PEPTIC ULCER

DISEASE

K.THULASI RAM .Msc(N)

ANATOMY AND PHYSIOLOGY OF GI TRACT

DEFINITIONPeptic ulcer disease is a condition

characterised by erosion of GI mucosa resulting from the digestive action of HCL acid and pepsin.

Common sites are lower oesophagus, stomach and duodenum.

PEPTIC ULCER DISEASE

PREVALANCE IN INDIA 4 t0 10 per

1000 population

STOMACH DEFENSE SYSTEMS Mucous layer

Coats and lines the stomachFirst line of defense

BicarbonateNeutralizes acid

ProstaglandinsHormone-like substances that keep blood vessels dilated for good blood flow

Thought to stimulate mucus and bicarbonate production

RISK FACTORS Lifestyle

SmokingAcidic drinksMedications

H. Pylori infection90% have this

bacteriumPassed from person

to person (fecal-oral route or oral-oral route)

AgeDuodenal 30-50Gastric over 60

GenderDuodenal: are

increasing in older women

Genetic factorsMore likely if family

member has History

Stress can worsen but not the cause

Drugs - NSAIDS

TYPES

Acute

Chronic

ACUTEIs associated

with superficial erosion

Minimal inflammation

Short duration and resolves

quickly

CHRONIC Chronic ulcer is

one of long duration eroding

the muscular wall .It may be present continuously for many months throughout the

person’s life time

BASED ON LOCATION

•Gastric•Duodenal

PATHOPHYSIOLOGYH.PYLORI,

ACIDS,NSAIDS, ALCOHOL

BREAK DOWN THE GASTRIC

MUCOSAL LAYER

ACID BACK DIFFUSION INTO

MUCOSA

HISTAMINE RELEASE

INCREASED VASODILATATION

MUCOSAL EDEMADESTRUCTION OF MUCOSAL CELLS

INCREASED ACID AND PEPSIN RELEASE• FURTHER BREAK DOWUN OF

MUCOSA AND BLEEDING

• ULCERATION

GENERAL PEPTIC ULCER SYMPTOMS

Epigastric tendernessGastric: epigastrium; left of midline

Duodenal: mid to right of epigastrium

Sharp, burning, aching, gnawing pain

Dyspepsia (indigestion) Nausea/vomiting/constipation/diarrhea

Belching Pyrosis (heartburn) Black Tarry stools

Gastric ulcer Duodenal Ulcermiddle age 50-60 Any age specially 30-40 Age

More in male More in male Sex

Same Stress job eg. Manager Occupation

Epigastric. Can radiate to back

Epigastric , discomfort Pain

Immediately after eating

2-3 hours after eating & midnight

Onset

Eating Hunger Agg.by

Gastric ulcer Duodenal UlcerLying down or vomiting Eating Relived by

Few weeks 1-2 months Duration

Common(to relieve the pain)

Uncommon Vomiting

Patient afraid to eat Good Appetite

Avoid fried food Good , eat to relieve the pain Diet

wt. Loss No wt. loss Weight

60% 40% Hematemesis

40% 60% Melena

DIAGNOSTIC STUDIES History and physical examination Upper GI endoscopy with biopsy Helicobacter testing of breath, urine, blood

and tissue Upper GI barium contrast study Complete blood count – anemia – secondary

to bleeding ulcer Liver enzymes Stools examination for occult blood Serum amylase – pancreatic function –

duodenal ulcer Serum electrolytes Urine analysis

DIAGNOSTIC STUDIES Esophagogastrodeuodenoscopy

Visualizes ulcer type and locationAbility to take tissue biopsy to R/O cancer

and diagnose H. pylori

Upper gastrointestinal series Barium swallowX-ray that visualizes structures of the upper

GI tract

Urea Breath TestingUsed to detect H.pyloriClient drinks a carbon-enriched urea

solutionExcreted carbon dioxide is then measured

COLLABORATIVE MANAGEMENT

The aim of treatment is to decrease gastric

acidity, enhance mucosal defense mechanism and

minimise the harmful effects on the mucosa

REGIMEN

Adequate rest

Dietary modification

s

Drug therapy

Elimination of smoking

Long term follow up

DIETARY MODIFICATIONS Bland diet Take six meals per day Avoid mil and milk products – delays

gastric emptying Avoid high fat diet Avoid spicy foods, pepper, salted

fish Avoid food with preservatives Avoid coffee and caffeine products , Plenty of water

ADEQUATE REST

Adequate rest both physical and

emotional

Quiet, calm environment at

home and in job

Stress reduction strategies -

meditation

DRUG THERAPY H2- receptor blockers – ranitidine, cimetidine

Proton pump inhibitors – pantoprazole

Antibiotics for H.pylori – amoxicillin, tetracycline and clarithromycin

Antacids – aluminun hydroxide gels – syp gelusil

Cytoprotective drugs – sucralfate

No smoki

ng

No alcoh

ol consumptio

n

LONG TERM FOLLOW UP

Healing of ulcer requires many weeks of therapy

Pain disappears with in 3 to 6 days But healing much slower

Continuous treatment and long term follow up is quit essential

Completely avoid NSAIDS and ASPIRIN

switch to enteric coated

tablets

Co- administration

with PPI

SURGICAL MANAGEMENT Greatly decreased in the last 20-30 years secondary to the discovery of H. pylori

Required when/ indicationsPerforated ulcerAcute bleedingNon-responsive to medications

TYPES OF SURGICAL PROCEDURES

VagotomyCuts vagus nerveEliminates acid-secretion stimulus

PYLOROPLASTY Pyloroplasty

Widens the pylorus to guarantee stomach emptying even without vagus nerve stimulation

BILLROTH IGASTRODUODENOSTOMY

Distal portion of the stomach is removed

The remainder is anastomosed to the duodenum

BILLROTH IIGASTROJEJUNOSTOMY

The lower portion of the stomach is removed and the remainder is anastomosed to the jejunum

POSTOPERATIVE CARENG tube – care and management - NPO

Continuous gastric aspiration monitor for bleeding

Observe for bowel movementsIVF replacementStrict intake and outputSplinting of abdomen while coughing

Monitor for post-operative complications

COMPLICATIONS OF PEPTIC ULCERS

HemorrhageBlood vessels damaged as ulcer erodes into the

muscles of stomach or duodenal wallCoffee ground vomitus or occult blood in tarry

stools

PerforationAn ulcer can erode through the entire wallBacteria and partially digested food spill into

peritoneum=peritonitis

Narrowing and obstruction (pyloric)Swelling and scarring can cause obstruction of

food leaving stomach=repeated vomiting

COMPLICATION - DUMPING SYNDROME

Rapid emptying of food and fluids from the stomach into the jejunum

SymptomsWeaknessFaintnessPalpitationsFullnessDiscomfortNauseadiarrhea

MINIMIZE DUMPING SYNDROME

Decrease CHO intake Eat slowly Avoid fluids during meals Increase fat Eat small, frequent meals

NURSING DIAGNOSIS Acute pain related to increased gastric

secretions ,decreased mucosal protection ,and ingestion of gastric irritants as evidenced by burning cramp like pain in epigastrium and abdomen

Nausea related to acute exacerbation of disease process as evidenced by episodes of nausea and vomiting

Imbalanced nutrition less than body requirement related to decreased appetite

Ineffective therapeutic regimen management related to lack of knowledge of long term management of peptic ulcer disease and

NURSING INTERVENTIONS Relieving pain Reducing anxiety Maintaining optimal nutritional status

Maintaining optimal nutritional status

Teaching patients self-care

Thank you