Peptic Ulcers - Nursing Care Management

Peptic ulcers are open sore(excavation) that develop on the mucosa of the esophagus, stomach and sometimes the duodenum. The erosion may extend deeply into the muscle layers or through the peritoneum.

Based on the location of occurrence, it may be classified as either may be esophageal, gastric, or duodenal.

Peptic ulcers occur more in the duodenum than in the esophagus and stomach.

Chronic gastric ulcers tend to occur more in the lesser curvature of the stomach near the pylorus

Esophageal ulcers occur as a result of the backward flow of hydrochloric acid from the stomach to the esophagus (GERD)

Table of Contents

Causes of Peptic Ulcers

Helicobacter pylori infection
Excessive usage of NSAIDS
Blood group. Individuals with blood group O are more susceptible
Zollinger Ellison syndrome (ZES): Excessive gastrin produced by benign or malignant tumors from the pancreas and duodenum
Excessive alcohol consumption
Tobacco and cigarette smoking
Stress
Radiology treatments

Pathophysiology of Peptic Ulcers

It occurs mainly in the gastroduodenal mucosa because this tissue cannot withstand the digestive action of hydrochloric acid and pepsin
The erosion is caused by increased concentration or activity of acid pepsin or by decreased resistance of the normally protective mucosal barrier.
Usage of NSAIDS inhibits prostaglandins which is associated with a disruption of the normally protective mucosal barrier which leads to decreased resistance to bacteria and thus infection from H pylori may occur.
As a response to bacteria, cytokines, neutrophils and other substances are activated and cause epithelial cell necrosis that produce substances that damage the mucus.
H pylori attaches to the gastric mucosa and propagates the overproduction of hydrochloric acid which exacerbates the erosive effects.

Clinical Manifestations

Dull gnawing pain or burning sensation in the mid-epigastrium or the back
With gastric ulcers, pain occurs immediately after eating while in duodenal ulcers, pain occurs 2 to 3 hours after meals and patients can respond to antacids
Vomiting
Constipation
Diarrhea
Bleeding
Sour eructation (burping) on an empty stomach
Melena (black tarry stool) and hematemesis ( blood in vomitus)
Peptic ulcers may result to perforation and the patients report sharp upper abdominal pain which is referred to the shoulder, extreme abdominal tenderness, nausea and vomiting, hypertension and tachycardia which are indications of shock.

Assessment and Diagnostic Findings

Physical exam may reveal epigastric tenderness or abdominal distension
Upper endoscopy will visualize inflammatory changes, ulcers and lesions
Biopsy. Rapid urease test of the histological tissue may show H pylori infection
Serological testing for antibodies against H pylori antigen, stool antigen test and urea breath test
Periodic CBCs for a bleeding peptic ulcer
Stools tests may reveal occult blood
Gastric secretion studies are of value in diagnosing ZES, achlorhydria (lack of hydrochloric acid), hypochlorhydria (low levels of hydrochloric acid) or hyperchlorhydria (high levels of hydrochloric acid).
Chest and abdominal radiology may be done if perforation is suspected

Medical Management

Combination of antibiotics, proton pump inhibitors and sometimes bismuth salts that suppress or eradicate H pylori are used.
Antibiotics used include metronidazole, amoxicillin and clarithromycin
Proton pump inhibitors normally used include lansoprazole, omeprazole and rabeprazole
H2 blockers and proton pump inhibitors that reduce gastric acid secretion are used to treat ulcers not associated with H pylori infection such as Zollinger Ellison syndrome
Octreotide, a gastrin suppressant may be used
Patient is advised to adhere to the medication regimen and avoid usage of aspirin and other NSAIDS.
Patients at risk for stress ulcers such as those mechanically ventilated for mor than 48 hours may he treated prophylactically with either H2 blockers or proton pump inhibitors and cyclo-protective agents like misoprostol, and sucralfate because of the increased risk of upper GI tract hemorrhage.
Smoking cessation. Smoking decreases the pancreatic bicarbonate to the duodenum increasing its acidity
Dietary modification. Avoid extremes of temperature in food and beverages and overstimulation from the consumption of alcohol coffee and other caffeinated beverages
Neutralize acid by eating three regular meals a day. Small frequent meals are not necessary as long antacids or H2 blockers are taken
Surgery for intractable ulcers 12-16 weeks of medication life threatening hemorrhage perforation obstruction and for those with ZES unresponsive to medication.
Vagotomy with or without pyroplasty, transecting nerves that’s stimulate acid secretion and opening the pylorus, antrectomy removal of antrum (a pyloric portion of the stomach) with anastomosis surgical connection to either the duodenum (gastroduodenostomy or Billroth I) or jejunum (gastrojejunostomy or Billroth II)

Nursing Management

Assessment

Past medical conditions focusing on GI
Review prescription and OTC drugs
Inquire about corticosteroids chemotherapy or NSAIDS
Radiation treatments
GI surgeries especially gastrectomy which can cause chronic gastritis
Pain whether it occurs predictably after melas or at night and strategies to relieve it.
History of emesis. Frequency and important characteristics like appearance
List food intake in the past 72 hours
Lifestyle smoking alcohol NSAIDS family history of ulcer disease
Vitals and reports tachycardia and hypotension which may indicate anemia
Test stool for occult
Physical exam, abdominal palpation for localized tenderness

Nursing Diagnosis

Acute pain related to the effects of gastric acid secretion and tissue damages
Imbalanced nutrition less than the body requirement related to dietary changes

Complications

Hemorrhage
Perforation
Penetration
Gastric outlet obstruction

Nursing Interventions

Reliving pain. Avoid aspirin NSAIDS and alcohol. Eat meals regularly at paced intervals in a relaxing setting. Relaxing techniques to help reduce stress and pain
Reducing anxiety. Explain procedures eg test and medication to calm the patient. Provisions of emotional support
Maintenance of optimal nutrition status. Asses for nutrition and weight loss. After recovery the patient is advised about the importance of adhering to the medication regimen and dietary restriction
Monitoring and managing complications
Hemorrhage. Monitor vitals, and evaluate patient for tachycardia, hypotension and tachypnea hemoglobin, hematocrit., testing stool for occult or gross blood. Recording urine input output to detect anuria or oliguria
Perforation and penetration. Erosion of ulcer through gastric serosa into the peritoneum. Penetration is the erosion of the ulcer through gastric serosa to adjacent structures eg pancreas, biliary tract. Signs and symptoms of perforation are sudden severe upper abdominal pain, pain referred to the shoulders because of the irritation to the vagus nerve vomiting collapse extremely tender and rigid like abdomen hypotension and tachycardia indicating shock. Surgery should he urgent to close the perforation
During surgery and postoperatively, the stomach content is drained by means of an NG tube. The nurse monitors fluid and electrolyte balance and assesses the patient for localized infection or peritonitis (increased temp, abdominal pain, paralytic ileus, increased or absent bowel sounds abdominal distension). Antibiotics therapy is prescribed
Gastric outlet obstruction. Occurs when the area distal to the pyloric sphincter becomes scarred and stenosed from spams or edema or from scar tissue that forms when an ulcer alternatively heals and breaks down. The patient may have vomiting constipation epigastric fullness anorexia and later weight loss. An NGT is inserted to decompress the stomach.
Education. Drugs regimen to be adhered to and teach about side effects. Avoid NSAIDS

Evaluation

Reports freedom from pain between meals and at night
Reports less anxiety
Maintains weight
Demonstrates knowledge of self-care, avoiding NSAIDS, takes medications as prescribed
No evidence of complications hemorrhage perforation or penetration gastric outlet obstruction