Peptic Ulcer Disease

Manisha
2nd Year, M.Sc Nursing
Stomach anatomy..
Gastric mucosal defense
 Introduction

 A condition in which there is discontinuity in the entire

thickness of the gastric or duodenal mucosa.

 Break in the lining of the stomach or the duodenum

penetrating down to the muscularis mucosa.

 Peptic refers to ‘pepsin’ a stomach enzyme that breaks

down protein.
 Epidemiology

 According to WHO, it has been estimated that 10% of

the population worldwide has an peptic ulcer

 Male to female ratio of PUD is 2:1.

 Risk Factors
 H.Pylori Infections
 Age
 Alcohol
 Smoking
 Genetics
 Stress
 Lifestyle
 Medications; NSAIDs
 Coffee, Cola, Spicy foods
 Caffeine
 Etiology

 Chronic use of NSAID- Inhibits synthesis of

prostaglandins.
 H. Pylori Infection- The H.Pylori bacteria excretes the
enzyme urease, which converts urea into ammonia and
bicarbonate.
 The release of ammonia neutralizes the acidic
environment in the stomach which causes difficulty in
destroying the H.Pylori bacteria. Ammonia is toxic to the
bacterial cells and damages them hence it causes the
beginning of the ulcer formation.
 Etiology contd..
 Caffeine use
 Medications- Corticosteroids
 Stress- emotional, trauma and surgery
 Types

It has two types:

 Gastric ulcers
 Duodenal ulcers
 Gastric Ulcer Duodenal Ulcer
Occurence Stomach - Antrum & lesser curvature First part of small intestine –
(common), Greater curvature (less common) duodenum
Incidence Usually 50 years and above Age 30-60 years
Ratio Male: Female ratio is 1:1 Male: Female ratio is 1:2-3
Percentage 15% of peptic ulcers 80% of peptic ulcers
Hcl Production Hyposecretion Hypersecretion
Symptoms  Pain occurs 1-2 hours after eating, rarely
 Pain occurs 3-4 hours after eating
occurs at night may be relieved by vomiting
 Often awaken between 1-2 am
 ingestion of food does not help, sometimes
 Ingestion of food relieves pain
causes pain
 Vomiting uncommon
 Vomiting common
 Perforation more likely to occur
 Hemorrhage more likely to occur.
Malignancy Ocassionaly takes place Rare
Causes melena hematemesis
Diet Has a special diet No special diet
Risk factors H.Pylori, gastritis, alcohol, Smoking, NSAIDs, H.Pylori, alcohol, smoking, Cirrhosis,
stress Stress
Sarin’s Classification
Pathophysiology
 Clinical Manifestations
 Abdominal pain
 classical sign of ulcer is epigastric pain, which occurs with regards to
meals.
 Burning in nature
 Pain involved may be characterized as gnawing or similar to the
feeling when one feels hunger. The pain may also radiate up to the
sternum because of acids in the esophagus.
 Nausea and vomiting
 Severe acidity of the stomach that irritates the gastric or duodenal
lining causes feelings of nausea and vomiting. There is also copious
vomiting because of increased production of stomach acids.
 Abdominal bloating
 Ulcerations also cause more gas production leading to bloating and
fullness.
 Clinical Manifestations contd..
 Loss of appetite
 Intense pain with nausea and vomiting often leads to anorexia
especially when gastric ulcer pain is aggravated by eating.
 Waterbash
 This is the presence of sudden increase in saliva in the mouth to
neutralize the gastric acids that went up the esophagus.
 Hematemesis
 Hematemesis is the presence of blood in the vomitus as a result of
bleeding in the ulcers.
 Melena
 Melena is characterized by presence of black tarry stool as a result of
bleeding in the upper gastrointestinal tract. This may result from
bleeding in the ulcers in the stomach, esophagus or duodenum. The
blood has already been oxidized as it travels down the
gastrointestinal tract, thereby presenting as black and tarry.
 Clinical Manifestations contd..
 Abdominal discomfort usually occurs in the epigastric
area
 Fatigue
 Chest pain
 Diarrhea
 Burning, aching, gnawing
 Acid reflux and heartburn.
 Peptic Ulcer bleeding – most common in adult
 Unintended weight loss. (Anorexia)
 Decreased appetite.
 Diagnostic tests

 History and Physical examination

 Laboratory tests- CBC, LFT
 Upper GI radiography- chest x-rays.
 Upper GI Endoscopy
 H.Pylori testing- Blood, breath, stool and tissue tests.
 Invasive test- Urease, Culture
 Non-Invasive test- Serology
Endoscopic findings
 H. Pylori testing
 Urea breath test- Breath testing is a non-invasive, pain-free
method to test for H Pylori. This test requires people to provide a
breath sample before and after drinking a solution which will react to
the presence of H Pylori bacteria by releasing carbon dioxide.

 H.Pylori Antibody blood test- These antibodies will typically be

present if a person has had a recent or past infection and may
remain detectable 12-18 months after treatment.

 Stool antigen test

Urea breath test
 Complications
 Bleeding- As an ulcer erodes the muscles of stomach, or duodenal
wall, blood vessels may also be damaged, which causes the
bleeding. Over a period of time, patient becomes anemic
 Perforation- Sometimes, ulcer causes a hole in the stomach or
duodenum. Bacteria and partially digested food can spill through the
opening into the sterile abdominal cavity which causes peritonitis.
 Narrowing and Obstruction- ulcers lacated at the end of the
stomach where the duodenum is attached may cause swelling and
scarring this can narrow and close the intestinal opening and can
prevent food from leaving stomach and entering the small intestine
 Peritonitis
 Scarring of the gastric or duodenal mucosa
 Malignancy
 Zollinger ellison syndrome
 Zollinger–Ellison syndrome
 It is a disease in which tumors cause the stomach to
produce too much acid, resulting in peptic ulcers.
 Symptoms include abdominal pain and diarrhea.
 The syndrome is caused by a gastrinoma, a
neuroendocrine tumor that secretes a hormone called
gastrin.
 The tumor causes excessive production of gastric acid,
which leads to the growth of gastric mucosa and
proliferation of parietal and ECL cells.
 ZES may occur on its own or as part of an autosomal
dominant syndrome...
 Treatment

 Non-pharmacologic treatments

 Pharmacological treatment

 Surgery
 Non-pharmacologic treatments:

 Reduce stress
 Cessation of cigarette smoking
 Stop use of NSAIDS
 Avoid spicy foods, caffeine, alcohol
 Drink plenty of water
 Avoid fasting and maintain optimum gap between meals
 Pharmacological treatment
 H2receptor antagonists (Ranitidine, Famotidine, Cimetidine)
 Antacids (Sodium bicarbonate, Magnesium, Aluminum
hydroxide)
 Proton Pump Inhibitors (Omeprazole, Pantaprazole)
 Mucosal Protective Agents (Sulcralfate, Bismuth)
 Antibiotics (Amoxicillin, Tetracycline, Metronidazole)

 H.Pylori negative PUD:

 H2receptor antagonists: Ranitidine 300 mg, cimetidine 800 mg
during 8 weeks
 Proton Pump Inhibitors: Omeprazole 20 mg, pantoprazole 40
mg, Rabeprazole 20 mg during 8 weeks.
H.Pylori positive PUD
 Combination therapies: Bleeding

 adrenaline 1:10,000 with either thermal or mechanical

treatment
 Proton Pump Inhibitors
 Aspirin or NSAIDs should be avoided
 Endoscopic injection therapy
 fibrin glue
 Mechanical endoscopic treatment
 thermocoagulation using a heater probe or endoscopic
clipping
 COMPLICATIONS OF PUD Contd..
 Pyloric stenosis
 Acid-suppressive therapy
 If medical therapy fails to relieve the obstruction, endoscopic balloon
dilation or surgery may be required.

 Zollinger–Ellison syndrome
 Proton Pump Inhibitors
 Somatostatin analogue octreotide

 Stress Ulcers
 Intravenous acid-suppression therapy
 Histamine H2 receptor antagonists
 PPIs
 Nasogastric tube administration of sucralfate (4-6g daily in divided
doses)
 Ranitidine 50 mg every 8h reducing to 25 mg in severe renal impairment
 UNCOMPLICATED PUD

 Discontinuation of NSAIDs for Uncomplicated Peptic Ulcer Disease

 For H. pylori eradication use triple therapy consists of
 OCA: Omeprazole 20 mg, Clarithromycin 500 mg and Amoxicillin 1 g
 OCM: Omeprazole 20 mg, Clarithromycin 250 mg, Metronidazole 400
mg
 2nd line H. pylori eradication consists of
 PPI, Amoxicillin or Tetracyline, Metronidazole
 H. pylori eradication for antibiotic resistance consists of
 PPI, Amoxicillin or Tetracyline, Metronidazole, Bismuth subsalicylate
 Surgery

 Surgery is necessary when patient have bleeding, perforation or

obstruction.

It includes:
 Endoscopic surgery
 Vagotomy and drainage
 Highly elective vagotomy
 Vagotomy with anterectomy

 Vagotomy
 Severing of the vagus nerve.
 Decreases gastric acid by diminishing cholinergic stimulation to the
parietal cells, making them less responsive to gastrin.
 May be performed via open surgical approach, laparoscopy, or
thorascopy.
 May be performed to reduce gastric acid secretion. A drainage type
of procedure is usually performed to assist with gastric emptying
(because there is total denervation of the stomach)

 Adverse Effects: some patients experience problems with feeling of

fullness, dumping syndrome, diarrhea, and gastritis
 Truncal vagotomy
 Severs the right and left vagus nerve as they enter the stomach at
the distal part of the esophagus; most commonly used to decrease
acid secretions

 Adverse Effects: some patients experience problems with feelings of

fullness, dumping syndrome, diarrhea, or constipation.
 Contd..
 Selective vagotomy- Severs vagal innervation to the stomach but
maintains innervation to the rest of the abdominal organs

 Adverse Effects: fewers associated adverse effects than with truncal

vagotomy

 Pyloroplasty- Longitudinal incision is made into the pylorus and

transversely sutured closed to enlarge the outlet and relax the
muscle; usually accompanies truncal and selective vagotomies.
 Antrectomy Billroth I
(gastroduodenostomy)-

 Removal of the lower portion of the antrum of the

stomach (which contains the cells that secrete gastrin) as
well as a small portion of the duodenum and pylorus.
 The remaining segment is anastomosed to the
duodenum.
 May be performed in conjunction with a truncal
vagotomy.

 Adverse Effects: patients may have problems with feeling

of fullness, dumping syndrome, and diarrhea.
Antrectomy Billroth II (gastrojejunostomy)
 Removal of lower portion (antrum) of stomach with
anastomosis to jejunum. Dotted lines show portion
removed (antrectomy).
 A duodenal stump remains and is over- sewn.

 Adverse Effects: patients frequently have associated

dumping syndrome, anemia, malabsorption, weight loss.
 Perforation: Graham patch repair

 A Graham patch defines a surgical procedure to close an opening in

the duodenum caused by a peptic ulcer.
 The technique is named after a Canadian doctor who successfully
used a flap of skin inside the abdominal cavity to repair perforated
ulcers. Called the omentum, this piece of fatty tissue hangs from the
stomach and drapes into the abdomen, covering the intestines.
 The omentum is coated with the same membrane found inside the
stomach.
 Post operative complications:

 Bleeding
 Duodenal stump leak
 Dumping syndrome
 Anemia
 Malabsorption of fats
 Nursing Diagnosis
 Acute pain R/t increased secretion of gastric acid

 Risk for fluid volume deficit R/t GI bleeding

 Imbalanced nutrition less than body requirements

 Knowledge deficit R/t management and treatment of

peptic ulcer disease

 Potential complications: perforation, hamerrohage

 Nursing Management

 Administer prescribed medications.

 Medications may include antacids, anticholinergics, histamine-receptor
antagonist, proton-pump inhibitors, and mucosal protective agents.
 Medication for ulcers caused by H. pylori include bismuth subsalicylate,
metronidazole, and tetracycline.
 These medications administered together eradiate H. pylori bacteria in
the gastric mucosa.

 Provide client and family teaching.

 Instruct the client to quit smoking, which decreases the secretion of
bicarbonate from the pancreas into the duodenum, resulting in increased
acidity in the duodenum.
 Teach the client about necessary lifestyle modifications aimed at
decreasing stress and maximizing effective coping. Biofeedback,
hypnosis, or behavior modification may be suggested.
 Nursing Management contd..
 Teach the client methods to minimize symptoms while
maintaining adequate nutrition.
 Avoid foods that previously have caused pain.
 Specific dietary restrictions vary from client to client.
 Eat three regular meals a day, small, frequent meals are unnecessary
as long as the medication is taken before meals.
 Avoid a diet rich in milk and creams, which are acid stimulants.
 Prepare the client for diagnostic procedures, and provide
postprocedure care.
 Prepare for barium swallow includes no oral intake after midnight
and possible laxatives to clean the GI tract.
 After a barium swallow, administer a laxative if indicated to
preventconstipation.
 Stools are monitored until all barium has been eliminated.
 Nursing Management contd..

 For the client undergoing gastroscopy.

 obtain informed consent, and instruct the client not to eat nor drink
anything for 8 hours before the procedure.
 After the procedure, assess the gag reflex before the client consumes
foods and fluids.
 Monitor for signs of perforation (e.g pain, bleeding, abdominal
distention)
 Prepare the client for surgery if indicated. (e.g. ulcers that have
not responded to treatment after 12 to 16 weeks, life-
threatening hemorrhage or perforation)
 Nursing Management contd..
 Preoperative care
 Obtain informed consent
 Clear and empty the GI tract by administering enemas and allowing
nothing by mouth

 Postoperative care
 Pain management
 Observe nasogastric tube aspirate
 Assess the surgical dressing
 Provide routine postoperative care
 Provide medications
 Assess complications
 Provide discharge teaching
summary