PEPTIC ULCER DISEASE
PRESENTED BY LAYTON
KYOTALIMYE
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OBJECTIVES
Definition of PUD
Classify of pud
Etiology and risk factors for PUD
clinical features of PUD
Medical and nursing management
Nursing diagnosis
complications
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Review of anatomy
The wall of the gastro intestinal tract is formed by
walls ;mucus layer, submucous layer, muscular
layer which Consists of a break in the superficial
epithelial cells penetrating down to the muscularis
mucosa
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Stomach Defense Systems against HCL
destruction
Mucous layer
Coats and lines the stomach
First line of defense
Bicarbonate
Neutralizes acid
Prostaglandins
Hormone-like substances that keep blood
vessels dilated for good blood flow
Also stimulate mucus and bicarbonate
production
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PUD Refers to ulceration in the mucosa of the
lower oesophagus , stomach or duodenum by
disruption of normal balance of corrosive effect of
gastric juice and the protective effect of the mucus
on the gastric epithelial cells.
It is called peptic ulcer because any portion that
comes into contact with the gastric contents
(pepsin /HCL) maybe affected.
The most common sites for ulcers are Stomach,
the 1st few cms of the duodenum. And in the lower
2/3 of the Oesophagus following reflux of gastric
juice in GERD.
LAYTONK@MEDICINE
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Peptic Ulcer Disease sites
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Etiology and risk factors for PUD
if factors associated with the maintenance of the
health mucosa are impaired the acidic gastric juice
gains access to the epithelium causing initial
damage that leads to ulceration with repeated.
The main factors that are impaired include ,.
Normal blood supply.
Mucosa secretion.
Cell replacement and bicarbonate ions
secretion.
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Pud: pathogenesis
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Risk Factors
Lifestyle Gender
Smoking Duodenal: are increasing in
Acidic/spiced foods older women
Medications eg Genetic factors
NSAIDS(aspirin,diclofenac) More likely if family member
has Hx
Other factors:
H. Pylori infection
90% have this bacterium - stress related to
Passed from person to person
physiological conditions
(fecal-oral route or oral-oral
which lead to release of
route) adrenaline and cortisol
causing vasoconstiction
Age
Duodenal 30-50 years
-zolliger ellison syndrome leads
to hypersecretion of gastric
Gastric over 60 years
juice causing chronic gastritis
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Classification of PUD
According to site; Gastric and duodenal ulcer are the
commonest, Both are associated with an imbalance
between protective and aggressive factors to the
gastrointestinal tract
According to onset; Can be acute; associated with
superficial erosion and minimal inflammation of mucosa,
having a short course duration and easily resolve with
treatment and lifestyle modification
Chronic PUD has a long duration lasting for months
presenting with complications.
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Gastric and Duodenal Ulcers
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Gastric Ulcers
• Pain occurs 1-2 hours after meals
• Pain usually does not wake patient
• Increased by ingestion of food
• Risk for malignancy/chronicity
• Deep and penetrating and usually occur on the lesser
curvature of the stomach
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Duodenal Ulcers
Pain occurs 2-4 hours after meals
Pain wakes up patient
Pain relieved by food
Very little risk for malignancy and it’s the commonest
form of PUD
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clinical features
Patients may remain asymptomatic for
sometime because the mucosa is poorly
innervated
Recurrent epigastic pain; its sharp, burning,
aching,gnawing
Persistent severe pain may suggest
penetration into other viscera
Back pain may indicate penetrating
LAYTONK@MEDICINE 10/10/2022
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Anorexia
weight loss/Gain may occur in Gus
Dyspepsia
Nausea may be accompanied and/or
relieved by vomiting
belching
Heart burn
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investigation and diagnosis
For helicobacter pylori. Serological tests: Test for
IgG
Sensitivity (90%); specificity (83%)
Urea breath Test
endoscopy (and biopsy of ulcers) to rule out
gastric cancer for all patients with ALARM
symptoms (, weight loss, vomiting, anorexia,
hematemesis/melana)
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Barium meal and contrast studies
LAYTONK@MEDICINE 10/10/2022
Drug Therapy and Goals of management
• Provide pain relief
– Antacids and mucosa protectors
• Eradicate H. pylori infection
– Two antibiotics and one acid suppressor
• Heal ulcer
– Eradicate infection
– Protect until ulcer heals
• Prevent recurrence
– Decrease high acid stimulating foods in susceptible people
– Avoid use of potential ulcer causing drugs
– Stop smoking
• Prevent complications
- (bleeding, perforation, penetration, obstruction)
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Proton Pump Inhibitors
E.g omeprazole, rabeprazole, lansoprazole, esomeprazole
Suppress acid production
Omeprazole 20-40mg od 4-8weeks,before food as a whole
capsule
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H2-Receptor Antagonists
E.g Ranitidine, cimetidine, famotidine,nizatidine
Block histamine-stimulated gastric secretions ie reduce gastric
acid secretion by blocking the action of histamine at the H2
recepors in the pariental cells of the stomach.
Cimetidine 400mg bdnocte 4-6 weeks
Ranitidine 150mg bd 4-8weeks or iv 50mg diluted with 20ml
ns 6hrly
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Prostaglandin Analogs
Eg misoprostol; tabs 200mcg
Reduce gastric acid, enhances mucosal resistance to injury
and promote secretion of bicarbonate ions and mucus.
Contraindicated in pregnancy, and lactating mothers
Adult dose is 800mcg in 2-4 divided doses with food for 4-8
weeks
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Drugs cont’d
ANTACIDS.
- An antacid may be taken in addition to aPPIor H2receptor agnoist..
Instead of reducing acid secretion, antacids neutralize existing
stomach acid and can provide rapid pain relief for short period of
time.
- Examples; Magnessium hydroxide, Aluminium
Hydroxide,magnesium trisillicate.
Nb.other igredients may be added into the antiacids to counteract
the effects eg dyspesia and flatulence like simethicone
Mg antiacids tend to cause diarrhea where as aluminium based
antiacids cause constipation, so they be given in combination to
relieve effects of each.
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CYTOPROTECTIVE AGENTS./mucosal
protective drugs
- These medications help protect the mucosal lining of the
stomach and small intestine by forming abarrier which coats
the ulcer. They should not be combined with
antiacids,because the work in an acidic environment.
-They include; Sucralfate, and Bismuth subsalicylate tbs
120mg.
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Eradication of H.pylori (tripple therapy)
Examples of Regimens (7 – 14 days of Rx)
Omeprazole (20mg) +clarithromycin (500mg) +
amoxicillin (1g) twice daily.
Omeprazole (20mg) + Metronidazole (400mg)
+clarithromycin (500mg) twice daily.
Eradication failure regimen:
Bismuth chelates (120mg X 4 daily) + Metro (400mg
X 3 daily) + Tetracycline (500mg X 4 daily) + PPI (20-
40mg X 2 daily)
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Surgical intervention
• Required if ulcer in one of these states
– Perforated and overflowed into the abdomen
– Scarred or swelled so that there is obstruction
– Acute bleeding
– Non-responsive to medications
– Interventions include; gastroenterostomy, vagotomy,
pyloroplasty ,subtotal gastrectomy
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Nursing diagnosis for PUD
Acute pain related to increased gastric secretions,
decreased mucosal protection as evidenced by
burning sensation in the epigastric region and
abdomen
Ineffective therapeutic regime management related
to lack of knowledge about PUD therapy,
unwillingness to adjust lifestyle modifications
manifested by non compliance to treatment and
reoccurrence of painful episodes
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Nursing care
Admission; PUD patients are managed in out patient
department, they are only admitted during severe acute
episodes of pain and PUD complications like
perforation and hemorrhage, for close monitoring
During admission; pain management is very important,
vital observations
Patient education about treatments and lifestyle
modification
All other nursing care is given like for all admitted
patients And manage patient according to presentation
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PUD: prevention
Dietary modification; decrease intake of acid
stimulating foods
Avoid drugs that have corrosive effect on the
GUT
Educate and counsel about drug compliance
Avoid alcoholism and smoking
Co-administration of PPIs in patients on chronic
NSAID use reduces risk of PUD
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Complications of Peptic Ulcers
Hemorrhage
Blood vessels damaged as ulcer erodes into the muscles of
stomach or duodenal wall
Coffee ground vomitus (haematemesis) or occult blood in stools
Perforation
An ulcer can erode through the entire wall
Bacteria and partially digested food spill into peritoneum
leading to peritonitis.
Narrowing and obstruction (pylorus)
Scarring can cause obstruction of food leaving stomach due to
pyloric stenosis. Will manifest as repeated vomiting
Reoccurance of ulcers
Gastric cancer
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