1. NUR 120 PEPTIC ULCER DISEASE

2. Pathophysiology  Normally, a physiologic balance exists between peptic acid secretion and gastric mucosal defense  The gastric mucosal barrier protects the underlying tissue from gastric acids and digestive juices  When a disruption occurs with this protective barrier, the mucosal lining is exposed and corroded by acid, resulting in an ulcer

4. Causes of PUD  H pylori bacteria  Chronic use of NSAIDS  Hypersecretion of Stomach Acid  Stress  Zollinger-Ellison Syndrome

5. To Test for H Pylori  Endoscopic gastric samples  Collect medication history prior  Urea breath testing  NPO prior to test  IgG serologic test can detect antibodies  Stool sample

6. Ulcer Classification  Location: ulcer on stomach=Gastric Ulcer ulcer on upper intestine=Duodenal Ulcer ulcer on esophagus=Esophageal Ulcer  Duration : Acute or Chronic

7. Signs and Symptoms  o Symptoms vary from person to person  o Can be confused with GERD and dyspepsia  o Common signs and symptoms:  o Gnawing, burning and aching in the epigastrium, and  o Dyspepsia that feels like heartburn  o Bloating and nausea  o Pain  o Symptoms vary from person to person  o Can be confused with GERD and dyspepsia  o Common signs and symptoms:  o Gnawing, burning and aching in the epigastrium, and  o Dyspepsia that feels like heartburn  o Bloating and nausea  o Pain

8. o Less common symptoms: o Pyloric obstruction- vomiting after meals o Vomiting blood that looks like coffee grounds o Black stools that looks like tar or that has dark red in them

9. Gastric UlcerDuodenal Ulcer 30 to 60 min after meal1.5 to 3 hr after meal Rarely occurs at nightOften occurs at night Pain worsens with food ingestionPain relieved by food ingestion o Peptic ulcer disease can be differentiated between gastric, duodenal, and stress ulcers.

10. o Silent ulcers may occur with pts with diabetes, NSAID users such as aspirin and ibuprofen. o If left untreated, complications may occur such as bleeding, perforation, penetration or the obstruction of the digestion tract.

11.  Combination of lifestyle changes and pharmacotherapy best  Treatment goals  Eliminate infection by H. pylori  Promote ulcer healing  Prevent recurrence of symptoms Treatment of Peptic Ulcer Disease

12.  Drugs used in treatment  H2-receptor antagonists  Proton pump inhibitors  Antacids  Antibiotics and miscellaneous drugs Treatment of Peptic Ulcer Disease (continued)

13.  Goals of treatment  Primary: bacteria completely eradicated  Ulcers heal more rapidly  Ulcers remain in remission longer  Very high reoccurrence when H. pylori not eradicated  Infection can remain active for life if not treated. Treatment of H. pylori

14.  Slow acid secretion by stomach  Often drugs of choice in treating PUD  Cimetidine used less frequently  Drug-drug interactions are numerous.  Do not take antacids at same time as H2-receptor blockers.  Decreases absorption H2-Receptor Blockers

15.  Prototype drug: ranitidine (Zantac)  Mechanism of action: acts by blocking H2- receptors in stomach to decrease acid production  Primary use: to treat peptic ulcer disease  Adverse effects: possible reduction in number of red and white blood cells and platelets, impotence or loss of libido in men H2-Receptor Blockers

16.  Dysrhythmias and hypotension have occurred with IV cimetidine  Ranitidine (Zantac) or famotidine (Pepcid) can be administered intravenously  Assess kidney and liver function  Evaluate client’s CBC for possible anemia during long-term use H2-Receptor Antagonist Therapy

17.  Prototype drug: omeprazole (Prilosec)  Mechanism of action: reduces acid secretion in stomach by binding irreversibly to enzyme H+, K+- ATPase  Primary use: for short-term, 4- to 8-week therapy for peptic ulcers and GERD  Adverse effects: headache, nausea, diarrhea, rash, abdominal pain  Long-term use associated with increased risk of gastric cancer Proton Pump Inhibitors

18.  Take 30 minutes prior to eating, usually before breakfast  May be administered at same time as antacids  Often administered in combination with clarithromycin (Biaxin) Proton Pump Inhibitor Therapy for PUD

19.  Prototype drug: aluminum hydroxide (Amphojel)  Mechanism of action: neutralizes stomach acid by raising pH of stomach contents  Primary use: in combination with other antiulcer agents for relief of heartburn due to PUD or GERD  Adverse effects: minor; constipation Antacids

20.  Administered to treat H. pylori infections of gastrointestinal tract  Two or more antibiotics given concurrently  Increase effectiveness  Lower potential for resistance  Regimen often includes  Proton pump inhibitor  Bismuth compounds  Inhibit bacterial growth  Prevent H. pylori from adhering to gastric mucosa Antibiotics

21.  Several additional drugs are beneficial in treating PUD  Sucralfate  Coats ulcer and protects it from further erosion  Misoprostol  Inhibits acid and stimulates production of mucus  Pirenzepine  Inhibits autonomic receptors responsible for gastric-acid secretion Miscellaneous Drugs

22. Peptic Ulcer Disease Pain Management: Assess location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors to determine appropriate intervention Provide client with optimal pain relief by using prescribed analgesics to provide comfort. Use a variety of measures of relief such as pharmacologic, nonpharmacologic, and interpersonal techniques to facilitate pain relief. Teach the use of nonpharmacologic techniques which include relaxation, music therapy, guided imagery, distraction, acupressure, and massage before after and if possible during painful activities before pain occurs or increases. Relaxation helps decrease acid production and reduces pain Nursing Interventions:

23. Nursing Interventions cont’d: – Treament Regimen: Explain the pathophysiology of the disease and how it relates to anatomy and physiology to help the patient understand the disease. Discuss lifestyle changes that may be required to prevent future complications and/or control the disease process. Instruct patient on which signs and symptoms to report to the health care provider to ensure early initiation of treatment. – Hemorrhage/Bleeding: Assess for evidence of hematemesis, bright red or melena stool, abdominal pain or discomfort, symptoms of shock (decreased BP, cool/clammy skin, dyspnea, tachycardia, decreased urine output) If ulcer is actively bleeding, observe NG tube aspirate or emesis for amount and color to assess degree of bleeding. Take vital signs every 15-30 mins to help determine patient’s hemodynamic status and as indicators for shock. Maintain IV infusion line to provide ready access for blood and fluid replacement. Monitor hematocrit and hemoglobin as indicators of severity of hemorrhage and need for fluid and blood replacement.

24. Nursing Interventions cont’d: – Perforation: Observer for manifestations of perforation such as sudden, severe abdominal pain; rigid, boardlike abdomen; radiating pain to shoulders; increasing distention; decreasing bowl sounds. Take vital signs every 15-30 mins. Maintain NG tube to suction to provide continuous aspiration and gastric decompression. Administer pain medication to promote comfort and reduce anxiety.

25. Dietary modifications  Avoid foods that cause epigastric distress.  Avoid milk, sweets, or sugars  Small, frequent meals rather than large meals.  Limit the fluid intake at one time.

26.  Avoid Cigarettes and alcohol.  Avoid OTC drugs unless approved by HCP.  Take all medications as provided.

27. Report any of the following:  Increased nausea and or vomiting.  Increase in epigastric pain.  Bloody emesis or tarry stools.  Encourage stress reducing activities or relaxation strategies.