
Responsive to: Cholesterol
☒ Verbal Stimuli ☒ Painful Stimuli ☐ Drug Abuse ☐ DM
☐ Oral Contraceptives
Glasco Coma Scale:
☐Menopausal ☐ Overweight
Eye Opening
Verbal Response
Motor Response
Do you experience any of the following:
GCS Score
none?
☐ Blurring ☐ Diplopia ☐ Photophobia
Cushing Triad: ☐ Positive ☒ Negative
(Respiratory changes, Increase BP, ☐ Pain ☐ Inflammation ☐ Cataract
Decreasing LOC) ☐ Glaucoma ☐ Headache
☐ Unusual Discharges
Pupillary Size: ☒ PERRLA ☐
Anisocoric ☐ Moves All Extremities
(MAE)
Signs
Brudzinski’s sign: ☐ Positive ☒
Negative
17
Unusualities regarding patient’s level of Deficient fluid volume
consciousness was noted due to
dehydration.
HEAD:
Normocephalic
Hair: evenly
FACE: distributed
Symmetric Cognitive:
No unusual Lethargic
movements 18
EYES: CIRCULATORY:
Symmetric
20/20 vision BP = 50/40
VIII. ANATOMY AND PHYSIOLOGY OF THE DIGESTIVE SYSTEM
The function of the digestive system is to break down the foods you eat,
release their nutrients, and absorb those nutrients into the body. Although the small
intestine is the workhorse of the system, where the majority of digestion occurs,
and where most of the released nutrients are absorbed into the blood or lymph, each of
the digestive system organs makes a vital contribution to this process (Figure 1).
systems, the digestive system does not work in isolation; it functions cooperatively
with the other systems of the body. Consider for example, the interrelationship
organs with oxygen and processed nutrients, and veins drain the digestive tract.
These intestinal veins, constituting the hepatic portal system, are unique; they do not
19
return blood directly to the heart. Rather, this blood is diverted to the liver where its
nutrients are off-loaded for processing before blood completes its circuit back to the
heart. At the same time, the digestive system provides nutrients to the heart muscle
glands, as well as endocrine cells of the pancreas, the stomach, and the small intestine,
contribute to the control of digestion and nutrient metabolism. In turn, the digestive
system provides the nutrients to fuel endocrine function. Table 23.1 gives a quick
glimpse at how these other systems contribute to the functioning of the digestive
system.
Accessory Structures
Each accessory digestive organ aids in the breakdown of food (Figure 23.3).
Within the mouth, the teeth and tongue begin mechanical digestion, whereas the
salivary glands begin chemical digestion. Once food products enter the small
20
organs because they sprout from the lining cells of the developing gut (mucosa)
and augment its function; indeed, you could not live without their vital contributions,
and many significant diseases result from their malfunction. Even after development
Throughout its length, the alimentary tract is composed of the same four tissue
layers; the details of their structural arrangements vary to fit their specific functions.
Starting from the lumen and moving outwards, these layers are the
dermis. In addition, the mucosa has a thin, smooth muscle layer, called the muscularis
Epithelium—In the mouth, pharynx, esophagus, and anal canal, the epithelium
contact with the lumen, the space inside the alimentary canal. Interspersed among its
epithelial cells are goblet cells, which secrete mucus and fluid into the lumen, and
21
enteroendocrine cells, which secrete hormones into the interstitial spaces between
cells. Epithelial cells have a very brief lifespan, averaging from only a couple of days
(in the mouth) to about a week (in the gut). This process of rapid renewal helps
preserve the health of the alimentary canal, despite the wear and tear resulting from
contains numerous blood and lymphatic vessels that transport nutrients absorbed
through the alimentary canal to other parts of the body. The lamina propria also serves
substantial in the distal ileum where they are known as Peyer’s patches. When you
consider that the alimentary canal is exposed to foodborne bacteria and other foreign
matter, it is not hard to appreciate why the immune system has evolved a means of
tension, pulling the mucosa of the stomach and small intestine into undulating folds. These
folds dramatically increase the surface area available for digestion and absorption.
As its name implies, the submucosa lies immediately beneath the mucosa. A broad
layer of dense connective tissue, it connects the overlying mucosa to the underlying
The third layer of the alimentary canal is the muscalaris (also called the
layer of smooth muscle: an inner circular layer and an outer longitudinal layer.
22
The contractions of these layers promote mechanical digestion, expose more of the
food to digestive chemicals, and move the food along the canal. In the most proximal
and distal regions of the alimentary canal, including the mouth, pharynx, anterior part
of the esophagus, and external anal sphincter, the muscularis is made up of skeletal
muscle, which gives you voluntary control over swallowing and defecation. The basic
two-layer structure found in the small intestine is modified in the organs proximal and
distal to it. The stomach is equipped for its churning function by the addition of a
third layer, the oblique muscle. While the colon has two layers like the small intestine,
its longitudinal layer is segregated into three narrow parallel bands, the tenia coli,
which make it look like a series of pouches rather than a simple tube.
The serosa is the portion of the alimentary canal superficial to the muscularis.
Present only in the region of the alimentary canal within the abdominal cavity, it
tissue. Instead of serosa, the mouth, pharynx, and esophagus have a dense sheath of
collagen fibers called the adventitia. These tissues serve to hold the alimentary canal
The digestive system uses mechanical and chemical activities to break food
down into absorbable substances during its journey through the digestive system.
Table 23.3 provides an overview of the basic functions of the digestive organs.
23
Table 23.3
24
Digestive Processes
The first of these processes, ingestion, refers to the entry of food into the alimentary
canal through the mouth. There, the food is chewed and mixed with saliva, which
contains enzymes that begin breaking down the carbohydrates in the food plus some
lipid digestion via lingual lipase. Chewing increases the surface area of the food and
Food leaves the mouth when the tongue and pharyngeal muscles propel it into the
25
digestive tract. It includes both the
muscles, which act to propel food along (Figure 23.5). These waves also play a role
in mixing food with digestive juices. Peristalsis is so powerful that foods and liquids
you swallow enter your stomach even if you are standing on your head.
digestion is a purely physical process that does not change the chemical nature of the
food. Instead, it makes the food smaller to increase both surface area and mobility.
food into smaller bits and mix food with saliva. Although there may be a tendency to
think that mechanical digestion is limited to the first steps of the digestive process, it
occurs after the food leaves the mouth, as well. The mechanical churning of food in
the stomach serves to further break it apart and expose more of its surface area to
the muscularis layer of the alimentary canal. These contractions isolate small sections
of the intestine, moving their contents back and forth while continuously subdividing,
breaking up, and mixing the contents. By moving food back and forth in the intestinal
complex food molecules into their chemical building blocks (for example, proteins
26
into separate amino acids). These secretions vary in composition, but typically contain
water, various enzymes, acids, and salts. The process is completed in the small
intestine.
Food that has been broken down is of no value to the body unless it enters the
bloodstream and its nutrients are put to work. This occurs through the process of
absorption, which takes place primarily within the small intestine. There, most
nutrients are absorbed from the lumen of the alimentary canal into the bloodstream
through the epithelial cells that make up the mucosa. Lipids are absorbed into lacteals
and are transported via the lymphatic vessels to the bloodstream (the subclavian veins
near the heart). The details of these processes will be discussed later.
Age-related changes in the digestive system begin in the mouth and can affect
virtually every aspect of the digestive system. Taste buds become less sensitive, so
when you have lost teeth, your gums are diseased, and your salivary glands aren’t
slowly through the alimentary canal because of reduced strength and tone of muscular
and peptic ulcer disease—can occur at greater frequencies as you age. Problems in the
27
constipation. Conditions that affect the function of accessory organs—and their
ingestion occurs only in the mouth and defecation only in the anus. However, most
digestive processes involve the interaction of several organs and occur gradually as
Some chemical digestion occurs in the mouth. Some absorption can occur in the
Figure 23.6 Digestive Processes The digestive processes are ingestion, propulsion, mechanical digestion,
chemical digestion, absorption, and defecation.
28
The Stomach
alimentary canal that lies immediately inferior to the esophagus, the stomach links the
esophagus to the first part of the small intestine (the duodenum) and is relatively fixed
in place at its esophageal and duodenal ends. In between, however, it can be a highly
active structure, contracting and continually changing position and size. These
about the size of your fist, but can stretch to hold as much as 4 liters of food and fluid,
or more than 75 times its empty volume, and then return to its resting size when
empty. Although you might think that the size of a person’s stomach is related to how
much food that individual consumes, body weight does not correlate with stomach
size. Rather, when you eat greater quantities of food—such as at holiday dinner—you
Popular culture tends to refer to the stomach as the location where all
digestion takes place. Of course, this is not true. An important function of the stomach
is to serve as a temporary holding chamber. You can ingest a meal far more quickly
than it can be digested and absorbed by the small intestine. Thus, the stomach holds
food and parses only small amounts into the small intestine at a time. Foods are not
processed in the order they are eaten; rather, they are mixed together with digestive
juices in the stomach until they are converted into chyme, which is released into the
small intestine.
As you will see in the sections that follow, the stomach plays several important roles
29
initial digestion of proteins and triglycerides. Little if any nutrient absorption occurs
in the stomach, with the exception of the negligible amount of nutrients in alcohol.
Structure
There are four main regions in the stomach: the cardia, fundus, body, and pylorus
(Figure 23.15). The cardia (or cardiac region) is the point where the esophagus
connects to the stomach and through which food passes into the stomach.
Located inferior to the diaphragm, above and to the left of the cardia, is the dome-
shaped fundus. Below the fundus is the body, the main part of the stomach. The
funnel-shaped pylorus connects the stomach to the duodenum. The wider end of the
funnel, the pyloric antrum, connects to the body of the stomach. The narrower end is
called the pyloric canal, which connects to the duodenum. The smooth muscle pyloric
In the absence of food, the stomach deflates inward, and its mucosa and submucosa
Figure 23.15 Stomach The stomach has four major regions: the cardia, fundus, body, and pylorus. The addition of an inner oblique
smooth muscle layer gives the muscularis the ability to vigorously churn and mix food.
30
The convex lateral surface of the stomach is called the greater curvature; the concave
medial border is the lesser curvature. The stomach is held in place by the lesser
omentum, which extends from the liver to the lesser curvature, and the
greater omentum, which runs from the greater curvature to the posterior abdominal
wall.
Histology
The wall of the stomach is made of the same four layers as most of the rest of
the alimentary canal, but with adaptations to the mucosa and muscularis for the
unique functions of this organ. In addition to the typical circular and longitudinal
smooth muscle layers, the muscularis has an inner oblique smooth muscle layer
(Figure 23.16). As a result, in addition to moving food through the canal, the stomach
can vigorously churn food, mechanically breaking it down into smaller particles.
Figure 23.16 Histology of the Stomach The stomach wall is adapted for the functions of the stomach. In the epithelium, gastric pits lead to
gastric glands that secrete gastric juice. The gastric glands (one gland is shown enlarged on the right) contain different types of cells that
secrete a variety of enzymes, including hydrochloride acid, which activates the protein-digesting enzyme pepsin.
The stomach mucosa’s epithelial lining consists only of surface mucus cells,
which secrete a protective coat of alkaline mucus. A vast number of gastric pits dot
31
mark the entry to each gastric gland, which secretes a complex digestive fluid
Although the walls of the gastric pits are made up primarily of mucus cells,
the gastric glands are made up of different types of cells. The glands of the cardia and
the pyloric antrum secrete mucus and a number of hormones, including the majority
of the stimulatory hormone, gastrin. The much larger glands of the fundus and body
of the stomach, the site of most chemical digestion, produce most of the
include parietal cells, chief cells, mucous neck cells, and enteroendocrine cells.
are parietal cells, which are among the most highly differentiated of the body’s
epithelial cells. These relatively large cells produce both hydrochloric acid (HCl)
and intrinsic factor. HCl is responsible for the high acidity (pH 1.5 to 3.5) of the
acidity also kills much of the bacteria you ingest with food and helps to
factor is a glycoprotein necessary for the absorption of vitamin B12 in the small
intestine.
Chief cells—Located primarily in the basal regions of gastric glands are chief
Mucous neck cells—Gastric glands in the upper part of the stomach contain
mucous neck cells that secrete thin, acidic mucus that is much different from the
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mucus secreted by the goblet cells of the surface epithelium. The role of this mucus is
Figure 23.16 Histology of the Stomach The stomach wall is adapted for the
functions of the stomach. In the epithelium, gastric pits lead to gastric glands that
secrete gastric juice. The gastric glands (one gland is shown enlarged on the right)
Table 23.6
Gastric Secretion
Stimuli in the brain, stomach, and small intestine activate or inhibit gastric juice
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production. This is why the three phases of gastric secretion are called the cephalic,
gastric, and intestinal phases (Figure 23.17). However, once gastric secretion begins,
pha
ses :
Figure 23.17 The Three Phases of Gastric Secretion Gastric secretion occurs in three
cephalic, gastric, and intestinal. During each phase, the secretion of gastric juice can
be stimulated or inhibited.
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The cephalic phase (reflex phase) of gastric secretion, which is relatively
brief, takes place before food enters the stomach. The smell, taste, sight, or thought of
food triggers this phase. For example, when you bring a piece of sushi to your
lips, impulses from receptors in your taste buds or the nose are relayed to your brain,
which returns signals that increase gastric secretion to prepare your stomach for
if you like or want a particular food. Depression and loss of appetite can suppress the
cephalic reflex.
The gastric phase of secretion lasts 3 to 4 hours, and is set in motion by local
neural and hormonal mechanisms triggered by the entry of food into the stomach. For
example, when your sushi reaches the stomach, it creates distention that activates
digested proteins, caffeine, and rising pH stimulate the release of gastrin from
stomach does have a natural means of avoiding excessive acid secretion and potential
heartburn. Whenever pH levels drop too low, cells in the stomach react by
The intestinal phase of gastric secretion has both excitatory and inhibitory
elements. The duodenum has a major role in regulating the stomach and its emptying.
When partially digested food fills the duodenum, intestinal mucosal cells release a
hormone called intestinal (enteric) gastrin, which further excites gastric juice
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secretion. This stimulatory activity is brief, however, because when the intestine
distends with chyme, the enterogastric reflex inhibits secretion. One of the effects
of this reflex is to close the pyloric sphincter, which blocks additional chyme from
The mucosa of the stomach is exposed to the highly corrosive acidity of gastric juice.
Gastric enzymes that can digest protein can also digest the stomach itself. The
forms a physical barrier, and its bicarbonate ions neutralize acid. Second, the
epithelial cells of the stomach's mucosa meet at tight junctions, which block gastric
juice from penetrating the underlying tissue layers. Finally, stem cells located where
gastric glands join the gastric pits quickly replace damaged epithelial mucosal cells,
when the epithelial cells are shed. In fact, the surface epithelium of the stomach is
The stomach participates in virtually all the digestive activities with the exception of
ingestion and defecation. Although almost all absorption takes place in the small
intestine, the stomach does absorb some nonpolar substances, such as alcohol and
aspirin.
Mechanical Digestion
Within a few moments after food after enters your stomach, mixing waves begin to
peristalsis that mixes and softens the food with gastric juices to create chyme. The
initial mixing waves are relatively gentle, but these are followed by more intense
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waves, starting at the body of the stomach and increasing in force as they reach the
pylorus. It is fair to say that long before your sushi exits through the pyloric sphincter,
The pylorus, which holds around 30 mL (1 fluid ounce) of chyme, acts as a filter,
permitting only liquids and small food particles to pass through the mostly, but not
waves force about 3 mL of chyme at a time through the pyloric sphincter and into the
duodenum. Release of a greater amount of chyme at one time would overwhelm the
capacity of the small intestine to handle it. The rest of the chyme is pushed back into
the body of the stomach, where it continues mixing. This process is repeated when the
Gastric emptying is regulated by both the stomach and the duodenum. The presence
prevents additional chyme from being released by the stomach before the duodenum
Chemical Digestion
The fundus plays an important role, because it stores both undigested food and gases
that are released during the process of chemical digestion. Food may sit in the fundus
of the stomach for a while before being mixed with the chyme. While the food is in
the fundus, the digestive activities of salivary amylase continue until the food begins
mixing with the acidic chyme. Ultimately, mixing waves incorporate this food with
the chyme, the acidity of which inactivates salivary amylase and activates lingual
lipase. Lingual lipase then begins breaking down triglycerides into free fatty acids,
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The breakdown of protein begins in the stomach through the actions of HCl and the
enzyme pepsin. During infancy, gastric glands also produce rennin, an enzyme that
Its numerous digestive functions notwithstanding, there is only one stomach function
vitamin B12, which is necessary for both the production of mature red blood cells and
normal neurological functioning, cannot occur without intrinsic factor. People who
for example—can survive with minimal digestive dysfunction if they receive vitamin
B12 injections.
The contents of the stomach are completely emptied into the duodenum within 2 to 4
hours after you eat a meal. Different types of food take different amounts of time to
Meals with a high triglyceride content remain in the stomach the longest. Since
enzymes in the small intestine digest fats slowly, food can stay in the stomach for 6
hours or longer when the duodenum is processing fatty chyme. However, note that
this is still a fraction of the 24 to 72 hours that full digestion typically takes from start
to finish.
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39
IX. PATHOPHYSIOLOGY
ETIOLOGY
Hypertrophy and hyperplasia of the 2 (circular and longitudinal) muscular layers of
the pylorus occurs, leading to narrowing of the gastric antrum. The pyloric canal
becomes lengthened, and the whole pylorus becomes thickened. The mucosa is
usually edematous and thickened. In advanced cases, the stomach becomes markedly
dilated in response to near-complete obstruction.
Surgery: Pyloromyotomy
Control hydration
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X. MEDICAL/SURGICAL MANAGEMENT
Treatment: Pyloromyotomy
often scheduled on the same day as the diagnosis. If your baby is dehydrated or has
In pyloromyotomy, the surgeon cuts only through the outside layer of the
thickened pylorus muscle, allowing the inner lining to bulge out. This opens a
instrument (laparoscope) is
After surgery, the patient might be given intravenous fluids for a few hours.
You can start feeding your baby again within 12 to 24 hours. The patient might want
to feed more often since some vomiting may continue for a few days.
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Potential complications from pyloric stenosis surgery include bleeding and
infection. However, complications aren't common, and the results of surgery are
generally excellent. Also, there are no known medications for this condition.
Blood tests will reveal low blood levels of potassium and chloride in
association with an increased blood pH and high blood bicarbonate level due to loss
of stomach acid (which contains hydrochloric acid) from persistent vomiting. There
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XII. DIAGNOSTIC PROCEDURES
Ultrasonography
hypertrophied muscle
May show the "double track" sign when thin tracks of barium are compressed
After upper GI barium study, irrigating and removing any residual barium
Endoscopy
Reserved for patients with atypical clinical signs when ultrasonography and
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44
XIII. NURSING CARE PLANS
Cause analysis: The negative fluid balance causing dehydration results from increased output.
Goal: The patient will be able to maintain fluid volume at functional level
-mother states that At the end of 2 hours -Establish rapport to - To gain trust and Goal successfully met.
the patient exhibits of continuous nursing care the client and significant confidence After 2hrs of nursing care
excessive thirst. and proper health others and proper health
teachings the patient will teachings the patient
Objective: - Monitored and - To obtain baseline data
manifest: manifested:
recorded v/s
-Dry mucous membrane
- Decreased risk for * Decreased risk for
- Provide proper - To avoid other fluid
- Increased body complications of fluid complications of fluid
ventilation and cool loses through excessive
temperature volume deficit volume deficit
environment. sweating.
-Increased pulse rate -Significant others will * Significant others
Collaborative:
know the proper understand the
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-Dry skin intervention of the - IVF administered as - To deliver fluids intervention of the
problem. ordered. Maintained at accurately at desired rates. problem
- Sunken eyeballs
proper regulation.
- Establish normal Long Term Goal:
- Slightly sunken
body temperature of 37°C
fontanels Goal met as evidenced by
Long Term: no further abnormal
-vaguely weak in
changes in vital signs.
appearance After 2 days of
continuous nursing care
and proper health
teachings the client will
maintain fluid volume at
functional level as
evidenced by:
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Problem 2 (PE format): Hyperthermia r/t dehydration
Cause analysis: Body temperature elevated above normal range due to surface blood vessels constricting which effectively halted sweat
production.
-mother states that At the end of 1 hour - Provide tepid sponge - Enhances heat loss by After 1 hour of nursing
the patient is hot to touch of continuous nursing care bath evaporation and intervention, the client’s
Objective: and proper health - Assess fluid loss and conduction. temperature decreased
- Body temperature teachings the patient’s facilitate oral intake. - Increases metabolic rate from 38.5°C to 37°C as
above normal range temperature will return to - Provide proper and diaphoresis. evidenced by relief from
(38.5°C) normal as manifested by: ventilation and cool - Dissipates heat by discomfort of patient no
- Flushed skin: warm to - Temperature within environment. convection. further abnormal changes
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-Facial grimacing, 38°C) - Notes progress and
- Weak in appearance discomfort such as - Maintain IV fluids as Goal met as the patient
grimacing and crying. ordered by the physician. - Prevents dehydration. was able to maintain
maintain body
temperature in normal
range as 36.5°C-38°C
Problem 3 (PE format): Imbalanced nutrition: less than body requirements r/t inability to ingest/digest food
Cause analysis: Intake of nutrients insufficient to meet metabolic needs due to underlying condition of pyloric stenosis
- Mother states that After 4hrs of nursing - Ascertain significant - To determine Goal successfully met.
the patient experiences intervention and proper others’ understanding of informational need of the After 4hrs of nursing care
excessive vomiting and health teaching, the individual nutritional client. and proper health
has not gain weight since client’s family will be able needs. teachings the patient’s
- Weak in appearance known and necessary - IVF administered as - To deliver fluids factors when known and
- Hyperactive bowel interventions ordered. Maintained at accurately at desired rates. necessary interventions.
- Weakness of muscles independent and treating/managing prevent patient discomfort Long Term Goal:
factors.
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interventions, patient will - Consult
no longer experience
excessive vomiting.
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XIV. Discharge Plan
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Spiritual connection to God by prayers and attending mass.
Encourage the family to mediate to peaceful body and
soul.
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