What is a peptic ulcer?
an excavation that forms in mucosal wall of stomach, pylorus (opening between stomach and duodenum), in duodenum, or esophagus
• Cause = Helicobactor pylori infection
• erosion of mucous membrane, may extend into muscle or through to peritoneum
Where in the stomach do chronic ulcers tend to occur?
Most common place in general?
Chronic ulcers tend to occur in lesser curvature near pylorus
•Most often occur in duodenum
Esophageal ulcers often result of?
GERD
When does PUD commonly occur?
PUD typically occurs in ages 40-60yrs
but can be in children and infants; rare in women of childbrearing age
How does helicobactor pylori spread?
DO all of those infected get PUD?
- In food and water, person-to-person via emesis
* Not all infected by H. Pylori have ulcers – mechanism of this is not entirely understood
Risk factors for PUD?
- Stress, Caffeine, smoking, milk, and alcohol can lead to inc HCl production, which is turn can contribute
- Predispositions: Type O blood (familial ties), COPD, chronic renal disease, chronic NSAID use, alcohol + smoking
WHat is a stress ulcer?
= acute mucosal ulceration that occurs after physiological stressful event (burns, shock, sever sepsis) → not peptic ulcers, will grow in numbers until stressful event subsides, typical after sx
o Result from shock → causing ischemia, resulting in inc acid and pepsin
Patho of PUD?
- Gastroduodenal mucosa can’t withstand digestive action of HCl and pepsin
- Damaged mucosa cannot secrete enough mucus for protection
- NSAIDs dec mucous secretion
- Gastric ulcer = typically abn high HCl secretion; duodenal = abn low or normal levels of HCl
Clinical manifestations of PUD?
- Many ppl have no symptoms or may be intermittent
- May disappear and reappear, last days to months
- Perforation or hemorrhage may occur in 20-30% of those with no preceding mnfts
- Have dull, gnawing pain or burning sensation in midepigastrium or back
- Pain relieved by eating (or taking alkali) b/c food neutralizes acid
- Sharply localized tenderness with pressure
- Vomiting rare in duodenal ulcer, caused by obstruction of pyloric orifice (may not be preceded by nausea but rather bout of pain and bloating)
- Constipation and diarrhea possible
- Melena (tarry stools) occurs d/t bleeding – 15% of cases bleed
Diagnostics in PUD?
- Physical exam: pain, epigastric tenderness, or abdominal distension
- Endoscopy preferred b/c can have visualization of lesion, biopsy taken
- Barium study may show ulcer
- Stools may be tested periodically
- H Pylori found via endoscopy, histology, serology, stool antigen test, urea breath test
Medical management of PUD?
• Goal is to eradicate H pylori and manage gastric acidity
• Medications, lifestyle changes, and surgical intervention used
- Stress reduction
- Smoking reduction
- Dietary modifications
- Sx mangement
• Pharmacology: abx, PPI’s, H2RAs, and bismuth salts (aka Pepto Bismol) to suppress H Pylori
o Pt given rest, sedatives, and tranquilizers for comfort
Possible stress reduction measures used in pt’s with IBD?
biofeedback, hypnosis, behavior mod & massage may be helpful
Why is smoking cessation important for PUD?
smoking reduced bicarbonate production from pancreas (makes duodenum more acidic)
Dietary changes made in PUD?
to reduce acid production and hypermotility
Avoid consumption of extreme temp foods, meat extracts, alcohol, coffee, caffeine, milk and cream
3 regular meals; stop consumption of those foods that cause pain
When is surgical management used in PUD?
rare but recommended for those with intractable ulcers (fail to health w 12-16wks medical treatment), hemorrhage, performation, obstruction, etc
Assessments done for PUD pt? What kind of fundings?
When does pain typically occur?
What is it relieved by?
• Pain – usually occurs 2 hours after meal, awakens pt between midnight and 3AM
–> Relieved by antacids, vomiting, eating
- Qualities of emesis, tarry stool?
- Describe food habits
- Smoking, alcohol, NSAID use
- Vitals – tachycardia and hypotension possibl from GI bleed
- Palpation of abdomen for tenderness
- Stool sample
Typical nursing diagnoses related to PUD?
- Acute pain r/t effects of gastric acid secretion on damaged tissue
- Imbalanced nutrition r/t changes in diet
- Anxiety r/t acute illness
- Deficient knowledge about prevention of symptoms and management of condition
Possible PUD complications?
hemorrhage, perforation, penetration, pyloric obstruction
Primary nursing interventions for PUD?
1) Pain relief
2) Reducing anxiety
3) Maintain optimal nutritional status (assess for malnutrition and weight loss)
4) Monitoring and managing potential complications
What interventions are possible for pain relief in PUD?
give meds
avoid aspirin, caffeine, decaf coffee
relaxation techniques
What complication is most common in pUD?
Hemorrhage (10-20% of cases)
How might hemm be seen in PUD?
• Seen as hematemesis or melena (may vomit bright red or coffee grounds)
- Assess for faintness, dizziness, nausea
- Look for tachycardia, hypotension, tachypnea
- Monitor HCt, Hb
- Stool tests for frank or occult blood
- Hourly urinary output (look for anuria or oliguria)
What is important to determine if pt seems to be hemorrhaging?
- Important to identify extent of bleeding – can be fatal!
* High blood loss or recurrence likely requires sx
Interventions if hemorrhage in occurring?
• Insert peripheral IV for LR, NS, or blood products
- NG tube inserted to differentiate fresh blood and coffee grounds, aid in removal of clots and acid, prevent nausea and vomiting
- Possible urinary catheter + monitor output
- O2 sats
- Positioning pt: recumbent for hypotension, on side if vomiting
- Treating hemorrhagic shock
- Possible endoscopic repair or selective embolization (inserting clot to prevent bleeding)
