Peptic ulcers form in the lining of the stomach, esophagus, or duodenum due to erosion caused by gastric acid. Risk factors include H. pylori bacteria, NSAIDs, smoking, alcohol, and stress. Diagnosis involves endoscopy, stool tests, or a urea breath test to detect H. pylori. Treatment consists of antibiotics, proton pump inhibitors, and lifestyle changes. Complications include hemorrhage, perforation, and gastric outlet obstruction. Nursing care focuses on pain relief, nutrition, anxiety reduction, and monitoring for complications.

1. Mr. HIREN GEHLOTH
JG COLLEGE OF NURSING

2. • A peptic ulcer may be referred to as a gastric,
duodenal, or esophageal ulcer, depending on its
location.
• A peptic ulcer is an excavation (hollowed-out
area) that forms in the mucosal wall of the
stomach, in the pylorus (the opening
between the stomach and duodenum), in the
duodenum (the first part of the small
intestine), or in the esophagus.
• Erosion of a circumscribed area of mucous membrane is the cause.
• This erosion may extend as deeply as the muscle layers or through the muscle to the
peritoneum.

3. Erosion is characterized by the partial loss of the epithelium, with the basement membrane left intact.

4. • Peptic ulcers are more likely to occur in the duodenum than in the
stomach.
• As a rule they occur alone, but they may occur in multiples.
• Chronic gastric ulcers tend to occur in the lesser curvature of the
stomach, near the pylorus.
• Esophageal ulcers occur as a result of the
backward flow of HCl from the stomach
into the esophagus (gastroesophageal reflux
disease [GERD]).

5. CAUSES AND RISK FACTORS
• Helicobacter pylori (H. pylori) bacteria.
• Pain-relieving NSAID medications
• Hypersecretion state (Excessive secretion of gastric acid)
• Tobacco, smoking, alcohol
• Stress
• Genetic factors
Zollinger Ellision Syndrome (Multiple ulcers extreme
gastric hyperacidity)

7. • Stress ulcer is a term given to acute mucosal
ulceration of the duodenal or gastric area that occurs
after physiologically stressful events, such as burns,
shock, severe sepsis, and multiple organ trauma.
• Fiberoptic endoscopy within 24 hours of trauma or
injury shows shallow erosions of the stomach wall;
by 72 hours, multiple gastric erosions are observed,
and as the stressful condition continues, the ulcers
spread.
• When the patient recovers, the lesions are reversed;
this pattern is typical of stress ulceration.

8. Peptic ulcer mostly occur in
gastro duodenal mucosa because
this tissue cannot defense the
digestive action of HCL and
pepsin.

11. ASSESSMENT AND DIAGNOSTIC EVALUATION
• Physical examination (epigastric tenderness,
abdominal distention).
• Endoscopy (preferred, but upper gastrointestinal
[GI] barium study may be done).
• Diagnostic tests include analysis of stool
specimens for occult blood, gastric secretory
studies, and biopsy and histology with culture to
detect H. pylori (serologic testing, stool antigen
tests, or a Urea breath test may also detect H.
pylori).

12. UREA BREATH TEST
• During the test patient will swallow a capsule containing urea, which is made
from an isotope of carbon. (Isotopes of carbon occur in minuscule amounts
in nature, and can be measured with special testing machines.) If H. pylori is
present in the stomach, the urea is broken up and turned into carbon dioxide.
The carbon dioxide is absorbed across the lining
of the stomach and into the blood.
It then travels in the blood to the lungs where it
is excreted in the breath.
Samples of exhaled breath are collected, and the
isotopic carbon in the exhaled carbon dioxide is
measured.

13. Pharmacologic Therapy
 • Antibiotics combined with proton pump inhibitors and bismuth salts to suppress
H. pylori.
 •H2-receptor antagonists (in high doses in patients with Zollinger–Ellison
syndrome) to decrease stomach acid secretion; maintenance doses of H2-receptor
antagonists are usually recommended for 1 year. Proton pump inhibitors may also
be prescribed.
 • Cytoprotective agents (protect mucosal cells from acid or NSAIDs).
 • Antacids in combination with cimetidine (Tagamet) or ranitidine (Zantac) for
treatment of stress ulcer and for prophylactic use.
MANAGEMENT

16. COMPLICATIONS
• Hemorrhage
• Perforation
• Penetration
• Gastric Outlet Obstruction

18. SURGICAL MANAGEMENT
1.Vagotomy:
Cut the vegus nerve to
reduce the gastric acid
secretion

19. 2. Pyloroplasty:
Longitudinal incision in pylorus and
transversely suturing to relax the
pylorus muscle and enlarge the
outlet.

20. 3.Anterectomy Billroth 1: (GASTRODUODENOSTOMY)
Removal of the lower portion of the antrum
of the stomach (which contains the cells
that secrete gastrin) as well as a small
portion of the duodenum and pylorus.
The remaining segment is anastomosed
to the duodenum.

21. 3.Anterectomy Billroth 2: (GASTROJEJUNOSTOMY)
Removal of lower portion (antrum) of
stomach with anastomosis to jejunum.
Dotted lines show portion removed
(antrectomy). A duodenal stump remains
and is oversewn.

23. NURSING MANAGEMENT
Assessment
• Assess pain and methods used to relieve it; take a thorough history, including a 72-
hour food intake history.
• If patient has vomited, determine whether emesis is bright red or coffee ground in
appearance. This helps identify source of the blood.
• Ask patient about usual food habits, alcohol, smoking, medication use (NSAIDs),
and level of tension or nervousness.
• Ask how patient expresses anger (especially at work and with family), and
determine whether patient is experiencing occupational stress or family problems.
• Obtain a family history of ulcer disease.
• Assess vital signs for indicators of anemia (tachycardia, hypotension).
• Assess for blood in the stools with an occult blood test.
• Palpate abdomen for localized tenderness.

24. NURSING DIAGNOSIS
1. Acute pain related to the effect of gastric acid secretion on
damaged tissue
2. Anxiety related to coping with an acute disease
3. Imbalanced nutrition related to changes in diet
4. Deficient knowledge about preventing symptoms and managing
the condition.

25. Nursing Interventions
Relieving Pain and Improving Nutrition
• Administer prescribed medications.
• 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.

26. 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.

27. Monitoring and Managing Complications
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.

29. 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).
• 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.