1. Adult Medical-Surgical Nursing
Gastro-intestinal Module:
Gastritis and Peptic Ulcer

2. Gastritis

3. Gastritis
Gastritis is an acute or chronic inflammation of the gastric mucosa
Risk factors include:
Spicy food
Overuse of Aspirin, NSAIDs
Excessive alcohol and caffeinated drinks
Smoking; stressful lifestyle
Helicobacter pylori or other pathogen

4. Gastritis: Pathophysiology
The gastric mucosa is protected from the high acidity of hydrochloric acid in the stomach by mucus secretion
Mucosal damage occurs through:
Interference with the amount of acid: hypersecretion or achlorhydria
Reduction of mucus production
Generalised inflammation results. Where acute can lead to necrosis, scarring or perforation

5. Helicobacter Pylori
H pylori is an organism which has been closely related to gastritis and peptic ulcer
It can be detected in blood and breath tests
Where present, treatment includes antibiotics in addition to control of peptic acid content

6. Gastritis: Clinical Manifestations
Anorexia
Heartburn after eating
Flatulence (belching)
Nausea/ vomiting
Sour taste in mouth

7. Gastritis: Diagnosis Clinical symptoms and dietary history
Breath test, stool or serological test for H pylori
Endoscopy:
Inspection
Gastric washings for H. pylori
Biopsy
Serum B12 (may be ↓ if intrinsic factor affected)

8. Gastritis: Treatment/ Counselling
Dietary changes
↓ smoking
Less stressful lifestyle
Antibiotics
Acid reduction through:
H2 receptor inhibitors (Ranitidine)
Proton pump inhibitors (Lanzoprazole)

9. Peptic Ulcer

10. Peptic Ulcer
The gastric and intestinal wall layers are: mucosa → sub-mucosa → muscle→ serosa→ peritoneum
A peptic ulcer is an erosion of the mucosa of the stomach, pylorus, duodenum or oesophagus in a circumscribed area. It may pass through all layers and eventually perforate to the peritoneum
Multiple ulcers may be present at once

11. Gastric Ulcers (15% of total): Main Features
Later onset: usually after 50 years of age
Similar occurance in male : female (1:1)
Normal, ↑ HCl or ↓ HCl (achlorhydria)
Epigastric pain occurs after a meal (within the following hour), relieved by vomiting
Associated with weight loss
Risk of haemorrhage
Long-term risk for gastric malignancy

12. Duodenal Ulcers (80% of total): Main Features
Affect younger age group (30-60 years)
Occurence in male: female is 2-3 :1
Related to hyperacidity (↑ HCl secretion)
Epigastric dull, gnawing pain occurs 2-3 hours after food, often awakens the patient, relieved by food
Vomiting not common
Increased risk of perforation
Less risk of malignancy

13. Peptic Ulcer: Aetiology
Risk factors for peptic ulcer include:
H pylori (70% in gastric; 95% in duodenal)
Genetic link: blood group “O”
Spicy food; also milk and cream
Smoking
Stressful lifestyle
Use of aspirin, NSAIDs, corticosteroids
Excessive alcohol and caffeinated drinks

14. Peptic Ulcer: Stress Ulcers
Stress ulcers are usually found in ICU patients (prophylaxis given routinely)
Related to physiological stress
Also related to corticosteroid therapy
Usually preceded by shock (severe trauma, burns, sepsis) → reduced blood flow to the mucosa and reflux of duodenal contents to the stomach → outpouring of HCl and pepsin on less protected mucosa → ulceration

15. Peptic Ulcer: Pathophysiology
Peptic ulcer is largely related to:
Increased concentration and action of HCl on the mucosa (stress, spicy foods, smoking, caffeine, alcohol)
Reduced mucus secretion: ↓ mucosal resistance and protection from the digestive action of HCl (stress, aspirin, NSAIDs, corticosteroids, H pylori)

16. Peptic Ulcer: Clinical Manifestations
Dull, gnawing epigastric or back pain (thought to be the effect of acid on exposed nerve endings)
Relieved by vomiting (gastric) or by food (duodenal)
Tenderness over the epigastrium
Possible weight loss
Anaemia if acute or chronic haemorrhage
Haematemesis or malaena (“tarry” stool)

17. Peptic Ulcer: Diagnosis
History and physical examination
CBC (anaemia)
Stool: Guiac test for occult blood
Breath test, stool or serum (antibodies) for Helicobacter pylori
Endoscopy: Inspection
Biopsy of mucosa for histology
Gastric washings for culture of H pylori

18. Peptic Ulcer: Medical Management
Lifestyle changes
Medical treatment:
Antibiotics (Flagyl and one other antibiotic)
H2-receptor antagonist (Ranitidine) or Proton-pump inhibitor (Lanzoprazole)
Mucosal protection (Misoprostol)
(Usually avoid antacids as interfere with treatment)

19. Peptic Ulcer: Surgery Surgery is less used now. Mainly for:
Ulcers not healing after 12 – 16 weeks
Life-threatening complications:
Haemorrhage
Perforation/ penetration
Pyloric obstruction

20. Peptic Ulcer: Surgery Types of surgical procedure:
Vagotomy (resection of the vagus, parasympathetic nerve: ↓ HCl secretion)
Pyloroplasty (with or without vagotomy)
Gastro-enterostomy (bypass from stomach to jejunum)

21. Peptic Ulcer Complications: Haemorrhage
Haemorrhage: ulcer has eroded a blood vessel
Haematemesis, especially gastric ulcer: fresh blood or “coffee-ground” vomit
Malaena (more obvious if duodenal ulcer)
May be an emergency → hypovolaemic shock
GXM, IV fluids, vital signs, NG tube, NPO
Rest, mouth care, surgical prep (if needed)

22. Peptic Ulcer Complications: Perforation
Ulcer has perforated layers to the peritoneum
Acid contents leaking into peritoneum
Patient in severe shock from extreme pain of chemical peritonitis
Rigid, board-like abdomen, extremely tender
Hypotension: emergency requiring immediate resuscitation and preparation for surgery to repair

23. Peptic Ulcer: Nursing Care
Pre-operative care: (may well be emergency)
General physical check-up, chest Xray, ECG
Blood profile, IVI, group and cross-match (GXM)
Breathing exercises to prepare for post-op
Thrombo-embolic stockings/ prophylactic heparin
Explanation of operation, consent and emotional support

24. Peptic Ulcer: Nursing Care
Post-operative care:
Pain relief
Monitor vital signs, pulse oximetry, IV fluids, urine output and fluid balance
Semi-sitting position once recovered
Breathing and leg exercises
NPO initially→ graduated intake (mouth care)
NG tube aspirations, wound, drain care