Peptic Ulcer Disease Therapy

Peptic Ulcer Disease Collaborative Care Medical regimen consists of Adequate rest Dietary modification Drug therapy Elimination of smoking Long-term follow-up care

Peptic Ulcer Disease Collaborative Care Aim of treatment program ↓ degree of gastric acidity Enhance mucosal defense mechanisms Minimize harmful effects on mucosa

Peptic Ulcer Disease Collaborative Care Generally treated in ambulatory care clinics Requires many weeks of therapy Pain disappears after 3 to 6 days

Peptic Ulcer Disease Collaborative Care Healing may take 3 to 9 weeks Should be assessed by means of x-rays or endoscopic examination Moderation in daily activity is essential NSAIDs that are COX-2 inhibitors are used

Peptic Ulcer Disease Drug Therapy Includes use of Antacids H2R blockers PPIs Antibiotics Anticholinergics Cytoproctective therapy

Peptic Ulcer Disease Drug Therapy Recurrence of peptic ulcer is frequent Interruption or discontinuation of therapy can have detrimental results No drugs, unless prescribed by health care provider, should be taken Ulcerogenic effect

Peptic Ulcer Disease Drug Therapy Histamine-2 receptor blocks (H2R blockers) Used to manage peptic ulcer disease Block action of histamine on H2 receptors ↓ HCl acid secretion ↓ conversion of pepsinogen to pepsin ↑ ulcer healing

Peptic Ulcer Disease Drug Therapy Proton pump inhibitors (PPI) Block ATPase enzyme that is important for secretion of HCl acid Antibiotic therapy Eradicate H. pylori infection No single agents have been effective in eliminating H. pylori

Peptic Ulcer Disease Drug Therapy Antacids Used as adjunct therapy for peptic ulcer disease ↑ gastric pH by neutralizing acid Anticholinergic drugs Occasionally ordered for treatment ↓ cholinergic stimulation of HCl acid

Peptic Ulcer Disease Drug Therapy Cytoprotective drug therapy Used for short-term treatment of ulcers Tricyclic antidepressants Serotonin reuptake inhibitors

Peptic Ulcer Disease Nutritional Therapy Dietary modifications may be necessary so that foods and beverages irritating to patient can be avoided or eliminated Nonirritating or bland diet consisting of 6 small meals a day during symptomatic phase

Peptic Ulcer Disease Nutritional Therapy Include a sample diet with a list of foods that usually cause distress Hot, spicy foods and pepper, alcohol, carbonated beverages, tea, coffee, broth Foods high in roughage may irritate an inflamed mucosa

Peptic Ulcer Disease Nutritional Therapy Protein considered best neutralizing food Stimulates gastric secretions Carbohydrates and fats are least stimulating to HCl acid secretion Do not neutralize well

Peptic Ulcer Disease Nutritional Therapy Milk can neutralize gastric acidity and contains prostaglandins and growth factors Protects GI mucosa from injury

Peptic Ulcer Disease Therapy Related to Complications Acute exacerbation Treated with same regimen used for conservative therapy Situation is more serious because of possible complications of perforation, hemorrhage, gastric outlet obstruction Accompanied by bleeding, ↑ pain and discomfort, nausea, vomiting

Peptic Ulcer Disease Therapy Related to Complications Acute exacerbation (cont.) Recurrent vomiting, gastric outlet obstruction NG tube placed in stomach with intermittent suction for about 24 to 48 hours Fluids and electrolytes are replaced by IV infusion until patient is able to tolerate oral feedings without distress

Peptic Ulcer Disease Therapy Related to Complications Acute exacerbation (cont.) Management is similar to that for upper GI bleeding Blood or blood products may be administered Careful monitoring of vital signs, intake and output, laboratory studies, signs of impending shock

Peptic Ulcer Disease Therapy Related to Complications Acute exacerbation (cont.) Endoscopic evaluation reveals degree of inflammation or bleeding and ulcer location 5-year follow-up program is recommended

Peptic Ulcer Disease Therapy Related to Complications Perforation Immediate focus to stop spillage of gastric or duodenal contents into peritoneal cavity and restore blood volume NG tube is placed into stomach Placement of tube as near to perforation site as possible facilitates decompression

Peptic Ulcer Disease Therapy Related to Complications Perforation (cont.) Circulating blood volume must be replaced with lactated Ringer’s and albumin solutions Blood replacement in form of packed RBCs may be necessary Central venous pressure line, indwelling urinary cater should be inserted and monitored hourly

Peptic Ulcer Disease Therapy Related to Complications Gastric outlet obstruction Decompress stomach Correct any existing fluid and electrolyte imbalances Improve patient’s general state of health NG tube inserted in stomach, attached to continuous suction to remove excess fluids and undigested food particles

Peptic Ulcer Disease Therapy Related to Complications Gastric outlet obstruction (cont.) Continuous decompression allows Stomach to regain its normal muscle tone Ulcer can begin to heal Inflammation and edema subside When aspirate falls below 200 ml, within normal range, oral intake of clear liquids can begin

Peptic Ulcer Disease Therapy Related to Complications Gastric outlet obstruction (cont.) Watch patient carefully for signs of distress or vomiting IV fluids and electrolytes are administered according to degree of dehydration, vomiting, electrolyte imbalance

Peptic Ulcer Disease Nursing Management Overall Goals Comply with prescribed therapeutic regimen Experience a reduction or absence of discomfort related to peptic ulcer disease

Peptic Ulcer Disease Nursing Management Overall Goals (cont.) Exhibits no signs of GI complications Have complete healing Lifestyle changes to prevent recurrence

Peptic Ulcer Disease Nursing Implementation Health Promotion Identify patients at risk Early detection and ↓ morbidity Encourage patients to take ulcerogenic drugs with food or milk Teach patients to report symptoms related to gastric irritation to health care provider

Peptic Ulcer Disease Nursing Implementation Acute Intervention Patient generally complains of ↑ pain, nausea, vomiting, and some bleeding May be maintained on NPO status for a few days, have NG tube inserted, fluids replaced intravenously Physical and emotional rest are conducive to ulcer healing

Peptic Ulcer Disease Nursing Implementation Hemorrhage Changes in vital signs, ↑ in amount and redness of aspirate signal massive upper GI bleeding ↑ amount of blood in gastric contents ↓ pain because blood helps neutralize acidic gastric contents Keep blood clots from obstructing NG tube

Peptic Ulcer Disease Nursing Implementation Perforation Sudden, severe abdominal pain unrelated in intensity and location to pain that brought patient to hospital

Peptic Ulcer Disease Nursing Implementation Perforation (cont.) Indicated by a rigid, boardlike abdomen Severe generalized abdominal and shoulder pain Shallow, grunting respirations

Peptic Ulcer Disease Nursing Implementation Perforation (cont.) Ensure any known allergies are reported on chart Antibiotic therapy is usually started Surgical closure may be necessary if perforation does not heal spontaneously

Peptic Ulcer Disease Nursing Implementation Gastric outlet obstruction Can occur at any time Likely in patients whose ulcer is located close to pylorus Gradual onset Constant NG aspiration of stomach contents may relieve symptoms Regular irrigation of NG tube

Peptic Ulcer Disease Ambulatory and Home Care General instructions should cover aspects of disease, drugs, possible lifestyle changes, regular follow-up care Patient motivation ↑ when they understand why they should comply with therapy and follow-up care

Peptic Ulcer Disease Surgical Therapy < 20% of patients with ulcers need surgical intervention Indications for surgical interventions Intractability History of hemorrhage, ↑ risk of bleeding Prepyloric or pyloric ulcers

Peptic Ulcer Disease Surgical Therapy Indications for surgical interventions (cont.) Multiple ulcer sites Drug-induced ulcers Possible existence of a malignant ulcer Obstruction

Peptic Ulcer Disease Surgical Therapy Surgical procedures Gastroduodenostomy Gastrojejunostomy Vagotomy Pyloroplasty

Peptic Ulcer Disease Surgical Therapy A. Billroth I Procedure B. Billroth II Procedure Fig. 40-16

Peptic Ulcer Disease Postoperative Complications Dumping syndrome Postprandial hypoglycemia Bile reflux gastritis

Peptic Ulcer Disease Dumping Syndrome Direct result of surgical removal of a large portion of stomach and pyloric sphincter ↓ reservoir capacity of stomach

Peptic Ulcer Disease Dumping Syndrome Associated with meals having a hyperosmolar composition Experienced by one-third to one-half of patients after peptic ulcer surgery

Peptic Ulcer Disease Postprandial Hypoglycemia Considered a variant of dumping syndrome Result of uncontrolled gastric emptying of a bolus of fluid high in carbohydrate into small intestine Release of excessive amounts of insulin into circulation

Peptic Ulcer Disease Bile Reflux Gastritis Prolonged contact of bile causes damage to gastric mucosa Administration of cholestyramine relieves irritation Also, aluminum hydroxide antacids

Peptic Ulcer Disease Nutritional Therapy Start as soon as immediate postoperative period is successfully passed Patient should be advised to eliminate drinking fluid with meals

Peptic Ulcer Disease Nutritional Therapy Diet should consist of Small, dry feedings daily Low in carbohydrates Restricted in sugars Moderate amounts of protein and fat 30 minutes of rest after each meal Interventions are diet instruction, rest, and reassurance

Peptic Ulcer Disease Gerontologic Considerations ↑ patients > 60 years of age ↑ use of NSAIDs First manifestation may be frank gastric bleeding or ↓ hematocrit Treatment similar to younger adults Emphasis placed on prevention of both gastritis and peptic ulcers