PEPTIC ULCER

Peptic ulcer disease refers to ulcerations in the mucosa of the lower esophagus, stomach, or duodenum (see Figure 18-4).

FIGURE 18-4 Esophageal, gastric, and duodenal ulcer sites.

Pathophysiology and Etiology

• Etiology of peptic ulcers disease is multifactorial.
  • H. pylori infection—present in most patients with peptic ulcer disease.
  • NSAID-induced injury—presents as a chemical gastropathy.
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  • Acid secretory abnormalities (especially in duodenal ulcers).
  • Zollinger-Ellison syndrome (hypersecretory syndrome) should be considered in refractory ulcers.
• Risk factors may include drugs (NSAIDs, prolonged high-dose corticosteroids), family history, Zollinger-Ellison syndrome, cigarettes, stress, blood group O, and lower socioeconomic status.
• Studies are inconclusive in determining an association between ulcer formation and diet or the intake of alcohol and caffeine.

Clinical Manifestations

• Gnawing or burning epigastric pain occurring 1½ to 3 hours after a meal
• Nocturnal epigastric, abdominal pain or burning. May awaken patient at night, usually around midnight to 3 a.m.
• Epigastric tenderness on examination
• Early satiety, anorexia, weight loss, heartburn, belching (may indicate reflux disease)
• Dizziness, syncope, hematemesis, or melena (may indicate hemorrhage)
• Anemia

NURSING ALERT

Sudden, intense midepigastric pain radiating to the right shoulder may indicate ulcer perforation.

Diagnostic Evaluation

• Upper GI endoscopy with possible tissue biopsy and cytology. Pyloritek, a biopsy urea test, is up to 95% specific in detecting H. pylori.
• Upper GI radiographic examination (barium study)
• Serial stool specimens to detect occult blood
• Gastric secretory studies (gastric acid secretion test and serum gastric level test)—elevated in Zollinger-Ellison syndrome
• Serology to test for H. pylori antibodies
• C or C-urea breath test to detect H. pylori

Management

General Measures

• Eliminate use of NSAIDs or other causative drugs.
• Eliminate cigarette smoking (impairs healing).
• Well-balanced diet with meals at regular intervals. Avoid dietary irritants.

Drug Therapy

• Multiple drug regimens are used to treat H. pylori (see Table 18-2)

  TABLE 18-2 Drug Regimens for Eradication of Helicobacter pylori

  DRUG DOSAGE DURATION Omeprazole (Prilosec) 20 mg PO bid 7-14 days Clarithromycin (Biaxin) 500 mg PO bid Amoxicillin 1,000 mg PO bid Omeprazole (Prilosec) 20 mg bid 10 days Bismuth subsalicylate (Pepto-Bismol) 2 tabs PO qid Days 4-10 only Metronidazole (Flagyl) 500 mg tid Tetracycline 500 mg PO qid Omeprazole (Prilosec) 20 mg bid 7-14 days Clarithromycin (Biaxin) 250 mg bid Metronidazole (Flagyl) 500 mg bid Note: Omeprazole may be substituted with lansoprazole, pantoprazole, ranitidine bismuth citrate or, possibly, ranitidine.

DRUG ALERT

Stop antisecretory proton pump inhibitor at least 2 weeks before the C-urea breath test. It can cause false-negative test result.

Surgery

• Surgical interventions may be indicated for hemorrhage, obstruction, perforation, and acid reduction (see Figure 18-5). Surgery may also be indicated with ulcer disease of long duration or severity or difficulty with medical regimen compliance.
  

  FIGURE 18-5 Surgical procedures for peptic ulcer. (A) Gastrojejunostomy (Billroth II). The jejunum is anastomosed to the gastric stump after a partial gastrectomy (removal of antrum and pylorus). (B) Antrectomy and vagotomy. The resected portion includes a small cuff of duodenum, the pylorus, and the antrum (about one half of the stomach). The stump of the duodenum is closed by suture, and the side of the jejunum is anastomosed to the cut end of the stomach. (C) Subtotal gastrectomy. The resected portion includes a small cuff of the duodenum, the pylorus, and from two-thirds to three-quarters of the stomach. The duodenum or side of the jejunum is anastomosed to the remaining portion of the stomach. (D) Vagotomy and pyloroplasty. A longitudinal incision is made in the pylorus, and it is closed transversely to permit the muscle to relax and to establish an enlarged outlet. This compensates for the impaired gastric emptying produced by vagotomy. (E) Gastroduodenostomy (Billroth I). The duodenum is anastomosed to the gastric stump after removal of the antrum and pylorus (partial gastrectomy).

• Gastroduodenostomy (Billroth I).
  • Partial gastrectomy with removal of antrum and pylorus of stomach.
  • The gastric stump is anastomosed with the duodenum.
• Gastrojejunostomy (Billroth II)
  • Partial gastrectomy with removal of antrum and pylorus of stomach.
  • The gastric stump is anastomosed with the jejunum.
• Antrectomy
  • Gastric resection includes a small cuff of duodenum, the pylorus, and the antrum (lower half of stomach).
  • The duodenal stump is closed, and the jejunum is anastomosed to the stomach.
• Total gastrectomy
  • Also called an esophagojejunostomy.
  • Removal of the stomach with attachment of the esophagus to the jejunum or duodenum.
• Pyloroplasty
  • A longitudinal incision is made in the pylorus, and it is closed transversely to permit the muscle to relax and to establish an enlarged outlet.
  • Often, a vagotomy is performed at the same time.
• Vagotomy
  • The surgical division of the vagus nerve to eliminate the impulses that stimulate HCL secretion.
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  • There are three types: selective vagotomy, which severs only the branches that interrupt acid secretion; truncal vagotomy, which severs the anterior and posterior trunks to decrease acid secretion and gastric motility; and parietal vagotomy, which severs only the part of vagus that innervates the parietal acid-secreting cells.
  • Traditionally performed by laparotomy, the vagotomy procedure can also be done using a laparoscope.

Complications

• GI hemorrhage
• Ulcer perforation
• Gastric outlet obstruction

Nursing Assessment

• Determine location, character, radiation of pain, factors aggravating or relieving pain, how long it lasts, when it occurs.
• Ask about eating patterns, regularity, types of food, eating circumstances.
• Ask about medications (especially aspirin, anti-inflammatory drugs, or steroids).
• History of illnesses including previous GI bleeds.
• Obtain psychosocial history.
• Perform physical assessment with documentation of positive abdominal findings.
• Take vital signs, including lying, standing, and sitting BPs and pulses, to determine if orthostasis is present due to bleeding.

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Nursing Diagnoses

• Deficient Fluid Volume related to hemorrhage
• Acute Pain related to epigastric distress secondary to hypersecretion of acid, mucosal erosion, or perforation
• Diarrhea related to GI bleeding
• Imbalanced Nutrition: Less Than Body Requirements related to the disease process
• Deficient Knowledge related to physical, dietary, and pharmacologic treatment of disease

Nursing Interventions

Avoiding Fluid Volume Deficit

• Monitor intake and output continuously to determine fluid volume status.
• Monitor stools for blood and emesis.
• Monitor hemoglobin and hematocrit and electrolytes.
• Administer prescribed I.V. fluids and blood replacement, as prescribed.
• Insert NG tube as prescribed, and monitor the tube drainage for signs of visible and occult blood.
• Administer medications through the NG tube to neutralize acidity, as prescribed.
• Prepare patient for saline lavage, as ordered.
• Observe patient for an increase in pulse and a decrease in BP (signs of shock).
• Prepare patient for diagnostic procedure or surgery to determine or stop the source of bleeding.

Achieving Pain Relief

• Administer prescribed medication.
• Provide small, frequent meals to prevent gastric distention if not NPO.
• Advise patient about the irritating effects of certain drugs and foods.

Decreasing Diarrhea

• Monitor patient's elimination patterns to determine effects of medications.
• Monitor vital signs, and watch for signs of hypovolemia.
• Administer antidiarrheal medication as prescribed.
• Watch for signs and symptoms of impaired skin integrity (erythema, pain, pruritus) around anus to promote comfort and decrease risk of infection.

Achieving Adequate Nutrition

• Eliminate foods that cause pain or distress; otherwise, the diet is usually not restricted.
• Provide small, frequent meals that neutralize gastric secretions and may be better tolerated.
• Provide high-calorie, high-protein diet with nutritional supplements as ordered.
• Administer parenteral nutrition as ordered if bleeding is prolonged and patient is malnourished.

Educating the Patient About the Treatment Regimen

• Explain all tests and procedures to increase knowledge and cooperation; minimize anxiety.
• Review the health care provider's recommendations for diet, activity, medication, and treatment. Allow time for questions, and clarify any misunderstandings.
• Give the patient a chart listing medications, dosages, times of administration, and desired effects to promote compliance.
• Teach patient signs and symptoms of bleeding and when to notify the health care provider.

Patient Education and Health Maintenance

• Teach patient signs and symptoms of bleeding and when to notify the health care provider.
• Promote healthy lifestyle changes to include adequate nutrition, cessation of smoking, decreased alcohol consumption, stress reduction strategies.
• Teach purpose, dosage, and adverse effects of each medication prescribed.

Evaluation: Expected Outcomes

• Vital signs stable; fluid volume maintained
• Pain free
• No more than two to three loose stools per day
• Eats frequent small meals each day; reports no loss of weight
• Describes peptic ulcer disease, its treatment, and complications; complies with treatment regimen

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