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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 testing
NPO 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 meals
o Vomiting blood that looks like coffee
grounds
o 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.
Treatment of Peptic Ulcer Disease
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 (continued)
Drugs used in treatment
H2-receptor antagonists
Proton pump inhibitors
Antacids
Antibiotics and miscellaneous drugs
Treatment of H. pylori
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.
H2-Receptor Blockers
Slow acid secretion by stomach
Often 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 disease
Adverse effects: possible reduction in number
of red and white blood cells and platelets,
impotence or loss of libido in men
H2-Receptor
Antagonist Therapy
Dysrhythmias and hypotension have occurred
with IV cimetidine
Ranitidine (Zantac) or famotidine (Pepcid)
can be administered intravenously
Assess kidney and liver function
Evaluate client’s CBC for possible anemia
during long-term use
Proton Pump Inhibitors
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 Inhibitor
Therapy for PUD
Take 30 minutes prior to eating, usually
before breakfast
May be administered at same time as
antacids
Often administered in combination with
clarithromycin (Biaxin)
Antacids
Prototype drug: aluminum hydroxide (Amphojel)
Mechanism of action: neutralizes stomach acid by
raising pH of stomach contents
Primary use: in combination with other antiulcer
agents for relief of heartburn due to PUD or GERD
Adverse effects: minor; constipation
Antibiotics
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 growth
Prevent H. pylori from adhering to gastric
mucosa
Miscellaneous Drugs
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
Peptic Ulcer Disease
Nursing Interventions:
•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 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.