NURS 308: TOPIC 20 - PEPTIC ULCER DISEASE

What is peptic ulcer disease (PUD)?

Erosion of the GI mucosa caused by hydrochloric acid (HCl) and pepsin that extends beyond the mucosal layer into deeper tissues

Where in the GI tract do peptic ulcers commonly occur?

Lower esophagus, stomach, duodenum, and at post-op gastrojejunal anastomosis sites

What causes the tissue damage seen in PUD?

Excess acid and pepsin overwhelm mucosal defenses, leading to erosion of the GI lining

How are peptic ulcers classified?

Acute and chronic

What characterizes an acute peptic ulcer?

Superficial erosion with minimal inflammation

What characterizes a chronic peptic ulcer?

Deeper erosion into the muscular wall with fibrous tissue formation, often persistent for months or recurring over time

Which type of peptic ulcer is more common?

Chronic peptic ulcer

What is the normal protective mechanism of the gastric mucosa?

Gastric mucosa secretes bicarbonate & mucus to neutralize stomach acid & protect the lining.

What happens to the protective barrier in peptic ulcer disease (PUD)?

It becomes disrupted, leading to decreased protection of the gastric lining.

What is one major factor that contributes to the disruption of the gastric mucosal barrier in PUD?

A defect in the protective gastric mucosa that reduces bicarbonate secretion.

What is another major factor involved in the development of PUD?

Helicobacter pylori colonization.

How does H. pylori contribute to ulcer formation?

It inflames the mucosa, alters bicarbonate secretion, and causes cellular changes in the gastric lining.

What is the overall result of the disrupted protective mechanisms in PUD?

Gastric juices erode the inner layers of the GI wall, leading to ulcer formation.

Who typically gets gastric ulcers?

Females over 50 years old

Who typically gets duodenal ulcers?

Ages 35–45; most common type of peptic ulcer

When does gastric ulcer pain occur?

1–2 hours after meals; food may worsen the pain

When does duodenal ulcer pain occur?

2–5 hours after meals; pain is relieved by food; night pain is common

Where is gastric ulcer pain located?

High epigastric region

Where is duodenal ulcer pain located?

Midepigastric region or may radiate to the back

How does HCl secretion differ in gastric ulcers?

Normal or low HCl secretion

How does HCl secretion differ in duodenal ulcers?

High HCl secretion

What are the main causes of gastric ulcers?

H. pylori infection, NSAIDs, bile reflux

What is the main cause of duodenal ulcers?

H. pylori (about 90%)

Which type of ulcer has a higher risk of obstruction?

Gastric ulcers

What is notable about duodenal ulcer behavior?

Size about 1–2 cm; tend to occur, disappear, and recur

Which type has higher mortality, recurrence, and cancer risk?

Gastric ulcers

Which type has lower mortality risk?

Duodenal ulcers

What conditions are associated with higher risk of duodenal ulcers?

COPD, cirrhosis, pancreatitis, hyperparathyroidism, Zollinger-Ellison syndrome, chronic renal failure

What is Zollinger-Ellison Syndrome (ZES)?

Rare condition where a gastrinoma (tumor) in the pancreas or duodenum secretes excess gastrin

What does excess gastrin do in ZES?

Stimulates excessive HCl secretion leading to severe peptic ulceration

How is Zollinger-Ellison Syndrome diagnosed?

Serum gastrin level and secretin stimulation test

When should ZES be suspected?

Multiple ulcers, ulcers refractory to treatment, or ulcers in unusual locations

What is the #1 cause of peptic ulcer disease?

H. pylori infection

What strains of H. pylori are the most virulent and what do they cause?

CagA-positive strains; responsible for ~80% of gastric ulcers and ~90% of duodenal ulcers

What enzyme does H. pylori produce and what is its effect?

Urease; breaks down urea into ammonia, causing tissue damage and increased gastric secretion

How is H. pylori transmitted?

Person-to-person via oral-oral or fecal-oral routes; often from family member to child

Which population has a higher prevalence of H. pylori?

Hispanic populations

Does spicy food or caffeine cause H. pylori infection?

No; they are aggravating factors, not causes

What class of medications is a major cause of peptic ulcer disease due to mucosal damage?

NSAIDs

What combination of medications increases the risk of NSAID-induced ulcers?

NSAIDs with corticosteroids or anticoagulants

Can low-dose aspirin cause gastric injury?

Yes

What lifestyle factors increase the risk of peptic ulcer disease?

Alcohol use, cigarette smoking, and coffee

How do alcohol, smoking, and coffee affect the stomach?

They stimulate gastric acid secretion or impair mucosal defense

How does psychological stress affect peptic ulcers?

It can delay healing of existing ulcers

What chronic conditions are associated with increased risk of peptic ulcer disease?

Type 1 diabetes, chronic kidney disease, cirrhosis, COPD, and hyperparathyroidism

What are the common symptoms of peptic ulcer disease seen in both gastric and duodenal ulcers?

Bloating, nausea, vomiting, early satiety, belching, hematemesis, & melena

Why might peptic ulcer disease be silent in some patients?

Especially in older adults and those taking NSAIDs because pain is masked

What are the typical symptoms of a gastric ulcer in relation to meals?

Epigastric discomfort 1–2 hours after eating; burning or gaseous pain; food may worsen symptoms; perforation may be the first sign

How does pain present in a duodenal ulcer?

Burning or cramp-like midepigastric or back pain 2–5 hours after meals; often relieved by food; may include nighttime pain that wakes the patient

Why does food relieve pain in a duodenal ulcer but worsen it in a gastric ulcer?

Food buffers stomach acid in duodenal ulcers, relieving pain; in gastric ulcers, food stimulates acid and worsens irritation

What are key warning signs of a peptic ulcer in older adults?

Unexplained weight loss, anemia, or sudden complications like hemorrhage or perforation

Why should there be a lower threshold for screening PUD in older adults on NSAIDs?

Because they often have asymptomatic or silent ulcers with higher risk for serious complications

What is the most serious initial complication that may present in some gastric ulcer patients?

Perforation

What stool finding is associated with upper GI bleeding in PUD?

Melena (black, tarry stools)

What does hematemesis indicate in a patient with peptic ulcer disease?

Active upper gastrointestinal bleeding from the ulcer

When is pain typically worst in duodenal ulcers?

Between meals and at night (2–5 hours after eating)

What is the gold standard diagnostic test for peptic ulcer disease?

EGD (esophagogastroduodenoscopy)

What does an EGD allow the provider to do?

Direct visualization of the esophagus, stomach, and duodenum; allows biopsy to rule out cancer and test for H. pylori

What are key pre-procedure instructions for an EGD?

NPO after midnight

What is a critical post-procedure nursing assessment after an EGD?

Monitor gag reflex before allowing oral intake

When is follow-up EGD recommended after ulcer diagnosis?

3–6 months to confirm healing

What is the urea breath test used to detect?

H. pylori infection

How does the urea breath test work?

Patient drinks C13-labeled urea; H. pylori breaks it down, producing detectable substances in the breath

What medications must be held before a urea breath test?

PPIs and antibiotics

What does the fecal antigen test detect?

H. pylori antigens in stool

What does the serum/whole blood antibody test detect?

H. pylori antibodies

Why is the serum antibody test less useful for current infection?

Antibodies can remain positive after treatment, so it cannot confirm eradication

When is a serum gastrin + secretin stimulation test used?

When Zollinger-Ellison syndrome is suspected

What is the purpose of a CBC in suspected peptic ulcer disease?

Check for anemia from bleeding (e.g., guaiac-positive stools)

Why are coagulation studies done in PUD patients?

To assess bleeding risk and prepare for possible transfusion (type and crossmatch if needed)

What is the main aspiration risk after EGD?

Loss of gag reflex

What should be done post-EGD before giving oral intake?

Keep patient NPO until gag reflex returns

How long should vital signs and respiratory status be monitored after EGD?

At least 1 hour

What post-EGD symptoms should be reported to the provider?

Chest or abdominal pain, fever, bleeding

What is the recommendation after H. pylori treatment is completed?

Retest to confirm eradication

What is the overall treatment goal in peptic ulcer disease?

Decrease gastric acidity, enhance mucosal defense mechanisms, eradicate H. pylori, promote healing, and prevent recurrence

What conservative care measures are recommended for peptic ulcer disease?

Adequate rest, smoking cessation, dietary modifications, and long-term follow-up

What medications should be avoided in peptic ulcer disease, and when can they be used?

NSAIDs and aspirin should be avoided for 4–6 weeks unless given with a PPI, H2 blocker, or misoprostol

What dietary and lifestyle factors should be avoided in peptic ulcer disease?

Caffeine, alcohol, and foods that cause distress or irritation

What is the recommended follow-up evaluation for peptic ulcer healing?

Endoscopic evaluation and follow-up in 3–6 months to confirm healing

What is the role of drug therapy in peptic ulcer disease?

Drug therapy is a key part of treatment to reduce acid, protect the mucosa, and eradicate H. pylori

What are proton pump inhibitors (PPIs) used for in peptic ulcer disease?

To reduce gastric acid secretion; more effective than H2-receptor blockers and used with antibiotics to treat H. pylori

What is sucralfate used for in peptic ulcer disease?

Cytoprotective therapy that protects the gastric lining

What is endoscopic hemostasis (EGD) used for in peptic ulcer disease?

To control bleeding that cannot be managed by other methods

What are the complications and limitations of endoscopic therapy similar to?

Those associated with diagnostic EGD, requiring post-procedure monitoring

What is balloon dilation used to treat in PUD?

Gastric outlet obstruction caused by scar tissue

When is surgical therapy indicated for peptic ulcer disease?

When patients are unresponsive to medical treatment, noncompliant, at high risk for complications, or when there is concern for gastric cancer

What is the purpose of a vagotomy?

To decrease gastric acid secretion by severing part of the vagus nerve

What is an antrectomy?

Removal of the antrum to reduce gastrin production and acid stimulation, with the stomach reconnected to the duodenum

What is a gastroduodenostomy (Billroth I)?

Direct connection of the remaining stomach to the duodenum, considered the most physiologic procedure

What is a gastrojejunostomy (Billroth II)?

Connection of the stomach to the jejunum, used when Billroth I is not possible, with increased risk of dumping syndrome

What is a pyloroplasty?

Enlargement of the opening between the stomach and small intestine to promote gastric emptying

What is a partial gastrectomy?

Surgical removal of the portion of the stomach affected by the ulcer

What should be monitored postoperatively in PUD surgery regarding bowel sounds?

Absence of bowel sounds and signs of complications such as hemorrhage, infection, or anastomotic leak

Why should the head of the bed be elevated after surgery?

To reduce the risk of aspiration

What approach can be used to monitor pain postoperatively?

The five senses approach

What findings should be reported after PUD surgery?

Changes in vital signs, blood-tinged drainage, increased drainage, hematemesis, or changes in blood pressure

What should be done with medications and GI output postoperatively?

Administer medications as ordered and monitor gastrointestinal output

What should be monitored at the drain site?

Fluid color, amount, and odor

What medications may be administered to manage post-op complications?

Antidiarrheals, analgesics, and antiemetics