PEPTIC ULCER

 STOMACH DEFENSE MECHANISM

☪Mucous layer

• Coats and lines d stomach

• First line of defense

☪Bicarbonate

• Neutralizes acid.

☪ Prostaglandins

• Hormone like substance that keep blood vessel dilated for good blood flow

• Stimulate mucus and bicarbonate production.

N.B: NSAIDs inhibit the production of cyclo oxygenase that produces prostaglandins. Prostaglandins help to protect stomach lining from chemical and physical injury.

PEPTIC ULCER DISEASE

DEFINITION

A peptic ulcer is a sore in the lining of the stomach or first part of the small intestine called the duodenum secondary to erosion of d mucosa barrier.

Peptic ulcer is an erosion of gastrointestinal mucosa resulting frm d digestive action of HCL & pepsin.

Peptic ulcer damage d mucosa of d alimentary tract ,which extends thro d muscularis mucosa into the sub mucosa.

N.B Peptic ulcer can be 

• Acute or 

• Chronic

Classification of peptic ulcer

• Type 1 : Ulcer along the lesser curve of d stomach

• Type 2: Two ulcer present - One gastric and one duodenal

• Type 3 : Pre-pyloric ulcer

• Type 4: proximal gastroesophageal ulcer

• Type 5 : Anywhere

Types of peptic ulcer

• Stomach (gastric ulcer)

• Duodenum (Duodenal ulcer)

• esophagus (esophageal ulcer)

 Cause

99% of Peptic ulcer disease is caused by the helix form of bacteria called Helicobacter pylori. Which can be transmitted from person to person through fecal-oral route or oral- oral routes.

Risk Factors

• Lifestyle: Smoking, acidic drinks, alcohol consumption, NSAIDs chronic users.

• Age : Duodenal( 30-50years) Gastric (over 60years)

• psychological stress

• Blood group O (Duodenal ulcer)

• Improper diets, skips meals

• Regular use of blood thinners e.g warfarin

• Regular use of steroids

• Regular intake of Caffeines

• Genetic predisposition.

Specific Clinical manifestations

Duodenal ulcer

• Occurs in the duodenum

• Burning, gnawing, aching or hunger like pain primarily in d epigastric region

• Pain may occur or worsen wen stomach is empty, usually 2-5hrs after meal

• Pain occurs usually at night BTW 11pm and  2am wen acid secretion is at its peak

• Patient feels better when he/she drinks or takes food then worse 1-2 hrs later 

• Very little risk of malignancy

Gastric ulcer

• Occurs in d stomach

• Pain occurs 1-2 hrs after eating

• Pain usually doesn't wake patient.

• High risk for malignancy

• Deep and penetrating, usually occur on d lesser curvature of d stomach

• Pain not relieved by eating or drinking

• Pain is worse after eating or drinking.

General signs and symptoms

• Epigastric tenderness 

• Sharp, burning, aching, gnawing pain

• Dyspepsia

• Nausea/Vomiting

• Belching

Diagnostic evaluations

• Endoscopic procedures

• Upper G.I series( Barium swallow)

• Urea breath testing

• Blood test

• Biopsy urease test

• Histology

• Stool Antigen Test

MEDICAL MANAGEMENT

Goal of management

• Lowering the amount of acid that stomach makes.

• Neutralising the acid

• Prevent complications

• Minimize reoccurrences

Antibiotic medications: Combination of antibiotic is used in d treatment of 

H.pylori:  Amoxyl + Clarithromycin.

Acid blockers: (H-2) blockers reduce the amount of HCl released into d digestive tract which relieved ulcer pain. Examples include Cimetidine (Tagamet), ranitidine, famotidine.

Antacids: This may be taken in addition to an acid blocker. It neutralises existing stomach acid and thus relief pain.

Proton pump inhibitor (PPI): This helps reduce acid by blocking the action of pump secretory cells (parietal cells which secretes HCL). Example include Rabeprazole, lansoprazole, Omeprazole

Cytoprotective agents: This medication helps protect the tissues that lines d stomach and intestines. Example includes Misoprostol, Bismuth subsalicylate.

Bowel rest: Bed rest and clear fluids with no foods for few days allows d ulcer to heal without irritated

Nasogastric tube: This relieves pressure on d stomach and allows wound to heal

Surgical management

• Vagotomy

• Antrectomy

• Pyloroplasty

• Bilroth 1

• Bilroth 2

NURSING MANAGEMENT

• Perform complete physical assessment noting abdominal tenderness, pain dehydration and systematic disorders

• Encourage rest to conserve energy and to reduce stress

• Avoid foods and fluids by mouth for hours or days until acute symptoms subside

• Offer ice chips and clear liquid when symptoms subside

• Discouraged caffeinated beverages to reduce gastric activity and pepsin secretion

• Discourage alcohol and cigarette smoking/and avoid irritating food.

• Monitor daily intake and output

• Assess electrolyte values every 24hours for fluid imbalance

• Give prescribed analgesic to reduce pain

• Provide a list of substance to avoid e.g caffeine, nicotine, spicy foods irritating or highly seasoned foods and alcohol.

Complications

• G.I bleeding 

• Perforation

• Penetration

• Gastric outlet obstruction

• Anemia

NURSING DIAGNOSIS 

• Acute pain related to irritation of the stomach mucosa evidenced by patient verbalization

• imbalanced nutrition: less than body requirement related to anorexia, inadequate intake of nutrient evidenced by loss of weight

• Anxiety related to nature of disease evidenced by patient being  apprehensive.

• Deficient knowledge related to recurrent peptic ulcer disease evidenced by patient asking too many questions.

• Risk for deficient fluid volume related to Nausea and vomiting.

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