Peptic ulcer disease

1. Peptic Ulcer Disease
Carol Lynn Pence
RN, MSN

2. Anatomy and Physiology of GI
Tract

3. Peptic Ulcers
Defined
Ulcerated lesion in the mucosa of the
stomach or duodenum
Types
Gastric
Duodenal

4. Peptic Ulcer Disease

5. 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

6. 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

7. Gastric Ulcers
Pain occurs 1-2 hours after meals
Pain usually does not wake patient
Accentuated by ingestion of food
Risk for malignancy
Deep and penetrating and usually
occur on the lesser curvature of
the stomach

8. Gastric and Duodenal Ulcers

9. Duodenal Ulcers
Pain occurs 2-4 hours after meals
Pain wakes up patient
Pain relieved by food
Very little risk for malignancy

10. 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

11. 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
peritoneum=peritonitis
Narrowing and obstruction (pyloric)
Swelling and scarring can cause obstruction of food leaving
stomach=repeated vomiting

12. Diagnostic Tests
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

13. Etiology and Genetic Risk
PUD primarily associated with NSAID use and
infection with H. Pylori
Certain drugs may contribute to cause:
Theo-Dur
Caffeine – stimulates hydrochloric acid production
Corticosterioids – associated with an increased
incidence of PUD
Genetic factors

14. 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

15. Hyposecretory Drugs
Proton Pump Inhibitors
Suppress acid production
Prilosec, Prevacid
H2-Receptor Antagonists
Block histamine-stimulated
gastric secretions
Zantac, Pepcid, Axid
Antacids
Neutralizes acid and
prevents formation of
pepsin (Maalox, Mylanta)
Give 2 hours after meals
and at bedtime
Prostaglandin Analogs
Reduce gastric acid and
enhances mucosal
resistance to injury
Cytotec
Mucosal barrier fortifiers
Forms a protective coat
Carafate/Sucralfate
cytoprotective

16. 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

17. Types of Surgical Procedures
Gastroenterostomy
allows 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

18. Types of Surgical Procedures
Vagotomy
Cuts vagus nerve
Eliminates acid-
secretion stimulus

19. Surgical
Procedure/Pyloroplasty
Pyloroplasty
Widens the pylorus
to guarantee
stomach emptying
even without vagus
nerve stimulation

20. 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

21. Billroth I
Distal portion of the
stomach is removed
The remainder is
anastomosed to the
duodenum

22. Billroth II
The lower portion
of the stomach is
removed and the
remainder is
anastomosed to
the jejunum

23. Postoperative Care
NG tube – care and management
Monitor for post-operative complications

24. 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 (page
1303)
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

25. Dumping Syndrome
Rapid emptying of food and fluids from the
stomach into the jejunum
Symptoms
Weakness
Faintness
Palpatations
Fullness
Discomfort
Nausea
diarrhea

26. Minimize Dumping Syndrome
Decrease CHO intake
Eat slowly
Avoid fluids during meals
Increase fat
Eat small, frequent meals