TEXTBOOK DISCUSSION I.

Definition
A peptic ulcer is an excavation (hollowed-out area) that forms in the mucosal wall of the stomach, in the pylorus (opening between stomach and duodenum), in the duodenum (first part of small intestine), or in the esophagus. A peptic ulcer is frequently referred to as a gastric, duodenal, or esophageal ulcer, depending on its location, or as peptic ulcer disease. It is a term used to describe a group of ulcerativedisorders that occur in areas of the upper gastrointestinaltract that are exposed to acid-pepsin secretions.Erosion of a circumscribed area of mucous membrane is the cause. Gastric ulcer occurs usually at lesser curvature of stomach or at the point where the esophagus enters the stomach.

Repeated episodes of ulceration would result to perforation, thus Gastric Outlet Bleeding.

II. Risk Factors

y y y y y y y y y

Advancing age (usually 50 and over) Ratio of Male to Female is 1:1 H. pylori Gastritis Too much consumption of alcoholic beverages Smoking The use of NSAIDs (Nonsteroidal Ant-inflammatory Drugs) The use of Aspirin Stress

III. Signs and Symptoms

S/ Sx Found in Textbook Weight Loss Dull Gnawing Pain (1/2 to 1 hour after meal, rarely at night) Sharp Localized Tenderness Passage of Loose Tarry Stools/ Red Stools/ Coffee Ground Stools Hematemesis Heart Burn or Pyrosis (Burning Sensation in the Midepigastrium or in the back) Sour Eructation or Burping Constipation Vomiting of Undigested Foods Epigastric Fullness Shock Peritonitis (because gastrointestinal contents enter peritoneum through perforated GIT) Fever S/ Sx as manifested by the client (+) July 2011 (+) June 2011

(-) (+) July 2, 2011 (-) (-)

(+) July 16,2011 (+) July 2,2011 (-) (-) (-) (-)

V. Management
Medical Management

Pharmacologic Therapy:
y y y

y y

y y y

y y y

A combination of antibiotics, proton pump inhibitors, and bismuth salts suppress or eradicate H. pylori. The proton-pump inhibitorsblock the final stage of hydrogen ion secretion byblocking the action of the gastric parietal cell proton pump. Histamine2 (H2) receptor antagonists and proton pump inhibitors areused to treat NSAID-induced and other ulcers not associatedwith H. pylori ulcers.Maintenance dosages of H2 receptor antagonistsare usually recommended for 1 year. Histamine is the major physiologic mediator for hydrochloricacid secretion. The H2-receptor antagonists blockgastric acid secretion stimulated by histamine, gastrin, andacetylcholine. Acid-neutralizing, acid-inhibiting drugs and mucosal protective agents are used to relieve symptoms and promote healing of the ulcer crater; neutralization of gastric acid through the use of antacids. Rest, sedatives,and tranquilizers may add to the patients comfort and are prescribedas needed. Three types of antacids are used to reduce gastric acidity:calcium carbonate, aluminum hydroxide, and magnesium hydroxide. Calciumpreparationsare constipating and may cause hypercalcemiaand the milk-alkali syndrome. There is evidence thatoral calcium preparations increase gastric acid secretion after their buffering effect has been depleted. Magnesium hydroxideis a potent antacid that also has laxative effect and because magnesium is excretedthrough the kidneys, this formulation should not be used in persons with renal failure. Aluminum hydroxidereacts withhydrochloric acid to form aluminum chloride. It combineswith phosphate in the intestine, and prolonged use may leadto phosphate depletion and osteoporosis. The drug sucralfate,which is a complex salt of sucrose-containing aluminumand sulfate, selectively binds to necrotic ulcer tissue andserves as a barrier to acid, pepsin, and bile. The drug requires an acid pH for activation andshould not be administered with antacids or an H2 antagonist. Misoprostol, a prostaglandin analog, promotes ulcerhealing by stimulating mucus and bicarbonate secretionand by modestly inhibiting acid secretion. The drug causes dose-dependent diarrhea, and because ofits stimulant effect on the uterus, it is contraindicated inwomen of childbearing age.

Dietary Modification:
y y

y y y

The intent of dietary modification for patients with peptic ulcersis to avoid over-secretion of acid and hypermotility in the GI tract. These can be minimized by avoiding extremes of temperatureand overstimulation from consumption of meat extracts, alcohol, coffee (including decaffeinated coffee, which also stimulates acidsecretion) and other caffeinated beverages, and diets rich in milk and cream (which stimulate acid secretion). In addition, an effortis made to neutralize acid by eating three regular meals a day. Small, frequent feedings are not necessary as long as an antacid or a histamine blocker is taken. Diet compatibility becomes an individualmatter: the patient eats foods that can be tolerated and avoids those that produce pain.

Stress Reduction and Rest:

y

The patient mayneed help in identifying situations that are stressful or exhausting.A rushed lifestyle and an irregular schedule may aggravate symptomsand interfere with regular meals taken in relaxed settings andwith the regular administration of medications. The patient maybenefit from regular rest periods during the day, at least during the acute phase of the disease.

Biofeedback, hypnosis, or behaviormodificationmay be helpful.

Smoking Cessation:
y y y

Studies have shown that smoking decreases the secretion of bicarbonatefrom the pancreas into the duodenum, resulting in increased acidity of the duodenum. Research indicates that continuing tosmoke cigarettes may significantly inhibit ulcer repair. Therefore,the patient is strongly encouraged to stop smoking.

Surgical Management y y

y y y y y

Surgical proceduresinclude vagotomy, with or without pyloroplasty, and the Billroth I and Billroth II procedures. Vagotomy severing of the vagus nerve; decreasesgastric acid by diminishing cholinergicstimulation to the parietal cells, making them less responsive to gastrin; may be done via open surgical approach,laparoscopy, or thoracoscopy. Truncal Vagotomy severs the right and left vagus nerves asthey enter the stomach at the distalpart of the esophagus. Selective vagotomy severs vagal innervation to the stomachbut maintains innervation to therest of the abdominal organs. Proximal (parietal cell)gastric vagotomy withoutdrainage denervates acid-secreting parietal cellsbut preserves vagal innervation to thegastric antrum and pylorus. Pyloroplasty a surgical procedure in which a longitudinalincision is made into the pylorusand transversely sutured closedto enlarge the outlet and relax themuscle. Billroth I (Gastroduodenostomy) is the removal of the lower portion of theantrum of the stomach (which containsthe cells that secrete gastrin) aswell as a small portion of the duodenumand pylorus. The remainingsegment is anastomosed to the duodenum(Billroth I) or to the jejunum (Billroth II). Subtotal gastrectomy withBillroth I or II anastomosis - removal of distal third of stomach; anastomosis with duodenum or jejunum; removes gastrin-producing cells in theantrum and part of the parietal cells.

Nursing Management

Relieving Pain:
y y

Give analgesic medication as prescribed for pain relief to be achieved. Instruct the patient to avoid aspirin, foods and beverages that contain caffeine, anddecaffeinated coffee, and meals should be eaten at regularly paced intervals in a relaxed setting. Teach the patient with relaxation techniques to help manage stress and pain and to enhancesmoking cessation efforts.

Reducing Anxiety:
y y y y y

Assess the patients level of anxiety. Provide appropriate information at the patients level ofunderstanding, all questions are answered, and encourage the patient to express fears openly. Explain diagnostic tests andadministering medications on schedule also help to reduce anxiety. Interacts with the patient in a relaxed manner, help identify stressors, and explains various coping techniques and relaxation methods, such as biofeedback, hypnosis, or behavior modification. Encourage the patients family toparticipate in care and to provide emotional support.

Maintaining Optimal Nutritional Status:

y y

Assesses the patient for malnutrition and weight loss. After recovery from an acute phase of peptic ulcer disease, advise the patient about the importance of complying with the medicationregimen and dietary restrictions.

Monitoring and Managing Potential Complications:

Hemorrhage y Gastritis and hemorrhage from peptic ulcer are the two mostcommon causes of upper GI tract bleeding (which may also occurwith esophageal varices). Hemorrhage,the most common complication, occurs in about 15% of patientswith peptic ulcers. The site of bleeding is usuallythe distal portion of the duodenum. y Bleeding may be manifestedby hematemesis or melena (tarry stools). The vomited blood canbe bright red, or it can have a coffee grounds appearance (whichis dark) from the oxidation of hemoglobin to methemoglobin. y When the hemorrhage is large (2000 to 3000 mL), most of the blood is vomited. Because large quantities of blood may be lostquickly, immediate correction of blood loss may be required to prevent hemorrhagic shock. y Assess the patient for faintness or dizziness andnausea, which may precede or accompany bleeding. y Monitor vital signs frequently and evaluate the patientfor tachycardia, hypotension, and tachypnea. y Other nursing interventionsinclude monitoring the hemoglobin and hematocrit,testing the stool for gross or occult blood, and recording hourlyurinary output to detect anuria or oliguria (absence or decreasedurine production). y Related nursing and collaborativeinterventions include insertion of a peripheral IV line for the infusion of saline orlactated Ringers solution and blood products. The nursemay need to assist with the placement of a pulmonary arterycatheter for hemodynamic monitoring. y Inserting an NG tube to distinguish fresh blood from coffeegrounds material, to aid in the removal of clots and acid, toprevent nausea and vomiting, and to provide a means ofmonitoring further bleeding. y Inserting an indwelling urinary catheter and monitoringurinary output. y Monitoring oxygen saturation and administeringoxygen therapy. y Placing the patient in the recumbent position with the legselevated to prevent hypotension; or, to prevent aspirationfrom vomiting, placing the patient on the left side.

Perforation and Penetration y Monitor for symptomsof penetration include back and epigastric pain not relievedby medications that were effective in the past. y Monitor for signs and symptoms of perforation include the sudden, severe upper abdominal pain (persisting and increasingin intensity); pain may be referred to the shoulders,especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm; vomiting and collapse (fainting); extremely tender and rigid (boardlike) abdomen; hypotension and tachycardia, indicating shock. y Monitors fluid and electrolyte balance and asses the patient for peritonitis or localized infection (increasedtemperature, abdominal pain, paralytic ileus, increased orabsent bowel sounds, abdominal distention). y Antibiotic therapyis administered parenterally as prescribed.

References:

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Suzanne Smeltzer and Brenda Bare, Brunner and Suddarths Medical-Surgucal Nursing 10th Edition p. 1015-1021 Georgianne H. Heymann and Carol M. Porth, Essentials of pathophysiology P. 893-895 copyright 2004 Seeley, Stephens and Tate, Essentials of Anatomy and Physiology 6th edition p. 474 copyright 2007

Predisposing Factors y y y y y y H. Pylori Advanced age (55-70) Stress NSAID intake,aspirin Clotting problems Gender

Precipitating Factors y y Lifestyle: alcohol drinker, smoker 65 years old

Increased concentration/ activity of acid (HCl)- pepsin in stomach

y y

Sharp localized tenderness fever

Erosion of mucosal /gastric lining of stomach

Dull gnawing pain

Gastric ulcer

Shock if excessive blood loss

Bleeding of the stomach lining

healing of the muscularis layer

Passage of loose tarry stools/ red stools/ coffee ground stools

scarring of the gastric lining

decrease resistance of mucosal lining of stomach

repeated episodes of ulceration

Recurrent scarring

ulceration in the gastric outlet

y y y y

Constipation Vomiting Undigested foods Loss of appetite

stenosis

epigastric fullness

Gastric Outlet Bleeding