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Peptic ulcer disease


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Peptic ulcer disease

  1. 1. Peptic Ulcer Disease Carol Lynn Pence RN, MSN
  2. 2. Anatomy and Physiology of GI Tract
  3. 3. Peptic Ulcers <ul><li>Defined </li></ul><ul><ul><li>Ulcerated lesion in the mucosa of the stomach or duodenum </li></ul></ul><ul><li>Types </li></ul><ul><ul><li>Gastric </li></ul></ul><ul><ul><li>Duodenal </li></ul></ul>
  4. 4. Peptic Ulcer Disease
  5. 5. Stomach Defense Systems <ul><li>Mucous layer </li></ul><ul><ul><li>Coats and lines the stomach </li></ul></ul><ul><ul><li>First line of defense </li></ul></ul><ul><li>Bicarbonate </li></ul><ul><ul><li>Neutralizes acid </li></ul></ul><ul><li>Prostaglandins </li></ul><ul><ul><li>Hormone-like substances that keep blood vessels dilated for good blood flow </li></ul></ul><ul><ul><li>Thought to stimulate mucus and bicarbonate production </li></ul></ul>
  6. 6. Risk Factors <ul><li>Lifestyle </li></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Acidic drinks </li></ul></ul><ul><ul><li>Medications </li></ul></ul><ul><li>H. Pylori infection </li></ul><ul><ul><li>90% have this bacterium </li></ul></ul><ul><ul><li>Passed from person to person (fecal-oral route or oral-oral route) </li></ul></ul><ul><li>Age </li></ul><ul><ul><li>Duodenal 30-50 </li></ul></ul><ul><ul><li>Gastric over 60 </li></ul></ul><ul><li>Gender </li></ul><ul><ul><li>Duodenal: are increasing in older women </li></ul></ul><ul><li>Genetic factors </li></ul><ul><ul><li>More likely if family member has Hx </li></ul></ul><ul><li>Other factors: stress can worsen but not the cause </li></ul>
  7. 7. Gastric Ulcers <ul><li>Pain occurs 1-2 hours after meals </li></ul><ul><li>Pain usually does not wake patient </li></ul><ul><li>Accentuated by ingestion of food </li></ul><ul><li>Risk for malignancy </li></ul><ul><li>Deep and penetrating and usually occur on the lesser curvature of the stomach </li></ul>
  8. 8. Gastric and Duodenal Ulcers
  9. 9. Duodenal Ulcers <ul><li>Pain occurs 2-4 hours after meals </li></ul><ul><li>Pain wakes up patient </li></ul><ul><li>Pain relieved by food </li></ul><ul><li>Very little risk for malignancy </li></ul>
  10. 10. General Peptic Ulcer Symptoms <ul><li>Epigastric tenderness </li></ul><ul><ul><li>Gastric: epigastrium; left of midline </li></ul></ul><ul><ul><li>Duodenal: mid to right of epigastrium </li></ul></ul><ul><li>Sharp, burning, aching, gnawing pain </li></ul><ul><li>Dyspepsia (indigestion) </li></ul><ul><li>Nausea/vomiting </li></ul><ul><li>Belching </li></ul>
  11. 11. Complications of Peptic Ulcers <ul><li>Hemorrhage </li></ul><ul><ul><li>Blood vessels damaged as ulcer erodes into the muscles of stomach or duodenal wall </li></ul></ul><ul><ul><li>Coffee ground vomitus or occult blood in tarry stools </li></ul></ul><ul><li>Perforation </li></ul><ul><ul><li>An ulcer can erode through the entire wall </li></ul></ul><ul><ul><li>Bacteria and partially digested fool spill into peritoneum=peritonitis </li></ul></ul><ul><li>Narrowing and obstruction (pyloric) </li></ul><ul><ul><li>Swelling and scarring can cause obstruction of food leaving stomach=repeated vomiting </li></ul></ul>
  12. 12. Diagnostic Tests <ul><li>Esophagogastrodeuodenoscopy (EGD) </li></ul><ul><ul><li>Endoscopic procedure </li></ul></ul><ul><ul><ul><li>Visualizes ulcer crater </li></ul></ul></ul><ul><ul><ul><li>Ability to take tissue biopsy to R/O cancer and diagnose H. pylori </li></ul></ul></ul><ul><ul><li>Upper gastrointestinal series (UGI) </li></ul></ul><ul><ul><ul><li>Barium swallow </li></ul></ul></ul><ul><ul><ul><li>X-ray that visualizes structures of the upper GI tract </li></ul></ul></ul><ul><ul><li>Urea Breath Testing </li></ul></ul><ul><ul><ul><li>Used to detect H.pylori </li></ul></ul></ul><ul><ul><ul><li>Client drinks a carbon-enriched urea solution </li></ul></ul></ul><ul><ul><ul><li>Excreted carbon dioxide is then measured </li></ul></ul></ul>
  13. 13. Etiology and Genetic Risk <ul><li>PUD primarily associated with NSAID use and infection with H. Pylori </li></ul><ul><li>Certain drugs may contribute to cause: </li></ul><ul><ul><li>Theo-Dur </li></ul></ul><ul><ul><li>Caffeine – stimulates hydrochloric acid production </li></ul></ul><ul><ul><li>Corticosterioids – associated with an increased incidence of PUD </li></ul></ul><ul><li>Genetic factors </li></ul>
  14. 14. Drug Therapy/Primary Goals <ul><li>Provide pain relief </li></ul><ul><ul><li>Antacids and mucosa protectors </li></ul></ul><ul><li>Eradicate H. pylori infection </li></ul><ul><ul><li>Two antibiotics and one acid suppressor </li></ul></ul><ul><li>Heal ulcer </li></ul><ul><ul><li>Eradicate infection </li></ul></ul><ul><ul><li>Protect until ulcer heals </li></ul></ul><ul><li>Prevent recurrence </li></ul><ul><ul><li>Decrease high acid stimulating foods in susceptible people </li></ul></ul><ul><ul><li>Avoid use of potential ulcer causing drugs </li></ul></ul><ul><ul><li>Stop smoking </li></ul></ul>
  15. 15. Hyposecretory Drugs <ul><li>Proton Pump Inhibitors </li></ul><ul><ul><li>Suppress acid production </li></ul></ul><ul><ul><li>Prilosec, Prevacid </li></ul></ul><ul><li>H2-Receptor Antagonists </li></ul><ul><ul><li>Block histamine-stimulated gastric secretions </li></ul></ul><ul><ul><li>Zantac, Pepcid, Axid </li></ul></ul><ul><li>Antacids </li></ul><ul><ul><li>Neutralizes acid and prevents formation of pepsin (Maalox, Mylanta) </li></ul></ul><ul><ul><li>Give 2 hours after meals and at bedtime </li></ul></ul><ul><li>Prostaglandin Analogs </li></ul><ul><ul><li>Reduce gastric acid and enhances mucosal resistance to injury </li></ul></ul><ul><ul><li>Cytotec </li></ul></ul><ul><li>Mucosal barrier fortifiers </li></ul><ul><ul><li>Forms a protective coat </li></ul></ul><ul><ul><ul><li>Carafate/Sucralfate </li></ul></ul></ul><ul><ul><ul><ul><li>cytoprotective </li></ul></ul></ul></ul>
  16. 16. Surgery <ul><li>Greatly decreased in the last 20-30 years secondary to the discovery of H. pylori </li></ul><ul><li>Required if ulcer in one of these states </li></ul><ul><ul><li>Perforated and overflowed into the abdomen </li></ul></ul><ul><ul><li>Scarred or swelled so that there is obstruction </li></ul></ul><ul><ul><li>Acute bleeding </li></ul></ul><ul><ul><li>Non-responsive to medications </li></ul></ul>
  17. 17. Types of Surgical Procedures <ul><li>Gastroenterostomy allows regurgitation of alkaline duodenal contents into the stomach </li></ul><ul><li>Creates a passage between the body of stomach to small intestines </li></ul><ul><li>Keeps acid away from ulcerated area </li></ul>
  18. 18. Types of Surgical Procedures <ul><li>Vagotomy </li></ul><ul><ul><li>Cuts vagus nerve </li></ul></ul><ul><ul><li>Eliminates acid-secretion stimulus </li></ul></ul>
  19. 19. Surgical Procedure/Pyloroplasty <ul><li>Pyloroplasty </li></ul><ul><ul><li>Widens the pylorus to guarantee stomach emptying even without vagus nerve stimulation </li></ul></ul>
  20. 20. Types of Surgical Procedures <ul><li>Antrectomy/ Subtotal Gastrectomy </li></ul><ul><ul><li>Lower half of stomach (antrum) makes most of the acid </li></ul></ul><ul><ul><li>Removing this portion (antrectomy) decreases acid production </li></ul></ul><ul><li>Subtotal gastrectomy </li></ul><ul><ul><li>Removes ½ to 2/3 of stomach </li></ul></ul><ul><li>Remainder must be reattached to the rest of the bowel </li></ul><ul><ul><li>Billroth I </li></ul></ul><ul><ul><li>Billroth II </li></ul></ul>
  21. 21. Billroth I <ul><li>Distal portion of the stomach is removed </li></ul><ul><li>The remainder is anastomosed to the duodenum </li></ul>
  22. 22. Billroth II <ul><li>The lower portion of the stomach is removed and the remainder is anastomosed to the jejunum </li></ul>
  23. 23. Postoperative Care <ul><ul><li>NG tube – care and management </li></ul></ul><ul><ul><li>Monitor for post-operative complications </li></ul></ul>
  24. 24. Post-op Complications <ul><li>Bleeding </li></ul><ul><ul><li>Occurs at the anastomosed site </li></ul></ul><ul><ul><li>First 24 hours and post-op days 4-7 </li></ul></ul><ul><li>Duodenal stump leak </li></ul><ul><ul><li>Billroth II </li></ul></ul><ul><ul><li>Severe abdominal pain </li></ul></ul><ul><ul><li>Bile stained drainage on dressing </li></ul></ul><ul><li>Gastric retention </li></ul><ul><ul><li>WILL NEED TO PUT NG TUBE BACK IN </li></ul></ul><ul><li>Dumping Syndrome (page 1303) </li></ul><ul><ul><li>Prevalent with sub total gastrectomies </li></ul></ul><ul><ul><li>Early-30 minutes after meals </li></ul></ul><ul><ul><li>Vertigo, tachycardia, syncope, sweating, pallor, palpatations </li></ul></ul><ul><ul><li>Late – 90 min-3 hours after meals </li></ul></ul><ul><li>Anemia </li></ul><ul><ul><li>Rapid gastric empyting decreases absorption of iron </li></ul></ul><ul><li>Malabsorption of fat </li></ul><ul><ul><li>Decreased acid secretions, decreased pancreatic secretions, increased upper GI mobility </li></ul></ul>
  25. 25. Dumping Syndrome <ul><li>Rapid emptying of food and fluids from the stomach into the jejunum </li></ul><ul><li>Symptoms </li></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><li>Faintness </li></ul></ul><ul><ul><li>Palpatations </li></ul></ul><ul><ul><li>Fullness </li></ul></ul><ul><ul><li>Discomfort </li></ul></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>diarrhea </li></ul></ul>
  26. 26. Minimize Dumping Syndrome <ul><li>Decrease CHO intake </li></ul><ul><li>Eat slowly </li></ul><ul><li>Avoid fluids during meals </li></ul><ul><li>Increase fat </li></ul><ul><li>Eat small, frequent meals </li></ul>