Peptic Ulcer 114943

PEPTIC ULCER DISEASE – (PUD) – excoriation / erosion of submucosa & mucosal lining due to: a.) Hyper secretion of acid – pepsin b.) Decrease resistance to mucosal barrier Incidence Rate: 1. Men – 40 – 55 yrs old 2. Aggressive persons/ type A personality 3. Hereditary 4. Emotional Stress Predisposing factors: 1. Hereditary 2. Emotional 3. Smoking – vasoconstriction – GIT ischemia 4. Alcoholism – stimulates release of histamine = Parietal cell release Hcl acid = ulceration 5. Caffeine – tea, soda, chocolate 6. Irregular diet 7. Rapid eating 8. Ulcerogenic drugs – NSAIDS, aspirin, steroids, indomethacin, ibuprofen Indomethacin - S/E corneal cloudiness. Needs annual eye check up. NSAID and steroids= gastropathy 9. Gastrin producing tumor or gastrinoma – Zollinger Ellisons syndrome 10. Microbial invasion – helicobacter pylori. Metronidazole (Flagyl)

Types of ulcers Ascending to severity 1. Acute – affects submucosal lining 2. Chronic – affects underlying tissues – heals & forms a scar, deeper According to location 1. Stress ulcer 2. Gastric ulcer 3. Duodenal ulcer – most common Stress ulcers – common among critically ill clients 2 types 1. Curling’s ulcer – cause: trauma & Burns Hypovolemia GIT schemia Decrease resistance of mucosal barriers to Hcl acid Ulcerations 2. Cushing’s ulcer – cause – stroke/CVA/ head injury Increase vagal stimulation Hyperacidity Ulcerations Treatment: Vagotomy - done to prevent hemorrhage and shock prior to surgery on the stomach

GASTRIC ULCER SITE PAIN

HYPERSECRETION VOMITING HEMORRHAGE WT COMPLICATIONS HIGH RISK INCIDENCE

Antrum or lesser curvature - 30 min – 1 hr after eating - epigastrium - gaseous & burning - not usually relieved by food & antacid - Eating leads to pain Normal gastric acid secretion common hematemesis Wt loss a. stomach cancer b. hemorrhage 50 or 60 years old and above Male; female = 1:1 15% of peptic ulcers are gastric

DUODENAL ULCER Duodenal bulb - 2-3 hrs after eating - mid epigastrium - cramping & burning pain - usually relieved by food & antacid - 12 MN – 3am pain - Eating lessens pain Increased gastric acid secretion Not common Melena Wt gain a. perforation 20 years old and above Male: Female = 2-3:1 80% of peptic ulcers are duodenal

90-95% is cases of duodenal ulcers - less bicarbonate ions, decrease so increase incidence Diagnosis: 1. Endoscopic exam 2. Stool from occult blood (+) 3. Gastric analysis – Gastric Ulcer: normal gastric acid secretion Duodenal: increased gastric acid secretion 4. GI series – confirms presence of ulceration Nursing Mgt: 1. Diet – bland, non irritating, non spicy 2. Avoid caffeine & milk/ milk products Increase gastric acid secretion 3. ister meds a.) Antacids ACA Aluminum containing antacids

Magnesium containing antacids

ex. aluminum hydroxide gel ex. milk of magnesia (Amphogel) S/E diarrhea S/E constipation Maalox (fever S/E) b.) H2 receptor antagonist: 1. Ranitidine (Zantac) SE: fever 2. Cimetidine (Tagamet)—hastens the effect of oral anticoagulants 3. Famotidine (Pepcid) SE: fever - Avoid smoking – decrease effectiveness of drug Nursing Mgt: 1. ister antacid & H2 receptor antagonist (Cimetidine) – 1hr apart -Cemetidine decrease antacid absorption & vise versa c.) Cytoprotective agents Ex 1. Sucralfate (Carafate) - Provides a paste like subs that coats mucosal lining of stomach 2. Misoprostol (Cytotec) –SE: menstrual spotting d.) Sedatives/ Tranquilizers - Valium, lithium e.) Anticholinergics / Antispasmodic 1. Atropine SO4 2. Prophantheline Bromide (Profanthene) (Pt has history of hpn crisis with peptic ulcer disease. Rn should not ister alka seltzer- has large amount of Na. 3. Surgery: subtotal gastrectomy - Partial removal of stomach Billroth I (Gastroduodenostomy) 

Removal of ½ of stomach & anastomoses of gastric stump to the duodenum.

Billroth II (Gastrojejunostomy)  Removal of ½ -3/4 of stomach & duodenal bulb & anastomostoses of gastric stump to jejunum.

Before surgery for BI or BII - Do vagotomy (severing of vagus nerve) & pyloroplasty (drainage) first. Nursing Mgt: 1. Monitor NGT output or drainage immediately post op- bright red a.) Immediately post op should be bright red b.) Within 36- 48h – output is yellow green c.) After 48h – output is dark red due to HCl acid 2. ister meds: a.) Analgesic b.) Antibiotic c.) Antiemetics 3. Maintain patent IV line 4. VS, I&O & bowel sounds 5. Complications: a.) Hemorrhage – hypovolemic shock Late signs – anuria b.) Peritonitis c.) Paralytic ileus – most feared d.) Hypokalemia e.) Thrombophlebitis f.) Pernicious anemia g.) Septicemia