Peptic ulcer disease

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1. Peptic Ulcer Disease 1 logman Mohammed

2. 2 Peptic Ulcer Disease This occurs anywhere where pepsin and acid occur together. It is caused by an imbalance b/w secretion of acid and pepsin , mucosal defense mechanism . An acid and reduced mucosal defenses provide ideal circumstances for pepsin to cause mucosal ulceration. If there is no acid peptic ulceration cannot occur. logman Mohammed

3. cont Over secretion of acid associated with duodenal ulceration. Breakdown of the mucosal defences occurs in gastric ulceration. logman Mohammed 3

4. cont Exacerbating factors in peptic ulceration include : smoking,alcohol,NSAIDs,steroid,hyperparathyrodism,zolinger-ellison syndrome. infection with helicobacter pylori(HP)may impair mucosal defences and has recently been associated with DU and gastritis and to a lesser extent GU . logman Mohammed 4

5. Types PU Acute Superficial erosion Minimal erosion Chronic Muscular wall erosion with formation of fibrous tissue Present continuously for many months or intermittently 5 logman Mohammed

6. Peptic Ulcer Disease Sites of ulcer development Lower esophagus Stomach( common in the lesser curvature ) Duodenum Jejunum( in zollinger-elison syndrome ) 6 logman Mohammed

7. Duodenal Ulcers Clinical Manifestations Epigastric pain, may radiate to back ,relieved by eating, worse at night. Symptoms are periodic and last about 14days and recur at3-4monthly intervals. They are often worse in spring and autumn.vomiting is rare ,if it occurs pyloric stenosis should be suspected. Examination reveals tenderness in epigastrium 7 logman Mohammed

8. Gastric Ulcers Clinical Manifestations Epigastric pain, not periodic, food may precipitate pain. Pain may be relieved by vomiting. Patient may be afraid to eat and weight loss result . Examination reveals tenderness in epigastrium 8 logman Mohammed

9. Other symptoms Dyspepsia, including belching, bloating, distention, and fatty food intolerance Heartburn Hematemesis or melena 9 logman Mohammed

10. 10 logman Mohammed

11. Diagnostic Studies Upper GI Endoscopy procedure most often used Tissue specimens can be obtained to identify H. pylori and to rule out gastric cancer 11 logman Mohammed

12. Diagnostic Studies Tests for H. pylori Noninvasive tests Serum or whole blood antibody tests Immunoglobin G ( IgG ) Urea breath test Invasive tests Biopsy of stomach 12 logman Mohammed

13. Diagnostic Studies Barium contrast studies X-ray studies Ineffective in differentiating a peptic ulcer from a malignant tumor Gastric analysis Identifying a possible gastrinoma 13 logman Mohammed

14. Diagnostic Studies Laboratory analysis CBC Liver enzyme studies Serum amylase determination Stool examination 14 logman Mohammed

15. 15 Medical Management The purpose of medical management of peptic ulcer is to eradicate H. pylori and to manage gastric acidity. This is achieved through pharmacologic therapy, lifestyle changes, and surgical intervention. logman Mohammed

16. Management Life Style Changes Patient Education Stop smoking Avoid NSAID and aspirin use Avoid heavy alcohol use Stress reduction counseling might be helpful in individual 16 logman Mohammed

17. 17 Dietary modification is required to avoid over secretion of acid and hyper motility in the GI tract. Avoiding alcohol, coffee and other caffeinated beverages, and diets rich in milk and cream. Effort is made to neutralize acid by eating three regular meals a day. Dietary modification logman Mohammed

18. 18 Pharmacologic Therapy A combination of antibiotics (clarithromycin & amoxicillin), proton pump inhibitors (omeprazole), and bismuth salts (bismuth subsalicylate) that suppresses or eradicates H. pylori; Antibiotics assist in eradicating H. pylori bacteria. Histamine 2 (H2) receptor antagonists (Ranitidine) and proton pump inhibitors are used to treat NSAID-induced and other ulcers not associated with H. pylori ulcers. logman Mohammed

19. Pharmacologic Therapy for PU D Currently favored regimens are triple therapy with a PPI along with two antibiotics. For example: ■ Omeprazole 20 mg + metronidazole 400 mg and clarithromycin 500 mg (all twice daily) ■ Omeprazole 20 mg + clarithromycin 500 mg and amoxicillin 1 g (all twice daily). 19 logman Mohammed

20. cont Surgery: Failed medical tretment (unusual nowadys ) Complications- hemorrhage ,perforation, or obstruction. Operation include: Vagotomy Partial gastrectomy 20 logman Mohammed

21. Surgical procedure options 1. Gastroduodenostomy ( Billroth I ). Partial gastrectomy with removal of antrum and pylorus of stomach. b. The gastric stump is anastomosed with the duodenum. 2 . Gastrojejunostomy ( Billroth II) Partial gastrectomy with removal of antrum and pylorus of stomach. b . The gastric stump is anastomosed with the jejunum. 3. Antrectomy Gastric resection includes a small cuff of duodenum, the pylorus, and the antrum . b . The duodenal stump is closed, and the jejunum is anastomosed to the stomach. 21 logman Mohammed

22. 4. Total gastrectomy : Called an esophagojejunostomy . b . Removal of the stomach with attachment of the esophagus to the jejunum or duodenum . 5. 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. b . Often, a vagotomy is performed at the same time. 6. Vagotomy The surgical division of the vagus nerve to eliminate the impulses that stimulate HCL secretion. 22 logman Mohammed

23. Vagotomy Pyloroplasty Duodenal anastomosis Billroth II ( gastrojejunostomy ) Antrectomy Billroth I ( gastroduodenostomy ) 23 logman Mohammed

24. Peptic Ulcer Disease Complications Hemorrhage Perforation Gastric outlet obstruction Malignancy (GU) 24 logman Mohammed

25. 25 Nursing Management of Peptic Ulcer Assessment : The nurse asks the patient to describe the pain and the methods used to relieve. The nurse asks about history of vomiting and characteristics of the vomitus: Is it bright red, does it resemble coffee grounds? The nurse records vital signs and reports any tachycardia and hypotension. Is there any tenderness of abdomen? logman Mohammed

26. Assessment Has the patient noted any bloody or tarry stools? The nurse assess life style and habits such as drinking coffee ,alcohol , smoking . Does the patient take NSAIDs? Any anxiety or stress ? 26 logman Mohammed

27. 27 Acute pain related to the effect of gastric acid secretion on damaged tissue. Anxiety related to coping with an acute disease. Imbalanced nutrition related to changes in diet. Deficient knowledge about prevention of symptoms and management of the condition. Nursing diagnoses logman Mohammed

28. 28 To relieving pain: Administration of prescribed medications. The patient should avoid aspirin, foods and beverages that contain caffeine, and decaffeinated coffee Meals should be eaten at regularly paced intervals in a relaxed setting . Nursing interventions logman Mohammed

29. To reducing anxiety: The nurse assesses the patient’s level of anxiety. Appropriate information and explanation are provided all questions are answered patient is encouraged to express fears openly. The patient’s family is encouraged to participate in care and to provide emotional support 29 logman Mohammed

30. Maintaining optimal nutritional status: The nurse assesses the patient for malnutrition and weight loss. The patient is advised about the importance of complying with the medication regimen and dietary restrictions. 30 logman Mohammed

31. 31 Instructs the patient about the factors that will help or aggravate the condition. The nurse provides information about medications to be taken at home, stressing the importance of continuing to take medications The patient is instructed to avoid certain medications and foods that exacerbate symptoms It is important to counsel the patient to eat meals at regular times. Informs the patient about the irritant effects of smoking on the ulcer. To improve the patient knowledge logman Mohammed