CARE OF PATIENTS WITH PEPTIC ULCER

DISEASE
WHAT IS PEPTIC ULCER DISEASE
• Peptic ulcers are soars that develop due to the digestion or ulceration of the GI
mucosa prone to the action of the peptic acid. It may involve the lower
esophagus, stomach or the duodenum.
• Epigastric pain usually occurs within 15-30 minutes following a meal in patients
with a gastric ulcer; on the other hand, the pain with a duodenal ulcer tends to
occur 2-3 hours after a meal.
Classification of Peptic ulcer is classified into gastric, duodenal or esophageal
ulcer.
• Gastric ulcer. Gastric ulcer tend to occur in the lesser curvature of the stomach,
near the pylorus.
• Duodenal ulcer. Peptic ulcers are more likely to occur in the duodenum than in
the stomach.
• Esophageal ulcer. Esophageal ulcer occur as a result pf the backward flow of HCl
from the stomach into the esophagus.
The Pathophysiology of PUD
• An imbalance between the digestive juices produced by the stomach and the
various factors that protect the lining of the stomach causes ulcer or soar in the
stomach and duodenal lining.
• Mucus lines the digestive tract and acts as a barrier against the acidic gastric
secretions.
• Too little mucus production coupled with too much acid production will leave the
digestive tract vulnerable to acid erosion and ulceration. Erosion of the mucosal
lining may result in the formation of a fistula.
• The fistula would allow the acidic gastric contents to leak out into the peritoneum,
resulting in peritonitis.
• Stress, caffeine, cigarette, smoking and alcohol consumption increase acid
production.
• Medications such as Non Steroidal Anti Inflammatory Drugs and aspirin inhibit
prostaglandins responsible for the protection of mucosal lining
• A bacterium, Helicobacter pylori, is the main cause of
ulcers in this area. H. pylori bacterial infection leads to
death of the mucosal epithelial cells of the stomach and
duodenum.
• The bacteria release toxins and enzymes that reduce the
efficiency of mucous in protecting the mucosal lining of
the gastrointestinal tract.
• In response to the bacterial infection, the body initiates an
inflammatory response which results in further destruction
of the mucosal lining and ulceration.
Signs and symptoms
• Pain (dull, gnawing or burning sensation in the mid – epigastrium radiating to the
back)
• Localized epigastric tenderness on palpation
• Pyrosis (heartburn)
• Vomiting (rare in duodenal ulcer)
• Constipation or diarrhea
In severe cases
• Dark coloured stool(melena)
• hematemesis
• Weight loss severe pain in the
• Recurrent vomitting
Causes
• Peptic ulcer disease (PUD) has various causes; however, Helicobacter
pylori-associated PUD and NSAID-associated PUD account for the
majority of the disease etiology.
Causes of Peptic Ulcer Disease
Common
• H. pylori infection
• Chronic use of NSAIDs
• Ingestion of milk and caffeinated beverages (by causing increased Hcl
secretion)
• Smoking/alcohol intake
• Familial tendency
• Anxiety
Rare
• Zollinger-Ellison syndrome
• Malignancy (gastric/lung cancer, lymphomas)
• Stress (Acute illness, burns, head injury)
• Viral infection
• Vascular insufficiency
• Radiation therapy
• Crohn disease
• Chemotherapy
• Rare variants
• Zollinger-Ellison syndrome (ZES) – severe peptic ulcers due to extreme
gastric hyperacidity and gastrin-secreting tumors (gastrinomas) of the
pancreas
• Stress ulcers – gastroduodenal mucosal ulcerations associated with
stressful conditions
• Cushing’s ulcers – common in patients with head injury
• Curling’s ulcer – frequently observed about 72 hours after extensive
burns
Diagnosis
• Diagnosis of PUD requires history taking, physical examination, and
invasive/non-invasive medical tests.
• A careful history should be obtained and noted for the presence of any
complications.
• Patient reporting of epigastric abdominal pain, early satiety, and fullness
following a meal raise suspicion of PUD
• Esophagogastroduodenoscopy (EGD): Gold standard and most accurate
diagnostic test with sensitivity and specificity up to 90% in diagnosing
gastric and duodenal ulcers.
• Barium swallow: A barium swallow, also known as an upper GI series, is
a radiographic (X-ray)
• Examination of the upper gastrointestinal tract, which includes the
esophagus, stomach, and the first part of the small intestine (duodenum).
• This diagnostic procedure is used to visually inspect these areas for
abnormalities, including peptic ulcers.
• During the procedure, the patient drinks a liquid that contains barium
sulfate, a radiopaque contrast medium.
• This liquid coats the lining of the upper GI tract, making the outline of
these organs visible on X-ray images.
• Helicobacter pylori testing
• Upper gastrointestinal Endoscopy. Endoscopy is the preferred diagnostic
procedure because it allows direct visualization of inflammatory changes,
ulcers, and lesions.
• Occult blood. Stools may be tested periodically until they are negative for
occult blood.
Complications
• Peptic ulcer disease (PUD) if not diagnosed and treated promptly can
lead to serious complications.
Following complications can occur in PUD:
• Upper gastrointestinal bleeding
• Gastric outlet obstruction
• Perforation
• peritonitis
• Gastric cancer
• Acute renal failure
• Bleeding
• Shock
Medical Treatment
• Antisecretory drugs used for peptic ulcer disease (PUD) include H2-receptor antagonists and
the proton pump inhibitor (PPIs) e.g rabeprazole omeprazole, pentoprazole
• Proton Pump Inhibitors have largely replaced H2 receptor blockers due to their superior
healing and efficacy.
• PPIs block acid production in the stomach, providing relief of symptoms and promote healing.
• NSAIDs induced PUD can be treated by stopping the use of NSAIDs or switching to a lower
dose.
• Corticosteroids, bisphosphonates, and anticoagulants should also be discontinued if possible
due to the risk of immunosuppression and anti inflammatory actions of corticosteroids and the
risk for bleeding during endoscopy for patients on anticoagulants)
• Prostaglandin analogs (misoprostol) are sometimes used as prophylaxis for NSAID-induced
peptic ulcers.
• First-line treatment for H. pylori-induced PUD is a triple regimen comprising two antibiotics
and a proton pump inhibitor. Pantoprazole, clarithromycin, and metronidazole, or amoxicillin
are used for 7 to 14 days.
• Antibiotics and PPIs work synergistically to eradicate H. pylori.
• If first-line therapy fails, quadruple therapy with bismuth and different antibiotics is used.
Nursing management
1. Assessment
• Pain: Location, character (burning, gnawing), timing (e.g., pain relieved by
eating or worsened after meals).
• GI symptoms: Nausea, vomiting, bloating, hematemesis (vomiting blood),
melena (black, tarry stools).
• Medical history: NSAID use, smoking, alcohol intake, history of H. pylori
infection.
• Vital signs: Monitor for signs of bleeding (tachycardia, hypotension, pallor).
• Lab values: Hemoglobin, hematocrit (to assess for anemia), stool occult
blood test.
Nursing Interventions
• a) Pain Management
• Administer prescribed medications:
• Proton pump inhibitors (PPIs) (e.g., omeprazole, pantoprazole)
• H2-receptor antagonists (e.g., ranitidine)
• Antacids for symptom relief.
• Schedule medications properly (e.g., PPIs before meals).
• Monitor effectiveness and side effects of medications.
b) Promote Healing
• Ensure adherence to medication regimen (especially antibiotics for H. pylori).
• Advise small, frequent meals if recommended.
• Avoid irritating foods (spicy foods, caffeine, alcohol).
c)Prevent Complications
• Watch for signs of:
• Hemorrhage (vomiting blood, black stools, drop in blood pressure).
• Perforation (sudden, severe abdominal pain, rigid abdomen).
• Obstruction (vomiting, abdominal distention).
• Prepare for possible endoscopic intervention if bleeding is suspected.
• d) Lifestyle Modification Counseling
• Advise cessation of:
• Smoking (delays healing).
• Alcohol consumption.
• NSAIDs and corticosteroids if possible (or use with protective agents).
• Stress management techniques (stress can worsen symptoms).
• e) Nutritional Support
• Encourage a balanced diet.
• Avoid foods that increase gastric acidity (e.g., chocolate, fatty foods, carbonated
beverages).
Evaluation
• Patient reports pain relief.
• No signs of bleeding or complications.
• Patient verbalizes understanding of medication regimen and lifestyle
changes.
• Healing of the ulcer is confirmed (clinically and possibly via
endoscopy).
Surgical Management
• If the ulcer persists despite addressing the above risk factors, patients can be candidates for
surgical treatment. Surgical options include vagotomy or partial gastrectomy.
Nursing management
• Patient assessment including history taking and physical examination. Assessment for a
description of pain, Assessment of relief measures to relieve the pain, Assessment of the
characteristics of the vomitus, Assessment of the patient’s usual food intake and food
habits.
Nursing Diagnosis
Based on the assessment data, the patient’s nursing diagnoses may include the following:
• Acute pain related to the effect of gastric acid secretion on damaged tissue.
• Anxiety related to an acute illness.
• Imbalanced nutrition related to changes in the diet.
• Deficient knowledge about prevention of symptoms and management of the condition.
Nursing Responsibilities during Endoscopy
Before the Procedure:
• Patient Education:
• Explain the procedure, its purpose, and what the patient can expect.
• Inform about fasting (usually NPO for 6–8 hours before the procedure).
• Discuss any sensations (e.g., mild discomfort, pressure) during the procedure.
• Obtain informed consent after ensuring patient understanding.
• Preparation:
• Confirm NPO status (no food, fluids, gum, or smoking).
• Check for allergies, especially to anesthetics or contrast dyes.
• Review the patient’s medical history, including anticoagulant or antiplatelet use.
• Administer prescribed medications (e.g., sedatives, prophylactic antibiotics if indicated).
• Remove dentures, glasses, jewelry, and other prosthetics.
• Psychological Support:
• Reassure and calm the patient to reduce anxiety.
• Answer last-minute questions.
Physical Preparation:
• Ensure proper identification (ID band, procedure consent).
• Place an IV line for sedation/fluids.
• Monitor vital signs: baseline blood pressure, heart rate, respiratory rate,
and oxygen saturation.
During the Procedure:
• Monitoring:Continuously monitor vital signs and oxygen saturation.
• Observe for signs of distress (e.g., choking, cyanosis).
• Assist in positioning (commonly left lateral for upper GI endoscopy).
• Assistance: Help the physician with equipment and specimen collection if necessary.
• Suction oral secretions to prevent aspiration.
• Support sedation and maintain airway if needed.
After the Procedure:
• Recovery Monitoring: Monitor vital signs frequently until the patient is stable.
• Assess for complications: bleeding, respiratory distress, perforation signs (severe pain,
abdominal distention).
• Patient Care: Maintain NPO status until the gag reflex returns (usually within 1–2
hours).Encourage the patient to lie on their side to prevent aspiration.
• Provide comfort measures (e.g., throat lozenges if sore throat occurs).
• Documentation: Record procedure details, medications given, patient’s response, and any
complications.
• Discharge Instructions: Instruct the patient not to drive or operate machinery for 24 hours
if sedated.
• Inform about signs to report immediately (e.g., severe abdominal pain, fever, vomiting
blood, black stools).
GASTRO – ESOPHAGEAL REFLUX DISEASE
• Gastroesophageal reflux disease (GERD) is a common condition
encountered in clinical practice, characterized by the abnormal reflux of
stomach or duodenal contents back into the esophagus.
• This reflux leads to symptoms such as heartburn, regurgitation, and
potentially more serious complications.
• Excessive reflux may be due to incompetent lower esophageal sphincter,
pyloric stenosis, or a motility disorder
• Esophagus: A muscular tube that carries food and liquids from the
mouth to the stomach.
• Lower Esophageal Sphincter (LES): A band of muscle at the lower end
of the esophagus that acts as a valve between the esophagus and the
stomach. It relaxes during swallowing to allow food to pass into the
stomach.
• Normally, the LES closes immediately after swallowing to prevent the
backflow (reflux) of gastric contents.
Pathophysiology
• Abnormal LES Function:
• LES Dysfunction: The most common cause of GERD is the dysfunction
of the LES, which can either be due to transient relaxations that are
not related to swallowing or a sustained low pressure in the LES,
allowing reflux.
• Hiatal Hernia: Often contributes to GERD. This condition involves part
of the stomach pushing up through the diaphragm into the chest
cavity, disrupting the normal pressure gradient and LES function.
actors Enhancing Reflux:
• Increased Intra-abdominal Pressure: Obesity, pregnancy, and tight clothing can
increase abdominal pressure, promoting reflux.
• Delayed Gastric Emptying: Conditions or habits that slow gastric emptying (like high-fat
meals or certain medications) can cause prolonged gastric retention of food, increasing
the likelihood of reflux.
Esophageal Sensitivity:
• Mucosal Damage: Repeated exposure to acidic gastric contents can damage the
esophageal lining, leading to symptoms and complications. The severity of symptoms
often correlates with the degree of mucosal injury.
• Visceral Hypersensitivity: Some individuals may experience GERD symptoms due to
increased sensitivity of the esophageal lining, even without significant mucosal damage.
Clinical Manifestations
• Typical Symptoms: Heartburn (a burning sensation in the chest),
regurgitation of gastric contents, and dysphagia (difficulty
swallowing).
• Atypical Symptoms: Cough, asthma-like symptoms, chronic laryngitis,
or non-cardiac chest pain.
Clinical Manifestations
• Pyrosis (burning sensation in the esophagus)
• Dyspepsia (indigestion)
• Regurgitation
• Dysphagia (difficulty in swallowing)
• Odynophagia (pain on swallowing)
• Hyper salivation
• Esophagitis
Diagnosis
• Clinical Evaluation: Based on symptom presentation and response to
initial treatment (like proton pump inhibitors).
• Endoscopy: Used to assess the degree of esophageal damage and
screen for complications.
• pH Monitoring: Measures acid exposure in the esophagus and
confirms the diagnosis when typical symptoms are absent.
Management
• Lifestyle Modifications: Avoidance of trigger foods, elevating the
head of the bed, and weight management.
• Pharmacological Treatment: Antacids, H2 receptor blockers, and
proton pump inhibitors are commonly used.
• Surgical Interventions: Procedures like Nissen fundoplication are
considered when medical therapy is ineffective or not tolerated.
Nursing Considerations
• Education: Teaching patients about the triggers of GERD and lifestyle
modifications.
• Medication Management: Assisting with the administration of
medications and monitoring for side effects.
• Support and Monitoring: Supporting patients in lifestyle changes and
monitoring for signs of complications.
Complications
• Esophagitis: Inflammation of the esophagus which can lead to ulcers.
• Stricture Formation: Chronic inflammation can lead to scarring and
narrowing of the esophagus.
• Barrett's Esophagus: A condition where the normal esophageal lining
is replaced with tissue similar to the intestinal lining, increasing the
risk of esophageal cancer.
NURSING DIAGNOSIS
• Risk for Aspiration Related to Gastroesophageal Reflux
• Impaired Comfort Related to Esophageal Irritation and Inflammation
evidenced by complains of heart burns
• Ineffective Coping Related to Chronic Illness and Lifestyle Modifications
• Risk for Imbalanced Nutrition: Less Than Body Requirements Related to
Dietary Restrictions
Management
• Eat a low-fat diet :
Rationale: Fatty foods are known to delay gastric emptying, which can increase
the amount of time food and acid remain in the stomach. This prolonged gastric
emptying can heighten the risk of gastric contents refluxing into the esophagus,
exacerbating GERD symptoms. A low-fat diet helps speed gastric emptying and
reduce the likelihood of reflux.
• Avoid caffeine, tobacco, beer, milk, peppermint and carbonated beverages
Rationale: These substances can weaken the lower esophageal sphincter (LES),
the muscle that closes off the esophagus from the stomach.
• A weaker LES is less effective at preventing stomach acids from traveling back
up into the esophagus, leading to increased GERD symptoms. Additionally,
carbonated beverages increase stomach pressure, which can promote reflux
• Avoid eating or drinking 2 hours before bedtime
• Avoid eating or drinking 2 hours before bedtime
Rationale: Lying down soon after eating can cause the contents of the stomach
to flow back into the esophagus more easily due to the removal of the benefit of
gravity. Keeping upright for at least two hours after eating allows time for the
stomach to empty, reducing this risk.
• Maintain normal body weight
• Rationale: Excess weight, particularly around the abdomen, can increase
pressure on the stomach. This pressure can force food and acid back into the
esophagus, aggravating reflux symptoms. Achieving and maintaining a
healthy weight can decrease this pressure and subsequently reduce GERD
symptoms.
• Avoid tight – fitting clothes
Rationale: Tight-fitting clothes can squeeze the abdomen, similarly increasing
intra-abdominal pressure. This pressure can push stomach contents back up into
the esophagus, particularly when bending over or lying down, worsening GERD
symptoms.
•
• Sleep with head elevated on bed blocks or pillows
Rationale: Elevating the head while sleeping uses gravity to help keep stomach acids in the
stomach, reducing the likelihood of reflux. Using bed blocks or a wedge pillow that elevates
the upper body from the waist up is more effective than just using more pillows under the
head, as the latter can actually increase abdominal pressure and worsen reflux.
Medications;
• Antacids; Antacids are a class of medications that neutralize stomach acid and provide
quick relief from the symptoms of heartburn, indigestion, and other stomach-related
discomforts
• Antacids can interfere with the absorption of other medications, such as tetracyclines,
fluoroquinolones, iron supplements, and some forms of medication used to treat
osteoporosis (bisphosphonates).
• It’s generally recommended to administer these medications at least 2 hours before or after
antacid intake.
• Common side effects of antacids include constipation (often associated with aluminum-
containing antacids) or diarrhea (often associated with magnesium-containing antacids).
Calcium-containing antacids may cause kidney stones if used frequently over long periods.
Monitoring for these side effects allows for timely intervention
Histamine receptor blockers;
blocks the action of histamine on histamine H2 receptors in the stomach.
• This action reduces the production of gastric acid by parietal cells in the stomach lining
e.g Ranitidine, cimetidine : Oral: 800 mg daily in divided doses (e.g., 400 mg twice daily
or 200 mg four times daily), with meals and at bedtime.
Intravenous (IV): 300 mg every 6-8 hours, not to exceed 2.4 grams/day.
Proton pump inhibitors; PPI
• PPIs are prodrugs that require activation in the acidic environment. Once activated, they
bind irreversibly withproton pump or gastric hydrogen-potassium ATPase.
• inhibiting the final step in the secretion of gastric acid in the parietal cells. e.g
omeprazole, 20 mg once daily for 4-8 weeks in GERD; maintenance therapy may require
20 mg once daily.
Prokinetic agents (accelerate gastric emptying)
Surgical intervention:
• Fundoplication (wrapping of a portion of the gastric fundus around the sphincter area of
the esophagus)
Nursing Interventions
Nursing interventions for the patient may include:
Relieving Pain and Improving Nutrition
• Administer prescribed medications.
• Avoid aspirin, which is an anticoagulant, and foods and beverages that contain acid-
enhancing caffeine (colas, tea, coffee, chocolate), along with decaffeinated coffee.
• Encourage patient to eat regularly spaced meals in a relaxed atmosphere; obtain regular
weights and encourage dietary modifications.
• Encourage relaxation techniques.
Reducing Anxiety
• Assess what patient wants to know about the disease, and evaluate level of anxiety;
encourage patient to express fears openly and without criticism.
• Explain diagnostic tests and administering medications on schedule.
• Interact in a relaxing manner, help in identifying stressors, and explain effective coping
techniques and relaxation methods.
• Encourage family to participate in care, and give emotional support.
Monitoring and Managing Complications
If hemorrhage is a concern:
• Assess for faintness or dizziness and nausea, before or with bleeding; test stool
for occult or gross blood; monitor vital signs frequently
(tachycardia, hypotension, and tachypnea).
• Insert an indwelling urinary catheter and monitor intake and output; insert and
maintain an IV line for infusing fluid and blood.
• Monitor laboratory values (hemoglobin and hematocrit).
• Insert and maintain a nasogastric tube and monitor drainage; provide lavage as
ordered.
• Monitor oxygen saturation and administering oxygen therapy.
• Place the patient in the recumbent position with the legs elevated to prevent
hypotension, or place the patient on the left side to prevent aspiration from
vomiting.
• Treat hypovolemic shock as indicated.
if perforation and penetration are concerns:
• Note and report symptoms of penetration (back and
epigastric pain not relieved by medications that
were effective in the past).
• Note and report symptoms of perforation (sudden
abdominal pain, referred pain to shoulders, vomiting
and collapse, extremely tender and rigid
abdomen, hypotension and tachycardia, or other signs
of shock).
Home Management and Teaching Self-Care
• Assist the patient in understanding the condition and factors that help or
aggravate it.
• Teach patient about prescribed medications, including name, dosage, frequency,
and possible side effects. Also identify medications such as aspirin that patient
should avoid.
• Instruct patient about particular foods that will upset the gastric mucosa, such as
coffee, tea, colas, and alcohol, which have acid-producing potential.
• Encourage patient to eat regular meals in a relaxed setting and to avoid
overeating.
• Explain that smoking may interfere with ulcer healing; refer patient to programs
to assist with smoking cessation.
• Alert patient to signs and symptoms of complications to be reported.
These complications include hemorrhage (cool skin, confusion,
increased heart rate, labored breathing, and blood in the stool),
penetration and perforation (severe abdominal pain, rigid and tender
abdomen, vomiting, elevated temperature, and increased heart rate),
and pyloric obstruction (nausea, vomiting, distended abdomen, and
abdominal pain).
• To identify obstruction, insert and monitor nasogastric tube; more
than 400 mL residual suggests obstruction.
Evaluation
• Expected patient outcomes include:
• Relief of pain.
• Reduced anxiety.
• Maintained nutritional requirements.
• Knowledge about the management and prevention of ulcer
recurrence.
• Absence of complications.
Zollinger-Ellison Disease
• Zollinger-Ellison Disease is characterized by the development of a
tumor (gastrinoma) or tumors that secrete excessive levels of gastrin
• Gastrin is a hormone that stimulates production of acid by the
stomach.
• Gastrinomas have the potential to be cancerous (malignant).
• In most patients, the tumors arise within the pancreas and/or the
upper region of the small intestine (duodenum).
• Due to excessive acid production (gastric acid hypersecretion),
individuals with ZES may develop peptic ulcers of the stomach, the
duodenum, and/or other regions of the digestive tract