NURS 329

Introduction to Peptic Ulcer Disease (PUD)

  • Definition: Peptic Ulcer Disease (PUD) refers to ulceration of the gut wall, primarily affecting the stomach and the first part of the small intestine (duodenum).
  • Importance: Understanding PUD is crucial due to its complications and the impact on patient comfort and health outcomes.

Pathophysiology of Peptic Ulcer Disease

  • Physical Changes:

    • Ulceration causes wearing away of tissue layers in the gut wall.
    • Layers affected include:
    • Mucosa (innermost layer)
    • Submucosa
    • Muscularis

  • Complications of PUD:

    • If untreated, PUD can lead to:
    • Hemorrhage
    • Perforation

  • Consequences of Full Thickness Ulceration:

    • Complete ulceration can result in:
    • Infection (bacteria migrating to the peritoneal cavity).
    • Peritonitis: Inflammatory response to infection, potentially leading to severe systemic effects, including septic shock.
    • Symptoms of Peritonitis:
    • Fever
    • Nausea
    • Difficulty maintaining blood pressure (drop in blood pressure, increased heart rate).

Signs and Symptoms of Complications

  • Signs of Complicated PUD:
    • Presence of gut contents in the peritoneum will manifest as:
    • Abdominal pain
    • Fever
    • Nausea
    • Anemia due to potential bleeding:
    • May be slow, leading to fatigue, tachycardia, lightheadedness, and headaches.

Defensive vs. Aggressive Factors

  • Balance of Defensive and Aggressive Factors:
    • PUD typically results from an imbalance, where aggressive factors (causing damage) outweigh defensive factors (providing protection).
    • Aggressive Factors:
    • Increased acid production
    • Chronic use of NSAIDs (decrease prostaglandin production reducing mucosal protection)
    • Smoking (delays ulcer healing)
    • Defensive Factors:
    • Mucus production (protective barrier).
    • Blood flow (ensures sufficient oxygen and nutrient supply to the gut).
    • Bicarbonate secretion (helps to neutralize stomach acid).

Causes of PUD

  • Common Causes:
    • Helicobacter pylori infection (H. pylori), a bacterium that can exist as part of the normal gut flora but can lead to ulceration in symptomatic patients.
    • Stress-related mucosal damage due to physiological or emotional stress.
    • Zollinger-Ellison Syndrome (excessive acid production resulting in ulcers).

Clinical Presentation of PUD

  • Typical Symptoms:
    • Pain that typically worsens with an empty stomach and is relieved by food or antacids.
    • Potential for significant weight loss and nutritional issues if ulcerations cause persistent discomfort.

Diagnosis and Management of PUD

  • Initial Steps in Management:
    • Testing for H. pylori presence is essential; antibiotics are prescribed if present.
    • If H. pylori is absent, antibiotics should not be given.

Pharmacological Interventions

Proton Pump Inhibitors (PPIs)

  • Main Drugs:
    • Omeprazole (primary choice).
  • Function:
    • Suppress gastric acid secretion, addressing aggressive factors by inhibiting proton pumps.
  • Side Effects:
    • Common: Headaches, diarrhea.
    • Long-term effects: Vitamin B12 deficiency, increased risk of C. difficile infection, pneumonia, fracture risk, hypomagnesemia.
    • Important interactions:
    • Acid-dependent absorption of medications (e.g., iron, ketoconazole, clopidogrel).

Histamine H2-Receptor Antagonists (H2 Blockers)

  • Common H2 Blockers:
    • Famotidine, ranitidine, and cimetidine.
  • Function:
    • Reduce acid secretion by blocking histamine receptors in the stomach.
  • Adverse Effects:
    • Confusion, especially in older adults, renal impairment risks, gynecomastia, decreased libido.
    • Ranitidine has been withdrawn from the market due to safety concerns (possible carcinogen).

Monitoring and Patient Considerations

  • Regularly assess the patient’s symptom control, potential adverse effects, and any signs of complications (e.g., GI bleeding).
  • Tailor drug therapy to each patient’s individual needs, considering comorbidities, symptom severity, and risk factors.

Conclusion

  • Understanding the pathophysiology and management strategies for PUD is critical for improving patient outcomes and preventing serious complications.