Transcript Peptic Ulcers

Peptic Ulcer Disease
Therapy
Peptic Ulcer Disease
Collaborative Care
 Medical regimen consists of
 Adequate
rest
 Dietary modification
 Drug therapy
 Elimination of smoking
 Long-term follow-up care
Peptic Ulcer Disease
Collaborative Care
 Aim of treatment program
↓


degree of gastric acidity
Enhance mucosal defense mechanisms
Minimize harmful effects on mucosa
Peptic Ulcer Disease
Collaborative Care
 Generally treated in ambulatory care
clinics
 Requires many weeks of therapy
 Pain disappears after 3 to 6 days
Peptic Ulcer Disease
Collaborative Care
 Healing may take 3 to 9 weeks
 Should
be assessed by means of x-rays
or endoscopic examination
 Moderation in daily activity is essential
 NSAIDs that are COX-2 inhibitors are
used
Peptic Ulcer Disease
Drug Therapy
 Includes use of
 Antacids
 H 2R
blockers
 PPIs
 Antibiotics
 Anticholinergics
 Cytoproctective
therapy
Peptic Ulcer Disease
Drug Therapy
 Recurrence of peptic ulcer is frequent
 Interruption
or discontinuation of
therapy can have detrimental results
 No drugs, unless prescribed by health
care provider, should be taken
 Ulcerogenic effect
Peptic Ulcer Disease
Drug Therapy
 Histamine-2 receptor blocks (H2R
blockers)
 Used to manage peptic ulcer disease
 Block action of histamine on H2
receptors
↓ HCl acid secretion
 ↓ conversion of pepsinogen to pepsin
 ↑ ulcer healing

Peptic Ulcer Disease
Drug Therapy
 Proton pump inhibitors (PPI)
 Block ATPase
enzyme that is important
for secretion of HCl acid
 Antibiotic therapy
 Eradicate H. pylori infection
 No single agents have been effective in
eliminating H. pylori
Peptic Ulcer Disease
Drug Therapy
 Antacids
 Used
as adjunct therapy for peptic
ulcer disease
 ↑ gastric pH by neutralizing acid
 Anticholinergic drugs
 Occasionally ordered for treatment
 ↓ cholinergic stimulation of HCl acid
Peptic Ulcer Disease
Drug Therapy
 Cytoprotective drug therapy
 Used
for short-term treatment of ulcers
 Tricyclic antidepressants
 Serotonin reuptake inhibitors
Peptic Ulcer Disease
Nutritional Therapy
 Dietary modifications may be necessary
so that foods and beverages irritating to
patient can be avoided or eliminated
 Nonirritating or bland diet consisting of 6
small meals a day during symptomatic
phase
Peptic Ulcer Disease
Nutritional Therapy
 Include a sample diet with a list of foods
that usually cause distress
 Hot, spicy foods and pepper, alcohol,
carbonated beverages, tea, coffee,
broth
 Foods high in roughage may irritate an
inflamed mucosa
Peptic Ulcer Disease
Nutritional Therapy
 Protein considered best neutralizing food
 Stimulates
gastric secretions
 Carbohydrates and fats are least
stimulating to HCl acid secretion
 Do not neutralize well
Peptic Ulcer Disease
Nutritional Therapy
 Milk can neutralize gastric acidity and
contains prostaglandins and growth
factors
 Protects
GI mucosa from injury
Peptic Ulcer Disease
Therapy Related to Complications
 Acute exacerbation
 Treated
with same regimen used for
conservative therapy
 Situation is more serious because of
possible complications of perforation,
hemorrhage, gastric outlet obstruction
 Accompanied by bleeding, ↑ pain and
discomfort, nausea, vomiting
Peptic Ulcer Disease
Therapy Related to Complications
 Acute exacerbation (cont.)
 Recurrent
vomiting, gastric outlet
obstruction
NG tube placed in stomach with
intermittent suction for about 24 to 48
hours
 Fluids and electrolytes are replaced by IV
infusion until patient is able to tolerate
oral feedings without distress

Peptic Ulcer Disease
Therapy Related to Complications
 Acute exacerbation (cont.)
 Management
is similar to that for
upper GI bleeding
 Blood or blood products may be
administered
 Careful monitoring of vital signs,
intake and output, laboratory studies,
signs of impending shock
Peptic Ulcer Disease
Therapy Related to Complications
 Acute exacerbation (cont.)
 Endoscopic
evaluation reveals degree
of inflammation or bleeding and ulcer
location
 5-year follow-up program is
recommended
Peptic Ulcer Disease
Therapy Related to Complications
 Perforation
 Immediate
focus to stop spillage of
gastric or duodenal contents into
peritoneal cavity and restore blood
volume
 NG tube is placed into stomach

Placement of tube as near to perforation
site as possible facilitates decompression
Peptic Ulcer Disease
Therapy Related to Complications
 Perforation (cont.)
 Circulating
blood volume must be
replaced with lactated Ringer’s and
albumin solutions
 Blood replacement in form of packed
RBCs may be necessary
 Central venous pressure line,
indwelling urinary cater should be
inserted and monitored hourly
Peptic Ulcer Disease
Therapy Related to Complications
 Gastric outlet obstruction
 Decompress
stomach
 Correct any existing fluid and
electrolyte imbalances
 Improve patient’s general state of
health
 NG tube inserted in stomach, attached
to continuous suction to remove excess
fluids and undigested food particles
Peptic Ulcer Disease
Therapy Related to Complications
 Gastric outlet obstruction (cont.)
 Continuous
decompression allows
Stomach to regain its normal muscle tone
 Ulcer can begin to heal
 Inflammation and edema subside

 When
aspirate falls below 200 ml,
within normal range, oral intake of
clear liquids can begin
Peptic Ulcer Disease
Therapy Related to Complications
 Gastric outlet obstruction (cont.)
 Watch
patient carefully for signs of
distress or vomiting
 IV fluids and electrolytes are
administered according to degree of
dehydration, vomiting, electrolyte
imbalance
Peptic Ulcer Disease
Nursing Management
 Overall Goals
 Comply
with prescribed therapeutic
regimen
 Experience a reduction or absence of
discomfort related to peptic ulcer
disease
Peptic Ulcer Disease
Nursing Management
 Overall Goals (cont.)
 Exhibits
no signs of GI complications
 Have complete healing
 Lifestyle changes to prevent recurrence
Peptic Ulcer Disease
Nursing Implementation
 Health Promotion
 Identify
patients at risk
 Early detection and ↓ morbidity
 Encourage patients to take ulcerogenic
drugs with food or milk
 Teach patients to report symptoms
related to gastric irritation to health
care provider
Peptic Ulcer Disease
Nursing Implementation
 Acute Intervention
 Patient
generally complains of ↑ pain,
nausea, vomiting, and some bleeding
 May be maintained on NPO status for
a few days, have NG tube inserted,
fluids replaced intravenously
 Physical and emotional rest are
conducive to ulcer healing
Peptic Ulcer Disease
Nursing Implementation
 Hemorrhage
 Changes
in vital signs, ↑ in amount and
redness of aspirate signal massive
upper GI bleeding
 ↑ amount of blood in gastric contents ↓
pain because blood helps neutralize
acidic gastric contents
 Keep blood clots from obstructing NG
tube
Peptic Ulcer Disease
Nursing Implementation
 Perforation
 Sudden,
severe abdominal pain
unrelated in intensity and location to
pain that brought patient to hospital
Peptic Ulcer Disease
Nursing Implementation
 Perforation (cont.)
 Indicated
by a rigid, boardlike
abdomen
 Severe generalized abdominal and
shoulder pain
 Shallow, grunting respirations
Peptic Ulcer Disease
Nursing Implementation
 Perforation (cont.)
 Ensure
any known allergies are
reported on chart

Antibiotic therapy is usually started
 Surgical
closure may be necessary if
perforation does not heal
spontaneously
Peptic Ulcer Disease
Nursing Implementation
 Gastric outlet obstruction
 Can

occur at any time
Likely in patients whose ulcer is located
close to pylorus
 Gradual
onset
 Constant NG aspiration of stomach
contents may relieve symptoms
 Regular irrigation of NG tube
Peptic Ulcer Disease
Ambulatory and Home Care
 General instructions should cover aspects
of disease, drugs, possible lifestyle
changes, regular follow-up care
 Patient motivation ↑ when they
understand why they should comply with
therapy and follow-up care
Peptic Ulcer Disease
Surgical Therapy
 < 20% of patients with ulcers need
surgical intervention
 Indications for surgical interventions
 Intractability
 History of hemorrhage, ↑ risk of
bleeding
 Prepyloric or pyloric ulcers
Peptic Ulcer Disease
Surgical Therapy
 Indications for surgical interventions
(cont.)
 Multiple ulcer sites
 Drug-induced ulcers
 Possible existence of a malignant ulcer
 Obstruction
Peptic Ulcer Disease
Surgical Therapy
 Surgical procedures
 Gastroduodenostomy
 Gastrojejunostomy
 Vagotomy
 Pyloroplasty
Peptic Ulcer Disease
Surgical Therapy
A. Billroth I Procedure
B. Billroth II Procedure
Fig. 40-16
Peptic Ulcer Disease
Postoperative Complications
 Dumping syndrome
 Postprandial hypoglycemia
 Bile reflux gastritis
Peptic Ulcer Disease
Dumping Syndrome
 Direct result of surgical removal of a
large portion of stomach and pyloric
sphincter
 ↓ reservoir capacity of stomach
Peptic Ulcer Disease
Dumping Syndrome
 Associated with meals having a
hyperosmolar composition
 Experienced by one-third to one-half of
patients after peptic ulcer surgery
Peptic Ulcer Disease
Postprandial Hypoglycemia
 Considered a variant of dumping
syndrome
 Result of uncontrolled gastric emptying
of a bolus of fluid high in carbohydrate
into small intestine
 Release of excessive amounts of insulin
into circulation
Peptic Ulcer Disease
Bile Reflux Gastritis
 Prolonged contact of bile causes damage
to gastric mucosa
 Administration of cholestyramine
relieves irritation
 Also, aluminum hydroxide antacids
Peptic Ulcer Disease
Nutritional Therapy
 Start as soon as immediate postoperative
period is successfully passed
 Patient should be advised to eliminate
drinking fluid with meals
Peptic Ulcer Disease
Nutritional Therapy
 Diet should consist of
 Small,
dry feedings daily
 Low in carbohydrates
 Restricted in sugars
 Moderate amounts of protein and fat
 30 minutes of rest after each meal
 Interventions are diet instruction, rest,
and reassurance
Peptic Ulcer Disease
Gerontologic Considerations
 ↑ patients > 60 years of age
↑
use of NSAIDs
 First manifestation may be frank gastric
bleeding or ↓ hematocrit
 Treatment similar to younger adults
 Emphasis placed on prevention of both
gastritis and peptic ulcers