PEPTIC ULCER DISEASE 1 P a g e PEPTIC ULCER DISEASE P 987 998 Definition Erosion of the GI mucosa due to HCl acid and pepsin Types of PUD Acute o o o Chronic superficial erosion and minimal inflammation short duration resolved quickly when cause is identified and removed Long duration Eroded through muscular wall Fibrous tissue formation o o o o More common Gastric Duodenal Differences of gastric vs duodenal listed in pg 987 Etiology and Pathophysiology Lifestyle Factors o High alcohol intake o Coffee o o o Stress and depression Smoking Infection with herpes and CMV Gastric Ulcers Less common than duodenal ulcers Duodenal ulcers 80 of all peptic ulcers Incidence highest between 35 45 o o o Clinical Manifestations Gastric o Dyspepsia about 1 2 hours after meals o o Burning or gaseous pain Food aggravates pain Duodenal o 2 5 hours after a meal Back diffusion of HCl acid into gastric mucosa cellular destruction and inflammation H pylori o o Leads to intestinal metaplasia in stomach chronic gastritis tissue damage PUD Produces urease release of inflammatory cytokines Medication Induced Injury o Ulcerogenic drugs aspirin NSAID s inhibit prostaglandin synthesis and increases gastric secretion o Corticosteroids affect mucosal cell renewal and decreases protective effects o o SSRI s Anticoagulants PEPTIC ULCER DISEASE 2 P a g e o o Burning or cramplike pain Back pain Silent o Older adults o NSAID s Complications Hemorrhage Most common Duodenal ulcers Perforation Most lethal complication Seen in duodenal ulcers Ulcer penetrates surface with spillage of gastric duodenal contents in peritoneal cavity Large perforations immediate surgical closure Clinical manifestations of perforations include Sudden and dramatic onsent Sudden severe upper abdominal pain that spreads throughout abdomen Pain not relieved by food or antacids o o o o Rigid and boardlike abdomen Shallow and rapid respirations o Elevated heart rate o o Weak pulse o Absent bowel sounds Untreated o Leads to peritonitis within 6 12 hours Gastric Outlet Obstruction Obstruction in distal stomach and duodenum edema inflammation fibrous scar tissue Discomfort or pain that is worse towards the end of the day Relief by belching or vomiting which is projectile with food particles and is offensive Constipation Diagnostic Studies Endoscopy H pylori infection confirmation o o o o o Biopsy gold standard for h pylori diagnosis Stool testing Breath testing Serum or whole blood antibody tests IGG Stool antigen tests Barium contrast study for ulcer detection X ray Fasting serum gastrin levels Lab tests o CBC o Urinalysis o o o Liver enzyme studies Stool tests Serum amylase determination for pancreatic function Conservative Therapy Adequate rest Drug therapy PEPTIC ULCER DISEASE 3 P a g e Elimination of smoking Dietary modifications if needed Follow u care Ambulatory care clinics Usual follow up evaluation 3 6 months after diagnosis and treatment Discontinue nonselective NSAIDs and aspirin Take PPI s and H2 receptor blockers or minsoprostol when taking NSAIDs and aspirin Drug Therapy Histamine H2 Receptor Blockers Ranitidine Zantac famotidine Pepcid Promote ulcer healing Onset of action starts 1 hour Therapeutic effects last 12 hours Used in combo with antibiotics to treat ulcers r t h pylori Proton Pump Inhibitors More effective than H2 s in reducing gastric acid and promoting ulcer healing Omeprazole pantoproazole Antibiotic Therapy Amoxicillin metronidazole Flagyl tetracycline Used with PPI or H2 For h pylori 7 14 days Antacids Increase gastric pH by neutraliazing HCl acid Magnesium hydroxide aluminum hydroxide Magnesium not for renal failure due to mag toxicity most common SE diarrhea Empty stomach 20 30 minutes because they are quickly evacuated Take after meals so effects last 3 4 hours Administered hourly when acute bleeding has diminished Aluminum SE constipation Cytoprotective Drug Therapy Sulcrafate o o o Short term treatment for ulcers Provides cytoprotection for esophagus stomach and duodenum Accelerates ulcer healing Misoprostol Protective and antisecretory effects on gastric mucosa o o Only drug approved in the US Other Drugs Tricyclic antidepressants Anticholinergic drugs Nutritional Therapy No specific diet Eat and drink foods and fluids that do not distress symotoms o Caffeine avoid o o No spicy hot foods Eliminate alcohol Therapy Related to Complications of Peptic Ulcer Disease PEPTIC ULCER DISEASE 4 P a g e Acute Exacerbation Bleeding Increased pain Discomfort N V Similar management to upper GI bleed 981 892 Endoscopic evaluation Perforation Stop spillage of gastric or duodenal contents into peritoneal cavity Restore blood volume NG tube inserted into stomach Lactated ringer s and albumin solutions Packed RBC s Central venous pressure line Indwelling urine catheter inserted and monitored hourly ECG monitoring Broad spectrum antibiotic therapy to treat peritonitis Administration of pain meds Open or laparoscopic procedures for repair Gastric Outlet Obstruction Decompress the stomach Correct electrolyte and fluid imbalances NG tube Clamp NG tube after several days and measure gastric residual volume frequently When aspirate falls to 200 mL and below begine clear liquids at 30 mL hr Nursing Management Diagnoses ACUTE PAIN R T INCREASED GASTRIC SECRETIONS DECREASED MOCUOSAL PROTECTION AND INGESTION OF GASTRIC IRRITANTS AEB burning cramplike pain in abdomen pain onset 1 2 hrs after meals with gastric ulcer pain onset 2 4 hours after meals with duodenal ulcer Comprehensive assessment of pain Provide pain relief with prescribed analgesics Select variety of measures Teach use of nonpharmacologic techniques o Relaxation o Guided imagery o Music o Distraction o Acupressure Pain control measures INEFFECTIVE SELF HEALTH MANAGEMENT r t lack of knowledge Teaching Disease Process Review patient s knowledge about condition Explain pathophysiology of disease and how it relates to anatomy and physiology Discuss therapy treatment options Describe rationale behind management therapy treatment Discuss lifestyle changes that may be required to prevent future complications Explore patient what he or she has done already to manage symptoms NAUSEA r t acute exacerbation of disease process AEB episodes of nausea and or vomiting Maintain IV infusion lines Assess hematemesis bright red or melena stool abdominal pain or discomfort Observe NG tube aspirate or emesis for amount and color of blood Take vital signs every 15 30 minutes PEPTIC ULCER DISEASE 5 P