‫كلية التمريض‬

‫المرحلة الثانية‬

‫‪Peptic Ulcer‬‬
‫أ‪.‬حيدر بدر‬
‫باطني جراحي‬

‫‪2020‬‬
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Anatomy and physiology

1. Anatomy

The GI tract is a pathway 7 to 7.9 meters (23 to 26 feet) in length that extends from the mouth to the
esophagus, stomach, small and large intestines, and rectum, to the terminal structure, the anus

The esophagus is located in the mediastinum, anterior to the spine and posterior to the trachea and heart.
This hollow muscular tube, which is approximately 25 cm (10 inches) in length, passes through the
diaphragm at an opening called the diaphragmatic hiatus.

The stomach is in the upper left abdominal quadrant, to the left of the liver and in front of the spleen. It is
a J-shaped, saclike organ that extends from the esophagus to the duodenum of the small intestine. The
four regions of the stomach are the cardia, fundus, body, and pylorus.The pylorus is divided into an antrum
and canal and narrows at the pyloric sphincter, which guards entry to the duodenum.
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The small intestine is the longest segment of the GI tract, accounting for about two thirds of the total
length. It folds back and forth on itself, providing approximately 70 m (230 ft) of surface area for secretion
and absorption. The most proximal section is the duodenum, the middle section is the jejunum, and the
distal section is the ileum.

2. Physiology

Physiology mean the “function”. Major functions of the gastrointestinal (GI) tract include:

1.Breakdown of food particles into the molecular form for digestion

2.Absorption into the bloodstream of small nutrient molecules produced by digestion

3.Elimination of undigested unabsorbed foodstuffs and other waste products

4.After food is ingested, it is propelled through the GI tract, coming into contact with a wide variety of
secretions that aid in its digestion, absorption, or elimination from the GI tract.

5.Peristalsis of the muscle layer in the wall of the esophagus propels food inferiorly to the stomach.

6.The stomach mainly serves as a reservoir for food so that digestion may take place gradually. It includes
the following mechanism:

1-Gastric juice begins secretion at the sight or smell of food; this is a parasympathetic response.

2-The presence of food in the stomach stimulates the secretion of the hormone gastrin by the
gastric mucosa. Gastrin increases the secretion of gastric juice.

3-The three layers of smooth muscle in the stomach wall achieve efficient mechanical digestion,
changing ingested food to a thick liquid called chyme.

4-The pyloric sphincter contracts when the stomach is churning food and relaxes at intervals to
allow small amounts of chyme to pass into the duodenum.

5-Carbohydrates are most readily digested by the stomach, followed by proteins and fats.

7. Digestion is completed in the small intestine, and the end products of digestion are absorbed into the
blood and lymph.
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Digestive Secretion

Peptic
Ulcer

definition:

Is a condition in which the lining of the stomach, pylorus, duodenum, or the esophagus is eroded, usually
from infection with H. pylori. The erosion may extend into the muscular layers or the peritoneum. Peptic
ulcers occur in the portions of the GI tract that are exposed to hydrochloric acid and pepsin.

Pathophysiology:

The erosion is due to an increase in the concentration or activity of hydrochloric acid and pepsin. The
damaged mucosa is unable to secrete enough mucus to act as a barrier against the hydrochloric acid. Some
individuals have more rapid gastric emptying, which, combined with hypersecretion of acid, creates a large
amount of acid moving into the duodenum. As a result, peptic ulcers occur more often in the duodenum.
Ulcers are named by their location: esophageal, gastric, or duodenal. Duodenal ulcers are more common
than gastric ulcers.
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Epidemiology

Peptic ulcer disease may occur in both genders and in all ages.

• Peptic ulcer disease occurs with the greatest frequency in people between 40 and 60 years of age.

• It is relatively uncommon in women of childbearing age, but it has been observed in children and even in
infants.

• After menopause, the incidence of peptic ulcers in women is almost equal to that in men.

Etiology:

stress, diet, and alcohol or caffeine ingestion. However, PUD is primarily caused by infection with the
Gram-negative bacterium H. pylori.

Risk factors:

Risk factors that contribute to peptic ulcer disease include smoking, chewing tobacco, stress, caffeine use,
and medications such as steroids, aspirin, and non-steroidal anti-inflammatory drugs (NSAIDs). Peptic ulcer
development is influenced by smoking because it increases the harmful effects of H. pylori, alters
protective mechanisms, and decreases gastric blood flow.

**Gastric ulcers tend to strike people with type A blood while duodenal ulcers tend to afflict people with
type O blood.

Signs and Symptoms:

1. Gastric ulcer
-Intermittent high left epigastric or upper abdominal burning or gnawing
-pain, increased 1–2 hours after meals or with food
-Antacids ineffective
-Patient may be malnourished
-Hematemesis more common than melena
2. Duodenal ulcer
-Intermittent midepigastric or upper abdominal burning or cramping pain, increased 2–4 hours
after meals or in the middle of the night Relieved by food or antacids
-Patient usually well nourished
-Melena more common than hematemesis
-Anorexia
-Nausea and vomiting
-Bleeding (stomach secretions or stool positive for occult blood)
-Urea breath

Complications:
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1. Bleeding
2. Perforation
3. Obstruction.

Bleeding can occur in varying degrees from occult blood in stool and emesis to massive bright red
bleeding. Hemorrhage tends to occur more often with gastric ulcers in older adults. The patient may
experience signs and symptoms of shock.

Diagnostic tests:

1. Physical examination. A physical examination may reveal pain, epigastric tenderness, or abdominal
distention.
2. Urea breath test
3. Immunoglobulin G antibody detection test for H. pylori
4. Biopsy/ Culture
5. Upper GI series (barium swallow)
6. Esophagogastroduodenoscopy

Treatment:

Pharmacological management

1-Treatment for H. pylori, triple therapy are used two antibiotics to decrease resistance of the bacteria and

a PPI or H2 antagonist is used. Treatment lasting 14 days has better eradication rates than 10-day
treatments.

2.Bismuth subsalicylate (e.g., in Pepto-BismolTM) may also be used for its antibacterial effects.

3.PPIs are powerful agents that stop the final step of gastric acid secretion to reduce mucosa erosion and
aid in healing ulcers.

4.H2 antagonists block H2 receptors to decrease acid secretion.

Surgical Management

• Pyloroplasty. Pyloroplasty involves transecting nerves that stimulate acid secretion and opening the
pylorus.

• Antrectomy. Antrectomy is the removal of the pyloric portion of the stomach with anastomosis to either
the duodenum or jejunum.

Life style modification

1. A bland diet may also be recommended, and foods known to cause discomfort to the patient, such
as spicy foods, carbonated drinks, and caffeine, should be avoided until the ulcer heals. Alcohol
should also be avoided during the healing period.
2. Smoking cessation.
3. Stress reduction.
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Nursing management:

The management of the patient with peptic ulcer is as follows:.

Nursing Assessment

Nursing assessment includes:

• Assessment for description of pain.

• Assessment of relief measures to relieve the pain.

• Assessment of the characteristics of the vomitus.

• Assessment of the patient’s usual food intake and food habits.

Nursing Diagnosis

Based on the assessment data, the patient’s nursing diagnosis may include the following:

• Acute pain related to the effect of gastric acid secretion on damaged tissue.

• Anxiety related to an acute illness.

• Imbalanced nutrition related to changes in the diet.

• Deficient knowledge about prevention of symptoms and management of the condition.

Nursing Care Planning & Goals

The goals for the patient may include:

• Relief of pain.

• Reduced anxiety.

• Maintenance of nutritional requirements.

• Knowledge about the management and prevention of ulcer recurrence.

• Absence of complications.

Nursing Interventions

Nursing interventions for the patient may include:

1.Relieving Pain and Improving Nutrition

• Administer prescribed medications.

• Avoid aspirin, which is an anticoagulant, and foods and beverages that contain acid-enhancing caffeine
(colas, tea, coffee, chocolate), along with decaffeinated coffee.
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• Encourage patient to eat regularly spaced meals in a relaxed atmosphere; obtain regular weights and
encourage dietary modifications.

• Encourage relaxation techniques.

2.Reducing Anxiety

• Assess what patient wants to know about the disease, and evaluate level of anxiety; encourage patient
to express fears openly and without criticism.

• Explain diagnostic tests and administering medications on schedule.

• Interact in a relaxing manner, help in identifying stressors, and explain effective coping techniques and
relaxation methods.

• Encourage family to participate in care, and give emotional support.

3.Monitoring and Managing Complications

If hemorrhage is a concern:

• Assess for faintness or dizziness and nausea, before or with bleeding; test stool for occult or gross blood;
monitor vital signs frequently (tachycardia, hypotension, and tachypnea).

• Insert an indwelling urinary catheter and monitor intake and output; insert and maintain an IV line for
infusing fluid and blood.

• Monitor laboratory values (hemoglobin and hematocrit).

• Insert and maintain a nasogastric tube and monitor drainage; provide lavage as ordered.

• Monitor oxygen saturation and administering oxygen therapy.

• Place the patient in the recumbent position with the legs elevated to prevent hypotension, or place the
patient on the left side to prevent aspiration from vomiting.

• Treat hypovolemic shock as indicated.

If perforation and penetration are concerns:

• Note and report symptoms of penetration (back and epigastric pain not relieved by medications that
were effective in the past).

• Note and report symptoms of perforation (sudden abdominal pain, referred pain to shoulders, vomiting
and collapse, extremely tender and rigid abdomen, hypotension and tachycardia, or other signs of shock).

Home Management and Teaching Self-Care

• Assist the patient in understanding the condition and factors that help or aggravate it.
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• Teach patient about prescribed medications, including name, dosage, frequency, and possible side
effects. Also identify medications such as aspirin that patient should avoid.

• Instruct patient about particular foods that will upset the gastric mucosa, such as coffee, tea, colas, and
alcohol, which have acid-producing potential.

• Encourage patient to eat regular meals in a relaxed setting and to avoid overeating.

• Explain that smoking may interfere with ulcer healing; refer patient to programs to assist with smoking
cessation.

• Alert patient to signs and symptoms of complications to be reported.

Evaluation

Expected patient outcomes include:

• Relief of pain.

• Reduced anxiety.

• Maintained nutritional requirements.

• Knowledge about the management and prevention of ulcer recurrence.

• Absence of complications.

Discharge and Home Care Guidelines

The patient should be taught self-care before discharge.

• Factors that affect. The nurse instructs the patient about factors that relieve and those that aggravate
the condition.

• Medications. The nurse reviews information about medications to be taken at home, including name,
dosage, frequency, and possible side effects, stressing the importance of continuing to take medications
even after signs and symptoms have decreased or subsided.

• Diet. The nurse instructs the patient to avoid certain medications and foods that exacerbate symptoms
as well as substances that have acid-producing potential.

• Lifestyle. It is important to counsel the patient to eat meals at regular times and in a relaxed setting and
to avoid overeating.

Documentation Guidelines

The focus of documentation should include:

• Client’s description of response to pain.

• Acceptable level of pain.

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• Expectations of pain management.

• Prior medication use.

• Level of anxiety.

• Description of feelings (expressed and displayed).

• Awareness and ability to recognize and express feelings.

• Caloric intake.

• Individual cultural or religious restrictions and personal preferences.

• Learning style, identified needs, presence of learning blocks.

• Plan of care.

• Teaching plan.

• Response to interventions, teaching, and actions performed.

• Attainment or progress toward desired outcomes.

• Modifications to plan of care.

• Long term needs.