PUD and GERD

Peptic Ulcers and GERD Study Notes

Peptic Ulcer Disease (PUD)

  • Definition: Peptic ulcer disease (PUD) refers to an erosion of the mucosal lining of the stomach, esophagus, or duodenum, commonly caused by a bacterial infection, specifically Helicobacter pylori (H. pylori).

    • Ulcers may penetrate as deep as the muscularis mucosa or the peritoneal wall of the abdomen.

    • Damage to the stomach lining or the first part of the small intestine results in the formation of a sore (ulcer).

Risk Factors

  • Age: Particularly affects individuals aged 65 and older.

  • H. pylori: Presence contributes significantly to ulcer development.

  • Medication Use: Prolonged use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) such as aspirin or ibuprofen, and corticosteroids.

  • Lifestyle Factors: Alcohol consumption and smoking.

  • Medical Conditions: Chronic Obstructive Pulmonary Disease (COPD), cirrhosis of the liver, chronic kidney disease.

  • Other: Type O blood and pernicious anemia.

  • Note: Stress and spicy foods do not cause peptic ulcers but can exacerbate symptoms in individuals who already have them.

Prevention Strategies

  • Limit alcohol consumption, practice moderation.

  • Engage in smoking cessation and avoid tobacco products.

  • Implement stress management techniques.

  • Avoid NSAIDs when possible, or use as indicated.

  • Limit consumption of caffeine-containing beverages.

  • Adhere to a balanced diet, focusing on clean and properly cooked foods, as well as safe drinking water, while avoiding irritants like spicy foods.

  • Avoid skipping meals.

  • Eat small, frequent meals throughout the day.

  • Maintain good hygiene practices.

  • Engage in regular physical exercise.

Assessment Findings

  • Symptoms may include:

    • Dyspepsia: Heartburn, bloating, nausea, and vomiting (vomiting is rare and linked to potential gastric outlet obstruction).

    • Pain Characteristics: Dull and gnawing or burning sensation in the upper mid-epigastrium or radiating to the back.

    • Gastrointestinal Symptoms: Constipation, diarrhea, and bloating.

    • Eating-Related Pain: Pain occurring immediately after eating, or a cyclical pattern of pain, feeling better after the first meal, then recurring after 2-3 hours.

    • Hematemesis: Presence of bloody vomit.

    • Melena: Black, tarry stools indicating upper GI bleeding.

    • Weight Loss: Due to pain-associated eating behaviors.

    • Epigastric Pain: General upper abdominal pain.

Types of Ulcer Pain

  1. Gastric Ulcer:

    • Location: Right side of the stomach.

    • Timing: Pain typically occurs 30-60 minutes after eating; worsening pain during the day.

    • Associated Symptoms: Malnourishment and hematemesis (bloody vomit).

  2. Duodenal Ulcer:

    • Location: First part of the small intestine (duodenum).

    • Timing: Pain occurs 1.5-3 hours after eating or at night; generally relieved after eating but worsens at night.

    • Associated Symptoms: Patients are often well-nourished; melena (black, tarry stools).

Diagnostic Tests

  • H. pylori Testing:

    • Gastric samples are collected via endoscopy to check for H. pylori presence.

    • Urea Breath Test:

    • Client exhales into a collection container, drinks a carbon-enriched urea solution, and is subsequently tested for CO2; must be NPO prior to this test.

    • Serologic Testing: Detects H. pylori antibodies.

    • Stool Sample Tests: Checks for H. pylori antigen in fecal matter.

  • Complete Blood Count (CBC): Assesses for potential blood loss from ulcers (notably if hemoglobin is lower than 8 mg/dl).

  • Fecal Occult Blood Test: Detects gastrointestinal bleeding.

  • Saline Lavage via NG Tube: Used in cases of suspected hemorrhage to clear clots and prevent electrolyte imbalances.

  • Gastrin Levels: If Zollinger-Ellison syndrome (ZES) is suspected.

  • Liver and Pancreatic Enzymes: To rule out other causes of GI symptoms.

  • Esophagogastroduodenoscopy (EGD): Flexible endoscopy to visualize the esophagus, stomach, and duodenum for ulcers, inflammation, and tumors; allows for biopsy when necessary.

Nursing Actions

  • Monitor vitals until sedation from any procedures wears off.

  • Keep the client NPO until the gag reflex returns post-procedure.

  • Ensure the patient has been NPO for 6-8 hours prior to diagnostic procedures.

  • Monitor for potential complications such as bleeding, perforation, or difficulty swallowing.

Patient-Centered Care

  • Instruct clients to avoid irritant foods (e.g., coffee, tea, carbonated beverages).

  • Monitor for orthostatic changes in vital signs and tachycardia.

  • Encourage adequate rest periods and reduction of environmental stressors; promote smoking cessation and reduced alcohol intake.

  • Monitor laboratory results for any abnormalities.

Medications

  • Antibiotics:

    • Example: Metronidazole (Flagyl) and Amoxicillin - typically used in combination; patients must complete the full course of the antibiotics.

  • Histamine-Receptor Antagonists:

    • Examples: Famotidine, Cimetidine, Nizatidine – These medications suppress gastric acid secretion by selectively blocking H2 receptors in parietal cells lining the stomach; often combined with antibiotics in ulcer treatment.

    • Indicated for preventing stress ulcers in patients who are NPO following major surgery.

  • Proton Pump Inhibitors (PPIs):

    • Examples: Pantoprazole, Esomeprazole - Long-term use of PPIs can increase risks for fractures, pneumonia, acid rebound, and C. difficile infection.

    • Patients should not crush these medications; advised to take them before meals.

    • Monitor for potential electrolyte imbalances.

  • Antacids:

    • Example: Tums - Administered 1-3 hours post-meals and at bedtime to neutralize gastric acid that occurs during food ingestion.

    • Monitor renal function; other medications should be taken at least 1-2 hours before or after antacid administration.

  • Mucosal Protectants:

    • Example: Bismuth subsalicylate (Pepto-Bismol) – Protects H. pylori from binding to the mucosal wall of the stomach.

    • Should be administered on an empty stomach, 1 hour before meals and at bedtime; monitor for constipation as an adverse effect.

    • Advisable to avoid aspirin products to prevent salicylate toxicity; temporary harmless black stools can occur with use.

Complications of PUD

  • Pernicious Anemia: Disruption in vitamin B12 absorption can occur.

  • Hemorrhage: With severe ulcers that cause bleeding.

  • Hypovolemic Shock: Resulting from significant blood loss.

  • Dumping Syndrome: Can occur post-gastrectomy; involves rapid release of metabolic peptides following ingestion of food, presenting as either early or late symptoms.

  • Pyloric Obstruction: Caused by scarring, edema, or spasm distal to the pyloric sphincter, preventing stomach emptying; symptoms include fullness, distention, nausea, and vomiting of undigested food.

    • Management may require the insertion of an NG tube for gastric decompression and monitoring fluid/electrolyte status.

Gastroesophageal Reflux Disease (GERD)

  • Definition: GERD is characterized by the backflow of stomach acids into the esophagus, leading to irritation of the esophageal lining and potentially serious complications.

    • Primary treatment involves lifestyle and dietary changes, progressing to medication and possibly surgical interventions.

    • Long-term untreated GERD can lead to complications, including esophageal strictures and Barrett's esophagus.

Risk Factors

  • Obesity: Increases incidence due to pressure effects.

  • Older Age: Contributes to delayed gastric emptying and reduced lower esophageal sphincter (LES) tone.

  • Sleep Apnea: Associated with increased intra-abdominal pressure.

  • Hiatal Hernias: Can predispose to GERD.

  • Stress, Dietary Triggers: Alcohol, coffee, chocolate, citrus fruits, and nitrates.

  • Other Factors: H. pylori infection, lying down after eating.

Prevention Strategies

  • Avoid lying down 2-3 hours after eating; elevate the head of the bed by 6-8 inches.

  • Identify and avoid trigger foods along with caffeine and carbonated beverages.

  • Use NSAIDs cautiously, considering timing and potential side effects.

  • Eat small, frequent meals, and avoid late-night eating.

  • Chew food thoroughly and eat slowly to facilitate digestion.

  • Maintain a healthy body weight and engage in smoking cessation and limited alcohol consumption.

  • Manage stress levels.

  • Avoid tight-fitting clothing around the abdomen.

Assessment Findings

  • Symptoms:

    • Heartburn: Primary symptom in GERD.

    • Regurgitation: May produce a bitter taste.

    • Radiating Pain: Can mimic heart attack pain (in neck, jaw, back).

    • Pyrosis: A burning sensation in the esophagus.

    • Odynophagia: Pain during swallowing.

    • Pain that worsens after eating, lasting 20 minutes to an hour, and exacerbated by postural changes or straining.

    • Occurs frequently (4-5 times weekly).

Diagnostic Procedures

  • EGD (Esophagogastroduodenoscopy): Evaluates the esophageal lining for changes; may identify high-grade dysplasia (HGD).

  • pH Monitoring:

    • A catheter is placed directly into the esophagus for 24-48 hours to assess acid exposure and correlating activities; highly accurate for diagnosing GERD.

    • Clients should keep a food and symptom diary during this period.

  • Esophageal Manometry: Tests the pressure and peristaltic activity of the esophagus by having the patient swallow three small tubes.

  • Barium Swallow: Identifies structural abnormalities, hiatal hernias, or strictures contributing to GERD, utilizes X-ray to visualize swallowing.

Medications

  • Proton Pump Inhibitors (PPIs):

    • Examples: Pantoprazole, Omeprazole - Monitor for electrolyte imbalances, particularly hypomagnesemia, and signs of C. difficile infection. Increased fracture risk for long-term users, especially older adults.

    • Patients must take these PPIs before meals.

  • Antacids:

    • e.g., Tums - Monitor for interactions with other medications and kidney function, timing of administration is crucial (1-3 hours after meals, at bedtime, and at least 1 hour apart from other drugs).

  • Histamine2 Receptor Antagonists:

    • Examples: Famotidine, Cimetidine - Used cautiously with renal impairment. Timing for administration should be with meals or at bedtime, while ensuring at least an hour gap from antacids.

  • Prokinetics:

    • Example: Metoclopramide - Enhances motility of the esophagus and stomach; monitor for adverse effects; can be administered orally or via IV.

Complications

  • Aspiration Risk: Gastric secretions can potentially be aspirated into the trachea, requiring nursing interventions like positioning.

  • Barrett’s Epithelium: Results from continual irritation and healing of the esophageal lining, leading to replacement of normal tissues with premalignant changes.