Medical Management of H pylori Infection

Peptic Ulcer Disease (PUD)

• A peptic ulcer is an excavation (hollowed-out area) that forms in the mucosal wall due to erosion of the GI mucosa, resulting from the digestive action of HCl acid and pepsin.

Types of PUD

• Acute PUD: characterized by superficial erosion, minimal inflammation, and short duration; resolves quickly when the cause is identified and removed.
• Chronic PUD: characterized by muscular wall erosion with formation of fibrous tissue, long duration, and present continuously for many months or intermittently; 4 times as common as acute erosion.

Pathophysiology

• Causes of erosion: increased concentration or activity of HCl-pepsin or decreased resistance of gastric mucosa.
• Patients with duodenal ulcer secrete more acid, while those with gastric ulcer secrete normal or decreased levels of acid.

Etiology and Pathophysiology

• Stomach protective mechanisms: gastric mucosal barrier, mucus secretion, and bicarbonate secretion.
• Impaired mucosal barrier leads to cellular destruction and inflammation.
• Risk/predisposing factors: smoking, alcohol, stress, eating habits, familial tendency, people with blood type O, milk and caffeinated beverages, chronic use of NSAIDs, aspirin, corticosteroids, cytotoxic drugs, and Helicobacter pylori infection.

Gastric Ulcers

• Occur in any portion of the stomach, with normal or hyposecretion of gastric acid (HCl).
• Weight loss may occur, and pain occurs 1/2 to 1 hour after a meal, which may be relieved by vomiting; ingestion of food does not help and may increase pain.
• Vomiting is common, and hemorrhage is more likely to occur than with duodenal ulcer.

Duodenal Ulcers

• Account for ~80% of all peptic ulcers, with a familial tendency (people with blood group O have an increased risk).
• Associated with increased HCl acid secretion, and H. pylori is found in 90% to 95% of patients, but not all individuals with H. pylori develop ulcers.
• Vomiting is uncommon, and hemorrhage is less likely than with gastric ulcer, but if present, melena is more common than hematemesis; more likely to perforate than gastric ulcers.

Clinical Manifestations

• Symptoms may last for a few days, weeks, or months and may disappear then reappear.
• Many people with ulcers have no symptoms; perforation or hemorrhage may occur in 20%-30% of patients who had no preceding manifestations.
• Dull, gnawing pain or burning sensation in the midepigastrium or back, which is relieved by eating or taking antacids.

Medical Management

• Conservative therapy consists of adequate rest, dietary modification, drug therapy, elimination of smoking and alcohol, and stress management.
• Pharmacologic therapy includes triple therapy (2 antibiotics and a proton pump inhibitor) or quadruple therapy (2 antibiotics, proton pump inhibitor, and bismuth salts) for 10 to 14 days to treat H. pylori infection.

Surgical Therapy

• Surgical procedures: vagotomy (totally or partially) with or without pyloroplasty, performed to reduce gastric acid secretion, and done in conjunction with gastrectomy; pyloroplasty: increases gastric emptying.

Nursing Care Plan

• Assessment: pain and methods used to relieve it, vomiting, food habits, lifestyle habits, use of irritating substances, smoking, alcohol, NSAIDs, anxiety, stress, family history of ulcer disease.