Management of Patient with Peptic Ulcer Disease PDF

Management of patient with Peptic Ulcer Disease  Peptic Ulcer A peptic ulcer is an excavation found in the mucosal wall of the oesophagus, the stomach, in the pylorus, or in the duodenum due to the erosion of a circumscribed area of its mucous membrane. ...

Management of patient with Peptic Ulcer Disease  Peptic Ulcer A peptic ulcer is an excavation found in the mucosal wall of the oesophagus, the stomach, in the pylorus, or in the duodenum due to the erosion of a circumscribed area of its mucous membrane.  Types of Peptic Ulcer There are three different types of peptic ulcers. Esophageal Ulcers: These are open sores or lesions, which form in the lining of the esophagus. Gastric Ulcers: These are the ulcers, which form in the lining of the stomach. Duodenal Ulcers: These ulcers form in the upper part of the small intestine, an area known as duodenum.  Pathophysiology of Peptic Ulcer Acid secretion is controlled by gastrin endocrine, neural, and Acid secretion acetylcholine panacrine factor histamine 100nm thick layer of gel Mucosal defenses (mucosa,Tunica mascularies, Serosa) like mucus 95% water mucosa secrete bicarbonate help maintain pH. &5% glycoprotein Effects of H. pylori: (production urease, neutral gastric acid and toxic effect of mucosal in epithelial cell Effects of NSAIDs: mucosal irritant and inflammation inhibition of cyclooxygenase (COX) an enzyme need to production of prostaglandins Maintain normal mucosa defense.  Causes and Risk factors Helicobacter pylori (H. pylori) infection Use of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Zollinger-Ellison syndrome : (gastrinoma): gastrin-producing-tumor in pancreas Severe stress such as surgery, trauma, head injury or burns Cigarette smoking Excessive alcohol intake Aging (older age) Pain 1. Types: a. Pain or discomfort - sharply localized in midepigastrium. b. Heartburn (substernal burning). c. Pain may radiate to the back if the Duodenal Ulcer has begun. 2. Time of occurrence: a. Pain is worst when stomach is empty - usual 30 minutes to 2 hours after meals; it may waken patient in early a.m. hours (12 midnight - 3 A.M.). b. Pain is seldom present when patient first wakens, because gastric secretion is lowest at this time. c. Periodicity occurs in clusters - patient may have trouble for days to weeks. 3. Relief: Obtained by food or antacids - if truly effective, this occurs within 5 - 10 minutes. Nausea and Vomiting: Reflex vomiting occurs in 10 - 20% of patients; it is associated with ulcer pain, also seen with duodenal obstruction in chronic ulcer disease when it usually occurs with or just after evening meal. Belching: Belching is due to increased air swallowing. Heartburn (Pyrosis):This is burning sensation in lower oesophagus and just below the sternum.  ▪Urea breath test ▪Stool Test: for H. pylori H. Pylori ▪Biopsy ▪Upper GI series (barium swallow) Diagnostic Tests ▪Esophago-gastro-duodeno-scopy(EGDS) Peptic ulcer ▪Upper gastrointestinal X-ray (GI X-ray) ▪Gastric secretory studies: are of value mainly to check for Zollinger-Ellison syndrome.  Peptic Ulcer complication Haemorrhage Perforation Pyloric Obstruction Intractability Shock Peritonitis Dehydration Incapacitation Surgery Therapeutic Measures ✓ Antibiotics: Amoxicillin (Amoxil), clarithromycin (Biaxin) ✓Proton pump inhibitors (PPIs): are powerful agents that stop the final step of gastric acid secretion to reduce mucosa erosion. ✓H2 antagonists or histamine antagonists are drugs designed to block the action of histamine on gastric cells and reduce acid production in the stomach. ✓Antacids: neutralize the acid present in the stomach ✓Bland diet (soft food) not spicy. ✓Avoiding irritants, such as smoking, caffeine, alcohol, trigger foods  Gastric Cancer Gastric cancer refers to malignant lesions found in the stomach. It is more common in men than in women. H. pylori infection plays a role in gastric cancer development. Other factors that may be associated with gastric cancer development include pernicious anemia; exposure to occupational substances such as lead A poor prognosis is often associated with gastric cancer because most patients have metastasis at the time of diagnosis.  Signs and Symptoms: Rarely detected during early stages, symptoms often mistaken for PUD: indigestion, anorexia, pain, weight loss, nausea, vomiting, anemia Late symptoms include involvement of other organs such as the liver. Diagnostic Tests X-ray studies Gastroscopy Gastric fluid analysis (NG Tube) Therapeutic Measures : Medical treatment not very effective Surgical treatment: subtotal or total Gastrectomy. Complications : Related to disease and surgery: hemorrhage, acute gastric distention, nutritional problems subtotal Gastrectomy  Gastric Bleeding Gastric bleeding may be caused by ulcer perforation, tumors, gastric surgery, or other conditions. Bleeding is the most common cause of blood loss into the stomach or intestine. GASTRIC BLEEDING SUMMARY Signs and Occult blood in stool Symptoms Hematemesis Melena Hypovolemic shock Diagnostic Endoscopy Tests Low hemoglobin and hematocrit Therapeutic Measures Treat hypovolemic shock: NPO (nothing by mouth), IV fluids, oxygen therapy, nasogastric tube Removal or ligation of bleeding area Medications to decrease gastric acid Complications Hypovolemic shock Disorders of lower GI tract  Appendicitis Acute appendicitis is an inflammation of the appendix due to an infection. It is almost always a surgical problem. Incidence: Occurs most frequently in young adults but may occur in any age group. Appendix is small fingerlike 10cm(4 inch). Acute appendicitis result from obstruction narrow lumen of the appendix most often with a fecalith (hardened feces) or foreign body. Clinical Manifestation of Appendicitis Begins with a progressively severe abdominal pain, beginning in midabdomen (periumbilical) and moving to right lower quadrant. Within a few hours, the acute tenderness becomes localized in the right lower quadrant (McBurney’s point). Anorexia Slight or moderate temperature elevation, Mild change in bowel habit (usually constipation) Nausea and vomiting Diagnosis 1. Physical examination, noting especially location and localization of pain, rebound tenderness, etc. 2. Blood studies with particular attention to white blood cell count; urinalysis. A white blood count reveals a moderate leukocytcisis. 3. Careful history to rule out other possibilities. Complications ❖If perforation occurs (pain is severe, and temperature is elevated. ❖Abscess of the appendix(separated from the peritoneal cavity). ❖ Peritonitis are major complications of appendicitis. With perforation  Treatment and Nursing Management Palliative Preoperative Care: 1. Place patient in comfortable position to relieve abdominal pain and tension - usually upright position. 2. See that patient takes nothing by mouth - to decrease peristalsis and to allow stomach to empty preparatory to surgery. 3. Place ice bag to right lower quadrant - NEVER HEAT because of the possibility of causing a rupture of the appendix and peritonitis. 4. Frequently evaluate vital signs - to assess progression of infection. 5. When diagnosis of acute appendicitis is made, administer antibiotics. Operative Care: : If diagnosis of acute appendicitis is established, a simple appendectomy is performed. NOTE: If there is evidence that perforation has occurred recently and a generalized peritonitis has developed, operative urgency is increased.  Peritonitis Peritonitis: is an inflammation of the peritoneal cavity. Etiology: 1. Bacterial infections caused by E. Coli, Proteus, Pseudomonas 2. Trauma: Secondary peritonitis comes from external sources by injury or by extension of inflammation from an extraperitoneal organ. Example - Inflammation of the kidney. 3. Appendicitis 4. Perforated Ulcers 5. Diverticulitis 6. Bowel Perforation 7. Peritonitis may be associated with abdominal trauma, operative procedures and peritoneal dialysis.  Types of Peritonitis 1. Primary Peritonitis: Occurs primarily in young females; often due to pathogenic bacteria (streptococci, gonococci) introduced through the fallopian. 2. Secondary Peritonitis: Caused by appendicitis, peptic ulceration, biliary tract disease and colonic inflammation. May occur following trauma such as gunshot wound, stab wounds and motor vehicle accidents.  common signs Pain that increases with movement Rebound tenderness Signs of paralytic ileus (abdominal distention, absent bowel signs) Rigidity of the abdomen and abdominal tenderness  Peritonitis Cont… Diagnostic test 1. Blood studies - Elevated WBC count 2. Urine analysis - May indicate urinary tract problems 3. Peritoneal aspiration - To check the presence of blood, pus, bile. bacteria, amylase, etc. in the peritoneal fluid 4. Cultures of peritoneal fluid 5. Abdominal x-ray  Peritonitis Cont… Management: 1. Fluid, colloid and electrolyte replacement 2. NGT intubation and suction 3. Oxygen therapy 4. Antibiotics 5. Surgery- Directed toward excision (appendicitis), resection with or without anastomosis (intestines), repair (perforation) and drainage (abscess).  Diverticulosis and Diverticulitis A Diverticulum is a herniation or outpouching of the bowel mucous membrane caused by increased pressure within the colon and weakness in the bowel wall. Diverticulosis: is a condition in which multiple diverticula are present without evidence of inflammation. Many people have diverticulosis without knowing it because it develops gradually. When bacteria are trapped in a diverticulum, inflammation and infection develop. This is called diverticulitis.  Signs and Symptoms oThe patient is generally asymptomatic, the patient exhibits bowel changes, lead to constipation o Crampy pain is the most common symptom. oAs the condition worsens, bleeding may occur, along with weakness, fever, tenderness, fatigue, and anemia leading to peritonitis. Diagnostic Tests Colonoscopy Barium enema may show irregular narrowing of the colon and thickened muscle walls. A stool specimen may show occult blood. An abdominal X-ray examination to identify a perforated diverticulum. Etiology oChronic constipation: oDecreased intake of dietary fiber. oPeople older than age 60 Prevention and Therapeutic Measures ✓Increasing dietary fiber to prevent constipation ✓ In sever case hospitalized for administration of IV antibiotics ✓Pain control ✓An NG tube, IV fluids ✓NPO status may be ordered until, nausea or vomiting  Crohn’s Disease Crohn’s disease is an inflammatory bowel disease (IBD) that can involve any part of the GI tract but most commonly affects the terminal portion of the ileum, or first part of the large intestine. The inflammation extends through the intestinal mucosa, which leads to the formation of abscesses, fistulas (abnormal connections between structures), and fissures (unnatural tracts or ulcers).  Ulcerative Colitis ??? Definition: Ulcerative Colitis is an inflammatory disease of mucosa and less frequently, the submucosal of the colon and rectum.  Ulcerative Colitis Etiology and Incidence: 1. Unknown (idiopathic) a. Emotional response alters blood supply to colon mucosa which eventually causes ulceration. b. Unidentifiable organisms cause pathology. c. A combination of causative factors: infection, stress, allergy, autoimmunity. 2. Most common in young adulthood and middle life; almost equal been sexes, more prevalent among Jews  Ulcerative Colitis Clinical Manifestations: 1. Bloody diarrhoea, tenesmus (painful straining), sense of urgency and cramping. 2. Multiple crypt abscesses of intestinal mucosa that may become necrotic and lead to ulceration. 3. There often is weight loss, fever, dehydration, hypokalaemia, anorexia, nausea and vomiting, iron- deficiency anaemia and cachexia (extreme weight loss). Diagnostic Evaluation: 1. Stool examination to rule out bacillary dysentery or ameobic dysentery 2. Sigmoidoscopy 3. Barium enema and x-ray NOTE: lf disease is in acute stage, laxatives may be contraindicated because it may cause exacerbation and lead to toxic megacolon. 4. Review of nursing history for patterns of fatigue and overwork. 5. Assessment of behavioral manifestations indicative of emotional concerns. 6. Assessment of food habits that may have a bearing on triggering symptoms (milk intake may be a problem). 7. Careful clinical assessment to rule out diverticulitis, cancer, etc.  Complications 1 Skin ulcers 6. Anal fistula 2. Bowel obstruction 7. Electrolyte imbalance 3. Malnutrition 8. hemorrhage 4. Anemia 9. Malignancy (colonic cancer) 5. Abscess formation 10. Peritonitis Medical Management of Inflammatory Bowel Disorders ▪ High-protein diets with supplemental vitamin therapy and iron replacement are effective in meeting nutritional needs. ▪Fluid and electrolyte imbalance due to dehydration caused by diarrhea is corrected by intravenous therapy. ▪Any foods that exacerbate diarrhea should be avoided. ▪In addition, cold foods are to be avoided, along with smoking, because both increase intestinal motility. ▪Total parenteral nutrition may be indicated. ▪Sedative and antidiarrheal/antiperistaltic medications are used to reduce to a minimum the colonic peristalsis to rest the inflamed bowel. ▪Antibiotics are used for secondary infections Surgical Management of Inflammatory Bowel Disorder The surgical procedures of choice are the following: ✓ Segmental colectomy (removal of a segment of the colon) with anastomosis (joining of the remaining portions of the colon). ✓Subtotal colectomy (removal of nearly all of the colon) with ileorectal anastomosis (joining of the ileum and rectum). ✓Total colectomy (excision of the entire colon).  Nursing Process of Patient with gastric disorders Assessment: Assess for health history: a. Pain, character, degree, time related to meal, relieved by antacid. b. Nausea /Vomiting; color bright red or coffee ground. c. Melena d. Food habits e. Smoking, stress f. Weight loss, anorexia g. Family history of gastric disease h. Assess vital signs for indicators of anemia i. Physical examination is performed, palpated abdominal for tenderness. Nursing Diagnoses: 1. Pain, related to the effect of gastric acid secretion on damaged tissue. 2. Anxiety, related to coping with an acute disease. Planning and Implementation - Goals: 1. Relief of pain. 2. Reduction of anxiety. Nursing Interventions 1. Relief of pain: a. Administer medication as prescribed (Anticholinergics, histamine antagonists, antacids). b. Avoid aspirin and foods and beverages that contain caffeine (cola, tea). c. The patient is encouraged to learn relaxation techniques to help him cope with stress and pain and to stop smoking. d. Regularity spaced meals are encouraged in a relax atmosphere. 2. Reduction of anxiety: a. The nurse should assess what the patient wants to know about his disease. b. The patient is allowed to express his fears openly and without criticism. c. Explanation about diagnostic tests and medication intake, should be done. d. The nurse interacts with the patient in a relaxing manner. e. The nurse encourages the participation of the patient’s family in his care  Evaluation: Expected Outcomes: 1. Experiences no pain: a. is free of pain between meals. b. Uses antacids as prescribed. c. Avoid foods and fluids that cause pain. d. Eats meals at regular times. e. No side effects of antacids (diarrhea or constipation). 2. Experiences less anxiety a. Identifies situation that produce stress. b. Identify life-style adjustments. c. Involves family in decisions regarding life-style adjustments. d. Uses sedative and tranquilizers as prescribed.