MedSurg- Peptic Ulcer Disease

What is occurring during Peptic Ulcer Disease? 

Ulcers and erosions in the stomach and the duodenum 

What is an ulcer?

Break in the lining of the mucosa down to the submucosa

With erosion what occurs?

Breaks in the epithelium

Since pepsin is a proteolytic in an acid environment? 

The mucosal breaks

The two classification of ulcers?

• Acute/Chronic 

• Gastric/Duodenal 

What occurs when pepsinogen breaks down?

There will be pepsin in the presence of HCL acid and a pH of 2-3

What occurs when HCL gets into the gastric mucosa? 

Cellular destruction and inflammation

When histamine is released from damaged mucosa what happens? 

• Increase in vasodilation 

• Increase in capillary permeability

• Secretion of more acid and pepsin

What is disruptive to the gastric mucosal barrier?

A decrease in mucosal blood flow

Bacteria most common with PUD?

Helicobacter pylori

How is this H. pylori transported?

In your childhood through the family

• Fecal-oral; oral-oral 

• CogA - Positive strains 

What occurs when H.pylori colonizes the gastric epithelium? 

• Makes urease 

• Activates the immune response

• Increases gastric secretion and causes tissue damage

Why might NSAIDs induce injury to GI tract?

• inhibits prostaglandin synthesis

• increases gastric acid secretions

• Decreases integrity of GMB 

• Increased risk in the presence of H.pylori

• Increased risk with corticosteroids

• Increased risk with anticoagulants  

What occurs with alcohol ingestion?

Causes acute mucosal lesions and stimulates acid secretion 

How does cigarette smoking affect the gut?

• Death to mucosal cells 

• Inhibition of cell renewal

• Decrease in Gi mucosal blood flow

• Interference with mucosal immune system 

• Promotion of tumor growth

• Stimulates acid secretion 

What occurs with coffee or caffeine consumption?

Stimulates acid secretion

What factors delay the healing of ulcers?

• Psychological distress

• STRESS 

• Depression 

• Smoking

Clinical Manifestation for gastric ulcers? 

Pain high in epigastrium 

• Burning, gaseous 

• Occurs 1 to 2 hrs after a meal

• Food makes pain worse

Clinical Manifestation for a duodenal ulcer?

Burning mid-epigastric pain

• Burning and cramp like 

• Pain when acid is in contact with ulcer since food isn’t there to buffer 

• 2 to 5 hrs after a meal- pain improves with food since it buffers acid

• May experience back pain 

For a diagnosis of an upper GI endoscopy what is going to be done?

• View the mucosa

• Get a tissue specimen (r/o cancer) 

For a diagnosis of H.pylori what is going to be done? 

• Biopsy of antral mucosa to test for urease 

  • get a “rapid urease test”

What tests are done for H.pylori?

Serology, stool and breath testing

Other ways to diagnose PUD?

• Barium Contrast Study

• Stool for blood 

What does an increase in fasting gastrin levels mean? 

Gastrinoma 

• Lead to Zollinger-Ellison Syndrome

Blood tests that can be done?

• CBC (anemia)

• Liver Function tests (cirrhosis)

• Serum Amylase (pancreas)

Goals for interprofessional management of PUD?

• Decrease the gastric acidity

• Enhance mucosal defense mechanisms

Treatment for the interprofessional management of PUD?

• Rest

• Drug Therapy

• Smoking Cessation

• Diet Manifestations

• Long Term follow up care

When will pain be relived from ulcer?

In 3-6 days

How long does the ulcer take to heal?

3-9 weeks

When should you get a follow up endoscopy? 

3-6 months 

How long should NSAIDs be stopped for?

4-6 weeks

What alternatives can be taken in place of an NSAID? 

ASA (antiplatelet) can be given with a: 

• PPI

• H2RA

• Misoprostal

Why is it important to stop smoking?

• Irritates the mucosa 

• Delays healing 

How can you improve the healing of an ulcer?

• Rest 

• Avoid alcohol use 

How is H.pylori going to be treated?

Antibiotics and a PPI for 14 days 

How is acid suppression going to be dealt with? 

• H2 receptor antagonists 

• PPIs

• Anticholinergics 

What do antacids do?

• Neutralize HCI 

  • Aluminum hydroxide binds to bile salts causing a decrease in damage of bile on the mucosa

What does misoprostol do?

Prevents ulcers in chronic NSAID use

Other drug therapies that can be used?

• Sucralfate (Carafate) 

• Analgesics with adjunct antidepressants 

Nutrition therapy to consider?

• No specific diet 

• Eat foods that don’t cause pain

• Avoid food/liquid that delays healing

What foods/liquids should you avoid as they may cause irritation? 

Pepper, carbonated beverages, broth, hot and spicy foods, caffiene

Where is GI bleeding a more common complication? 

Occurs more in the duodenal compared to gastric

Why are perforations a complication?

• Duodenal ulcers are the highest risk 

• Mortality risk is higher with gastric ulcers

• Peritonitis 

What is peritonitis?

• Sudden severe upper abdominal pain (2hrs) 

• Abdomen rigid, nausea and vomiting

What occurs with a gastric outlet obstruction complication? 

• Distal stomach and duodenum

•  Experience: edema, inflammation, pylorospasm, fibrous scar tissue formation

Some acute care nursing interventions to consider? 

• NPO

• NG tube to intermittent suction 

• IV fluid replacement

• Vital signs q 1 hr

• Rest 

• Analgesics

• I and O 

• Mouth Care

What labs should be assessed for interventions?

• H and H 

• Electrolytes 

How to care for GI bleeding?

• Usually pain decreases; blood neutralizes acid

• Keep NG tube patent with normal saline irrigations

What to do for a perforation? 

• Vital signs

• HG tube to intermittent suction

• IV fluids

• Analgesics and antibodies

How to care for a gastric outlet obstruction? 

• NG to suction; irrigate NG tube with normal saline 

• IV fluids and electrolyte replacement

• Turn them to side

• Intermittnet clamping of NG tube; measure and record NG aspirate

• Less than 200 mL is normal so can begin oral fluids (starting at 30 mL an hour)

Patient teachings? 

• Avoid foods that cause epigastric distress 

• Avoid cigarettes and smoking

• Stop alcohol use 

• Do not interchange brands of PPIs, H2RA or antacids (with OTC) 

• Follow prescribed drug therapy

• Report nausea and vomiting, epigatric pain, bloody emesis, tarry stools

• Stress management 

Why is it important to avoid OTC drugs? 

May contain aspirin or other irritating drugs