PEPTIC ULCER

- Is a lesion in the mucosa of the lower esophagus, stomach, pylorus, or duodenum.

- also known as ulcus pepticum, PUD or peptic ulcer disease, is an ulcer (defined as mucosal
erosions equal to or greater than 0.5 cm) of an area of the gastrointestinal tract that is usually
acidic and thus extremely painful
- Causative factors include mucosal infection by the bacterium Helicobacter pylori (mechanism
unclear).
- Use of non-steroidal anti-inflammatory drugs (NSAIDs), especially aspirin.
- Genetic factors such as cigarette smoking, stress, and lower socio-economic status may play a
role.
- Complications include GI hemorrhage, perforation, and gastric outlet obstruction.

Signs and symptoms

Symptoms of a peptic ulcer can be

* abdominal pain, classically epigastric with severity relating to mealtimes, after around 3 hours
of taking a meal (duodenal ulcers are classically relieved by food, while gastric ulcers are
exacerbated by it);
* bloating and abdominal fullness;
* waterbrash (rush of saliva after an episode of regurgitation to dilute the acid in esophagus);
* nausea, and copious vomiting;
* loss of appetite and weight loss;
* hematemesis (vomiting of blood); this can occur due to bleeding directly from a gastric ulcer,
or from damage to the esophagus from severe/continuing vomiting.
* melena (tarry, foul-smelling feces due to oxidized iron from hemoglobin);
* rarely, an ulcer can lead to a gastric or duodenal perforation, which leads to acute peritonitis.
This is extremely painful and requires immediate surgery.

A history of heartburn, gastroesophageal reflux disease (GERD) and use of certain forms of
medication can raise the suspicion for peptic ulcer. Medicines associated with peptic ulcer include
NSAID (non-steroid anti-inflammatory drugs) that inhibit cyclooxygenase, and most
glucocorticoids (e.g. dexamethasone and prednisolone).

In patients over 45 with more than two weeks of the above symptoms, the odds for peptic
ulceration are high enough to warrant rapid investigation by EGD (see below).

The timing of the symptoms in relation to the meal may differentiate between gastric and
duodenal ulcers: A gastric ulcer would give epigastric pain during the meal, as gastric acid is
secreted, or after the meal, as the alkaline duodenal contents reflux into the stomach. Symptoms
of duodenal ulcers would manifest mostly before the meal—when acid (production stimulated by
hunger) is passed into the duodenum. However, this is not a reliable sign in clinical practice.

Also, the symptoms of peptic ulcers may vary with the location of the ulcer and the patient's age.
Furthermore, typical ulcers tend to heal and recur and as a result the pain may occur for few days
and weeks and then wane or disappear. Usually, children and the elderly do not develop any
symptoms unless complications have arisen.

Burning or gnawing feeling in the stomach area lasting between 30 minutes and 3 hours
commonly accompanies ulcers. This pain can be misinterpreted as hunger, indigestion or
heartburn. Pain is usually caused by the ulcer but it may be aggravated by the stomach acid
when it comes into contact with the ulcerated area. The pain caused by peptic ulcers can be felt
anywhere from the navel up to the sternum, it may last from few minutes to several hours and it
may be worse when the stomach is empty. Also, sometimes the pain may flare at night and it can
commonly be temporarily relived by eating foods that buffer stomach acid or by taking anti-acid
medication. However, peptic ulcer disease symptoms may be different for every sufferer.
Complications

* Gastrointestinal bleeding is the most common complication. Sudden large bleeding can be
life-threatening. It occurs when the ulcer erodes one of the blood vessels.
* Perforation (a hole in the wall) often leads to catastrophic consequences. Erosion of the
gastro-intestinal wall by the ulcer leads to spillage of stomach or intestinal content into the
abdominal cavity. Perforation at the anterior surface of the stomach leads to acute peritonitis,
initially chemical and later bacterial peritonitis. The first sign is often sudden intense abdominal
pain. Posterior wall perforation leads to pancreatitis; pain in this situation often radiates to the
back.
* Penetration is when the ulcer continues into adjacent organs such as the liver and pancreas.
* Scarring and swelling due to ulcers causes narrowing in the duodenum and gastric outlet
obstruction. Patient often presents with severe vomiting.
* Cancer is included in the differential diagnosis (elucidated by biopsy), Helicobacter pylori as
the etiological factor making it 3 to 6 times more likely to develop stomach cancer from the ulcer.

Classification

* Stomach (called gastric ulcer)

* Duodenum (called duodenal ulcer)
* Oesophagus (called Oesophageal ulcer)
* Meckel’s Diverticulum (called Meckel’s Diverticulum ulcer)

Types of peptic ulcers

* Type I: Ulcer along the lesser curve of stomach

* Type II: Two ulcers present – one gastric, one duodenal
* Type III: Prepyloric ulcer
* Type IV: Proximal gastroesophageal ulcer
* Type V: Anywhere along gastric body, NSAID induced

Assessment

1. Abdominal pain
* Occurs in the epigastric area radiating to the back; described as dull, aching, and
gnawing.
* Pain may increase when the stomach is empty, at night, or approximately 1 to 3 hours
after eating. Pain is relieved by taking antacids (common with duodenal ulcers).
2. Nausea, anorexia, early satiety (common with gastric ulcers), belching.
3. Dizziness, syncope, hematemesis, melena with GI hemorrhage:
* Positive fecal occult blood
* Decreased hemoglobin and hematocrit, indicating anemia.
* Orthostatic blood pressure and pulse changes.
4. Peptic ulcer disease may be asymptomatic in up to 50% of persons affected
5. Differentiating Gastric and Duodenal Ulcers:

Diagnostic Evaluation

1. Upper GI series usually outlines ulcer or area of inflammation.

2. Endoscopy (esophagogastroduodenoscopy) visualizes duodenal mucosa and helps identify
inflammatory changes, lesions, bleeding sites, and malignancy (through biopsy and cytology).
3. Gastric secretory studies ( gastric acid secretion test, serum gastrin level tst) are elevated in
Zollinger-Ellison syndrome.
 4. H. pylori antibody titer may be positive, especially in recurrent ulcers; however, there is high
rate of false positive results; C-urea breath test or biopsy testing is more definitive test for H.
pylori.

Pharmacologic Interventions

1. Histamine2 (H2) receptor antagonists such as ranitidine to reduce gastric acid secretions.
2. Antisecretory or proton-pump inhibitor, such as omeprazole, to help ulcer heal quickly in 4 to
8 hours.
3. Cytoprotective drug sucralfate, which protects ulcer surface against acid, bile, and pepsin.
4. Antacids to reduce acid concentration and help reduce symptoms.
5. Anti-biotic as part of a multi-drug regimen to eliminate H. pylori to prevent reoccurrence.

Surgical Interventions

Surgery is indicated for hemorrhage, perforation, obstruction, and when unresponsive to medical
therapy. Procedures include:

1. Gastroduodenostomy (Billroth I)
* Partial gastrectomy with removal of antrum and pylorus; gastric stump is anastomosed to
duodenum.
2. Gastrojejunostomy (Billroth II)
* Partial gastrectomy with removal of antrum and pylorus; gastric stump is anastomosed to
jejunum.
3. Antrectomy
* Antrum (lower half of stomach), pylorus and small cuff of duodenum are resected;
stomach is anastomosed to jejunum and duodenal stump is closed.
4. Total gastrectomy
* Removal of stomach with anastomosis of esophagus to jejunum or duodenum.
5. Pyloroplasty
* Longitudinal incision is made in the pylorus, and closed transversely to permit the muscle
to relax and established an enlarged outlet; often performed with vagotomy.

Nursing Interventions

1. Monitor the patient for signs of bleeding through fecal occult blood, vomiting, persistent
diarrhea, and change in vital signs.
2. Monitor intake and output.
3. Monitor the patient’s hemoglobin, hematocrit, and electrolyte levels.
4. Administered prescribed I.V. fluids and blood replacements if acute bleeding is present.
5. Maintain nasogastric tube for acute bleeding, perforation, and postoperatively, monitor tube
drainage for amount and color.
6. Perform saline lavage if ordered for acute bleeding.
7. Encourage bed rest to reduce stimulation that may enhance gastric secretion.
8. Provide small, frequent meals to prevent gastric distention if not actively bleeding.
9. Watch for diarrhea caused by antacids and other medications.
10. Restrict foods and fluids that promote diarrhea and encourage good perineal care.
11. Advise patient to avoid extremely hot or cold food and fluids, to chew thoroughly, and to eat
in a leisurely fashion to reduce pain.
12. Administer medications properly and teach patient dose and duration of each medication.
13. Advise patient to modify lifestyle to include health practices that will prevent recurrences of
ulcer pain and bleeding.

http://nursingcrib.com/nursing-care-plan/nursing-care-plan-peptic-ulcer/
http://nursingcrib.com/nursing-notes-reviewer/peptic-ulcer/