MedSurg 3 - Peptic Ulcer Disease (Chap 58)

Question 0

Complications of PUD

Answer 0

HEMORRHAGE, PERFORATION, Pyloric Obstruction

Hemorrhage is the most serious complication. With massive bleeding, the patient vomits bright red or coffee-ground blood (HEMATEMESIS).

Minimal bleeding from ulcers is seen via occult blood in a tarry stool (MELENA).

Question 1

Peptic Ulcer

Answer 1

Mucosal lesion in the stomach or duodenum.
PUD results when mucosal defenses become impaired and no longer protect the epithelium from the effects of acid and pepsin

Question 2

H. Pylori

Answer 2

Caused most Peptic Ulcer Disease ( PUD)
H. Pylori is transmitted via fecal-oral route.
Urease, a substance secreted by H.pylori bacterium produces ammonia and creates more alkaline environment – so they are not damaged by the stomach acid!
Hydrogen ions are then released in response to the presence of ammonia and contribute further mucosal damage.

Question 3

PYLORIC OBSTRUCTION in PUD

Answer 3

Gastric outlet blockage occurs in a small percentage of patients and is manifested by vomiting caused by stasis and gastric dilation.

Treatment:

• decompress dilated stomach via nasogastric suctioning
• correcting metabolic alkalosis
• correcting dehydration
• NGT is clamped for 72 hrs
• check for retention of gastric contents
• IF the amt retained is not more than 50ml in 30 min, Oral fluid may be allowed

Question 4

PERFORATION from PUD

Answer 4

= Perforation occurs when the ulcer becomes so deep that the entire thickness of the stomach or duodenum is worn away.
= The stomach or duodenal contents can then leak into the peritoneal cavity. – very painful.
= The abdomen is tender, rigid and boardlike (PERITONITIS).
The patient usually assumes the knee-chest (fetal) position to decrease the tension of the abdominal muscles. Patient can be severely ill within hours and BACTERIAL SEPTICEMIA and HYPOVOLEMIC SHOCK may follow.
= Peristalsis diminishes and paralytic ileus develops.
** PEPTIC ULCER PERFORATION is a surgical Emergency and can be life threatening !!
= If pain that is intermittent and was relieved by food and antacids becomes constant and radiates to the back or upper quadrant, the ulcer may have been perforated.
= If perforation into the peritoneal cavity is present, the patient has a RIGID, BOARDLIKE ABDOMEN accompanied by rebound TENDERNESS and PAIN.
** Management:
– replace fluid, blood and electrolytes,
– antibiotics
– NPO

Question 5

PUD, H. Pylori and NSAIDS

Answer 5

NSAIDS break down the mucosal barrier and disrupt the mucosal protection.

NSAIDS cause decreased endogenous prostaglandins, resulting in local gastric mucosal injury.

NSAID-related ulcers are difficult to treat bec they have a high rate of reoccurence.

Question 7

Other substances that contribute to PUD

Answer 7

CORTECOSTEROIDS ( ex. Prednisone)

Theophylline (Theo-Dur)

Caffeine – stimulates HCl production

Radiation therapy may also develop GI ulcers

Question 8

PUD Signs and Symptoms

Answer 8

== DYSPEPSIA (indigestion) is the most commonly reported symptom associated with PUD.
== Pain Described as SHARP, BURNING, or GNAWING.
== GAstric Ulcer Pain – occurs in the upper epigastrium – left of the midline and is aggravated by food.
== Duodenal Ulcer pain – located to the right of the epigastrium. Pain occurs 90 min to 3 hrs after eating and often awakens the patient at night.
== Pain may be exacerbated by certain foods (tomatoes, hot spices, fried foods, alcohol, caffeine drinks) and certain drugs ( NSAIDs, Corticosteroids).
==NAUSEA & VOMITING – due to pyloric sphincter dysfunction, gastric stasis and pyloric obstruction.

Question 9

PPI- Triple Therapy

Answer 9

Common drug regimen for H. Pylori infection which includes:
Proton-pump inhibitor (ex. Lansoprazole) + 2 Antibiotics ( Metronidazole & Tetracycline OR Clarithromycin & Amoxicillin) for 7~14 days.

Question 9

Hemorrhage

Answer 9

== Hemorrhage is the most serious complication. With massive bleeding, the patient vomits bright red or coffee-ground blood (HEMATEMESIS).
== Minimal bleeding from ulcers is seen via occult blood in a tarry stool (MELENA).
== To assess for fluid volume deficit that occurs from bleeding, take orthostatic BP and monitor for signs of dehydration.
== Orthostatic changes signs: decrease of more than 20 mm Hg in systolic BP and/or decrease of 10 mm Hg in diastolic BP, and/or increase in pulse rate from lying to standing. .. Also dizziness present. 

• • Emergency : upper GI Bleeding
• • priority is to prevent hypovolemic shock and possible death
• -replace fluid with 0.9% normal Saline or lactated Ringer immediately – careful monitoring to prevent fluid overload.
• • packed red blood cells to expand volume and correct low Hgb and Hct.
• • for active bleeding, Fresh Frozen Plasma if thr prothrombin time is 1.5X higher than the midrange control value.
• • When blood loss exceeds 1L/24hrs, signs of SHOCK may occur:
• • HYPOTENSION, CHILLS, PALPITATIONS, DIAPHORESIS, WEAK THREADY PULSE

Question 10

ESOPHAGOGASTRODUODENOSCOPY (EGD)

Answer 10

EGD – For accurate diagnosis of PUD. May repeat test after 4 to 6 weeks to evaluate the response to therapy.

Also, RAPID UREASE TEST can confirm a quick diagnosis bec urease is produced by H. Pylori in the gastric mucosa.

Question 11

Proton pump inhibitors

Answer 11

Drug of choice for acid-related disorders.

OmePRAZOLE (Prilosec)
LansoPRAZOLE (Prevacid)
RabePRAZOLE (Aciphex)
PantoPRAZOLE (Protonix)
EsomePRAZOLE (Nexium)

Proton pump inhibitors (PPI) should NOT be used for prolonged period bec, over time, they may cause or contribute to OSTEOPOROTIC-related fractures.
Omeprazole reduces the effect of Clopidogrel (plavix), an antiplatelet drug.

Question 12

H2-Receptor Antagonist

Answer 12

Blocks histamine stimulated gastric secretions

may be used for indigestion and gastrisis.

Famotidine (Pepcid)
Niatidine (Axid)

Question 13

Proton pump inhibitors

Answer 13

Drug of choice for acid-related disorders.

OmePRAZOLE (Prilosec)
LansoPRAZOLE (Prevacid)
RabePRAZOLE (Aciphex)
PantoPRAZOLE (Protonix)
EsomePRAZOLE (Nexium)

Proton pump inhibitors (PPI) should NOT be used for prolonged period bec, over time, they may cause or contribute to OSTEOPOROTIC-related fractures.
Omeprazole reduces the effect of Clopidogrel (plavix), an antiplatelet drug.

Question 14

Antacids

Answer 14

Antacids buffer gastric a id and prevent formation of pepsin.

Aluminum hydroxide
magnesium Hydroxide

CAUTIOUSLY administer to patients with renal impairment – risk for toxicity.

Question 15

PUD nursing considerations:

Answer 15

Teach patient to avoid ALCOHOL & SMOKING bec they have stimulatory effects on gastric acid secretion.

Teach patient alternative therapies to reduce stress bec emotional stress worsens GI disorders such as PUD :
hypnosis, imagery, yoga, meditation.. Etc.

Enhances Ulcer Healing:

  - - Vitamin C, E, A
  - - Essential fatty acids
  - - Glutamine
  - - Acidophilus
  - - Zinc

Question 16

SURGICAL INTERVENTION for PUD patients

Answer 16

reason:

• for patients who do not respond to medical therapy
• surgical emergency that develop complication…. Ex. Perforation

Surgery can be done via conventional open surgery OR Minimal Invasive Surgery via laparoscopy