Peptic Ulcer Disease Chapter 23, pg' 680691

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Peptic Ulcer Disease(Chapter 23, pg. 680-691)
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Peptic Ulcers

• Defined
• Ulcerated lesion in the mucosa of the stomach or
  duodenum
• Types
• Gastric
• Duodenal

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Stomach Defense Systems

• Mucous layer
• Coats and lines the stomach
• First line of defense
• Bicarbonate
• Neutralizes acid
• Prostaglandins
• Hormone-like substances that keep blood vessels
  dilated for good blood flow
• Thought to stimulate mucus and bicarbonate
  production

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Risk Factors

• Lifestyle
• Smoking
• Acidic drinks
• Medications
• H. Pylori infection
• 90 have this bacterium
• Passed from person to person (fecal-oral route or
  oral-oral route)
• Age
• Duodenal 30-50
• Gastric over 60

• Gender
• Duodenal are increasing in older women
• Genetic factors
• More likely if family member has Hx
• Other factors stress can worsen but not the cause

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Gastric Ulcers

• Pain occurs 30-60 minutes after meals at night
  rarely
• Pain is made worse by the ingestion of food
• May be malnourished
• Risk for malignancy
• Deep and penetrating and usually occur on the
  lesser curvature of the stomach

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Duodenal Ulcers

• Pain occurs 2-3 hours after meals often awakens
  client between 1 and 2 am
• Pain relieved by ingestion of food
• Very little risk for malignancy

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Stress Ulcers

• Acute gastric mucosal lesions
• Associated with major surgery, head injury,
  burns, respiratory, failure, shock and sepsis
• Bleeding is principal manifestation
• Exact etiology is unknown
• Associated with lengthy hospital stays

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General Peptic Ulcer Symptoms

• Epigastric tenderness
• Gastric epigastrium left of midline
• Duodenal mid to right of epigastrium
• Sharp, burning, aching, gnawing pain
• Dyspepsia (indigestion)
• Nausea/vomiting
• Belching

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Complications of Peptic Ulcers

• Hemorrhage
• Blood vessels damaged as ulcer erodes into the
  muscles of stomach or duodenal wall
• Coffee ground vomitus or occult blood in tarry
  stools
• Perforation
• An ulcer can erode through the entire wall
• Bacteria and partially digested fool spill into
  peritoneumperitonitis
• Narrowing and obstruction (pyloric)
• Swelling and scarring can cause obstruction of
  food leaving stomachrepeated vomiting, nausea
  and bloating
• Intractable disease

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Etiology and Genetic Risk

• PUD primarily associated with NSAID use and
  infection with H. Pylori
• Certain drugs may contribute to cause, alter
  gastric secretion
• Theo-Dur
• Caffeine stimulates hydrochloric acid
  production
• Corticosterioids associated with an increased
  incidence of PUD
• Genetic factors

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Laboratory Tests

• Hemoglobin and hematocrit may be low, indicating
  bleeding
• Stool specimen may be positive for occult blood

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Diagnostic Tests

• Major diagnostic test for peptic ulcer disease is
  Esophagogastrodeuodenoscopy (EGD)
• Endoscopic procedure
• Visualizes ulcer crater
• Ability to take tissue biopsy to R/O cancer and
  diagnose H. pylori
• Upper gastrointestinal series (UGI)
• Barium swallow
• X-ray that visualizes structures of the upper GI
  tract
• Urea Breath Testing
• Used to detect H.pylori
• Client drinks a carbon-enriched urea solution
• Excreted carbon dioxide is then measured

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Nursing Diagnosis

• Acute pain
• Chronic pain
• Collaborative Problem
• Potential for gastrointestinal bleeding

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Drug Therapy/Primary Goals

• Provide pain relief
• Antacids and mucosa protectors
• Eradicate H. pylori infection
• Two antibiotics and one acid suppressor
• Heal ulcer
• Eradicate infection
• Protect until ulcer heals
• Prevent recurrence
• Decrease high acid stimulating foods in
  susceptible people
• Avoid use of potential ulcer causing drugs
• Stop smoking

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Drug Therapy for Peptic Ulcer Disease

• Proton pump inhibitors
• Suppress acid production
• Prilosec, Prevacid, Protonix, Nexium
• H2-Receptor Antagonists
• Block histamine-stimulated gastric secretions
• Zantac, Pepcid, Axid
• Antacids
• Neutralizes acid and prevents formation of pepsin
  (Maalox, Mylanta, Amphogel)
• Give 2 hours after meals and at bedtime
• Side effect is constipation

• Prostaglandin Analogs
• Reduce gastric acid and enhances mucosal
  resistance to injury
• Cytotec
• Mucosal barrier fortifiers
• Forms a protective coat
• Carafate/Sucralfate
• Cytoprotective
• Antimicrobials
• Biaxin, Amoxil, Flagyl

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Diet Therapy

• Bland diet may assist in relieving symptoms (no
  research that supports this)
• Avoid substances that increase gastric acid
  secretion
• Coffee, both caffeinated and decafeinated
• Avoid bedtime snacks
• Avoid alcohol and tobacco

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Potential for Gastrointestinal Bleeding

• Hypovolemia management
• Crystalloid solution
• Blood replacement
• Fresh frozen plasma if prothrombin time is 1.5
  times the higher than the midrange control value
• Monitor for s/s of GI bleed
• Vital signs, hemoglobin and hematocrit,
  coagulation studies, hidden (occult) blood

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Key Features of Gastrointestinal Bleeding

• Coffee-ground vomitus
• Tarry stools or frank blood in stools
• Melena (occult blood)
• Decreased blood pressure
• Increased weak and thready pulse
• Decreased Hgb/Hct
• Vertigo, dizziness, syncope, lightheadedness,
  nausea
• Acute confusion in the older adult

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Non-surgical Management of GI Bleed

• Endoscopic Therapy
• Acid suppresion
• Nasogastric tube placement and saline lavage

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Non-surgical Management of Perforation

• Replace fluid, blood, and electrolytes
• Administer antibiotics
• Keep NPO
• Maintain NG suction to drain gastric secretions
  and prevent further spillage into peritoneum
• Monitor vital signs, intake and output and
  monitor for shock

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Non-surgical Management of Pyloric Obstruction

• Restore fluid and electrolyte balance
• Decompress the stomach
• Correction of metabolic alkalosis and dehydration

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Surgery

• Greatly decreased in the last 20-30 years
  secondary to the discovery of H. pylori
• Required if ulcer in one of these states
• Perforated and overflowed into the abdomen
• Scarred or swelled so that there is obstruction
• Acute bleeding
• Non-responsive to medications

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Types of Surgical Procedures

• Gastroenterostomyallows regurgitation of
  alkaline duodenal contents into the stomach
• Creates a passage between the body of stomach to
  small intestines
• Keeps acid away from ulcerated area

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Types of Surgical Procedures

• Vagotomy
• Cuts vagus nerve
• Eliminates acid-secretion stimulus

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Surgical Procedure/Pyloroplasty

• Pyloroplasty
• Widens the pylorus to guarantee stomach emptying
  even without vagus nerve stimulation

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Types of Surgical Procedures

• Antrectomy/ Subtotal Gastrectomy
• Lower half of stomach (antrum) makes most of the
  acid
• Removing this portion (antrectomy) decreases acid
  production
• Subtotal gastrectomy
• Removes ½ to 2/3 of stomach
• Remainder must be reattached to the rest of the
  bowel
• Billroth I
• Billroth II

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Billroth I

• Distal portion of the stomach is removed
• The remainder is anastomosed to the duodenum

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Billroth II

• The lower portion of the stomach is removed and
  the remainder is anastomosed to the jejunum

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Minimally Invasive Gastrectomy

• Via laparoscopy
• Used to remove a chronic gastric ulcer or treat
  hemorrhage from perforation

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Postoperative Care

• NG tube care and management
• Monitor for post-operative complications
• Pain Management

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Post-op Complications

• Bleeding
• Occurs at the anastomosed site
• First 24 hours and post-op days 4-7
• Duodenal stump leak
• Billroth II
• Severe abdominal pain
• Bile stained drainage on dressing
• Gastric retention
• WILL NEED TO PUT NG TUBE BACK IN

• Dumping Syndrome
• Prevalent with sub total gastrectomies
• Early-30 minutes after meals
• Vertigo, tachycardia, syncope, sweating, pallor,
  palpatations
• Late 90 min-3 hours after meals
• Anemia
• Rapid gastric empyting decreases absorption of
  iron
• Malabsorption of fat
• Decreased acid secretions, decreased pancreatic
  secretions, increased upper GI mobility

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Dumping Syndrome

• Rapid emptying of food and fluids from the
  stomach into the jejunum
• Symptoms
• Weakness
• Faintness
• Palpatations
• Fullness
• Discomfort
• Nausea
• diarrhea

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Minimize Dumping Syndrome

• Decrease CHO intake
• Eat slowly
• Avoid fluids during meals
• Increase fat
• Eat small, frequent meals