Ch_37_Peptic_Ulcers1 2024.pdf

Peptic ulcer disease ch 37 Raed Shudifat Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peptic Ulcer Disease (PUD)  Ulcer : excavation (hollowed-out area) forms in mucosal wall  Due to Erosion of GI mucosa  R...

Peptic ulcer disease ch 37 Raed Shudifat Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peptic Ulcer Disease (PUD)  Ulcer : excavation (hollowed-out area) forms in mucosal wall  Due to Erosion of GI mucosa  Result from digestive action of HCl acid and pepsin Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of PUD Location  Lower esophagus ( due to GERD).  Stomach  Duodenum ( more than Stomach)  As a rule they occur alone, but they may occur in multiples  Acute or chronic  Depends on degree/duration of mucosal involvement Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of PUD  Acute  Superficial erosion  Minimal inflammation  Short duration  Resolves quickly when cause identified and removed Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of PUD  Chronic  Muscular wall erosion with formation of fibrous tissue  Long duration—present continuously for many months or intermittently  4 times as common as acute erosion Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Types of PUD Fig. 42-11 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peptic ulcer disease  More in people 40- 60 years  Uncommon in women of childbearing age  Observed in children and infants. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pathophysiology  Causes of Erosion Increase concentration or activity of HCL- pepsin, or Decrease resistance of gastric mucosa.  Patients with duodenal ulcer secrete more acid.  patients with gastric ulcer secrete normal or decreased levels of acid. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Etiology and Pathophysiology  Stomach protective mechanisms  gastric mucosal barrier  Mucus secretion  Bicarbonate secretion  impaired Mucosal barrier Cellular destruction and inflammation occur Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Etiology and Pathophysiology  Risk/ Predisposing factors (Destroyers of mucosal barrier)  Smoking  Alcohol  Stress: ↑ Vagal nerve stimulation  Eating habits - spicy foods.  Familial tendency  People with blood type O more susceptible to peptic ulcers than those with blood type A, B, or AB. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Etiology and Pathophysiology  milk and caffeinated beverages  There is an association between peptic ulcers and chronic pulmonary disease or chronic renal disease.  Drugs: Chronic use of NSAIDs, Aspirin Corticosteroids, cytotoxic drugs  Helicobacter pylori infection Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Gastric Ulcers  Occur in any portion of stomach  Normal- hyposecretion of gastric acid (HCl)  Weight loss may occur  Pain occurs 1/2 to 1 hour after meal  Pain may be relieved by vomiting  ingestion of food not help, sometimes increases pain Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Gastric Ulcers  Vomiting common  Hemorrhage more likely to occur than with duodenal ulcer  Hematemesis more common than melena Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Gastric Ulcers Causes  H. pylori  Drugs  Aspirin, NSAIDs, corticosteroids  Chronic alcohol abuse  Chronic gastritis  Smoking  Stress Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Duodenal Ulcers  Account for ~80% of all peptic ulcers  Familial tendency (Person with blood group O ↑ risk)  Associated with increased HCl acid secretion  H. pylori found in 90% to 95% of patients  Not all individuals with H. pylori develop ulcersCopyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Duodenal Ulcers ▪ Vomiting : uncommon ▪ Hemorrhage less likely than with gastric ulcer, but if present, melena more common than hematemesis ▪ More likely to perforate than gastric ulcers Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Duodenal Ulcers Risk Factors  H. pylori  Alcohol  Smoking  liver cirrhosis  stress Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations  Symptoms may last for 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 midepigastrium or in back. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Clinical Manifestations  Pain usually relieved by eating ( food neutralizes acid, or by taking antacid)  Pain occurs about 2 hours after meal and frequently awakens patient between midnight and 3 am.  pain returns when stomach emptied or antacid effect has decreased  Sharp localized tenderness  pyrosis (heartburn)  Vomiting  constipation or diarrhea (probably result of diet and medications)  GI Bleeding (15% of patients with peptic ulcer) melena (tarry stools) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications of chronic PUD  Perforation : Bacterial peritonitis may occur within 6 -12 hours  Hemorrhage  Pyloric obstruction All considered emergency situations  Large perforations: Immediate surgical closure Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Perforation Fig. 42-15 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic studies  Barium study of upper GI tract  Endoscopy with biopsy  Gastric analysis  Stool occult blood.  Blood tests  H. pylori infection (determined by endoscopy and or urea breath test) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Medical Management Goals  Eradicate H. Pylori  Manage gastric acidity.  Relive symptoms Treatment options : Medications Lifestyle changes Surgical intervention. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Medical Management  Generally treated in outpatient clinics  Ulcer healing requires many weeks of therapy  Pain disappears after 3-6 days  Complete healing may take 3 -9 weeks  Aspirin and NSAIDs may be stopped Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Medical Management Conservative therapy consists of  Adequate rest ( physical and emotional )  Dietary modification  Drug therapy  Elimination of smoking and alcohol  Stress management Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Pharmacologic Therapy Treatment of H pylori Infection = combination therapy  Recommended therapy for 10 to 14 days  triple therapy : 2 antibiotics (eg, metronidazole [Flagyl] or amoxicillin [Amoxil] and clarithromycin [Biaxin]) plus a proton pump inhibitor (eg, lansoprazole or omeprazole) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pharmacologic Therapy quadruple therapy:  2 antibiotics (metronidazole [Flagyl] and tetracycline) + proton pump inhibitor +bismuth salts (Pepto- Bismol).  Patient advised to adhere to and complete medication regimen to ensure complete healing of ulcer Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pharmacologic Therapy  Table 37-3 provides information about drug regimens used for peptic ulcer disease.  Table 37-1 presents details about medications that can be used to treat peptic ulcer disease. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Drug Therapy Histamine(H2)Receptors blockers ▪ Famotidine (Pepsid) proton pump inhibitors PPIs ( Examples  Esomeprazole (Nexium)  Omeprazole (Prilosec) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nutritional Therapy Dietary modifications  Avoid or eliminate Food irritating to patient  Avoid extremes of temperature of food and beverage  foods to avoid  Hot, spicy foods and pepper; alcohol; carbonated beverages; tea; coffee; broth, and diets rich in milk and cream (which stimulate acid secretion).  Foods high in roughage may irritate inflamed mucosa (raw fruit, salads, vegetables ) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nutritional Therapy  6 small meals / day during symptomatic phase  Small, frequent feedings not necessary as long as an antacid or a histamine blocker is taken.  Patient eats foods that are tolerated and avoids those that produce pain.  Pt determine suitable combination of foods Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Surgical Therapy  Uncommon because of availability of drugs indications for surgical interventions  Life-threatening hemorrhage  Perforation  Obstruction  Not responding to medical management (fail to heal after 12 to 16 weeks of medical treatment) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Surgical Therapy  Surgical procedures Table 37-4  Billroth I: Gastroduodenostomy  Partial gastrectomy with removal of distal 2/3 of stomach and anastomosis of gastric stump to duodenum  Billroth II: Gastrojejunostomy  Partial gastrectomy with removal of distal 2/3 of stomach and anastomosis of gastric stump to jejunum Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Surgical Therapy A. Billroth I Procedure B. Billroth II Procedure Fig. 42-16 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Surgical Therapy  Surgical procedures  Vagotomy (totally or partially) with or without pyloroplasty  Severing of vagus nerve.  performed to reduce gastric acid secretion  Done in conjunction with gastrectomy  Pyloroplasty : ↑ gastric emptying Incision made into pylorus and sutured to enlarge outlet and relax muscle Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Nursing care plan Assessment  Pain and methods used to relieve it ( eating food, vomiting, taking antacids).  If patient reports a recent history of vomiting, nurse determines how often emesis has occurred and notes important characteristics of vomitus:  Is it bright red, does it resemble coffee grounds, or is there undigested food from previous meals? Has patient noted any bloody or tarry stools? Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Assessment Nurse asks patient about  Usual food intake  Food habits (Speed of eating, regularity of meals, preference for spicy foods, use of seasonings, use of caffeinated beverages).  Lifestyle habits  Use of irritating substances?  Smoke cigarettes?  Alcohol? Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Assessment  Are NSAIDs used?  patient's level of anxiety  perception of current stressors.  How does patient express anger or cope with stressful situations?  Is patient experiencing occupational stress or problems within family?  Is there family history of ulcer disease? Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Assessment  vital signs (report tachycardia and hypotension, which may indicate anemia from GI bleeding)  Stool tested for occult blood  Perform physical examination ( palpation of abdomen for localized tenderness ) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing interventions  Patient education  Disease  Drugs  Lifestyle changes  compliance with plan of care  factors that will relieve and those that will aggravate condition  Smoking Cessation Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing interventions  Relieving Pain  Reducing Anxiety  Maintaining Optimal Nutritional Status  Monitoring and Managing Potential Complications  Hemorrhage  Perforation  Pyloric obstruction Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.