Peptic ulcer disease is caused by gastric or duodenal ulcers that form lesions in the stomach or duodenal mucosa. Risk factors include H. pylori infection, smoking, NSAID use, and genetic factors. Symptoms include epigastric pain relieved by food and antacids. Treatment aims to relieve pain, eradicate H. pylori infection, heal ulcers, and prevent recurrence through lifestyle changes and medication like PPIs or H2 blockers. Surgery was more common historically but is now rare due to H. pylori treatments, though it may be used for complications like perforation.

1. Peptic Ulcer Disease Carol Lynn Pence RN, MSN

2. Anatomy and Physiology of GI Tract

3. Peptic Ulcers Defined Ulcerated lesion in the mucosa of the stomach or duodenum Types Gastric Duodenal

4. Peptic Ulcer Disease

5. Stomach Defense Systems Mucous layer Coats and lines the stomach First line of defense Bicarbonate Neutralizes acid Prostaglandins Hormone-like substances that keep blood vessels dilated for good blood flow Thought to stimulate mucus and bicarbonate production

6. Risk Factors Lifestyle Smoking Acidic drinks Medications H. Pylori infection 90% have this bacterium Passed from person to person (fecal-oral route or oral-oral route) Age Duodenal 30-50 Gastric over 60 Gender Duodenal: are increasing in older women Genetic factors More likely if family member has Hx Other factors: stress can worsen but not the cause

7. Gastric Ulcers Pain occurs 1-2 hours after meals Pain usually does not wake patient Accentuated by ingestion of food Risk for malignancy Deep and penetrating and usually occur on the lesser curvature of the stomach

8. Gastric and Duodenal Ulcers

9. Duodenal Ulcers Pain occurs 2-4 hours after meals Pain wakes up patient Pain relieved by food Very little risk for malignancy

10. General Peptic Ulcer Symptoms Epigastric tenderness Gastric: epigastrium; left of midline Duodenal: mid to right of epigastrium Sharp, burning, aching, gnawing pain Dyspepsia (indigestion) Nausea/vomiting Belching

11. Complications of Peptic Ulcers Hemorrhage Blood vessels damaged as ulcer erodes into the muscles of stomach or duodenal wall Coffee ground vomitus or occult blood in tarry stools Perforation An ulcer can erode through the entire wall Bacteria and partially digested fool spill into peritoneum=peritonitis Narrowing and obstruction (pyloric) Swelling and scarring can cause obstruction of food leaving stomach=repeated vomiting

12. Diagnostic Tests Esophagogastrodeuodenoscopy (EGD) Endoscopic procedure Visualizes ulcer crater Ability to take tissue biopsy to R/O cancer and diagnose H. pylori Upper gastrointestinal series (UGI) Barium swallow X-ray that visualizes structures of the upper GI tract Urea Breath Testing Used to detect H.pylori Client drinks a carbon-enriched urea solution Excreted carbon dioxide is then measured

13. Etiology and Genetic Risk PUD primarily associated with NSAID use and infection with H. Pylori Certain drugs may contribute to cause: Theo-Dur Caffeine – stimulates hydrochloric acid production Corticosterioids – associated with an increased incidence of PUD Genetic factors

14. Drug Therapy/Primary Goals Provide pain relief Antacids and mucosa protectors Eradicate H. pylori infection Two antibiotics and one acid suppressor Heal ulcer Eradicate infection Protect until ulcer heals Prevent recurrence Decrease high acid stimulating foods in susceptible people Avoid use of potential ulcer causing drugs Stop smoking

15. Hyposecretory Drugs Proton Pump Inhibitors Suppress acid production Prilosec, Prevacid H2-Receptor Antagonists Block histamine-stimulated gastric secretions Zantac, Pepcid, Axid Antacids Neutralizes acid and prevents formation of pepsin (Maalox, Mylanta) Give 2 hours after meals and at bedtime Prostaglandin Analogs Reduce gastric acid and enhances mucosal resistance to injury Cytotec Mucosal barrier fortifiers Forms a protective coat Carafate/Sucralfate cytoprotective

16. Surgery Greatly decreased in the last 20-30 years secondary to the discovery of H. pylori Required if ulcer in one of these states Perforated and overflowed into the abdomen Scarred or swelled so that there is obstruction Acute bleeding Non-responsive to medications

17. Types of Surgical Procedures Gastroenterostomy allows regurgitation of alkaline duodenal contents into the stomach Creates a passage between the body of stomach to small intestines Keeps acid away from ulcerated area

18. Types of Surgical Procedures Vagotomy Cuts vagus nerve Eliminates acid-secretion stimulus

19. Surgical Procedure/Pyloroplasty Pyloroplasty Widens the pylorus to guarantee stomach emptying even without vagus nerve stimulation

20. Types of Surgical Procedures Antrectomy/ Subtotal Gastrectomy Lower half of stomach (antrum) makes most of the acid Removing this portion (antrectomy) decreases acid production Subtotal gastrectomy Removes ½ to 2/3 of stomach Remainder must be reattached to the rest of the bowel Billroth I Billroth II

21. Billroth I Distal portion of the stomach is removed The remainder is anastomosed to the duodenum

22. Billroth II The lower portion of the stomach is removed and the remainder is anastomosed to the jejunum

23. Postoperative Care NG tube – care and management Monitor for post-operative complications

24. Post-op Complications Bleeding Occurs at the anastomosed site First 24 hours and post-op days 4-7 Duodenal stump leak Billroth II Severe abdominal pain Bile stained drainage on dressing Gastric retention WILL NEED TO PUT NG TUBE BACK IN Dumping Syndrome (page 1303) Prevalent with sub total gastrectomies Early-30 minutes after meals Vertigo, tachycardia, syncope, sweating, pallor, palpatations Late – 90 min-3 hours after meals Anemia Rapid gastric empyting decreases absorption of iron Malabsorption of fat Decreased acid secretions, decreased pancreatic secretions, increased upper GI mobility

25. Dumping Syndrome Rapid emptying of food and fluids from the stomach into the jejunum Symptoms Weakness Faintness Palpatations Fullness Discomfort Nausea diarrhea

26. Minimize Dumping Syndrome Decrease CHO intake Eat slowly Avoid fluids during meals Increase fat Eat small, frequent meals