Peptic ulcer disease
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PEPTIC ULCER
DISEASE
K.THULASI RAM .Msc(N)
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ANATOMY AND PHYSIOLOGY OF GI TRACT
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DEFINITIONPeptic ulcer disease is a condition
characterised by erosion of GI mucosa resulting from the digestive action of HCL acid and pepsin.
Common sites are lower oesophagus, stomach and duodenum.
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PEPTIC ULCER DISEASE
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PREVALANCE IN INDIA 4 t0 10 per
1000 population
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STOMACH DEFENSE SYSTEMS Mucous layer
Coats and lines the stomachFirst line of defense
BicarbonateNeutralizes acid
ProstaglandinsHormone-like substances that keep blood vessels dilated for good blood flow
Thought to stimulate mucus and bicarbonate production
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RISK FACTORS Lifestyle
SmokingAcidic drinksMedications
H. Pylori infection90% have this
bacteriumPassed from person
to person (fecal-oral route or oral-oral route)
AgeDuodenal 30-50Gastric over 60
GenderDuodenal: are
increasing in older women
Genetic factorsMore likely if family
member has History
Stress can worsen but not the cause
Drugs - NSAIDS
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TYPES
Acute
Chronic
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ACUTEIs associated
with superficial erosion
Minimal inflammation
Short duration and resolves
quickly
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CHRONIC Chronic ulcer is
one of long duration eroding
the muscular wall .It may be present continuously for many months throughout the
person’s life time
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BASED ON LOCATION
•Gastric•Duodenal
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PATHOPHYSIOLOGYH.PYLORI,
ACIDS,NSAIDS, ALCOHOL
BREAK DOWN THE GASTRIC
MUCOSAL LAYER
ACID BACK DIFFUSION INTO
MUCOSA
HISTAMINE RELEASE
INCREASED VASODILATATION
MUCOSAL EDEMADESTRUCTION OF MUCOSAL CELLS
INCREASED ACID AND PEPSIN RELEASE• FURTHER BREAK DOWUN OF
MUCOSA AND BLEEDING
• ULCERATION
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GENERAL PEPTIC ULCER SYMPTOMS
Epigastric tendernessGastric: epigastrium; left of midline
Duodenal: mid to right of epigastrium
Sharp, burning, aching, gnawing pain
Dyspepsia (indigestion) Nausea/vomiting/constipation/diarrhea
Belching Pyrosis (heartburn) Black Tarry stools
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Gastric ulcer Duodenal Ulcermiddle age 50-60 Any age specially 30-40 Age
More in male More in male Sex
Same Stress job eg. Manager Occupation
Epigastric. Can radiate to back
Epigastric , discomfort Pain
Immediately after eating
2-3 hours after eating & midnight
Onset
Eating Hunger Agg.by
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Gastric ulcer Duodenal UlcerLying down or vomiting Eating Relived by
Few weeks 1-2 months Duration
Common(to relieve the pain)
Uncommon Vomiting
Patient afraid to eat Good Appetite
Avoid fried food Good , eat to relieve the pain Diet
wt. Loss No wt. loss Weight
60% 40% Hematemesis
40% 60% Melena
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DIAGNOSTIC STUDIES History and physical examination Upper GI endoscopy with biopsy Helicobacter testing of breath, urine, blood
and tissue Upper GI barium contrast study Complete blood count – anemia – secondary
to bleeding ulcer Liver enzymes Stools examination for occult blood Serum amylase – pancreatic function –
duodenal ulcer Serum electrolytes Urine analysis
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DIAGNOSTIC STUDIES Esophagogastrodeuodenoscopy
Visualizes ulcer type and locationAbility to take tissue biopsy to R/O cancer
and diagnose H. pylori
Upper gastrointestinal series Barium swallowX-ray that visualizes structures of the upper
GI tract
Urea Breath TestingUsed to detect H.pyloriClient drinks a carbon-enriched urea
solutionExcreted carbon dioxide is then measured
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COLLABORATIVE MANAGEMENT
The aim of treatment is to decrease gastric
acidity, enhance mucosal defense mechanism and
minimise the harmful effects on the mucosa
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REGIMEN
Adequate rest
Dietary modification
s
Drug therapy
Elimination of smoking
Long term follow up
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DIETARY MODIFICATIONS Bland diet Take six meals per day Avoid mil and milk products – delays
gastric emptying Avoid high fat diet Avoid spicy foods, pepper, salted
fish Avoid food with preservatives Avoid coffee and caffeine products , Plenty of water
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ADEQUATE REST
Adequate rest both physical and
emotional
Quiet, calm environment at
home and in job
Stress reduction strategies -
meditation
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DRUG THERAPY H2- receptor blockers – ranitidine, cimetidine
Proton pump inhibitors – pantoprazole
Antibiotics for H.pylori – amoxicillin, tetracycline and clarithromycin
Antacids – aluminun hydroxide gels – syp gelusil
Cytoprotective drugs – sucralfate
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No smoki
ng
No alcoh
ol consumptio
n
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LONG TERM FOLLOW UP
Healing of ulcer requires many weeks of therapy
Pain disappears with in 3 to 6 days But healing much slower
Continuous treatment and long term follow up is quit essential
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Completely avoid NSAIDS and ASPIRIN
switch to enteric coated
tablets
Co- administration
with PPI
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SURGICAL MANAGEMENT Greatly decreased in the last 20-30 years secondary to the discovery of H. pylori
Required when/ indicationsPerforated ulcerAcute bleedingNon-responsive to medications
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TYPES OF SURGICAL PROCEDURES
VagotomyCuts vagus nerveEliminates acid-secretion stimulus
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PYLOROPLASTY Pyloroplasty
Widens the pylorus to guarantee stomach emptying even without vagus nerve stimulation
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BILLROTH IGASTRODUODENOSTOMY
Distal portion of the stomach is removed
The remainder is anastomosed to the duodenum
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BILLROTH IIGASTROJEJUNOSTOMY
The lower portion of the stomach is removed and the remainder is anastomosed to the jejunum
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POSTOPERATIVE CARENG tube – care and management - NPO
Continuous gastric aspiration monitor for bleeding
Observe for bowel movementsIVF replacementStrict intake and outputSplinting of abdomen while coughing
Monitor for post-operative complications
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COMPLICATIONS OF PEPTIC ULCERS
HemorrhageBlood vessels damaged as ulcer erodes into the
muscles of stomach or duodenal wallCoffee ground vomitus or occult blood in tarry
stools
PerforationAn ulcer can erode through the entire wallBacteria and partially digested food spill into
peritoneum=peritonitis
Narrowing and obstruction (pyloric)Swelling and scarring can cause obstruction of
food leaving stomach=repeated vomiting
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COMPLICATION - DUMPING SYNDROME
Rapid emptying of food and fluids from the stomach into the jejunum
SymptomsWeaknessFaintnessPalpitationsFullnessDiscomfortNauseadiarrhea
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MINIMIZE DUMPING SYNDROME
Decrease CHO intake Eat slowly Avoid fluids during meals Increase fat Eat small, frequent meals
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NURSING DIAGNOSIS Acute pain related to increased gastric
secretions ,decreased mucosal protection ,and ingestion of gastric irritants as evidenced by burning cramp like pain in epigastrium and abdomen
Nausea related to acute exacerbation of disease process as evidenced by episodes of nausea and vomiting
Imbalanced nutrition less than body requirement related to decreased appetite
Ineffective therapeutic regimen management related to lack of knowledge of long term management of peptic ulcer disease and
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NURSING INTERVENTIONS Relieving pain Reducing anxiety Maintaining optimal nutritional status
Maintaining optimal nutritional status
Teaching patients self-care
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Thank you