PEPTIC ULCER

DISEASE
H.AKOUM
PEPTIC ULCER DISEASE
Peptic ulcer disease
refers to
ulcerations in the
mucosa of the
lower esophagus,
stomach, or
duodenum.
 Pathophysiology and Etiology

• Etiology of peptic ulcers disease is multifactorial.

– H. pylori infection present in most patients with peptic ulcer
disease.
– NSAID-induced injury presents as a chemical gastropathy.
– Acid secretory abnormalities (especially in duodenal ulcers).
– Zollinger-Ellison syndrome (hypersecretory syndrome) should
be considered in refractory ulcers.
• Risk factors may include drugs (NSAIDs, prolonged high-
dose corticosteroids), family history, cigarettes, stress,
blood group O, and lower socioeconomic status.
• Studies are inconclusive in determining an association
between ulcer formation and diet or the intake of alcohol
and caffeine.
 Clinical Manifestations

• Gnawing or burning epigastric pain occurring 1½

to 3 hours after a meal
• Nocturnal epigastric, abdominal pain or burning..
• Epigastric tenderness on examination
• Early satiety, anorexia, weight loss, heartburn,
belching (may indicate reflux disease)
• Dizziness, syncope, hematemesis, or melena (may
indicate hemorrhage)
• Anemia
 Diagnostic Evaluation
• Upper GI endoscopy with possible tissue
biopsy and cytology. Pyloritek, a biopsy
urea test, is up to 95% specific in
detecting H. pylori.
• Upper GI radiographic examination (barium
study)
• Serial stool specimens to detect occult
blood
• Serology to test for H. pylori antibodies
• C or C-urea breath test to detect H. pylori
 Management
General Measures
• Eliminate use of NSAIDs or other
causative drugs.
• Eliminate cigarette smoking (impairs
healing).
• Well-balanced diet with meals at
regular intervals. Avoid dietary
irritants.
 Management
Drug Therapy
Multiple drug regimens are used to treat H. pylori.
DRUG DOSAGE DURATION
Omeprazole 20 mg PO bid 7-14 days
Clarithromycin 500 mg PO bid
Amoxicillin 1,000 mg PO bid
Omeprazole 20 mg bid 10 days
Pepto-Bismol 2 tabs PO qid Days 4-10 only
Metronidazole 500 mg tid
Tetracycline 500 mg PO qid
Omeprazole 20 mg PO bid 7-14 days
Clarithromycin 250 mg bid
Metronidazole 500 mg bid
Note: Omeprazole may be substituted with lansoprazole,
pantoprazole, ranitidine bismuth citrate or, possibly, ranitidine.
 Surgery
Surgical interventions may be indicated
for hemorrhage, obstruction,
perforation, and acid reduction.
Surgery may also be indicated with
ulcer disease of long duration or
severity or difficulty with medical
regimen compliance.
 Surgery
• Gastroduodenostomy (Billroth I).
– Partial gastrectomy with removal of antrum and pylorus of stomach.
– The gastric stump is anastomosed with the duodenum.
• Gastrojejunostomy (Billroth II)
– Partial gastrectomy with removal of antrum and pylorus of stomach.
– The gastric stump is anastomosed with the jejunum.
• Antrectomy
– Gastric resection includes a small cuff of duodenum, the pylorus, and the antrum
(lower half of stomach).
– The duodenal stump is closed, and the jejunum is anastomosed to the stomach.
• Total gastrectomy
– Also called an esophagojejunostomy.
– Removal of the stomach with attachment of the esophagus to the jejunum or
duodenum.
• Pyloroplasty
– A longitudinal incision is made in the pylorus, and it is closed transversely to
permit the muscle to relax and to establish an enlarged outlet.
– Often, a vagotomy is performed at the same time.
• Vagotomy
– The surgical division of the vagus nerve to eliminate the impulses that stimulate
HCL secretion
– There are three types: selective vagotomy, which severs only the branches that
interrupt acid secretion; truncal vagotomy, which severs the anterior and
posterior trunks to decrease acid secretion and gastric motility; and parietal
vagotomy, which severs only the part of vagus that innervates the parietal acid-
secreting cells.
– Traditionally performed by laparotomy, the vagotomy procedure can also be done
using a laparoscope.
Billroth I
Billroth II
 Complications

• GI hemorrhage
• Ulcer perforation
• Gastric outlet obstruction
 Nursing Assessment
• Determine location, character, radiation of pain, factors
aggravating or relieving pain, how long it lasts, when it occurs.
• Ask about eating patterns, regularity, types of food, eating
circumstances.
• Ask about medications (especially aspirin, anti-inflammatory drugs,
or steroids).
• History of illnesses including previous GI bleeds.
• Obtain psychosocial history.
• Perform physical assessment with documentation of positive
abdominal findings.
• Take vital signs, including lying, standing, and sitting BPs and
pulses, to determine if orthostasis is present due to bleeding.
 Nursing Diagnoses

• Deficient Fluid Volume related to hemorrhage

• Acute Pain related to epigastric distress
secondary to hypersecretion of acid, mucosal
erosion, or perforation
• Diarrhea related to GI bleeding
• Imbalanced Nutrition: Less Than Body
Requirements related to the disease process
• Deficient Knowledge related to physical, dietary,
and pharmacologic treatment of disease
 Nursing Interventions
Avoiding Fluid Volume Deficit
• Monitor intake and output continuously to determine fluid volume status.
• Monitor stools for blood and emesis.
• Monitor hemoglobin and hematocrit and electrolytes.
• Administer prescribed I.V. fluids and blood replacement, as prescribed.
• Insert NG tube as prescribed, and monitor the tube drainage for signs of
visible and occult blood.
• Administer medications through the NG tube to neutralize acidity, as
prescribed.
• Prepare patient for saline lavage, as ordered.
• Observe patient for an increase in pulse and a decrease in BP (signs of
shock).
• Prepare patient for diagnostic procedure or surgery to determine or stop
the source of bleeding.
Achieving Pain Relief
• Administer prescribed medication.
• Provide small, frequent meals to prevent gastric distention if not NPO.
• Advise patient about the irritating effects of certain drugs and foods.
 Nursing Interventions
Decreasing Diarrhea
• Monitor patient's elimination patterns to determine effects of
medications.
• Monitor vital signs, and watch for signs of hypovolemia.
• Administer antidiarrheal medication as prescribed.
• Watch for signs and symptoms of impaired skin integrity
(erythema, pain, pruritus) around anus to promote comfort and
decrease risk of infection.
Achieving Adequate Nutrition
• Eliminate foods that cause pain or distress; otherwise, the diet is
usually not restricted.
• Provide small, frequent meals that neutralize gastric secretions
and may be better tolerated.
• Provide high-calorie, high-protein diet with nutritional supplements
as ordered.
• Administer parenteral nutrition as ordered if bleeding is prolonged
and patient is malnourished.
 Nursing Interventions
Educating the Patient About the Treatment Regimen
• Explain all tests and procedures to increase knowledge and cooperation;
minimize anxiety.
• Review the health care provider's recommendations for diet, activity,
medication, and treatment. Allow time for questions, and clarify any
misunderstandings.
• Give the patient a chart listing medications, dosages, times of
administration, and desired effects to promote compliance.
• Teach patient signs and symptoms of bleeding and when to notify the
health care provider.
Patient Education and Health Maintenance
• Teach patient signs and symptoms of bleeding and when to notify the
health care provider.
• Promote healthy lifestyle changes to include adequate nutrition, cessation
of smoking, decreased alcohol consumption, stress reduction strategies.
• Teach purpose, dosage, and adverse effects of each medication prescribed.
 Evaluation: Expected Outcomes

• Vital signs stable; fluid volume maintained

• Pain free
• No more than two to three loose stools per
day
• Eats frequent small meals each day;
reports no loss of weight
• Describes peptic ulcer disease, its
treatment, and complications; complies
with treatment regimen