Peptic Ulcer Disease Therapy. Peptic Ulcer Disease Collaborative Care Medical regimen consists of...

Peptic Ulcer Disease Therapy

Peptic Ulcer Disease Therapy

Peptic Ulcer DiseaseCollaborative Care Peptic Ulcer DiseaseCollaborative Care

Medical regimen consists ofMedical regimen consists ofAdequate restAdequate restDietary modificationDietary modificationDrug therapyDrug therapyElimination of smokingElimination of smokingLong-term follow-up care Long-term follow-up care


Aim of treatment programAim of treatment program↓ ↓ degree of gastric aciditydegree of gastric acidity Enhance mucosal defense mechanismsEnhance mucosal defense mechanisms Minimize harmful effects on mucosaMinimize harmful effects on mucosa


Generally treated in ambulatory care Generally treated in ambulatory care clinicsclinicsRequires many weeks of therapyRequires many weeks of therapyPain disappears after 3 to 6 days Pain disappears after 3 to 6 days


Healing may take 3 to 9 weeksHealing may take 3 to 9 weeksShould be assessed by means of x-rays Should be assessed by means of x-rays

or endoscopic examination or endoscopic examination

Moderation in daily activity is essentialModeration in daily activity is essential

NSAIDs that are COX-2 inhibitors are NSAIDs that are COX-2 inhibitors are usedused

Peptic Ulcer DiseaseDrug Therapy Peptic Ulcer DiseaseDrug Therapy

Includes use ofIncludes use ofAntacids Antacids HH22R blockersR blockers

PPIsPPIsAntibioticsAntibioticsAnticholinergics Anticholinergics Cytoproctective therapy Cytoproctective therapy


Recurrence of peptic ulcer is frequentRecurrence of peptic ulcer is frequentInterruption or discontinuation of Interruption or discontinuation of

therapy can have detrimental resultstherapy can have detrimental results

No drugs, unless prescribed by health No drugs, unless prescribed by health care provider, should be taken care provider, should be taken Ulcerogenic effectUlcerogenic effect


Histamine-Histamine-2 2 receptor blocks (Hreceptor blocks (H22R R

blockers)blockers)Used to manage peptic ulcer diseaseUsed to manage peptic ulcer diseaseBlock action of histamine on HBlock action of histamine on H22

receptorsreceptors ↓ ↓ HCl acid secretion HCl acid secretion ↓ ↓ conversion of pepsinogen to pepsinconversion of pepsinogen to pepsin ↑ ↑ ulcer healing ulcer healing


Proton pump inhibitors (PPI)Proton pump inhibitors (PPI)Block ATPase enzyme that is Block ATPase enzyme that is

important for secretion of HCl acidimportant for secretion of HCl acid Antibiotic therapyAntibiotic therapy

Eradicate Eradicate H. pyloriH. pylori infection infection No single agents have been effective in No single agents have been effective in

eliminating eliminating H. pyloriH. pylori


Antacids Antacids Used as adjunct therapy for peptic Used as adjunct therapy for peptic

ulcer diseaseulcer disease↑ ↑ gastric pH by neutralizing acid gastric pH by neutralizing acid

Anticholinergic drugsAnticholinergic drugsOccasionally ordered for treatmentOccasionally ordered for treatment↓ ↓ cholinergic stimulation of HCl acidcholinergic stimulation of HCl acid


Cytoprotective drug therapyCytoprotective drug therapyUsed for short-term treatment of Used for short-term treatment of

ulcersulcers Tricyclic antidepressantsTricyclic antidepressants Serotonin reuptake inhibitorsSerotonin reuptake inhibitors

Peptic Ulcer DiseaseNutritional Therapy Peptic Ulcer DiseaseNutritional Therapy

Dietary modifications may be necessary Dietary modifications may be necessary so that foods and beverages irritating to so that foods and beverages irritating to patient can be avoided or eliminated patient can be avoided or eliminated

Nonirritating or bland diet consisting of 6 Nonirritating or bland diet consisting of 6 small meals a day during symptomatic small meals a day during symptomatic phasephase


Include a sample diet with a list of foods Include a sample diet with a list of foods that usually cause distressthat usually cause distressHot, spicy foods and pepper, alcohol, Hot, spicy foods and pepper, alcohol,

carbonated beverages, tea, coffee, carbonated beverages, tea, coffee, broth broth

Foods high in roughage may irritate an Foods high in roughage may irritate an inflamed mucosa inflamed mucosa


Protein considered best neutralizing foodProtein considered best neutralizing foodStimulates gastric secretionsStimulates gastric secretions

Carbohydrates and fats are least Carbohydrates and fats are least stimulating to HCl acid secretion stimulating to HCl acid secretion Do not neutralize wellDo not neutralize well


Milk can neutralize gastric acidity and Milk can neutralize gastric acidity and contains prostaglandins and growth contains prostaglandins and growth factorsfactors

Protects GI mucosa from injury Protects GI mucosa from injury

Peptic Ulcer DiseaseTherapy Related to ComplicationsPeptic Ulcer DiseaseTherapy Related to Complications

Acute exacerbationAcute exacerbationTreated with same regimen used for Treated with same regimen used for

conservative therapyconservative therapySituation is more serious because of Situation is more serious because of

possible complications of perforation, possible complications of perforation, hemorrhage, gastric outlet obstructionhemorrhage, gastric outlet obstruction

Accompanied by bleeding, ↑ pain and Accompanied by bleeding, ↑ pain and discomfort, nausea, vomitingdiscomfort, nausea, vomiting


Acute exacerbation (cont.)Acute exacerbation (cont.)Recurrent vomiting, gastric outlet Recurrent vomiting, gastric outlet

obstructionobstruction NG tube placed in stomach with NG tube placed in stomach with

intermittent suction for about 24 to 48 intermittent suction for about 24 to 48 hourshours

Fluids and electrolytes are replaced by IV Fluids and electrolytes are replaced by IV infusion until patient is able to tolerate infusion until patient is able to tolerate oral feedings without distressoral feedings without distress


Acute exacerbation (cont.)Acute exacerbation (cont.)Management is similar to that for Management is similar to that for

upper GI bleedingupper GI bleedingBlood or blood products may be Blood or blood products may be

administeredadministeredCareful monitoring of vital signs, Careful monitoring of vital signs,

intake and output, laboratory studies, intake and output, laboratory studies, signs of impending shocksigns of impending shock


Acute exacerbation (cont.)Acute exacerbation (cont.)Endoscopic evaluation reveals degree Endoscopic evaluation reveals degree

of inflammation or bleeding and ulcer of inflammation or bleeding and ulcer locationlocation

5-year follow-up program is 5-year follow-up program is recommendedrecommended


PerforationPerforationImmediate focus to stop spillage of Immediate focus to stop spillage of

gastric or duodenal contents into gastric or duodenal contents into peritoneal cavity and restore blood peritoneal cavity and restore blood volume volume

NG tube is placed into stomach NG tube is placed into stomach Placement of tube as near to perforation Placement of tube as near to perforation

site as possible facilitates decompressionsite as possible facilitates decompression


Perforation (cont.)Perforation (cont.)Circulating blood volume must be Circulating blood volume must be

replaced with lactated Ringer’s and replaced with lactated Ringer’s and albumin solutionsalbumin solutions

Blood replacement in form of packed Blood replacement in form of packed RBCs may be necessaryRBCs may be necessary

Central venous pressure line, Central venous pressure line, indwelling urinary cater should be indwelling urinary cater should be inserted and monitored hourly inserted and monitored hourly


Gastric outlet obstruction Gastric outlet obstruction Decompress stomachDecompress stomachCorrect any existing fluid and Correct any existing fluid and

electrolyte imbalanceselectrolyte imbalancesImprove patient’s general state of Improve patient’s general state of

healthhealthNG tube inserted in stomach, attached NG tube inserted in stomach, attached

to continuous suction to remove excess to continuous suction to remove excess fluids and undigested food particles fluids and undigested food particles


Gastric outlet obstruction (cont.)Gastric outlet obstruction (cont.)Continuous decompression allowsContinuous decompression allows

Stomach to regain its normal muscle toneStomach to regain its normal muscle tone Ulcer can begin to healUlcer can begin to heal Inflammation and edema subsideInflammation and edema subside

When aspirate falls below 200 ml, When aspirate falls below 200 ml, within normal range, oral intake of within normal range, oral intake of clear liquids can beginclear liquids can begin


Gastric outlet obstruction (cont.)Gastric outlet obstruction (cont.)Watch patient carefully for signs of Watch patient carefully for signs of

distress or vomitingdistress or vomitingIV fluids and electrolytes are IV fluids and electrolytes are

administered according to degree of administered according to degree of dehydration, vomiting, electrolyte dehydration, vomiting, electrolyte imbalanceimbalance

Peptic Ulcer DiseaseNursing ManagementPeptic Ulcer DiseaseNursing Management

Overall GoalsOverall GoalsComply with prescribed therapeutic Comply with prescribed therapeutic

regimenregimenExperience a reduction or absence of Experience a reduction or absence of

discomfort related to peptic ulcer discomfort related to peptic ulcer diseasedisease

Peptic Ulcer DiseaseNursing ManagementPeptic Ulcer DiseaseNursing Management

Overall Goals (cont.)Overall Goals (cont.)Exhibits no signs of GI complicationsExhibits no signs of GI complicationsHave complete healingHave complete healingLifestyle changes to prevent Lifestyle changes to prevent

recurrence recurrence

Peptic Ulcer DiseaseNursing ImplementationPeptic Ulcer DiseaseNursing Implementation

Health PromotionHealth PromotionIdentify patients at riskIdentify patients at riskEarly detection and ↓ morbidity Early detection and ↓ morbidity Encourage patients to take ulcerogenic Encourage patients to take ulcerogenic

drugs with food or milkdrugs with food or milkTeach patients to report symptoms Teach patients to report symptoms

related to gastric irritation to health related to gastric irritation to health care providercare provider


Acute InterventionAcute InterventionPatient generally complains of ↑ pain, Patient generally complains of ↑ pain,

nausea, vomiting, and some bleedingnausea, vomiting, and some bleedingMay be maintained on NPO status for May be maintained on NPO status for

a few days, have NG tube inserted, a few days, have NG tube inserted, fluids replaced intravenously fluids replaced intravenously

Physical and emotional rest are Physical and emotional rest are conducive to ulcer healing conducive to ulcer healing


HemorrhageHemorrhageChanges in vital signs, ↑ in amount and Changes in vital signs, ↑ in amount and

redness of aspirate signal massive redness of aspirate signal massive upper GI bleedingupper GI bleeding

↑ ↑ amount of blood in gastric contents ↓ amount of blood in gastric contents ↓ pain because blood helps neutralize pain because blood helps neutralize acidic gastric contents acidic gastric contents

Keep blood clots from obstructing NG Keep blood clots from obstructing NG tubetube


PerforationPerforationSudden, severe abdominal pain Sudden, severe abdominal pain

unrelated in intensity and location to unrelated in intensity and location to pain that brought patient to hospital pain that brought patient to hospital


Perforation (cont.)Perforation (cont.)Indicated by a rigid, boardlike Indicated by a rigid, boardlike

abdomenabdomenSevere generalized abdominal and Severe generalized abdominal and

shoulder painshoulder painShallow, grunting respirationsShallow, grunting respirations


Perforation (cont.)Perforation (cont.)Ensure any known allergies are Ensure any known allergies are

reported on chartreported on chart Antibiotic therapy is usually started Antibiotic therapy is usually started

Surgical closure may be necessary if Surgical closure may be necessary if perforation does not heal perforation does not heal spontaneouslyspontaneously


Gastric outlet obstructionGastric outlet obstructionCan occur at any timeCan occur at any time

Likely in patients whose ulcer is located Likely in patients whose ulcer is located close to pylorus close to pylorus

Gradual onsetGradual onsetConstant NG aspiration of stomach Constant NG aspiration of stomach

contents may relieve symptomscontents may relieve symptomsRegular irrigation of NG tubeRegular irrigation of NG tube

Peptic Ulcer DiseaseAmbulatory and Home CarePeptic Ulcer DiseaseAmbulatory and Home Care

General instructions should cover aspects General instructions should cover aspects of disease, drugs, possible lifestyle of disease, drugs, possible lifestyle changes, regular follow-up carechanges, regular follow-up care

Patient motivation ↑ when they Patient motivation ↑ when they understand why they should comply with understand why they should comply with therapy and follow-up caretherapy and follow-up care

Peptic Ulcer DiseaseSurgical Therapy Peptic Ulcer DiseaseSurgical Therapy

< 20% of patients with ulcers need < 20% of patients with ulcers need surgical interventionsurgical intervention

Indications for surgical interventionsIndications for surgical interventionsIntractabilityIntractabilityHistory of hemorrhage, ↑ risk of History of hemorrhage, ↑ risk of

bleedingbleedingPrepyloric or pyloric ulcersPrepyloric or pyloric ulcers


Indications for surgical interventions Indications for surgical interventions (cont.)(cont.)Multiple ulcer sitesMultiple ulcer sitesDrug-induced ulcersDrug-induced ulcersPossible existence of a malignant ulcerPossible existence of a malignant ulcerObstructionObstruction


Surgical proceduresSurgical proceduresGastroduodenostomyGastroduodenostomyGastrojejunostomyGastrojejunostomyVagotomyVagotomyPyloroplastyPyloroplasty

Peptic Ulcer DiseaseSurgical Therapy

Peptic Ulcer DiseaseSurgical Therapy

Fig. 40-16A. Billroth I Procedure B. Billroth II Procedure

Peptic Ulcer DiseasePostoperative Complications Peptic Ulcer DiseasePostoperative Complications

Dumping syndromeDumping syndrome Postprandial hypoglycemiaPostprandial hypoglycemia Bile reflux gastritisBile reflux gastritis

Peptic Ulcer DiseaseDumping Syndrome Peptic Ulcer DiseaseDumping Syndrome

Direct result of surgical removal of a Direct result of surgical removal of a large portion of stomach and pyloric large portion of stomach and pyloric sphinctersphincter

↓ ↓ reservoir capacity of stomachreservoir capacity of stomach

Peptic Ulcer DiseaseDumping Syndrome Peptic Ulcer DiseaseDumping Syndrome

Associated with meals having a Associated with meals having a hyperosmolar composition hyperosmolar composition

Experienced by one-third to one-half of Experienced by one-third to one-half of patients after peptic ulcer surgery patients after peptic ulcer surgery

Peptic Ulcer DiseasePostprandial Hypoglycemia Peptic Ulcer DiseasePostprandial Hypoglycemia

Considered a variant of dumping Considered a variant of dumping syndromesyndrome

Result of uncontrolled gastric emptying Result of uncontrolled gastric emptying of a bolus of fluid high in carbohydrate of a bolus of fluid high in carbohydrate into small intestineinto small intestineRelease of excessive amounts of insulin Release of excessive amounts of insulin

into circulationinto circulation

Peptic Ulcer DiseaseBile Reflux Gastritis Peptic Ulcer DiseaseBile Reflux Gastritis

Prolonged contact of bile causes damage Prolonged contact of bile causes damage to gastric mucosato gastric mucosa

Administration of cholestyramine Administration of cholestyramine relieves irritationrelieves irritationAlso, aluminum hydroxide antacids Also, aluminum hydroxide antacids


Start as soon as immediate postoperative Start as soon as immediate postoperative period is successfully passedperiod is successfully passed

Patient should be advised to eliminate Patient should be advised to eliminate drinking fluid with mealsdrinking fluid with meals


Diet should consist of Diet should consist of Small, dry feedings daily Small, dry feedings daily Low in carbohydratesLow in carbohydratesRestricted in sugarsRestricted in sugarsModerate amounts of protein and fatModerate amounts of protein and fat30 minutes of rest after each meal30 minutes of rest after each meal

Interventions are diet instruction, rest, Interventions are diet instruction, rest, and reassurance and reassurance

Peptic Ulcer DiseaseGerontologic ConsiderationsPeptic Ulcer DiseaseGerontologic Considerations

↑ ↑ patients > 60 years of agepatients > 60 years of age↑ ↑ use of NSAIDsuse of NSAIDs

First manifestation may be frank gastric First manifestation may be frank gastric bleeding or ↓ hematocritbleeding or ↓ hematocrit

Treatment similar to younger adultsTreatment similar to younger adults Emphasis placed on prevention of both Emphasis placed on prevention of both

gastritis and peptic ulcersgastritis and peptic ulcers

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