Peptic Ulcer Disease Therapy

1
Peptic Ulcer Disease Therapy
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Peptic Ulcer DiseaseCollaborative Care

• Medical regimen consists of
• Adequate rest
• Dietary modification
• Drug therapy
• Elimination of smoking
• Long-term follow-up care

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Peptic Ulcer DiseaseCollaborative Care

• Aim of treatment program
• ? degree of gastric acidity
• Enhance mucosal defense mechanisms
• Minimize harmful effects on mucosa

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Peptic Ulcer DiseaseCollaborative Care

• Generally treated in ambulatory care clinics
• Requires many weeks of therapy
• Pain disappears after 3 to 6 days

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Peptic Ulcer DiseaseCollaborative 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

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Peptic Ulcer DiseaseDrug Therapy

• Includes use of
• Antacids
• H2R blockers
• PPIs
• Antibiotics
• Anticholinergics
• Cytoproctective therapy

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Peptic Ulcer DiseaseDrug 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

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Peptic Ulcer DiseaseDrug 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

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Peptic Ulcer DiseaseDrug 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

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Peptic Ulcer DiseaseDrug 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

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Peptic Ulcer DiseaseDrug Therapy

• Cytoprotective drug therapy
• Used for short-term treatment of ulcers
• Tricyclic antidepressants
• Serotonin reuptake inhibitors

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Peptic Ulcer DiseaseNutritional 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

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Peptic Ulcer DiseaseNutritional 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

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Peptic Ulcer DiseaseNutritional Therapy

• Protein considered best neutralizing food
• Stimulates gastric secretions
• Carbohydrates and fats are least stimulating to
  HCl acid secretion
• Do not neutralize well

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Peptic Ulcer DiseaseNutritional Therapy

• Milk can neutralize gastric acidity and contains
  prostaglandins and growth factors
• Protects GI mucosa from injury

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Peptic Ulcer DiseaseTherapy 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

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Peptic Ulcer DiseaseTherapy 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

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Peptic Ulcer DiseaseTherapy 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

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Peptic Ulcer DiseaseTherapy Related to
Complications

• Acute exacerbation (cont.)
• Endoscopic evaluation reveals degree of
  inflammation or bleeding and ulcer location
• 5-year follow-up program is recommended

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Peptic Ulcer DiseaseTherapy 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

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Peptic Ulcer DiseaseTherapy Related to
Complications

• Perforation (cont.)
• Circulating blood volume must be replaced with
  lactated Ringers 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

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Peptic Ulcer DiseaseTherapy Related to
Complications

• Gastric outlet obstruction
• Decompress stomach
• Correct any existing fluid and electrolyte
  imbalances
• Improve patients general state of health
• NG tube inserted in stomach, attached to
  continuous suction to remove excess fluids and
  undigested food particles

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Peptic Ulcer DiseaseTherapy 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

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Peptic Ulcer DiseaseTherapy 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

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Peptic Ulcer DiseaseNursing Management

• Overall Goals
• Comply with prescribed therapeutic regimen
• Experience a reduction or absence of discomfort
  related to peptic ulcer disease

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Peptic Ulcer DiseaseNursing Management

• Overall Goals (cont.)
• Exhibits no signs of GI complications
• Have complete healing
• Lifestyle changes to prevent recurrence

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Peptic Ulcer DiseaseNursing 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

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Peptic Ulcer DiseaseNursing 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

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Peptic Ulcer DiseaseNursing 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

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Peptic Ulcer DiseaseNursing Implementation

• Perforation
• Sudden, severe abdominal pain unrelated in
  intensity and location to pain that brought
  patient to hospital

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Peptic Ulcer DiseaseNursing Implementation

• Perforation (cont.)
• Indicated by a rigid, boardlike abdomen
• Severe generalized abdominal and shoulder pain
• Shallow, grunting respirations

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Peptic Ulcer DiseaseNursing 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

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Peptic Ulcer DiseaseNursing 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

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Peptic Ulcer DiseaseAmbulatory 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

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Peptic Ulcer DiseaseSurgical Therapy

• lt 20 of patients with ulcers need surgical
  intervention
• Indications for surgical interventions
• Intractability
• History of hemorrhage, ? risk of bleeding
• Prepyloric or pyloric ulcers

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Peptic Ulcer DiseaseSurgical Therapy

• Indications for surgical interventions (cont.)
• Multiple ulcer sites
• Drug-induced ulcers
• Possible existence of a malignant ulcer
• Obstruction

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Peptic Ulcer DiseaseSurgical Therapy

• Surgical procedures
• Gastroduodenostomy
• Gastrojejunostomy
• Vagotomy
• Pyloroplasty

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Peptic Ulcer DiseaseSurgical Therapy
B. Billroth II Procedure
A. Billroth I Procedure
Fig. 40-16
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Peptic Ulcer DiseasePostoperative Complications

• Dumping syndrome
• Postprandial hypoglycemia
• Bile reflux gastritis

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Peptic Ulcer DiseaseDumping Syndrome

• Direct result of surgical removal of a large
  portion of stomach and pyloric sphincter
• ? reservoir capacity of stomach

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Peptic Ulcer DiseaseDumping Syndrome

• Associated with meals having a hyperosmolar
  composition
• Experienced by one-third to one-half of patients
  after peptic ulcer surgery

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Peptic Ulcer DiseasePostprandial 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

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Peptic Ulcer DiseaseBile Reflux Gastritis

• Prolonged contact of bile causes damage to
  gastric mucosa
• Administration of cholestyramine relieves
  irritation
• Also, aluminum hydroxide antacids

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Peptic Ulcer DiseaseNutritional Therapy

• Start as soon as immediate postoperative period
  is successfully passed
• Patient should be advised to eliminate drinking
  fluid with meals

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Peptic Ulcer DiseaseNutritional 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

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Peptic Ulcer DiseaseGerontologic Considerations

• ? patients gt 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