PEPTIC ULCER Pathophysiology Nursing Melba Sahaya Sweety Chinna Chadayan Comprehensive Nursing Pediatric Nursing Child Health Nursing

2.  Peptic ulcer disease (PUD) refers to a group
of ulcerative disorders of the upper GI tract in
which painful sores or ulcers develop in the
lining of the stomach or the duodenum.
 Normally, a thick layer of mucus protects the
stomach lining from the effect of its digestive
juices. But many things can reduce this
protective layer, allowing stomach acid to
damage the tissue.

3. • Peptic ulcer is defined as an
excavation or hole sore that form in
the lining of the stomach, duodenum
(beginning of the small intestine) or
esophagus.
- BRUNNER & SUDDARTH

4. • Peptic ulcer disease may occur in both genders and in
all ages.
• Peptic ulcer disease occurs with the greatest
frequency in people between 40 and 60 years of age.
• 70-90% of stomach ulcers are associated with
Helicobacter pylori a bacterium lived in acidic
environment.
• In Bangladesh the point prevalence rate of Duodenal
ulcer is 11.98% and Gastric Ulcer is 3.58%.

5. Helicobacter pylori: H. pylori damage the mucous coating that protects the
stomach and duodenum.
Salicylates and NSAIDs: Chronic use of NSAID encourages ulcer
formation by inhibiting the secretion of prostaglandins.
Excess HCl: Excessive secretion of HCl in the stomach may contribute to
the formation of peptic ulcers.
Zollinger-Ellison syndrome: It is a rare condition in which one or more
tumors form in the pancreas or the upper part of the small intestine
(duodenum). These tumors, called gastrinomas, secrete large amounts of the
hormone gastrin, which causes stomach to produce too much acid.

6. Various illnesses: Pancreatitis, hepatic disease, Crohn’s disease, and
gastritis, are also known causes.
Blood type: Gastric ulcers tend to strike people with type A blood while
duodenal ulcers tend to afflict people with type O blood.
Smoking : Smoking and nicotine stimulate pepsinogen secretion and
increases bile salt reflux rate and gastric bile salt concentration thereby
increasing duodenogastric reflux that raises the risk of gastric ulcer in
smokers.
Alcohol : excessive alcohol consumption is widely considered to
increase the risk of developing an ulcer.

7. PEPTIC ULCER
Gastric Ulcer Duodenal Ulcer
Esophageal
Ulcer

8. GASTRIC ULCER
DEFINITION :
 The ulcer tend to occur in the lesser curvature
of the stomach, near the pylorus is called
Gastric Ulcer. The ulcer is usually 1 inch (2.5
cm).
 Gastric Ulcer are defined as a break in the
mucosal surface >5mm in size with depth to the
submucosa.
- JOYCE M BLACK

9. DUODENAL ULCER
DEFINITION : A duodenal ulcer is defined as a
sore that forms in the lining of the duodenum or
the first part of the small intestine.
ESOPHAGEAL ULCER
DEFINITION : An esophageal ulcer is defined as
an erosion that forms in the lining of the esophagus
the long tube that connects the throat to the
stomach.

10. Due to Smoking,
Alcoholism, NSAID,
aspirin and Anti-coagulants
H. pylori
infection
Physiological
stress
Improper food habits
and Intake of excess
gastric stimulants,
Family
history
Increased production of gastric acid and pepsin Reduced
mucosal
blood supply
Inflammation and erosion of gastric mucosa
Excess acid load and thinning of mucosal barrier protection
Peptic Ulcer

11. • Symptoms of ulcer may last for a few days,
weeks, months, and may disappear only to
reappear, often without an identifiable cause.
• Pain : The patient with an ulcer complains
of dull, gnawing pain or a burning sensation in
the mid epigastrium or the back that is relieved
by eating.
• Pyrosis : Pyrosis (heartburn) is a burning
sensation in the stomach and esophagus that
moves up to the mouth.

12. • Vomiting : Vomiting results
from obstruction of the pyloric orifice,
caused by either muscular spasm of the
pylorus or mechanical obstruction from
scarring.
• Constipation and diarrhea: Constipatio
n or diarrhea may occur, probably as a result
of diet and medications.
• Bleeding: 15% of patients may present with
GI bleeding as evidenced by the passage
of melena (tarry stools).

13. Other Manifestations in case of severe
peptic ulcer the person may experience
• Trouble breathing
• Feeling faint
• Unexplained weight loss
• Appetite changes

14. • History collection: Collect
detailed history of food intake,
medications taken, and history of any
diseases like pancreatitis, Crohn's
Disease, gastritis Etc.,
• Physical examination: A physical
examination may reveal pain,
epigastric tenderness, or abdominal
distention.

15. • Esophagogastroduodenoscopy:
Confirms the presence of an ulcer
and allows cytologic studies
and biopsy to rule out H. pylori
or cancer.
• Barium study: A barium study of
the upper GI tract may show an ulcer.

16. • Endoscopy : Endoscopy is the
preferred diagnostic procedure because it
allows direct visualization of
inflammatory changes, ulcers, and lesions.
• Occult blood: Stools may be tested
periodically until they are negative for
occult blood.
• Carbon 13 (13C) urea breath test :
Reflects activity of H. pylori.

17. Hemorrhage : Hemorrhage, the most
common complication, occurs in 10% to 20%
of patients with peptic ulcers in the form of
hematemesis or melena.
Perforation And
penetration:
Perforation is the erosion of the ulcer through
the gastric serosa into the peritoneal cavity
without warning, while penetration is the
erosion of the ulcer through the gastric serosa
into adjacent structures.

18. • Pyloric obstruction:
Pyloric obstruction occurs when the area
distal to the pyloric sphincter becomes
scarred and stenosed from spasm or
edema or from scar tissue that forms
when an ulcer alternately heals and
breaks down.

19. Pharmacological
Therapy
Dietary Modification
Lifestyle Modification
Surgical management
Follow up care.
• Pharmacological Therapy : For Ulcer
Healing
H2 Receptor Antagonists:
• Ranitidine 150mg BD or 300 mg at bedtime
• Cimetidine 400mg BD or 800 mg at bedtime
• Famotidine 20mg BD or 40 mg at bedtime
• Nizatidine 150mg BD or 300 mg at bedtime
Proton Pump Inhibitors:
• Omeprazole 20mg daily
• Lansoprazole 30mg daily
• Rabeprazole 20mg daily
• Pantoprazole 40mg daily
• Esomeprazole 40mg daily

20. • Pharmacological Therapy : For H. pylori infection
Triple therapy:
Proton pump inhibitors BD + clarithromycin 500 mg BD + Amoxicillin 1000 mg Bd ( or
Metronidazole 500 mg Bd ) for 10 – 14 days.
Quadruple therapy:
Bismuth subsalicylate 525 mg Qid , + tetracycline 500mg qid + metronidazole 250 mg qid
+ a proton pump inhibitors daily for 10 – 14 days
Pharmacological Therapy : For NSAID Ulcer
Proton pump inhibitors
Misoprostol 100 – 200 mcg qid.

21. • Dietary Modification :
 Avoiding extremes of temperature in food,
overstimulation from the consumption of
alcohol, coffee and other caffeinated beverages.
 Small and frequent feedings.
 Reduce spices and condiments in food.
• Lifestyle Modification :
Stop smoking because it decreases the secretion of
bicarbonate from the pancreas in to the
duodenum, resulting in increased acidity of the
duodenum. Thus it delayed the wound healing.

22. Surgical Management:
• A surgical operation in which
one or more branches of the
vagus nerve are cut, typically to
reduce the rate of gastric
secretion
Vagotomy

23. Surgical Management:
Truncal Vagotomy
A truncal vagotomy cuts the nerve at the gastroesophageal
junction, the place where the esophagus meets the stomach.
From this junction, the vagus nerve travels through the
organs of digestive system, including liver, gallbladder,
pancreas, stomach and intestines. This is considered the
“trunk” of the nerve tree that communicates with digestive
organs.
Cutting the nerve here reduces gastric acid secretion, but also
reduces functions of other organs that respond to the nerve. It
can reduce bile and enzyme secretions from liver,
gallbladder and pancreas. It can also reduce peristalsis, the
muscle movements that carry food through digestive system.

24. Surgical Management:
• Selective Vagotomy is done in
the division of the anterior and
posterior branches distal to the
branching of the hepatobiliary
and celiac branches.
Selective Vagotomy

25. Surgical Management:
• Instead of cutting the trunk of the tree, a
highly selective vagotomy cuts only the
branch of the vagus nerve that triggers
stomach acid. This branch connects to the
parietal cells in stomach that release
gastric acid. For this reason, the operation
is also called a parietal cell vagotomy.
Cutting this branch alone is equally
effective as a truncal vagotomy in
reducing stomach acid.
Proximal gastric vagotomy without
pyloroplasty

26. Surgical Management:
• Removal of the lower portion of
the antrum of the stomach as well
as a small portion of the duodenum
and pylorus. The remaining
segment is anastomosed to the
duodenum. May be performed in
conjunction with a truncal
vagotomy.
Billroth I : (Antrectomy) or
(gastroduodenostomy)

27. Surgical Management:
• Removal of lower portion (
antrum) of stomach with
anastomosis to jejunum. A
duodenal stump remains and is
oversewn.
Billroth II : (Antrectomy) or
(gastrojejunostomy)

28. Relieving pain:
Administer prescribed medications.
Reducing anxiety:
• Assess what patient wants to know about the disease, and evaluate
level of anxiety; encourage patient to express fears openly and
without criticism.
• Explain diagnostic tests and administering medications on schedule.
• Interact in a relaxing manner, help in identifying stressors, and
explain effective coping techniques and relaxation methods.
• Encourage family to participate in care, and give emotional support.

29. Maintaining optimal nutritional status:
• Avoid aspirin, which is an anticoagulant, and
foods and beverages that contain acid-enhancing
caffeine (colas, tea, coffee, chocolate), along with
decaffeinated coffee.
• Encourage patient to eat regularly spaced meals in
a relaxed atmosphere; obtain regular weights and
encourage dietary modifications.
• Encourage relaxation techniques.
• Administer IV fluids if necessary.

30. Monitoring and managing potential complication:
If hemorrhage is a concern:
• Assess for faintness or dizziness and nausea, before or with bleeding; test stool for
occult or gross blood; monitor vital signs frequently (tachycardia, hypotension, and
tachypnea).
• Insert an indwelling urinary catheter and monitor intake and output; insert and maintain
an IV line for infusing fluid and blood.
• Monitor laboratory values (hemoglobin and hematocrit).
• Insert and maintain a nasogastric tube and monitor drainage; provide lavage as ordered.
• Monitor oxygen saturation and administering oxygen therapy.
• Place the patient in the recumbent position with the legs elevated to prevent
hypotension, or place the patient on the left side to prevent aspiration from vomiting.
• Treat hypovolemic shock as indicated.

31. Monitoring and managing potential
complication:
If perforation and penetration are concerns:
• Note and report symptoms of penetration (back and
epigastric pain not relieved by medications that
were effective in the past).
• Note and report symptoms of perforation (sudden
abdominal pain, referred pain to shoulders, vomiting
and collapse, extremely tender and rigid
abdomen, hypotension and tachycardia, or other signs
of shock).

32. Home Management and Teaching Self-Care:
• Assist the patient in understanding the condition and
factors that help or aggravate it.
• Teach patient about prescribed medications,
including name, dosage, frequency, and possible side
effects. Also identify medications such as aspirin that
patient should avoid.
• Instruct patient about particular foods that will upset
the gastric mucosa, such as coffee, tea, colas, and
alcohol, which have acid-producing potential.

33. Home Management and Teaching Self-Care:
• Encourage patient to eat regular meals in a relaxed setting and to avoid
overeating.
• Explain that smoking may interfere with ulcer healing; refer patient to programs
to assist with smoking cessation.
• Alert patient to signs and symptoms of complications to be reported. These
complications include hemorrhage (cool skin, confusion, increased heart rate,
labored breathing, and blood in the stool), penetration and perforation (severe
abdominal pain, rigid and tender abdomen, vomiting, elevated temperature, and
increased heart rate), and pyloric obstruction (nausea, vomiting, distended
abdomen, and abdominal pain). To identify obstruction, insert and monitor
nasogastric tube; more than 400 mL residual suggests obstruction.

34. • Acute pain related to the effect of gastric acid secretion
on damaged tissue as manifested by Verbalization.
• Anxiety related to an acute illness as manifested by
facial expression.
• Imbalanced nutrition less than body
requirement related to changes in the diet as
manifested by weight loss.
• Deficient knowledge about prevention of symptoms
and management of the condition as manifested by
asking more quires.

35. THANK Uuuu…