peptic ulcer.pdf

 Outlines Peptic Ulcer Definition of peptic ulcer. Types of peptic ulcer. Classifications of peptic ulcer. Causes and risks for peptic ulcer. Clinical manifestations. Comparing gastric and duodenal ulcer Diagnostic studies....

 Outlines Peptic Ulcer Definition of peptic ulcer. Types of peptic ulcer. Classifications of peptic ulcer. Causes and risks for peptic ulcer. Clinical manifestations. Comparing gastric and duodenal ulcer Diagnostic studies. Complications. Medical management, dietary management Nursing process  The stomach is divided into 5 regions: 1. The cardia is the first part of the stomach 2. The fundus is the rounded 2 area that lies to the left of 1 the cardia 3. The body is the largest and main part of the stomach. 3 4. The antrum is the lower 5 part of the stomach 5. The pylorus is the part of 4 the stomach that connects to the small intestine  Peptic ulcer (Gastric & duodenal) Peptic ulcer disease (PUD) is a break in the continuity of the esophageal, gastric, or duodenal mucosa. PUD occurs in any part of gastrointestinal (GI) tract that comes in contact with hydrochloric acid (HCL) and pepsin (powerful enzyme in gastric juice that digest protein.  Locations of peptic ulcer Stomach (called gastric ulcer) Duodenum (called duodenal ulcer) Esophagus (called esophageal ulcer)  function of the stomach The main function of the stomach is to mix the food with acid, mucus and pepsin and then release the resulting chyme (semifluid mass of partly digest food expelled from stomach into duodenum (first section of small intestine, at a controlled rate into the duodenum to start absorption process Other functions of the stomach include the secretion of intrinsic factor (glycoprotine) necessary for the absorption of vitamin B12.  Causes of peptic ulcer 1- chronic inflammation with Helicobacter pylori; A major causative factor (60% of gastric and up to 90% of duodenal ulcers) It is a spiral-shaped bacterium that lives in the acidic environment of the stomach.  Causes of peptic ulcer H-pylori can cause a chronic active gastritis resulting in a defect in the regulation of gastrin (main stimulant of gastric acid secretion) production which stimulates the production of gastric acid that lead to the increase in acid which can contribute to the erosion of the mucosa and therefore ulcer formation.  Causes of peptic ulcer 2. Emotional stress. 3. drugs can cause or worsen ulcer such as Aspirin and other NSAIDs. 4. cigarettes Smoking and alcohol which increase HCL secretion. 5. Overuse of laxatives is also known to cause peptic ulcers.(side effect) 6. A family history is often present in duodenal ulcers, especially when blood group O is present, enhancing binding of H-pylori to epithelial cell.  Clinical manifestations Abdominal pain, epigastric pain with severity relating to mealtimes, the timing of the symptoms in relation to the meal may differentiate between gastric and duodenal ulcers: A gastric ulcer would give epigastric pain during the meal, as gastric acid is secreted. Duodenal ulcers are relieved by food, while gastric ulcers are exacerbated by it.  Water brash (increased saliva secretion after an episode of regurgitation to dilute the acid in esophagus). Nausea and vomiting Loss or increase appetite and weight loss or gain Hematemesis (vomiting of blood); due to bleeding directly from a gastric ulcer, or from damage to the esophagus from severe/continuing vomiting or melena (tarry, foul-smelling feces due to oxidized iron from hemoglobin) Constipation or diarrhea may occur  Comparison between duodenal ulcer & Gastric ulcer Feature Duodenal Gastric Incidence Age: 30 – 60 years Usually 50 and over - It is most common in 80% of - 15% of cases. cases. Signs and symptoms - Hyper-secretion of HCL -Normal or hypo-secretion of HCL - weight gain. - weight loss - Pain occurs 2-3 hours after -Pain occurs after 0.5-1 hour after meal, often awakened between eating. Rarely occur at night. 1-2 am. - Ingestion of food relieves pain. - ingestion of food increase pain. - Vomiting is uncommon - Vomiting is common - Hematemesis less, but melena - Hemorrhage more likely to occur. more common. Hematemesis more than melena. - perforation is common -More difficult to control medically. Pain relieved by Frequent meals Vomiting. ingestion of food does not help but sometimes increase it Malignancy possibility rarely Occasional  Diagnosis: 1- An esophagogastroduodenoscopy (EGD), a form of endoscope, gastroscopy, is used for direct visual identification for location and severity of an ulcer. Moreover, if no ulcer is present, EGD can often provide an alternative diagnosis. 2- The diagnosis of Helicobacter pylori can be made by: A. Direct culture from an EGD biopsy specimen; this is difficult to do, and can be expensive. B. Measurement of antibody levels in blood (does not require EGD). C. Stool antigen test for H pylori.  Medical management antacids (neuterilize action effect of HCL or an H2 antagonist (Zantac) that block histamine receptors, so decrease production of HCL. Avoid taking Non-steroidal anti-inflammatory Bismuth compounds may actually reduce or even clear organisms.  When H. pylori infection is present, the most effective treatments are combinations of 2 antibiotics (e.g., Amoxicillin (Amoxil), Metronidazole (Flagel) and 1 proton pump inhibitors (PPIs), sometimes together with a bismuth compound. N.B: PPIs action is decrease acid secretion of the stomach. e.g. Omeprazole, Lansoprazol, Pantoprazole.  In complicated, or resistant cases, 3 antibiotics e.g. (Clarithromycin + Amoxicillin + Metronidazole) used together with a PPIs and with bismuth compound. In the absence of H. pylori, long-term higher dose PPIs is often used. surgical procedures (vagotomy) (cut off vagus nerve which is responsible for stimulation of stomach to release acid)  Dietary modification To avoid over secretion of acid and hypermotility in GIT by: Avoiding extreme temperature Avoiding consumption of alcohol, coffee, and smoking and other caffeinated beverage (drinks) like cola and tea and diet rich in milk and cream. Regular eating pattern to neutralize acid by Small frequent feeding. Eat foods that can be tolerated and avoids those that produce pain.  Complications 1- Gastrointestinal bleeding: Is the most common complication. Sudden large bleeding can be life threatening. It occurs when the ulcer erodes one of the blood vessels. 2- Perforation (a hole in the wall). Erosion of the gastro-intestinal wall by the ulcer leads to spillage of stomach or intestinal content into abdominal cavity. Often first sign is sudden intense pain in the mid epigastric region and spread over the entire abdomen. Perforation at the anterior surface of stomach leads to acute peritonitis. Posterior wall perforation leads to pancreatitis.  The abdomen is tender, rigid, and board-like. The client assumes the knee-chest position in an attempt to decrease the tension on the abdominal muscles. ↓ Peristalsis, and paralytic ileus develops 3-Penetration is when the ulcer continues into adjacent organs such as liver and pancreas. 4- Scarring and swelling due to ulcers causes narrowing in the duodenum and gastric outlet obstruction. Patient often presents with severe vomiting. Nursing management Nursing process I-Assessment Ask the patient to describe the pain and methods used to relieve it. Ask patient to list his/ her usual food intake for 72 hours to describe food habits as speed of eating, regularity of meals preference, use of spicy foods, and caffeinated beverages; tea &coffee. Assess vital signs and report tachycardia and hypotension as they indicate anemia from GIT bleeding. The stool is tested for occult blood.  II-Nursing diagnosis Acute Pain R/T effect of gastric acid secretion of damaged tissue. 1. Relieve pain Administer medication as prescribed. Avoid aspirin, foods and beverages that contain caffeine as coffee and tea. Teach patient to practice relaxation techniques Follow regular meals.  Imbalanced nutrition R\T changes in diet The nurse assess the patient for malnutrition &weight loss After recovery from acute phase of peptic ulcer disease, the patient is advised about the importance of complying with the medication regimen and dietary instructions e.g Avoiding extreme temperature or over stimulation from consumption of meat extracts, alcohol, coffee, and smoking and other caffeinated beverage like coffee and tea and diet rich in milk and cream. Regular eating pattern to neutralize acid in Small frequent meals. Eat foods that can be tolerated and avoids those that produce pain anxiety R\T decreased coping with disease Reduce Anxiety – assess patient’s knowledge about the disease – Allow patient to express fear. – Explain diagnosis, treatment & medication. – Encourage the family to participate in patient care and emotional support.  Knowledge deficit R\T prevention of symptoms and management patient teaching Instruct patient about importance of continuing taking medication even after S&S have decreased. Instruct patient to avoid certain medications and foods that increase S&S. Instruct patient about eating diet at regular times. Avoid smoking Rest and stress reduction. Awareness of complications Follow up care  Risk for hemorrhage related to disease process Monitoring and managing potential complications Hemorrhage is the most common complication. It occurs in about 15% of patients. It may be manifested by Hematemesis or Melena. The vomited blood may be bright red or it can have a coffee ground appearance (dark) resulting from the oxidation of hemoglobin  The nurse should assess patient for bleeding as dizziness, nausea which may precedes (come first) bleeding, monitor vital signs, and monitor hemoglobin and hematocrit level and record hourly urinary output to detect anuria or oliguria  Hemorrhage Management Rapidly replace the blood lost. stopping the bleeding and stabilize the patient Infusion of saline or lactated ringers and blood product insert NG tube to remove blood clot and acid, prevent nausea and vomiting Insert urinary catheter to monitor urinary out put Administer O2 therapy. Place patient in recumbent position with legs elevated to prevent hypotension place patient on the left side to prevent aspiration from vomiting.