Transcript Peptic Ulcer

Adult MedicalSurgical Nursing
Gastro-intestinal Module:
Gastritis and Peptic Ulcer
 Gastritis
Gastritis
 Gastritis is an acute or chronic
inflammation of the gastric mucosa
 Risk factors include:
 Spicy food
 Overuse of Aspirin, NSAIDs
 Excessive alcohol and caffeinated drinks
 Smoking; stressful lifestyle
 Helicobacter pylori or other pathogen
Gastritis: Pathophysiology
 The gastric mucosa is protected from the
high acidity of hydrochloric acid in the
stomach by mucus secretion
 Mucosal damage occurs through:
 Interference with the amount of acid:
hypersecretion or achlorhydria
 Reduction of mucus production
 Generalised inflammation results. Where
acute can lead to necrosis, scarring or
perforation
Helicobacter Pylori
 H pylori is an organism which has been
closely related to gastritis and peptic
ulcer
 It can be detected in blood and breath
tests
 Where present, treatment includes
antibiotics in addition to control of peptic
acid content
Gastritis:
Clinical Manifestations
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Anorexia
Heartburn after eating
Flatulence (belching)
Nausea/ vomiting
Sour taste in mouth
Gastritis: Diagnosis
 Clinical symptoms and dietary history
 Breath test, stool or serological test for H
pylori
 Endoscopy:
 Inspection
 Gastric washings for H. pylori
 Biopsy
 Serum B12 (may be ↓ if intrinsic factor
affected)
Gastritis:
Treatment/ Counselling
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Dietary changes
↓ smoking
Less stressful lifestyle
Antibiotics
Acid reduction through:
H2 receptor inhibitors (Ranitidine)
Proton pump inhibitors (Lanzoprazole)
 Peptic Ulcer
Peptic Ulcer
 The gastric and intestinal wall layers are:
mucosa → sub-mucosa → muscle→
serosa→ peritoneum
 A peptic ulcer is an erosion of the
mucosa of the stomach, pylorus,
duodenum or oesophagus in a
circumscribed area. It may pass through
all layers and eventually perforate to the
peritoneum
 Multiple ulcers may be present at once
Gastric Ulcers (15% of total):
Main Features
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Later onset: usually after 50 years of age
Similar occurance in male : female (1:1)
Normal, ↑ HCl or ↓ HCl (achlorhydria)
Epigastric pain occurs after a meal
(within the following hour), relieved by
vomiting
 Associated with weight loss
 Risk of haemorrhage
 Long-term risk for gastric malignancy
Duodenal Ulcers (80% of
total): Main Features
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Affect younger age group (30-60 years)
Occurence in male: female is 2-3 :1
Related to hyperacidity (↑ HCl secretion)
Epigastric dull, gnawing pain occurs 2-3
hours after food, often awakens the
patient, relieved by food
 Vomiting not common
 Increased risk of perforation
 Less risk of malignancy
Peptic Ulcer: Aetiology
 Risk factors for peptic ulcer include:
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H pylori (70% in gastric; 95% in duodenal)
Genetic link: blood group “O”
Spicy food; also milk and cream
Smoking
Stressful lifestyle
Use of aspirin, NSAIDs, corticosteroids
Excessive alcohol and caffeinated drinks
Peptic Ulcer:
Stress Ulcers
 Stress ulcers are usually found in ICU
patients (prophylaxis given routinely)
 Related to physiological stress
 Also related to corticosteroid therapy
 Usually preceded by shock (severe
trauma, burns, sepsis) → reduced blood
flow to the mucosa and reflux of
duodenal contents to the stomach →
outpouring of HCl and pepsin on less
protected mucosa → ulceration
Peptic Ulcer:
Pathophysiology
 Peptic ulcer is largely related to:
 Increased concentration and action of
HCl on the mucosa (stress, spicy foods,
smoking, caffeine, alcohol)
 Reduced mucus secretion: ↓ mucosal
resistance and protection from the
digestive action of HCl (stress, aspirin,
NSAIDs, corticosteroids, H pylori)
Peptic Ulcer:
Clinical Manifestations
 Dull, gnawing epigastric or back pain
(thought to be the effect of acid on
exposed nerve endings)
 Relieved by vomiting (gastric) or by food
(duodenal)
 Tenderness over the epigastrium
 Possible weight loss
 Anaemia if acute or chronic haemorrhage
 Haematemesis or malaena (“tarry” stool)
Peptic Ulcer: Diagnosis
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History and physical examination
CBC (anaemia)
Stool: Guiac test for occult blood
Breath test, stool or serum (antibodies)
for Helicobacter pylori
 Endoscopy: Inspection
 Biopsy of mucosa for histology
 Gastric washings for culture of H pylori
Peptic Ulcer:
Medical Management
 Lifestyle changes
 Medical treatment:
 Antibiotics (Flagyl and one other antibiotic)
 H2-receptor antagonist (Ranitidine) or Protonpump inhibitor (Lanzoprazole)
 Mucosal protection (Misoprostol)
 (Usually avoid antacids as interfere with
treatment)
Peptic Ulcer: Surgery
 Surgery is less used now. Mainly for:
 Ulcers not healing after 12 – 16 weeks
 Life-threatening complications:
 Haemorrhage
 Perforation/ penetration
 Pyloric obstruction
Peptic Ulcer: Surgery
 Types of surgical procedure:
 Vagotomy (resection of the vagus,
parasympathetic nerve: ↓ HCl secretion)
 Pyloroplasty (with or without vagotomy)
 Gastro-enterostomy (bypass from
stomach to jejunum)
Peptic Ulcer
Complications: Haemorrhage
 Haemorrhage: ulcer has eroded a blood
vessel
 Haematemesis, especially gastric ulcer: fresh
blood or “coffee-ground” vomit
 Malaena (more obvious if duodenal ulcer)
 May be an emergency → hypovolaemic shock
 GXM, IV fluids, vital signs, NG tube, NPO
 Rest, mouth care, surgical prep (if needed)
Peptic Ulcer
Complications: Perforation
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Perforation:
Ulcer has perforated layers to the peritoneum
Acid contents leaking into peritoneum
Patient in severe shock from extreme pain of
chemical peritonitis
 Rigid, board-like abdomen, extremely tender
 Hypotension: emergency requiring immediate
resuscitation and preparation for surgery to
repair
Peptic Ulcer: Nursing Care
 Pre-operative care: (may well be emergency)
 General physical check-up, chest Xray, ECG
 Blood profile, IVI, group and cross-match
(GXM)
 Breathing exercises to prepare for post-op
 Thrombo-embolic stockings/ prophylactic
heparin
 Explanation of operation, consent and
emotional support
Peptic Ulcer: Nursing Care
 Post-operative care:
 Pain relief
 Monitor vital signs, pulse oximetry, IV fluids,
urine output and fluid balance
 Semi-sitting position once recovered
 Breathing and leg exercises
 NPO initially→ graduated intake (mouth care)
 NG tube aspirations, wound, drain care