PEPTIC ULCER DISEASE

DEFINITION Break in the gastrointestinal mucosa exposed to gastric acid and pepsin more than 5 mm in diameter. Manu K Thomas

TYPES Gastric ulcer Duodenal ulcer Manu K Thomas

Gastric Ulcer Manu K Thomas

Duodenal Ulcer Manu K Thomas

ETIOLOGY Hyper secretory states: Stress Drugs H. pylori Idiopathic Shock Sepsis Hyper secretory states: Zollinger –Ellison Syndrome, Crohn’s Disease Hepatic & biliary disease Stress Trauma or major illness Severe burns (Curling’ Ulcer) Head injury or intracranial disease (Cushing’s ulcer) Drugs NSAID’s, Aspirin, Steroids Zollinger-Ellison syndrome is a disorder where increased levels of the hormone gastrin are produced, causing the stomach to produce excess hydrochloric acid Crohn's disease is an inflammatory disease of the intestines that may affect any part of the gastrointestinal tract from mouth to anus, causing a wide variety of symptoms. Its an auto immune disease Manu K Thomas

H. Pylori Manu K Thomas

RISK FACTORS Gastric Ulcer Duodenal ulcer Alcohol Smoking Cirrhosis Stress Duodenal ulcer Gastritis Alcohol Smoking NSAID’s Stress Manu K Thomas

PATHOPHYSIOLOGY Gastric Ulcer The mucosal lining is protected by a mucosal barrier composed of prostaglandins NSAIDs reduces the prostaglandins Break in the mucosal barrier HCl is comes to contact with the mucosal lining Injury to the small vessels Edema & ulceration Manu K Thomas

Increase activity of vagus nerve Stimulates pyloric antrum cells Duodenal Ulcer Increase activity of vagus nerve Stimulates pyloric antrum cells Gastrin Acts on gastric parietal cells to secrete HCl Formation of excess HCl Ulceration Manu K Thomas

CLINICAL MANIFESTATIONS Duodenal ulcer Hypersecretion of stomach acid Epigastric pain 2 hours after meal or on a empty stomach or during night Pyrosis Vomiting is uncommon Good nutrition May have wt gain Hemorrhage is less common (melena is more common than Hematemesis) Gastric ulcer Normal – hyposecretion of acid Epigastric pain after meal or during meal Vomiting brings relief Vomiting is common Reduced nutrition Loss of weight Hemorrhage is common (Hematemesis is more common than melena) Upper dyspeptic syndrome – loss of appetite, nausea, vomiting, flatulence Manu K Thomas

DIAGNOSTIC METHODS Endoscopy: esophago gastroduodenoscopy Radiologic tests Computed tomography (CT) Magnetic resonance imaging (MRI) Scintigraphy Tests for H. pylori Motility tests Manu K Thomas

X RAY VIEW Manu K Thomas

DIAGNOSIS OF HELICOBACTER PYLORI INFECTION Invasive( through endoscopy) Gastric biopsy and staining Culture of biopsy specimen Non-invasive: Urea breath test H.Pylori antibodies Stool antigen Salivary antigen Manu K Thomas

MEDICAL MANAGEMENT Aim of treatment: Stop smoking Avoid alcohol Relieve symptoms Heal the ulcer Prevent complications Prevent recurrences Stop smoking Avoid alcohol Stop NSAIDs, Aspirin Diet avoid coffee, protein foods, milk Stress reduction & rest Manu K Thomas

PHARMACOLOGIC MANAGEMENT H.pylori (+) ⇒ eradication First-line treatment: Triple therapy → PPI + clarithromycin + amoxicillin Second line treatment: quadruple therapy → PPI + bismuth salts + metronidazole + tetracycline H.pylori (-) H2 receptor blockers PPI Sucralfate Antacids Prostaglandins Manu K Thomas

NURSING MANAGEMENT Relieving pain Reducing anxiety Maintaining nutritional status Monitoring potential Cx Manu K Thomas

NURSING DIAGNOSIS Acute pain r/t gastric mucosal injury Anxiety r/t coping with an acute disease Imbalanced nutrition r/t changes in diet Ineffective therapeutic regimen r/t knowledge deficit Manu K Thomas

COMPLICATIONS Hemorrhage Perforation Obstruction chronic (minor, cause anemia) acute (major, form affected vessel) Perforation Mostly anterior gastric wall acute violent pain bleeding can be present Obstruction Penetration - of the ulcer deeply through whole wall into neighbour organ (pancreas, liver) Stenosis narrow of the lumen caused by scar, oedema or inflammatory infiltration after healing of the ulcer rise only at pyloric localization vomiting of huge volume of gastric content Perforation – A small opening Penetration – ulcer pierce the stomach wall & affects the pancreas, omentum, biliary tract, liver etc. Manu K Thomas

A – penetration B – perforation C – bleeding D - stenosis Manu K Thomas

BLEEDING Manu K Thomas

OBSTRUCTION Manu K Thomas

LIFE-STYLE MODIFICATION Rest Relaxation Good sleep Diet: Bland diet Frequent small meals Caffeine-containing beverages Role of milk Fat diet Spices Alcohol Fiber Vitamin e and dietary fatty acids Manu K Thomas

SURGICAL MANAGEMENT Indications Bleeding Perforation Obstruction Non healing Manu K Thomas

SURGERIES Vagotomy Gastroenterostomy Antrectomy Subtotal Gastrectomy Manu K Thomas

VAGOTOMY To eliminate the acid secreting stimulus to gastric cells. 3 types are Truncal Vagotomy – each vagus nerve is completely cut Selective Vagotomy – partially cut the nerves to hepatic & celiac branches Proximal Vagotomy – partial cutting, only the parietal cell mass is denervated It can be done by Open surgical approach Laparoscopy Thoracoscopy Manu K Thomas

Manu K Thomas

GASTROENTEROSTOMY An opening is made in the bottom of the stomach & is attached with the jejunum It permits the regurgitation of alkaline duodenal contents Neutralizing the gastric acid Sometimes it is combines with vagotomy. Manu K Thomas

Manu K Thomas

ANTRECTOMY An antrectomy is the resection, or surgical removal, of a part of the stomach known as the antrum; thus the cells that secretes gastrin get removed Then the remaining portion of the stomach is anastomosis with duodenum Manu K Thomas

Manu K Thomas

SUBTOTAL GASTRECTOMY Defined as the surgery that involves partial removal of the stomach It is accompanied by 2 procedures Billroth I Billroth II Manu K Thomas

BILLROTH I It is also called as gastroduodenostomy Surgical removal of the distal portion of the stomach The remainder of the stomach is anastomosed to the duodenum Manu K Thomas

BILLROTH II The other name is gastrojejunostomy is a surgery in which the lower part of the stomach is removed and a loop of small bowel (jejunum) is brought up and joined to it in a side-to-side manner for drainage. Manu K Thomas

Manu K Thomas

Manu K Thomas

TOTAL GASTRECTOMY Surgery involves removal of the stomach, with anastomosis of the esophagus to the jejunum An esophagojejunostomy. Manu K Thomas

COMPLICATIONS AFTER SURGERIES Dumping syndrome – Ingested food rapidly enters the jejunum without proper mixing & without the proper duodenal digestive processing. Usually subsides in 6 – 12 months Early Manifestations are:- (within 5 – 30 min.) Vertigo Tachycardia Sweating Pallor Diarrhoea nausea Late manifestations :- (2 – 3 ) Epigastric fullness, distension Abd. Discomfort Abd. Cramping Borborygmi – rumbling sounds in the bowel Tenesmus – ineffectual & painful straining to defecate Mx. Limit intake of diet High protein, high fat & low carbohydrate diet Manu K Thomas

COMPLICATIONS AFTER SURGERIES Marginal ulcers – gastric acid is in contact with operative site Hemorrhage Nutritional problems Manu K Thomas