1. Gastric and Duodenal Ulcer

2. Learning Outcomes
By the end of this lecture, students will be able to:
Define peptic ulcer and identify the risk factors for its formation.
Describe the pathophysiology and clinical manifestations of peptic ulcer.
Describe assessment and diagnostic findings of a patient with peptic ulcer.
Discuss the medical management of peptic ulcer.
Discuss the nursing management of a patient with peptic ulcer.

4. What is a Peptic Ulcer?
It is a hole that forms in the mucosal wall of the stomach, in the pylorus (opening between stomach and duodenum), in the duodenum (first part of small intestine), or in the esophagus.
It is frequently referred to as a gastric, duodenal, or esophageal ulcer, depending on its location, or as peptic ulcer disease.
It is more likely to be in the duodenum than in the stomach.

5. Risk Factors For Peptic Ulcers
Infection with bacteria "Helicobacter pyloricus" (H. pylori).
Gastritis, alcohol, smoking, use of NSAIDs, and stress.
Familial tendency may be a significant predisposing factor. People with blood type O are more susceptible to peptic ulcers than are those with other types.
Rarely, ulcers are caused by excessive amounts of the hormone gastrin, produced by tumors. gastric hyperacidity, and gastrin-secreting benign or malignant tumors.

6. Pathophysiology
Peptic ulcers occur mainly in the tissue of gastroduodenal mucosa because it cannot withstand the digestive action of gastric acid (HCl) and pepsin.
A damaged mucosa cannot secrete enough mucus to act as a barrier against HCl. The use of NSAIDs inhibits the secretion of mucus that protects the mucosa.
Stress ulcer refers to the acute mucosal ulceration of the duodenal or gastric area that occurs after physiologically stressful events, such as burns, shock, severe sepsis, and multiple organ traumas. Stress ulcer is usually preceded by shock; this leads to decreased gastric mucosal blood flow and to reflux of duodenal contents into the stomach. In addition, large quantities of pepsin are released. The combination of ischemia, acid, and pepsin creates an ideal climate for ulceration.

7. Clinical Manifestations
Many people have symptomless ulcers, and in 20% to 30% perforation or hemorrhage may occur without any preceding manifestations.
Dull, gnawing ,pain or a burning sensation in the midepigastrium. The pain may occur when the increased acid content of the stomach and duodenum erodes the lesion and stimulates the exposed nerve endings. Pain is usually relieved by eating, or by taking alkali..

8. Pyrosis (heartburn), vomiting, and bleeding
Pyrosis (heartburn), vomiting, and bleeding. Pyrosis is a burning sensation in the esophagus and stomach that moves up to the mouth.
Heartburn is often accompanied by sour eructation, which is common when the patient’s stomach is empty.
Fifteen percent of patients with gastric ulcers experience bleeding, as evidenced by the passage of tarry stools.

9. Assessment and Diagnostic Findings
A physical examination may reveal pain, epigastric tenderness, or abdominal distention. Pain that is relieved by ingesting food or antacids and absence of pain on arising are also highly suggestive of an ulcer.
Endoscopy is useful procedure because it allows direct visualization of inflammatory changes, ulcers, and lesions. A biopsy of the gastric mucosa and of any suspicious lesions can be obtained. Biopsy and histology with culture can determine H. Pylori.
Stools may be tested for occult blood (OB).

10. Medical Management
The purpose of medical management of peptic ulcer is to eradicate H. pylori and to manage gastric acidity. This is achieved through pharmacologic therapy, lifestyle changes, and surgical intervention. These are described next.

11. Pharmacologic Therapy
A combination of antibiotics (clarithromycin & amoxicillin), proton pump inhibitors (omeprazole), and bismuth salts (bismuth subsalicylate) that suppresses or eradicates H. pylori;
Antibiotics assist in eradicating H. pylori bacteria.
Histamine 2 (H2) receptor antagonists (Ranitidine) and proton pump inhibitors are used to treat NSAID-induced and other ulcers not associated with H. pylori ulcers.
Bismuth salts suppress H. pylori bacteria in the gastric mucosa and assists with healing of mucosal lesions.
H2 receptor antagonists inhibit acid secretion by blocking the action of the histamine on the histamine receptors in the stomach.

12. Life Style Changes Stress reduction and rest Smoking cessation
The patient may need avoid situations that are stressful or exhausting. A rushed lifestyle and an irregular schedule may aggravate symptoms and interfere with regular meals taken in relaxed settings and with the regular administration of medications.
The patient may benefit from regular rest periods during the day, at least during the acute phase of the disease.
Smoking cessation
Smoking decreases the secretion of bicarbonate from the pancreas into the duodenum, resulting in increasing its acidity.
Smoking may significantly inhibit ulcer repair. Therefore, the patient is strongly encouraged to stop smoking.

13. Dietary modification Surgery
Dietary modification is required to avoid oversecretion of acid and hypermotility in the GI tract. Therefore, avoiding extremes of temperature and overstimulation from consumption of meat extracts, alcohol, coffee and other caffeinated beverages, and diets rich in milk and cream.
In addition, an effort is made to neutralize acid by eating three regular meals a day.
Surgery
Surgery is usually recommended for patients with intractable ulcers (those that fail to heal after 12 to 16 weeks of medical treatment), life-threatening hemorrhage, perforation, or obstruction.

14. Nursing Management of Peptic Ulcer
Assessment
The nurse asks the patient to describe the pain (burning or gnawing) and the methods used to relieve it (e.g., food, antacids). Pain occurs about 2 hours after a meal and frequently awakens the patient between midnight and 3 AM. Taking antacids, eating, or vomiting often relieves the pain.
The nurse asks about history of vomiting and characteristics of the vomitus:
Has the patient noted any bloody or tarry stools?
The nurse assess life style and habits such as drinking coffee and/ or alcohol, and smoking. Does the patient take NSAIDs? Any anxiety or stress?
The nurse records vital signs and reports any tachycardia and hypotension. Is there any tenderness of abdomen?

15. Relief of pain and reduced anxiety,
Nursing diagnoses
Acute pain related to the effect of gastric acid secretion on damaged tissue
Anxiety related to coping with an acute disease
Imbalanced nutrition related to changes in diet
Deficient knowledge about prevention of symptoms and management of the condition
Planning and goals
Relief of pain and reduced anxiety,
Maintenance of nutritional requirements,
Knowledge about the management and prevention of ulcer recurrence.

16. Nursing interventions
Relieving pain: Administration of prescribed medications. The patient should avoid aspirin, foods and beverages that contain caffeine,
Reducing anxiety: The nurse assesses the patient’s level of anxiety. Appropriate information and explanation are provided at the patient’s level of understanding, all questions are answered, and the patient is encouraged to express fears openly. The patient’s family is also encouraged to participate in care and to provide emotional support.
Maintaining optimal nutritional status: The nurse assesses the patient for malnutrition and weight loss. The patient is advised about the importance of complying with the medication regimen and dietary restrictions.

17. Knowledge about the management and prevention of ulcer recurrence
Knowledge about the management and prevention of ulcer recurrence. The nurse instructs the patient about the factors that will help or aggravate the condition. The nurse provides information about medications to be taken at home, stressing the importance of continuing to take medications even after signs and symptoms have decreased or subsided. The patient is instructed to avoid certain medications and foods that exacerbate symptoms as well as substances that have acid producing potential. It is important to counsel the patient to eat meals at regular times and in a relaxed setting, and to avoid overeating

18. Evaluation Reports freedom from pain between meals
Feels less anxiety by avoiding stress
Complies with therapeutic regimen
Avoids irritating foods and beverages
Eats regularly scheduled meals
Takes prescribed medications as scheduled
Uses coping mechanisms to deal with stress
Maintains weight