Peptic Ulcer

It 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.

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

Differentiating Gastric and Duodenal Ulcers:

Gastric Ulcer	Duodenal Ulcer
Gnawing epigastric pain occurring 30 minutes to 1 hour after meals	Gnawing epigastric pain occurring 2-3 hours after meals
Aggravated by eating (because acid secretion increase at meal time) leads to weight loss	Relieved by food (because the pyloric sphincter, at the junction of stomach and duodenum, closes upon eating to concentrate food in the stomach) causes weight gain
Relieved by vomiting (because acid is expelled out)	Not relived
No pain at hours of sleep (HCl production decreases at hours of sleep)	Pain at hours of sleep (because gastric emptying continuous at hours of sleep)
More common in persons older than age 50	More common between ages 25 and 50

  

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

Monitor the patient for signs of bleeding through fecal occult blood, vomiting, persistent diarrhea, and change in vital signs.

Monitor intake and output.

Monitor the patient’s hemoglobin, hematocrit, and electrolyte levels.

Administered prescribed I.V. fluids and blood replacements if acute bleeding is present.

Maintain nasogastric tube for acute bleeding, perforation, and postoperatively, monitor tube drainage for amount and color.

Perform saline lavage if ordered for acute bleeding.

Encourage bed rest to reduce stimulation that may enhance gastric secretion.

Provide small, frequent meals to prevent gastric distention if not actively bleeding.

Watch for diarrhea caused by antacids and other medications.

Restrict foods and fluids that promote diarrhea and encourage good perineal care.

Advise patient to avoid extremely hot or cold food and fluids, to chew thoroughly, and to eat in a leisurely fashion to reduce pain.

Administer medications properly and teach patient dose and duration of each medication.

Advise patient to modify lifestyle to include health practices that will prevent recurrences of ulcer pain and bleeding.