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Peptic Ulcer Disease

4 min read

References:

  1. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 15th Edition, ISBN 978-197-51-6103-3, by Janice L. Hinkle, Kerry H. Cheever, and Kristen J. Overbaugh (Ch. 30, [ebook] pp. 3443-3460) not yet adapted
  2. Course Module

A peptic ulcer is an excavation (hollowed-out area) that forms in the mucosa of the stomach, in the pylorus (the opening between the stomach and duodenum), in the duodenum (the first portion of the small intestine, between the stomach and the jejunum), or in the esophagus.

  • Peptic ulcers are more likely to occur in the duodenum than in the stomach. As a rule, they occur alone but they may occur in multiples.
  • Chronic gastric ulcers tend to occur in the lesser curvature of the stomach, near the pylorus.
  • Esophageal ulcers occur as a result of the backward flow of HCl from the stomach into the esophagus

This break may be caused by:

  • Mucus and bicarbonate secretion as a part of pH maintenance
  • Gastric mucosal prostaglandin increases resistance to ulceration. Inadequate production results in ulcer formation.
  • Inadequate blood supply
  • Pyloric Sphincter Dysfunction: bile and bile salts may enter the stomach and emulsify the lipid plasma membrane of the gastric mucosa.
  • Delayed Gastric Emptying
  • H. pylori infection
  • Duodenal Ulcer:
    • Rapid gastric emptying
    • Acid bolus delivery; reduced pH balancing ability of the duodenum.
    • Increased acid secretion from CHON rich food, calcium, and vagal excitation.
    • H. pylori produces urease, which hydrolyzes urea into ammonia. Ammonia stimulates the release of H+ ions, which causes damage.
  • Other factors: drugs, cigarette smoking, chronic anxiety, a Type A Personality

Assessment Findings

Duodenal Ulcer

  • Pain 90 to 180 minutes after meals; may wake the patient up during sleep at midnight to 3 AM.
  • Pain is relieved by food, antacids, and H2 blockers; not associated with vomiting (but complications may lead to vomiting).
  • High gastric acid levels
  • Positive test for H. pylori
  • Does not represent a malignancy.
  • Complications rarely occur; if they do, it is often pyloric stenosis or posterior penetrating duodenal ulcer.

Gastric Ulcer

  • Pain within a short time after meals.
  • Accompanied by nausea and vomiting after eating, and variable response to medications.
  • Low gastric acid levels
  • Positive test for H. pylori
  • 25% of GUs are accompanied by significant bleeding. Higher mortality and morbidity than DUs.

Complications

  • Hemorrhage: the most serious complication. This may manifest as hematemesis indicating upper GI bleeding.
  • Perforation: a surgical emergency; gastroduodenal contents leaks into the surrounding abdomen. Sharp pain, apprehension, assumption of knee-chest position, chemical peritonitis, bacterial septicemia, followed by hypovolemic shock. This results in diminished peristalsis and paralytic ileus.

Diagnostic Examination

  • Hemoglobin, Hematocrit decreases because of bleeding
  • Positive Fecal Occult Blood Test
  • Esophagogastroduodenoscopy (EGD) visualization of ulceration
  • Biopsy for H. pylori and malignancy testing
  • Gastric Analysis for gastric acidity: normal in gastric ulcer, higher in duodenal ulcer.

Nursing Interventions

  • Supportive care: rest, bland diet, stress management

Postoperative Considerations

  • Provide routine post-op care
  • Ensure adequate function of the NGT
  • Measure drainage accurately to determine necessity for fluid and electrolyte replacement. Notify the physician if no drainage occurs.
  • Anticipate frank (bright), red bleeding for 12 to 24 hours.
  • Promote adequate pulmonary ventilation.
  • Promote adequate nutrition: removal of NGT is followed by clear liquids, and small frequent bland feedings as tolerated. Monitor weight daily.
    • If regurgitation occurs, instruct the patient to eat at a slower pace.
  • Place the client in a mid- or high-fowler’s position to promote chest expansion; teach the client to splint high upper abdominal incisions before turning, coughing, and deep breathing.

Client Teaching and Discharge Planning

  • Wean food intake until 3 meals a day is tolerated.
  • Monitor weight daily.
  • Provide stress-reduction measures.
  • Report complications to the physician immediately: hematemesis, emesis, diarrhea, pain, melena, weakness, feeling of abdominal fullness/distension
  • Provide methods against dumping syndrome.

Medical Management

  • Antacids
  • Histamine Receptor Antagonists
  • Proton Pump Inhibitors
  • Anticholinergics: to reduce gastric juice secretion
    • Probanthine, Pirenzepine
  • Antibiotic for H. pylori infection
    • Metronidazole (Flagyl), Tetracycline, Pepto-bismol

Surgical Management

Various combinations of gastric resections and anastomoses. These are used if the ulcer does not respond to medical management.

  1. Gastroduodenostomy (Billroth I): the distal end of the stomach is removed, and the remaining stomach is anastomosed to the duodenum.
  2. Gastrojejunostomy (Billroth II): the antrum and distal end of the stomach is removed, and the remaining stomach is anastomosed to the jejunum.
  3. Vagotomy: to decrease stimulation of gastric secretion, vagus nerves are transected.
  4. Pyloroplasty: in conjunction with a vagotomy to widen the exit of the pylorus to facilitate emptying of stomach contents.
  5. Subtotal Gastrectomy: removal of 75% to 85% of the stomach.
  6. Antrectomy: removal of the antrum of the stomach to eliminate gastric phase of digestion.
  7. Gastroenterostomy: a connection between the jejunum and the stomach is created, allowing the alkaline contents of the jejunum to regurgitate into the stomach, neutralizing its acidity.
  8. Esophagojejunostomy (Total Gastrectomy): removal of the stomach, with a loop of the jejunum anastomosed to the esophagus.

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