1. Peptic Ulcer Disease Therapy

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

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

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

5. 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

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

7. 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

8. 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

9. 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

10. 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

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

12. 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

13. 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

14. 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

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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

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

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

27. 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

28. 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

29. 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

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

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

32. 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

33. 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

34. 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

35. 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

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

37. Peptic Ulcer Disease Surgical Therapy
Surgical procedures
Gastroduodenostomy
Gastrojejunostomy
Vagotomy
Pyloroplasty

38. Peptic Ulcer Disease Surgical Therapy
A. Billroth I Procedure
B. Billroth II Procedure
Fig

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

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

41. 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

42. 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

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

44. 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

45. 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

46. 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