1. PEPTIC ULCER DISEASE

2. DEFINITION
Break in the gastrointestinal mucosa exposed to gastric acid and pepsin more than 5 mm in diameter.
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3. TYPES
Gastric ulcer
Duodenal ulcer
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4. Gastric Ulcer
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5. Duodenal Ulcer
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6. 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
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7. H. Pylori
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8. RISK FACTORS Gastric Ulcer Duodenal ulcer Alcohol Smoking Cirrhosis
Stress
Duodenal ulcer
Gastritis
Alcohol
Smoking
NSAID’s
Stress
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9. 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
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10. 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
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11. 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
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12. DIAGNOSTIC METHODS Endoscopy: esophago gastroduodenoscopy
Radiologic tests
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Scintigraphy
Tests for H. pylori
Motility tests
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13. X RAY VIEW
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14. 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
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15. 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
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16. 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
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17. NURSING MANAGEMENT Relieving pain Reducing anxiety
Maintaining nutritional status
Monitoring potential Cx
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18. 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
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19. 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.
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20. A – penetration B – perforation C – bleeding D - stenosis
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21. BLEEDING
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22. OBSTRUCTION
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23. 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
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24. SURGICAL MANAGEMENT Indications Bleeding Perforation Obstruction
Non healing
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25. SURGERIES Vagotomy Gastroenterostomy Antrectomy Subtotal Gastrectomy
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26. 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
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28. 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.
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30. 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
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32. SUBTOTAL GASTRECTOMY
Defined as the surgery that involves partial removal of the stomach
It is accompanied by 2 procedures
Billroth I
Billroth II
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33. 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
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34. 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.
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37. TOTAL GASTRECTOMY
Surgery involves removal of the stomach, with anastomosis of the esophagus to the jejunum
An esophagojejunostomy.
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38. 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
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39. COMPLICATIONS AFTER SURGERIES
Marginal ulcers – gastric acid is in contact with operative site
Hemorrhage
Nutritional problems
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