NUR 120 PEPTIC ULCER

DISEASE

Pathophysiology

Normally, a physiologic balance exists between peptic acid secretion and gastric mucosal defense

The gastric mucosal barrier protects the underlying tissue from gastric acids and digestive juices

When a disruption occurs with this protective barrier, the mucosal lining is exposed and corroded by acid, resulting in an ulcer

Causes of PUD

H pylori bacteria Chronic use of NSAIDS Hypersecretion of Stomach Acid Stress Zollinger-Ellison Syndrome

To Test for H Pylori

Endoscopic gastric samples Collect medication history prior Urea breath testingNPO prior to test IgG serologic test can detect antibodies Stool sample

Ulcer Classification

Location:ulcer on stomach=Gastric Ulcer

ulcer on upper intestine=Duodenal Ulcer

ulcer on esophagus=Esophageal Ulcer

Duration:

Acute or Chronic

Signs and Symptoms

o Symptoms vary from person to person

o Can be confused with GERD and dyspepsia

o Common signs and symptoms: o Gnawing, burning and aching in the

epigastrium, and o Dyspepsia that feels like heartburn o Bloating and nausea o Pain

o Less common symptoms:o Pyloric obstruction- vomiting after mealso Vomiting blood that looks like coffee groundso Black stools that looks like tar or that has dark red in them

Gastric Ulcer Duodenal Ulcer

30 to 60 min after meal 1.5 to 3 hr after meal

Rarely occurs at night Often occurs at night

Pain worsens with food ingestion Pain relieved by food ingestion

o Peptic ulcer disease can be differentiated between gastric, duodenal, and stress ulcers.

o Silent ulcers may occur with pts with diabetes, NSAID users such as aspirin and ibuprofen.

o If left untreated, complications may occur such as bleeding, perforation, penetration or the obstruction of the digestion tract.

Combination of lifestyle changes and pharmacotherapy best

Treatment goals Eliminate infection by H. pylori Promote ulcer healing Prevent recurrence of symptoms

Treatment of Peptic Ulcer Disease

Drugs used in treatment H2-receptor antagonists Proton pump inhibitors Antacids Antibiotics and miscellaneous drugs

Treatment of Peptic Ulcer Disease (continued)

Goals of treatment Primary: bacteria completely eradicated Ulcers heal more rapidly Ulcers remain in remission longer

Very high reoccurrence when H. pylori not eradicated Infection can remain active for life if not treated.

Treatment of H. pylori

Slow acid secretion by stomachOften drugs of choice in treating PUD Cimetidine used less frequently Drug-drug interactions are numerous.

Do not take antacids at same time as H2-receptor blockers. Decreases absorption

H2-Receptor Blockers

Prototype drug: ranitidine (Zantac)Mechanism of action: acts by blocking H2-

receptors in stomach to decrease acid production

Primary use: to treat peptic ulcer diseaseAdverse effects: possible reduction in number

of red and white blood cells and platelets, impotence or loss of libido in men

H2-Receptor Blockers

Dysrhythmias and hypotension have occurred with IV cimetidine Ranitidine (Zantac) or famotidine (Pepcid)

can be administered intravenouslyAssess kidney and liver functionEvaluate client’s CBC for possible anemia

during long-term use

H2-Receptor Antagonist Therapy

Prototype drug: omeprazole (Prilosec) Mechanism of action: reduces acid secretion in

stomach by binding irreversibly to enzyme H+, K+-ATPase

Primary use: for short-term, 4- to 8-week therapy for peptic ulcers and GERD

Adverse effects: headache, nausea, diarrhea, rash, abdominal pain Long-term use associated with increased risk of

gastric cancer

Proton Pump Inhibitors

Take 30 minutes prior to eating, usually before breakfast

May be administered at same time as antacids

Often administered in combination with clarithromycin (Biaxin)

Proton Pump Inhibitor Therapy for PUD

Prototype drug: aluminum hydroxide (Amphojel)Mechanism of action: neutralizes stomach acid by

raising pH of stomach contentsPrimary use: in combination with other antiulcer

agents for relief of heartburn due to PUD or GERDAdverse effects: minor; constipation

Antacids

Administered to treat H. pylori infections of gastrointestinal tract

Two or more antibiotics given concurrently Increase effectiveness Lower potential for resistance

Regimen often includes Proton pump inhibitor Bismuth compounds

Inhibit bacterial growthPrevent H. pylori from adhering to gastric

mucosa

Antibiotics

Several additional drugs are beneficial in treating PUD Sucralfate

Coats ulcer and protects it from further erosion Misoprostol

Inhibits acid and stimulates production of mucus Pirenzepine

Inhibits autonomic receptors responsible for gastric-acid secretion

Miscellaneous Drugs

Peptic Ulcer Disease

• Pain Management:• Assess location, characteristics, onset/duration, frequency, quality,

intensity or severity of pain, and precipitating factors to determine appropriate intervention

• Provide client with optimal pain relief by using prescribed analgesics to provide comfort.

• Use a variety of measures of relief such as pharmacologic, nonpharmacologic, and interpersonal techniques to facilitate pain relief.

• Teach the use of nonpharmacologic techniques which include relaxation, music therapy, guided imagery, distraction, acupressure, and massage before after and if possible during painful activities before pain occurs or increases.

• Relaxation helps decrease acid production and reduces pain

Nursing Interventions:

•Nursing Interventions cont’d:– Treament Regimen:

• Explain the pathophysiology of the disease and how it relates to anatomy and physiology to help the patient understand the disease.

• Discuss lifestyle changes that may be required to prevent future complications and/or control the disease process.

• Instruct patient on which signs and symptoms to report to the health care provider to ensure early initiation of treatment.

– Hemorrhage/Bleeding:• Assess for evidence of hematemesis, bright red or melena stool, abdominal pain or

discomfort, symptoms of shock (decreased BP, cool/clammy skin, dyspnea, tachycardia, decreased urine output)

• If ulcer is actively bleeding, observe NG tube aspirate or emesis for amount and color to assess degree of bleeding.

• Take vital signs every 15-30 mins to help determine patient’s hemodynamic status and as indicators for shock.

• Maintain IV infusion line to provide ready access for blood and fluid replacement.• Monitor hematocrit and hemoglobin as indicators of severity of hemorrhage and need for

fluid and blood replacement.

•Nursing Interventions cont’d:–Perforation:• Observer for manifestations of perforation such as sudden,

severe abdominal pain; rigid, boardlike abdomen; radiating pain to shoulders; increasing distention; decreasing bowl sounds.• Take vital signs every 15-30 mins.• Maintain NG tube to suction to provide continuous

aspiration and gastric decompression.• Administer pain medication to promote comfort and

reduce anxiety.

Dietary modifications

Avoid foods that cause epigastric distress.

Avoid milk, sweets, or sugars

Small, frequent meals rather than large meals.

Limit the fluid intake at one time.

Avoid Cigarettes and alcohol.

Avoid OTC drugs unless approved by HCP.

Take all medications as provided.

Report any of the following:

Increased nausea and or vomiting.Increase in epigastric pain.Bloody emesis or tarry stools.Encourage stress reducing activities or

relaxation strategies.