Peptic Ulcer Disease

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PEPTIC ULCER DISEASE

PEPTIC ULCER DISEASE

• An excavation (hollowed-out area) that


forms in the mucosal wall
• Cause: Erosion of the circumscribed area
(may extend as deeply as the muscle layers
or through the muscle to the peritoneum)
•  Prevalence: 40-60 y.o, males, infants and
children; postmenopausal stage
• Causative Agent: Helicobacter pylori
PEPTIC ULCER DISEASE

Types:
1. Gastric
2. Duodenal
3. Esophageal
Significant Predisposing Factors
1. Increased secretion of HCl acid – may be assoc. with:
• Stress and anxiety
• Ingestion of milk and caffeinated beverages
• Smoking
• Alcohol
• Spicy foods 
2.Familial tendency – Type O blood
3. Co-morbid states – COPD, CKD, ZES
• ZES – Zollinger Ellison Syndrome ( gastrin-producing
malignant or benign tumors of the pancreas)
4. Infection – H. pylori; acquired through ingestion of
food and water, direct contact or exposure to emesis
5. Medications – NSAIDs, corticosteroids
Pathophysiology
Increase concentration or activity of acid-pepsin or
decrease resistance of the mucosa
 

Erosion and damage to gastroduodenal mucosa


 
Decreased resistance to bacteria
 

Possible infection to H. pylori


Stress Ulcers – acute mucosal ulceration of duodenal or gastric area that
occurs after physiologically stressful event such as burns, shock, severe sepsis 
Shock
 

Decreased gastric mucosal blood flow (ischemia) + reflux of duodenal


contents into the stomach + increase release of pepsin

Ulcerations
CLINICAL MANIFESTATIONS

1. Pain: dull, gnawing or burning sensation in the


midepigastrium or back
2. Sharp tenderness with gentle pressure at the epigastrium
or slightly right of midline
3. Pyrosis with sour eructation or burping (common with
empty stomach)
4. Vomiting – rare in uncomplicated duodenal ulcer but may
indicate obstruction in the pyloric orifice
• Emesis often has undigested food
• Follows a severe bout of pain and bloating (abdominal
distention)
5. Constipation or diarrhea
6. 15% of PUD has GI bleeding – melena 
ASSESSMENT AND DIAGNOSTIC FINDINGS

1. PE
2. Barium study of upper GIT – x-ray studies
3. Endoscopy – procedure of choice
4. Stool exam for occult blood
5. Gastric secretory studies – endoscopy and
histologic examination of a tissue specimen
obtained by biopsy
6. Serologic testing for H.pylori, urea breath test,
stool antigen test
Urea Breath Test
- To determine presence of H. pylori (which
metabolizes urea rapidly)
1. Ingest a capsule of carbon-labeled urea
(radioactive carbon 13c)
2. Breath sample obtained 10-20 min after (30min -
2hrs)
3. Carbon-labeled urea – absorbed quickly (+) H.
pylori
MEDICAL MANAGEMENT
1. Pharmacologic Therapy
• For ulcer healing: H2 receptor antagonist
and proton pump inhibitors (for NSAID-
induced and non-H.pylori associated PUD)
• H2 blockers: Ranitidine, Cimetidine,
Famotidine, Nizatidine
• PPI’s: Omeprazole, Lansoprazole,
Pantoprazole, Esomeprazole
• Initial Treatment for H. pylori
• 1st line: Triple therapy = PPI 2x/day +
Clarithromycin 2x/day or Metronidazole
2x/day for 10-14days
• 2nd line: Pepto-bismol 2 tabs 4x/day +
Tetracycline 4x/day + Metronidazole 4x/day
for 14 days

• ZES – high doses of H2 blockers +


Octreotide (Sandostatin)
2. Stress reduction and rest
3. Smoking cessation
4. Dietary modification – avoid extremes
of temperature of food and beverages
• Avoid overstimulation from meat extracts,
alcohol, caffeinated beverages, diets rich in
milk and cream
• Eat 3 regular meals per day
• Small frequent feedings are unnecessary if
client is taking antacid or H2 blocker
Surgical management – indicated for patients with
intractable ulcers, life-threatening hemorrhages,
perforation, or obstruction; and for those with ZES
unresponsive to treatment
Vagotomy with or without pyloroplasty
Antrectomy – removal of the pyloric (antrum)
portion of the stomach with anastomosis
b.1 Billroth I – Gastroduodenostomy
b.2 Billroth II – Gastrojejunostomy
Total Gastrectomy
• A.k.a. Esophagojejunostomy
• Pre-op Care
• Provide psychosocial support
• Teach deep breathing exercises &
coughing techniques (high abdominal
incision causes respiratory
complications)
• Provide nutritional support (TPN)
• Inform about post-op measures
• NGT
• TPN until peristalsis returns
• Post-op Care
• Promote patent airway and
ventilation
• Semi-fowler’s position
• Reinforce deep breathing & couging
exercises, incentive spirometry
• Administer analgesic before activities
• Splint incision before patient coughs
• Encourage early ambulation
• Promote adequate nutrition
• NPO until peristalsis returns
• Measure NG drainage accurately
(reddish for first 12 hours)
• Monitor for signs of leakage of
anastomosis (dyspnea, pain, fever,
when oral fluids are initiated)
• Small, frequent feedings
• Monitor for early satiety and
regurgitation
• Eat less food at a slower pace
• Monitor weight regularly
Potential COMPLICATIONS
1. BLEEDING – first 24 hours, 4th to 7th day post-op d/t
non-healing
• Monitor NG drainage for blood
• Avoid unnecessary irrigation or repositioning of NGT
2. PERFORATION
• Erosion of the ulcer through the gastric serosa into
the peritoneal cavity without warning
• Requires immediate surgery!
• s/s: sudden, sever upper abdominal pain radiating
to the right shoulder; board-like abdomen
• Monitor for signs of peritonitis: severe abdominal
pain, rigidity, fever
3. DUMPING SYNDROME
• – a group of unpleasant vasomotor and GI s/s caused by
rapid emptying of gastric content into the jejunum

Rapid emptying of hypertonic food from the stomach

Jejunum

Fluid shift from the bloodstream into jejunum

Decreased blood volume 

Shock-like manifestations
…Dumping syndrome
• Early s/s occur 5-30 min after eating:
• weakness, tachycardia, dizziness, diaphoresis, pallor, feeling of
fullness or discomfort, nausea, abdominal cramps and diarrhea
• Late s/s: occur 2-3 hrs after
• initially hyperglycemia then hypoglycemia
• Measures that slow gastric emptying:
• Eat in lying position
• Left-side lying position after meals
• SFF
• High protein diet (CHON empties stomach slowly in 3-4
hrs after eating)
• Limit CHO, no simple sugars
• Administer anticholinergics or antispasmodics 30 min
before meals
Nursing Diagnoses
• Acute Pain r/t the effect of gastric acid
secretion on damaged tissue
• Anxiety r/t to an acute illness
• Altered Nutrition: Less than Body
Requirements, r/t changes in diet
• Knowledge Deficit about prevention of
symptoms and management of the condition
• Fluid Volume Deficit r/t hemorrhage
Implementation
1. Relieving pain
• Administer prescribed meds.
• Advise patient about irritating effects of certain
drugs and foods
• Eat meals regularly at paced intervals
• Relaxation techniques
2. Reduce anxiety
• Give information
• Relaxed manner
• Identify stressors, coping and relaxation methods
• Family participation
3. Maintain optimal nutritional status
• Assess for malnutrition and weight loss
 
Evaluation
• Freedom from pain
• Feeling less anxious
• Complies with therapeutic regimen:
• Avoids irritating foods & beverages
• Eats regularly
• Uses coping mechanisms to deal with stress
• Maintains weight
• Exhibits no complications
END
GASTRITIS
GASTRITIS
• Inflammation of the gastric or stomach mucosa
• Acute (hours to days) or chronic (resulting from
repeated exposure to irritating agents or recurring
episodes of acute gastritis
Causes:
1. Acute
• dietary indiscretion (irritating, too highly seasoned,
contaminated with disease-causing microorganisms)
• overuse of aspirin/ NSAIDs
• excessive alcohol intake
• bile reflux
• radiation therapy
• ingestion of strong acid or alkali
• traumatic injuries, burns, severe infection, hepatic,
renal, or respiratory failure; major surgery
2. Chronic
• Benign or malignant ulcers of the stomach
• H.pylori infection
• Autoimmune diseases i.e. Pernecious anemia
• Diet: caffeine
• Medications: NSAIDs; biphosphonates
• Alcohol and smoking
• Chronic reflux of pancreatic secretions and
bile into the stomach
PATHOPHYSIOLOGY
Causative factors 

Gangrenous mucosa
 
Edematous & hyperemic
 
Superficial erosion hemorrhage
 
Decreased secretion of gastric juice (less acid but much
mucus) 
CLINICAL MANIFESTATIONS

Acute: (hours to days)


1. Abdominal discomfort
2. Headache
3. Lassitude
4. Nausea, anorexia and vomiting
5. Hiccupping
Chronic:
1. Anorexia
2. Heartburn after eating
3. Belching
4. Sour taste in the mouth
5. Nausea and vomiting
6. Some: mild epigastric discomfort or report
intolerance to spicy or fatty foods or slight pain
that is relieved by eating
7. Some: asymptomatic
ASSESSMENT AND DIAGNOSTIC FINDINGS

1. Achlorhydria or hypochlorhydria (absence or low levels of


HCl) or hyperchlorhydria (high levels of HCl)
2. Upper GI x-ray series
3. Endoscopy
4. Histologic examination of a tissue specimen obtained by
biopsy
5. H.pylori detection
MEDICAL MANAGEMENT
Acute:
• Capable of repairing itself (1 day)
• Refrain from alcohol and food until symptoms subside
• Diet: non-irritating
• If symptoms persist: IVF
• If caused by strong acid/alkali: dilute & neutralize the
offending agent (aluminum hydroxide for acids and
diluted lemon juice or diluted vinegar for alkalis); if
severe: avoid emetics and lavage
• NG intubation
• Analgesic agents, sedatives, antacids, IV fluids
• Extreme cases: emergency surgery to remove
gangrenous or perforated tissue
Chronic:
• Modify diet
• Promote rest
• Reduce stress
• Avoids alcohol and NSAIDs
• Initiate pharmacotherapy
• Treat H.pylori infection
NURSING MANAGEMENT 

1. Reducing Anxiety
• Offers supportive therapy
• Prepare patient for additional diagnostic
studies
• Use calm approach in assessing patient
and answering questions
• Explain all procedures
2. Promoting Optimal Nutrition
• No foods or fluids by mouth until acute
symptoms subside
• Monitor I/O and serum electrolyte
levels
• Ice chips then clear liquid then solid
foods
• Discourage caffeinated beverages,
alcohol and smoking
3. Promoting Fluid Balance
• Monitor I/O and electrolytes
• Monitor for hemorrhagic gastritis
(inform AP immediately)
• Hematemesis
• Tachycardia
• Hypotension
4. Relieving Pain
• Avoid irritating foods
• Correct use of medications
END

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