35. Peptic Ulcer Disease


I. Definition

A. A gastrointestinal ulcer is a loss of enteric surface epithelium that extends deeply enough to penetrate the muscularis mucosae.

B. PUD refers to a chronic disorder in which the patient has a lifelong underlying tendency to develop mucosal ulcers at sites that are exposed to peptic juice (i.e., acid and pepsin).

1. The most common locations are the duodenum and the stomach.

2. Ulcers may also occur in the esophagus, jejunum, and ileum, and at gastroenteric anastomoses.

III. Risk factors

A. Highly associated

1. Smoking more than than ½ pack of cigarettes per day

2. Drugs (NSAIDs)

3. Family history

4. Zollinger-Ellison syndrome (condition caused by non–insulin-secreting tumors of the pancreas, which secrete excess amounts of gastrin)

B. Possibly associated

1. Corticosteroids

2. Stress

C. Low association or no association

1. Spices

2. Alcohol

3. Caffeine

4. Acetaminophen

V. Subjective findings

A. Duodenal ulcers

1. Epigastric pain (“gnawing,” “aching,” “hunger-like”) occurs 1 to 3 hours after eating. The pain is rhythmic and periodic.

2. Nocturnal pain that awakens a patient from sleep

3. Usually relieved by antacid or food ingestion

4. Heartburn (suggests reflux disease)

5. Epigastric tenderness: usually midline or right of midline

B. Gastric ulcers

1. Epigastric pain similar to that associated with duodenal ulcers and also rhythmic and periodic

2. Pain is not usually relieved by food.

3. Food may precipitate symptoms.

4. Nausea and anorexia

VI. Physical findings

A. Often unremarkable

B. Patient may have epigastric tenderness.

1. At or to the left of the midline with gastric ulcer

2. Located 1 inch or farther to the right of midline with duodenal ulcer

C. Signs and symptoms of shock from acute or chronic blood loss

D. Nausea and vomiting if the pyloric channel is obstructed

E. Boardlike abdomen and rebound tenderness in the event of perforation

F. Hematemesis or melena if the ulcer is bleeding

VIII. Diagnostics

A. Upper GI barium studies

1. For uncomplicated dyspepsia

2. Those diagnosed with gastric ulcers should undergo endoscopy after 8 to 12 weeks of treatment to distinguish benign from malignant ulcers.

B. Endoscopy

1. Highest accuracy rate (90% to 95%)

2. Identifies superficial and very small ulcers

3. Biopsy may be performed.

4. Electrocautery of any bleeding ulcers can be carried out.

5. Gastric pH can be measured in suspected gastrinoma.

6. Esophagitis, gastritis, or duodenitis can be diagnosed.

7. H. pylori can be detected.

8. Higher cost than barium studies

IX. Complications of PUD

A. GI bleeding (20% of cases)

1. Clinical manifestations

a. Hematemesis

b. Melena

c. Hematochezia

d. “Coffee ground” emesis

2. Physical examination

a. Pallor

b. Tachycardia

c. Hypotension

d. Diaphoresis

3. Laboratory findings

a. Decreased hematocrit due to bleeding or hemodilution from IV fluids

b. BUN may rise owing to absorption of blood nitrogen from the small intestine and as the result of prerenal azotemia.

4. Diagnostics: endoscopy after the patient has stabilized

5. Management

a. In approximately 80% of cases, bleeding stops spontaneously within a few hours after admission to the hospital.

b. IV hydration with normal saline

c. Blood transfusion as required

d. Continuous IV infusion of H2 blockers at a dose adequate to maintain gastric pH above 4

e. Vasopressin (Pitressin) and IV octreotide (Sandostatin) should not be used for bleeding ulcers.

f. Surgery if bleeding persists

Mar 3, 2017 | Posted by in NURSING | Comments Off on 35. Peptic Ulcer Disease

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