Peptic ulcer ppt

Peptic ulcer

1. P RE S E N T E D B Y MR. ROMAN BAJRANG RE LI A N C E IN ST I T U T E O F NURSING TOPIC

2.  Peptic ulcer is a hole or open sore in the lining of the stomach, duodenum (beginning of the small intestine) or oesophagus. DEFINITION Edited by :-MR . ROMAN BAJRANG

3.  "peptic" refers to pepsin: a stomach enzyme that breaks down protein.  An ulcer occurs when the lining of these organs is corroded by acidic digestive juices secreted by the stomach cells.

4. LOCATION OF PEPTIC ULCER: Ulcer may be found : In oesophagus stomach duodenum,   jejunum at multiple levels (Zollinger Ellison syndrome).

5. Symptoms Abdominal discomfort usually occurs in epigastric area (upper middle part of the abdomen) radiating to the back described as : 1. A dull gnawing ache comes and goes for several days . 2. A pain may increase when the stomach is empty at night or half to three hours after meal . 3. A Pain is relieved by eating & antacid medication.

6. OTHER SYMPTOMS: Weight change Fatigue

7. Other symptoms Bloating

8. Other symptoms Chest pain B ur p i n g

9. Other symptoms  Nausea and Anorexia (common with gastric ulcer)

10. Other symptoms Vomiting (relieves episodes of severe pain due to evacuation of gastric acid content). Edited by :-MR . ROMAN BAJRANG

11. Less common symptoms: 1 -Constipation and 5% of the patients with chronic duodenal ulcers has predominantly colonic symptoms.  2-Heartburn and eructation are also commonly associated with ulcer activity.

12. CAUSES OF PEPTIC ULCER  While acid is still considered significant in ulcer formation, the leading cause of ulcer disease is currently believed to be infection of the stomach by bacteria called "Helicobacter pyloridus" (H. pylori).

13. STRESS INCREASES HCL SECRETION :-

14. Chronic use of anti-inflammatory medications, commonly referred to as NSAIDs ( Nonsteroidal anti- inflammatory drugs ).

15. (H. Pylori Bacterium (helicobacter pylori  The H. pylori bacteria excretes the enzyme urease, which converts urea into ammonia and bicarbonate. The release of ammonia ‘neutralize’ the acidic environment in the stomach, which explains the difficulty in destroying . The H . pylori bacterium.! Ammonia is toxic to the epithelial cells and damages them; hence the beginning of a stomach ulcer takes its course.

16. Diagnosing H. pylori H. pylori is diagnosed through:  blood,  breath,  stool,  and tissue tests.

17. Diagnosing H. pylori Blood tests are most common. They detect antibodies to H. pylori bacteria. Blood is taken at the doctor's office through a finger stick.

18. Diagnosing H. pylori  Urea breath tests are an effective diagnostic method for H. pylori . They are also used after treatment to see whether it worked. In the doctor's office, the patient drinks a urea solution that contains a special carbon atom. If H. pylori is present, it breaks down the urea, releasing the carbon. The blood carries the carbon to the lungs, where the patient exhales it. The br eath is accurate. Edited by :-MR . ROMAN BAJRANG

19. Diagnosing H. pylori  Stool tests detect H. pylori infection in the patient's fecal matter. Helicobacter pylori stool antigen (HPSA) test is accurate for diagnosing H. pylori .  Tissue tests are usually done using the biopsy sample that is removed with the endoscope.

20.  Coffee  Colas,  spicy foods,  and caffeine

21. :Types of Peptic Ulcer  Duodenal  Gastric  Oesophagal  Zollinger Ellison syndrome (severe peptic ulcer+gastric hyperacidity, gastrinoma: islet cell tumor in pancreas)  Curling's ulcer

22. Duodenal and Gastric Ulce rs

23. Duodenal ulcer Gastric ulcer -In c id enc e Age 30-60 Usually 50 years and above 2-3:1 ♀:♂ ♂:♀ 1:1 80% of peptic ulcers are duodenal 15% of peptic ulcers are gastric Comparison between Duodenal and Gastric Ulcer

24. -Signs and S y m pto m s Hypersecretion of HCl Hyposecretion of HCl Weight gain Weight loss Pain 2-3 hrs after meal; often awakened btw 1-2 AM; ingestion of food relieves pain Pain occurs 1\2-1 hr after meal; rarely occurs at night; may be relieved by vomiting; ingestion of food does not help, sometimes increases pain Vomiting uncommon It perforates more than gastric ulcer Vomiting common Hemorrhage more likely to occur than with duodenal ulcer.

25. -Malignancy r a re Occasionally takes place -Risk factors H.Pylori, alcohol, smoking, cirrhosis, stress H.Pylori, gastritis, alcohol, smoking, NSAIDs, stress

26. ESOPHAGEAL ULCER  An esophageal ulcer is a hole in the lining of the esophagus corroded by the acidic digestive juices secreted by the stomach cells .  An esophageal ulcer is usually located in the lower section of esophagus. Esophageal ulcers are not contagious . Esophageal ulcers may be a symptom of another disease or condition.. Bleeding from esophageal ulcers may cause iron deficiency anemia .  It is often associated with chronic GERD .

27. Zollinger -Ellison syndrome A large amount of excess acid is produced in response to the overproduction of the hormone gastrin, which in turn is caused by tumors on the pancreas or duodenum. These tumors are usually malignant, must be removed and acid production suppressed to relieve the recurrence of the ulcers.

28.  Curling's ulcer is an acute peptic ulcer of the duodenum resulting as a complication from severe burns when reduced plasma volume leads to sloughing of the gastric mucosa .  These stress ulcers were once a common complication of serious burns, especially common in child burn victims. They result in perforation and hemorrhage and had correspondingly high mortality rates. Curling's ulcer

29. Bleeding: As an ulcer erodes the muscles of stomach, or duodenal wall, blood vessels may also be damaged, which causes the bleeding. Over a period of time, the patient becomes anemic. Can be treated endoscopically by Locating the ulcer &cauterizing the BV With heating device or injected with material to stop bleeding. Perforation: Sometimes, ulcer eats a hole in wall of the stomach, or duodenum. Bacteria & partially digested food can spill through the opening into the sterile abdominal Cavity(paritonium). This causes paritonitis,an inflammation of the abdominal cavity & wall. Immediate hospitalization and surgery is usually required. Comp l ic at i ons

30. Barium X-ray examination (less expensive method of diagnosing peptic ulcer). But X-ray examination does have some limitations :  It is unable to define mucosal disease ex: gastritis .  It is not definitive in differentiating benign from malignant gastric ulcer .  It cannot delineate superficial, subacute gastric or duodenal erosions.  It cannot define complete healing of an ulcer.  Furthermore, as an ulcer heals, the surrounding tissue, especially in the duodenum, becomes scarred and deformed and radiologic assessment of activity of the ulcer becomes more difficult.

31. Receptors present on the cell membrane of parietal cells in stomach:  M1 Receptors : stimulated by acetylcholine secreted from the para-sympathetic nerve endings (vagus nerve).  Gastrin Receptors: stimulated by gastrin hormone from mucosa of stomach and duodenum into the blood. presence of food causes distention of the stomach this will cause stimulation of mucosa so gastrin hormone increases in blood and parietal cells increase the secretion of HCl.  H 2 Receptors: stimulated by histamine secreted from mast cells in stomach.

32. Medication Surgery Changing Life style T reat m ent Edited by :-MR . ROMAN BAJRANG

33. To relieve the symptoms (pain, vomiting, blood loss ). To eliminate the source of problem. A i m s of treatment To promote healing of ulcer . To prevent co m p li c a t i o ns of ulcer. To prevent recurrence of ulcer by maintenance therapy.

34. DRUGS Anti secretory Drugs: they reduce gastric acid secretion C y to p r o tec t i v e drugs having mucosal Protective properties H2 blocker: first line of treatment of peptic ulcer Anti- m u s c a r i n ic drugs Proton pump i n h i b i t ors Sucralfates Bi-chelates Misoprostol A n t a c i d s Antibiotics: To kill H. Pylori

35. D RU G S Anti secretory Drugs: they reduce gastric acid secretion H2 blocker: first line of treatment of peptic ulcer Anti- mu sc ari n i c drugs Proton pump i nh i b i t ors

36. H2 -Antihistam ine  Mode of action :  These are competitive antagonists with histamine on H2 receptors found on the parietal cells of the stomach so they can reduce gastric acid secretion . They are given as first line of treatment for 4 weeks then the patient is examined to see if ulcer healed.  If ulcer is healed so the patient moves to lower dosage regimen such as maintenance therapy.  If ulcer is not healed so shift to another line of treatment.  Side effects: constipation, diarrhea, H2 antihistaminics Ranitidine Cimetidene Nazitidine F a m o t i d i n e Axid (amp + c ap ) A po-famotidin e A po- ci metidin e C i m e tr i l A po-ranitidin e Ranicux R anta g Zanta c Ga st rodomin a Pepcid Famoda r Neutronor m

37. Ranitidine Edited by :-MR . ROMAN BAJRANG

38. Nazitidine

39. Proton Pump Inhibitor s  Mode of action:  They irreversibly inhibit H+ pump or H+/K+ ATPase which is an enzyme in the cell membrane of oxyntic or parietal cells, they block the final step for HCl secretion .  Regular use of these can cause achlorohydria because they act on HCl formation not on receptors that increase HCl secretion. They are the most potent anti-secretory drugs.  Side effects :- constipation, diarrhea, colic, nausea. P. pump i nh i b i t o r Rabeprazole Pantoprazole O m ep r a z ole la n sop r a z o l Gastrimut R ise k E p i r a z ole Ga st ra z ole Omepra l Opra z o l e P arie t Inipom p Takepron Lan z o r U lsto p Zimo r Esomeprazole Ne x iu m R abe c Lan z om i d e Omeda r Omize c O m i z

40. R ab e pr a zole

41. E so m epr a zole Omeprazole

42. Antimuscarinic Drugs  Mechanism of action: they are selective M1 antagonists.  They are used in combination with H 2 blocker because histamine is the main mediator for HCl secretion.

43. DRUGS C y to p r o tec t i v e drugs having mucosal Protective properties Sucralfates Bi-chelates Misoprostol A n t a c i d s

44. Bismuth chelates Mode of action: they have mucosal protective activity 1. increase prostaglandins 2. increase bicarbonate 3. increase mucus production They have toxic effect on Helicobacter pylori (bactericidal) can be used as first line treatment with H2 blocker if helicobacter infection is positive. Side effects : blackening of the tongue, teeth, and stools.

45. (Misoprostol ( Cytotec ) Mechanism of action : It causes mucosal protection by: Increasing mucus and bicarbonate production. Decreasing gastric HCl secretion Uses : It is only used for prevention of NSAID_induced ulceration in patients with high risk Elderly Smokers Patients with history of gastric bleeding. When NSAIDs are stopped, discontinue misoprostol. Side effects: Gastro intestinal disturbances (vomiting, diarrhea, colic) due to prostaglandin induced smooth muscle contraction. Gynecological disturbances (spotting,dysmennorhea). Uterine contractions (contra-indicated in pregnancy because they cause abortion).

46. Ant ac i ds  Mode of action: used for symptomatic relief. They act via neutralization of the gastric HCl. Antacid Al hydroxide Mg(hydro x i d e or trisilicate) Adverse rxn con s t ipa t i on diarrhea So a mixture of aluminum and magnesium is used in combination with H2 blocker and to relieve the symptoms of hyperacidity.

47. H. pylori can be very difficult to completely eradicate. Treatment requires a combination of several antibiotics, sometimes in combination with a proton-pump inhibitor, H 2 blockers or Bi-chelate. Without such treatment there is an eighty percent chance the ulcer will reoccur within one year. Eradication of H. pylori prevents the return of ulcers (a major problem with all other ulcer treatment options) Elimination of this bacteria may also decrease the risk of developing gastric cancer in the future.  An effective combination would be Amoxicillin + Metronidazole + Pantoprazole . Antibiotics

48. Fiber slows the movement of food and acidic fluid from the stomach to the intestines, which should help those with duodenal ulcer . Advice For Duodenal ulcer Patients

49. Lifestyle changes that may be helpful: Aspirin and related drugs ( NSAID ), alcohol , coffee , and tea can interfere with the healing of peptic ulcers. Smoking is also known to slow ulcer healing. Whether or not an ulcer is caused by infection , people with peptic ulcer should avoid use of these substances.

50. Nutritional supplements that may be helpful: 1. Vitamin A is needed to heal the linings (m.m) of the stomach and intestines. 2. High dose should not be taken by a pregnant woman, by a woman who could become pregnant , or by anyone else without careful supervision from a doctor. 3. The effect of lower amounts of vitamin A has not been studied in people with peptic ulcer.

51. Z I N C Zinc is also needed for the repair of damaged tissue and has protected against stomach ulceration in animal studies. Copper must be taken to avoid copper deficiency that would be induced by the zinc supplementation.

52. Glutamine Glutamine , an amino acid , is the principal source of energy for cells that line the small intestine and stomach . Glutamine has also prevented stress ulcers triggered by severe burns in another preliminary study.

53. VITAMIN C Little is known about the effects of Vitamin C in peptic ulcer cases . Vitamin C may also help eradicate H. pylori in people with gastritis. Vitamin C may one day prove to have a therapeutic effect for people with peptic ulcer; however, further research in this area is needed.

54. Licorice root has a long history of use for soothing inflamed and injured mucous membranes in the digestive tract. Licorice may protect the stomach and duodenum by increasing production of mucin. □ Flavonoids in licorice may also inhibit growth of H. pylori . Herbs that may be helpful:

55. CHAMOMILE Chamomile has a soothing effect on inflamed and irritated mucous membranes. It is also high in the flavonoid apigenin , another flavonoid that has inhibited growth of H. pylori . Chamomile is also available in capsules. Calendula is another plant with anti- inflammatory and healing activities that can be used as part of a traditional medicine approach to peptic ulcers . The same amount as chamomile can be used.

56. GARLIC Garlic has been reported to have anti- Helicobacter activity.

57. Preventions To decrease risk of ulcer from H. pylori infection:  Wash your hands after using the bathroom and before eating or preparing food.  Drink water from a safe source. Don’t smoke . Cigarette, smoking increases the chances of getting an ulcer.

58. Preventions To decrease the risk of ulcer from NSAIDs: 1. Use other drugs when possible for managing pain . 2. Take the lowest possible dose . 3. Do not take longer than needed. 4. Do not drink alcohol while taking the drugs.

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60. THANK YOU Edited by :-MR . ROMAN BAJRANG