PEPTIC ULCERS DISEASE OF THE GASTROINTESTINAL TRACT

Peptic ulcers are the lesions or erosion of the mucosal lining of the esophagus, stomach and duodenum.

1. BY
A.D CHUNGU
PEPTIC ULCERS
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2. General Objective
•At the end of the lecture, students should be able
to acquire knowledge Peptic Ulcer Disease and its
management
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3. SPECIFIC OBJECTIVES:
At the end of the lecture/ discussion, students should be able to:
1. Define peptic ulcer.
2. State the causes of peptic ulcers.
3. State the signs and symptoms of peptic ulcers.
4. Describe the pathophysiology of peptic ulcers
5.Discuss the management of peptic ulcers.
6.State the complications of peptic ulcers.
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4. DEFINITION
•A peptic ulcer is an erosion in the gut lining of the
stomach, duodenum, or esophagus which occurs
when the lining of these organs is corroded by
the acidic digestive juices which are secreted by
the stomach cells.(Lewis. et al 2011)
•It is a condition characterized by erosion of the
gastro-intestinal mucosa resulting from the
digestive action of hydrochloric acid and pepsin.
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5. •A peptic ulcer is erosion in a segment of the
gastrointestinal mucosa, typically in the stomach
or the first few centimeters of the duodenum ,
that penetrates through the muscularis mucosae.
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6. AETIOLOGY OF PEPTIC ULCERS
Cause-unknown
Predisposing factors
•Infection with Helicobacter Pylori
is a major causative factor. It
increases gastric production that
contribute to the erosion of the
mucosa and therefore ulcer formation.
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7. Predisposing factors
•Regular and prolonged use of Aspirin and
other nonsteroidalanti-inflammatory drugs.
•Heavy cigarette smoking which may
accelerate gastric acid emptying and promote
mucosal breakdown
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8. Predisposing factors
•Alcohol consumption increases risk when
associated with H. pyloriinfection.
•Zollinger-Ellison syndrome causes gastric and
duodenal ulcers. The tumor in the pancreas
releases high levels of a hormone, which causes an
increase in gastric acid.
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9. Predisposing factors
•Emotional stress, anxiety anger leads to
hypersecretion of gastric acid.
•Radiation treatments.
•Heredity–tendency to run in families
•Blood group –Type A is associated with
gastric while blood group O with duodenal
ulcers
•Prolonged intake of caffeincontaining
beverages increases gastric acid secretion.
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10. Predisposing factors
•Excessive secretion of hydrochloric acid
(Hyperchloridria) –increases gastric mucosa
erosion.
•Trauma or serious illness that reduce BP ,eg
major burns –reduces gastric blood hence reducing
the mucosa lining resistance to ulceration.
•Excessive intake of spice foods –irritates the
mucosa lining & increase gastric secretion
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11. CLASSIFICATION OF PEPTIC ULCERS
A. according to region/location
•Stomach-gastric ulcer ,less common.
•Duodenum -duodenal ulcer,the most common
of peptic ulcers
•Oesophagus -Oesophageal ulcer
•Meckel's Diverticulum -Meckel's Diverticulum
ulcer
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12. •Marginal Ulcers –where the remaining
stomach is connected to the intestines.
•Stress (curlings) Ulcers-occur under stress of
severe illness, burns or trauma. They don’t have
havea specific location.
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13. CLASSIFICATION OF PEPTIC ULCERS
B. According to duration
•Acute-is associated with superficial erosion
involving the mucosa and sub-mucosa layers and
minimal inflammation. It is of short duration and
resolve quickly when the cause is identified and
removed.
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14. CLASSIFICATION OF PEPTIC ULCERS
•Chronic–type with long duration, eroding
through the muscular layer with the
formation of fibrous tissue. It is present
continuously for many months or
intermittently throughout the person’s life
time.
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15. Common sites of peptic ulcers
•Lesser curvature –most common site
•Cardia-stomach
•Pylorus -stomach
•Proximal duodenum
•Distal oesophagus
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16. SITES FOR PEPTIC ULCER
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17. Differences btn gastric and Duodenal
ulcers
FeatureGastric Duodenal
Site stomach Duodenum
Blood
group
Common in A Common in O
Pain worse 1-2 hrs after
meals
Relieved after meals &
may return 2-4 hrs after
, midmorning ,afternoon
& midnight
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18. Differences btn gastric and Duodenal ulcers
Feature Gastric Duodenal
Incidence by
sex
Male : Female 4:1Male : Female 2:1
Weight lossmore marked less marked
Malignancybecome cancerousUsually never
becomecancerous
Age group
affected
older Younger : less than
40 years
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19. Differences btn gastric and
Duodenal ulcers
Feature Gastric Duodenal
Fat food
intolerance
Present Absent
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20. Clinical features of peptic ulcers
•Epigastric pain related to meals –due to nerve
ending irritation of affected part.
•heart burn(pyrosis) –retrosternal burning
sensation due to oesophageal irritation.
•Belching–expulsion of air through the mouth due
to accumulation of gasses in the GIT.
•malaena–dark tally stool due to partially
digested blood from ulcerated GIT
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21. Clinical features of peptic ulcers
•Nausea and vomiting associated with severe
abdominal pain.
•Weight loss especially in gastric ulcers due to
fear to take meals which stimulate abdominal
pain.
•Haematemesis–vomiting blood due to bleeding
ulcers.
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22. MANAGEMENT
Medical
INVESTIGATIONS
•History taking; involves abdominal pain location,
time, severity, blood group, lifestyle and medical
history egaspirin or Brufenintake.
•Physical examination; palpation may reveal pain,
usually epigastric tenderness.
•Barium study shows location of peptic ulcers.
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23. INVESTIGATIONS ctnued
•Endoscopyvisualises ulcerated gastric mucosa
•Biopsy; may be done for gastric ulcers to rule out
malignancy.
•Gastric secretory studies may reveal increased
gastric acid levels.
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24. INVESTIGATIONS ctnued
•Stool examination may reveal occult or
fresh blood which indicates bleeding
from GIT.
•Serologic test; to detect antibodies to
the Helicobacter pylori antigen.
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25. Treatment
Basically falls under three modalities
•Dietary modifications
•Drug therapy
•Surgery
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26. DIETARY MODIFICATION
Encourage patient
•to eat bland diet –avoid spices :red
and black pepper, hot chilli they
stimulate gastric secretion
•to avoid food that causes discomfort
and over distension of the stomach
•to avoid over eating –eat small
frequent meals
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27. DIETARY MODIFICATION
•to eat slowly and chew thoroughly to
prevent over distension and reflux.
•avoid caffeine containing beverages
coffee, tea, cola, beer and chocolate
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28. Drug therapy
•ANTACIDSlike magnesium trisilicate
250 –500mg chewed 8 hourly to
relieve symptoms
H2-RECEPTOR ANTAGONISTS
•eg. Cimetidine200mg tds(400mg –
800mg at bed time) to inhibit the
action of histamine on the parietal cells
thereby inhibiting the secretion of
gastric acids.
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29. Drug therapy
•PROTON PUMP INHIBITORS
•Inhibit secretion of hydrogen ions in
gastric lumen.
•relieves pain and heals peptic ulcers
more rapidly than H2 receptor
antagonists.
Eg. Omeprazole 20mg orally QID for
4 to 6 weeks
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30. Drug therapy
•ANTIBIOTICSto combat
helicobacter pylori, the underlying
cause for peptic ulcers.
•One or more antibiotics, and a drug
to reduce or neutralize gastric acids.
•eg. Metronidazole, 200mg -800mg tds
•or Amoxicillin 250mg –500mg tds
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31. SURGERY
Indications:
•failure of medical treatment.
•Complications like perforation, pyloric
stenosis & haemorrhage.
•Potential malignant lesions.
•Chronic recurring ulcers.
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32. Surgical intervention can be employed such as:
•Vagotomy-resection of the vagusnerve to
inhibit vagal stimulation in order to decrease
gastric motility and secretions.
•Gastrectomy-removal of the stomach.
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33. •Partial gastrectomy (BillrothI) –part of the
stomach affected by an ulcer is removed with
part of the pylorus and the stomach connected to
the duodenum.
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34. •Gastro-jejunostomy (BillrothII) –pyloric
area, duodenum and part of the stomach are
removed with the remaining stomach being
connected to the jejunum.
•Total gastrectomy –complete removal of the
stomach with anastomosis of oesophagus to the
jejunum in multiple ulcers.
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35. Surgical interventions ctnued
•Subtotal Gastrectomy is the
surgical removal of 60 –80% of the
stomach.
•Pyloroplasty-enlarges pylorus by
removing sphincter
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36. Surgical interventions ctnued
•Antrectomy; removal of the entire antrum of the
stomach to reduce acid secretion portion of the
stomach.
•Oesophagojejunostomyis a surgical procedure
involving the anastomosis of the inferior part of the
oesophagusto the jejunum.
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37. •Sleeve gastrectomy (vertical sleeve
gastrectomy and stomach stapling) is the removal
of a large part of the stomach to help with weight
loss. The surgeon uses staples to create a smaller
stomach and attaches the small intestine to the
remaining stomach
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40. PRE-OPERATIVE CARE
•Surgery is generally classified as elective or
emergency.
•ELECTIVE SURGERY
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41. PSYCHOLOGICAL CARE
•The condition is explained to the patient that surgery
intervention is the one only treatment for example in
the case of pyloric stenosis after endoscopy or barium
meal.
•The patient is explained to that Pyloric stenosis from
fibrous tissue results in partial or complete obstruction
of the gastric outlet.
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42. •Signs such as abdominal distension and projectile
vomiting may present hence the need for surgery.
All questions should be answered to allay anxiety
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43. CONSENT FORM
•After the patient has comprehended fully what is
being consented to, the patient writes his/ her
full names and other particulars, signs at the end
and the nurse counter signs. In case the patient
doesn’t know how to write, a thumb print is legal
and the nurse may finish off filling the consent
form.
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44. NUTRITION
•Prior to surgery, the patient should fast for 4hours
for fluids and 6hours for food.
•From the point of induction of anesthesia, stomach
contents may reflux and be inhaled through the
open larynx into the lungs causing Mendelsohn’s
Syndrome (Aspiration Pneumonia).
•An intravenous infusion of 5% Dextrose or Dextrose
Saline can be given for nutrition and hydration.
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45. HYGIENE
•The patient is asked to shower several hours
prior to theatre with soap and water and to dress
in a clean theatre gown to reduce post-operative
infections and exposure to nosocomial infections.
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46. IDENTIFICATON BAND
•A name band is written bearing patients name,
age, sex, type of procedure and ward. This is
important for identification and avoid perform a
different operation
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47. SPECIMEN
•Venous blood for hemoglobin, grouping and cross
match is collected and 2 pints of whole blood
collected in advance from the laboratory in
advance in case of severe bleeding.
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48. ELIMINATION
•The patient is catheterized prior surgery with a
urethral indwelling catheter.
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49. Observation
•The general condition of patient is
reviewed from head to toe and vital
signs checked.
•The general condition should be good
before surgery and vital signs should
be within normal range.
•Documentation is done afterwards
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50. •Pre Medication
•After the anesthetist has reviewed the patient,
•Diazepam 5mg stat is prescribed and given prior
surgery by the nurse and documented on the
drug chart.
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51. POST OPERATIVE CARE
•On patients return to the ward, the nurse will
monitor and/ observe for:
•Airway, blood pressure and pulse
•The nasogastric aspirate
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52. •Bleeding and drainage from the wound
•Skin color
•The intravenous infusion and site
•Urinary out put
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53. position
•From theatre, the patient is nursed on lateral
position and position changed 2 hourly to
prevent pressure sores and promote comfort.
•On the second day, patient is nursed in an
upright position.
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54. Observations
•Vital signs are done ¼ hourly, immediately after
an operation.
•Then changed to 1/2hourly, 2 hourly until
condition stabilizes.
•The dressing on the incision site is checked for any
bleeding.
•Any abnormality should be reported immediately
to the doctor.
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55. Environment
•The environment should be quite to promote rest
and clean to prevent infections
•The patient is nursed in acute bay immediately
after surgery.
•When condition stabilizes he /she is put in
another bay.
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56. Psychological care
•Patient’s questions are answered to allay anxiety
and procedures before being done should be
explained and feedback given afterwards.
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57. Exercises
•Patient is encouraged to mobilize in bed and
walking around to prevent Deep Vein Thrombosis
and deep breathing frequently until ambulating
well
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58. Medication
•strong analgesia such as Pethidine50-100mg
QID intramuscularly is given to relieve pain.
•Antibiotics are given to combat infection and
other drugs are given as prescribed and
documented.
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59. Nutrition
•The patient will be nil orally until bowel sounds
are heard by the patient and confirmed by the
nurse or the doctor. Initially, the patients will be
on intravenous fluid 3litres in 24hours.When
bowels return, sips of water will be given first,
free fluids, soups, porridge, semi-solid foods and
later normal diet.
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60. Wound care
•The nurse should observe aseptic technique
during wound dressing to prevent infection.
•The patient is advised to hold at the operation
site when coughing to prevent gaping of the
wound.
•Wound dressing is changed as ordered, suture
line swabbed with spirit, dressing changed and
sutures removed as ordered.
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61. Elimination
•The patient will have a urethral indwelling
catheter and catheter toilet is done once or twice
a day.
•Urine output is recorded amount and color
before discarding.
•By third day post operatively, it’s removed to
prevent ascending infections.
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62. Complications of peptic ulcers
(i)Perforated peptic ulcers
•This is the breaking through of the wall of the
stomach or the duodenum
s/s
Sudden severe abdominal pain radiating to one or
both shoulders usually the right due to subphrenic
irritation
Haemetemesis –vomiting blood due to ruptured
blood vessel along the perforation
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63. Perforated peptic ulcers ctnued
malaena–blood in stool
s/s of shock due to excess blood loss
Rigid abdomen with occasional silent bowel
sounds
Pelvic tenderness on rectal examination
Mgmt
Emergency surgery
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64. (ii) Peritonitis
inflammation of the peritoneum following
seepage of gastric contents into the peritoneal
cavity through perforated viscera.
s/s
Rebound tenderness and abdrigidity
Severe abdpain radiating to the tip of shoulder
fever
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65. mgmt
antibiotic cover
Emergency surgery
(iii) Pyloric stenosis–constriction of the pyloric sphincter
due to hypertrophy and fibrotic scarring of ulcers
s/s
Profuse vomiting, constipation
Electrolyte imbalance, weight loss
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66. Mgmt–surgery: pyloroplasty
(iv) Haemorrhage–bleeding of peptic ulcers
due to ruptured blood vessels
s/s–haemetemesis, malaenas/s shock
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67. Mgmt
BT
Vit k
NGT
if severe ;surgery
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68. (v) intractability
failure to heal by medical
management
Common for posterior ulcer which
may penetrate the pancreas
s/s-persistent pain without adequate
relief from milk or anti acids.
Mgmt -surgery : vagotomyor gastric
resection
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69. (vi) Malnutrition
•altered nutritional status marked by
weight loss especially in gastric ulcers
where food intake aggravates pain
mgmt
Small frequent nutritious meals
Drugs before and after meals to
relieve pain
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70. ( vii) Intestinal obstruction
May result from inflammation,
oedema or scarring of gastric outlet.
s/s
Vomiting faecal like matter ,abd
distension
Mgmt–surgery
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71. Information Education & Communication
Diet–bland diet : spice free
avoid caffeine containing beverages. Encourage
milk in btn meals to reduce gastric secretion
Drug therapy –adhere to treatment even when
pain stops. Avoid unprescribeddrugs which may
worsen the condition
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72. Information Education & Communication ctnued
•Life style change
Avoid alcohol intake and /or smoking –delays
healing.
Follow up care –encourage reviews as per
appointment to monitor response to treatment .
In case of pain worsening or haemetemesis to
report immediately.
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