5. RISK FACTORS
H. pylori,
Alcohol,
Smoking,
Cirrhosis,
Stress
Usually 50 and over
Male higher risk
Normal ,hyper secretion of stomach acid (HCl) (zollinger
Ellison syndrome)
Gastritis,
Use of NSAIDs
7. Acute
Is associated with superficial erosion and minimal
inflammation it is of short duration and resolves quickly
when the cause is identified and removed
8. Chronic
Chronic ulcer is one of long duration eroding through
the muscular wall with the formation of fibrous tissue it
may be present continuously for many months or
intermittently throughout the person’s life time
10. Comparison of gastric and deodenal ulcer
Gastric ulcers Duodenal ulcers
Lesion Superficial smooth margins ,not oval or
cone shaped
Penetrating
Associated with deformity of
duodenum from recurrent
healing
Location of
lesion
Predominantly antrum also in body and
funds
First 1-2 cm of duodenum
Gastric
secretion
Normal or decreased increased
Incidence
Greater in women
Peak age 50-60 yrs
Common in lower socio economic status
,increased with smoking use of drug use
and alcohol use seen in pyloric sphincter
and bile reflex
Greater women
Post menopausal women
higher risk
Associated with pyloric stress
Increased with smoking
alcohol and drug use associated
with other disease
COPD ,zollinger Ellison
syndrome chronic renal failure
Clinical
manifestation
Burning or gacious pressure in high left
epigastriam and back and upper abdomen
,pain 1-2 hrs after meal ,if penetrating
ulcer aggravation of discomfort with food
occasional nausea and vomiting
Burning,cramping pressure like
pain back pain
Recurrence
rate
high high
11. ETIOLOGY
stress and anxiety
gram-negative bacteria H. pylori
Stress
Excessesive secretion of HCL
Familial tendency
Blood group o
Use of NSAID
Alcohol
Excessive smoking
Hyperacidity
Gastrin secreting malignant tumors
Esophageal ulcers
GERD
12. PATHOPHYSIOLOGY
Peptic ulcer occurs mainly in the gastro duodenal
mucosa because this tissue cannot withstand the
digestive action of gastric acid HCl and pepsin. Vagus
nerve stimulates the parietal cells to secrete gastric acid.
The erosion is caused by the increased concentration or
activity of pepsin, or by decreased resistance of the
mucosa. A damaged mucosa cannot secrete enough
mucus to act as a barrier against HCl. The use of
NSAIDs inhibits the secretion of mucus that protects the
mucosa.
13.
14.
15. CLINICAL MANIFESTATIONS
dull, gnawing pain or a burning
Pain is usually relieved by eating
Tenderness
pyrosis (heartburn),
vomiting, constipation or diarrhea, and bleeding
burping
vomiting
bleeding
tarry stools
16. ASSESSMENT AND DIAGNOSTIC
FINDINGS
Pain,
Epigastric tenderness,
Abdominal distention.
A barium study
Stools study
Gastric secretory studies
H. Pylori infection
Breath test that detects H. Pylori
19. STRESS REDUCTION AND REST
Avoid stressful or exhausting situations
A rushed lifestyle
irregular schedule
Biofeed back
Hipnosis
Behavier modification
Change in job
20. SMOKING CESSATION
smoking decreases the secretion of bicarbonate from the
pancreas into the duodenum resulting in increased
acidity of the duodenum.
21. DIETARY MODIFICATION
avoiding
extremes of temperature
Over stimulation from consumption of meat extracts
alcohol,
coffee (including decaffeinated coffee)
Milk
cream
22. SURGICAL MANAGEMENT
Principles of surgery
Reduce acid secreting ability
Remove malignant or potentially malignant lesions treat
surgical emergency
Treat clients do not respond to medical intervention
23. VAGOTOMY
Vagotomy is performed to eliminate the acid secreting
stimulus to gastric cells
Truncal
Completely cutting each vagus nerve
Selective
The surgeon partially severs the nerves to preserve the
hepatic and celiac branches
Proximal
Only paritel cell mass is denerveted
26. GASTROENTEROSTOMY
Permits regurgitation of alkaline deodenal contents
thereby neutralizing gastric acid in this procedure a
drain is made on the bottom of the stomach and sewn to
an opening made in the jejunum
28. SUBTOTAL GASTERCTOMY
This is a genetic term referring to any surgery that
involves partial removal of the stomach may be
performed by either Billroth 1 or Billroth 2
29. BILLROTH GASTRECTOMY
Operation was devised more by accident than a surgery
design A gastro enterostomy was performed on a
gravely ill patient with a pyloric resection by Christian
Aiberl Theociot Billroth. 1829-1894, Professor of
Surgery, Vienna, Austria. Anton wolfler. 1850-1917,
Professor of Surgery, Prague, The Czech Republic
further refined the surgery The first successful
gastrectomy was performed by Billroth in January 1881,
and Wolfler performed the first gastroenterostomy in the
same year
30. BILROTH 1
The surgeon removes a part of distal portion of the
stomach including the andrum the remainder of the
stomach is anastomosed to duodenum this combined
procedure called gastrodeodenostomy this decreases
dumping syndrome
32. BILROTH II
This involves reanastomosis of the proximal remnant of
the stomach to the proximal jejunum pancreatic
secretions and bile continue to secrete in jejunum even
after surgery surgeons prefer Billroth 2 technique for
treatment of duodenal ulcers because recurrent ulcer
develops less frequent in this procedure
34. COMPLICATIONS
Dumping syndrome
Early dumping
Early dumping include abdominal and vasomotor
symptoms which are found in 5-10%of patients the
small bowel is filled with food from stomach which have
high osmotic load this lead to shift of fluid to
stomach from systemic circulation symptoms are
vertigo, tachycardia syncope sweating pallor palpitation
diarrhea and nausea etc
35. Late dumping
This is reactive hypoglycemia. The carbohydrate load
in the small bowel causes a rise in the plasma glucose
level, which, in turn, causes insulin levels to rise,
causing a secondary hypoglycemia. This can be easily
demonstrated by serial measurements of blood glucose
in a patient following a test meal. Other symptoms
include epigastric fullness distention discomfort
abdominal cramping nausea etc the treatment is
essentially the same as for early dumping
36. TREATMENT
The principal treatment is dietary manipulation, dry
meals are best, and avoiding fluids with a high carbo-
hydrate content
37. Other side effects
Hemorrhage
Marginal ulcers
Alkaline reflex gastritis
Nutritional deficiency ( Vitamin B12 and folic acid
deficiency)
38. FOLLOW-UP CARE
The likelihood of recurrence is reduced if the patient
avoids smoking, coffee (including decaffeinated coffee)
and their caffeinated beverages, alcohol, and ulcerogenic
medications (eg, NSAIDs)
39. NURSING PROCESS:
Assessment
Pain, (type timing, duration)
Use of antacids
Vomitus
Smoking
Use of alcohol
Use of NSAID
Eating habbits ,
Blood in stool
Physical examination
40. NURSING DIAGNOSES
Acute pain related to incresed gastric secretions ,decresed mucosal
protection ,and ingestion of gastric irritants as evidenced by burning
cramp like pain in epigastrium and abdomen
Nausea related to acute exacerbation of disease process as evidenced
by episodes of nausea and vomiting
Ineffective therapeutic regimen management related to lack of
knowledge of long term management of peptic ulcer disease and
consequence of not following treatment plan and unwillingness to
modify lifestyle as evidenced by frequent questions about home care
incorrect response to questions about peptic ulcer disease
42. RELIEVING PAIN
Pain relief can be achieved with prescribed
medications.
The patients hould avoid aspirin, foods and
beverages that contain caffeine, and decaffeinated
coffee,
meals should be eaten at regularly paced intervals
in a relaxed setting.
Some patients benefit from learning relaxation
techniques to help manage stress and pain and to
enhance smoking cessation efforts
43. REDUCING ANXIETY
The nurse assesses the patient’s level of anxiety.
Patients with peptic ulcers are usually anxious, but their anxiety is
not always obvious.
Appropriate information is provided at the patient’s level of
understanding, all questions are answered, and the patient is
encouraged to express fears openly.
Explaining diagnostic tests and administering medications on
schedule also help to reduce anxiety.
The nurse interacts with the patient in a relaxed manner, helps
identify stressors, and explains various coping techniques and
relaxation methods, such as biofeedback, hypnosis, or behavior
modification.
The patient’s family is also encouraged to participate in care and to
provide emotional support.
44. MAINTAINING OPTIMAL
NUTRITIONAL STATUS
assesses the patient for malnutrition and
weight loss.
After recovery from an acute phase of
peptic ulcer disease, the patients are
advised about the importance of
complying with the medication regimen
and dietary restrictions.
45. TEACHING PATIENTS SELF-CARE
Give information about medications to be taken at home, including name,
dosage, frequency, and possible side effects, stressing the importance of
continuing to take medications even after signs and symptoms have
decreased or subsided.
the patient is instructed to avoid certain medications and foods that
exacerbate symptoms as well as substances that have acid producing
potential (eg, alcohol; caffeinated beverages such as coffee, tea, and
colas).
It is important to counsel the patient to eat meals at regular times and in
a relaxed setting, and to avoid overeating
the nurse also informs the patient about the irritant effects of smoking on
the ulcer and provides information about smoking cessation programs.
The nurse reinforces the importance of follow-up care for approximately1
year,
the need to report recurrence of symptoms,
and the need for treating possible problems that occur after surgery,
such as intolerance to dairy products and sweet foods
47. Hemorrhage
1) Monitoring the hemoglobin and hematocrit to assist in evaluating
blood loss
2) Inserting an NG tube to distinguish fresh blood from “coffee
grounds” material, to aid in the removal of clots and acid, to
prevent nausea and vomiting, and to provide a means
monitoring further bleeding
3) Administering a room-temperature lavage of saline solution or
water. This is controversial; some authorities recommend using
ice lavage
4) Inserting an indwelling urinary catheter and monitoring urinary
output
5) Monitoring vital signs and oxygen saturation and administering
oxygen therapy
6) Placing the patient in the recumbent position with the legs
elevated to prevent hypotension; or, to prevent aspiration from
vomiting, placing the patient on the left side
7) Treating hemorrhagic shock
48. Perforation and Penetration
Hypotension and tachycardia, indicating shock
Because chemical peritonitis develops within a few hours after
perforation and is followed by bacterial peritonitis,
the perforationmust be closed as quickly as possible and
assesses the patient for peritonitis or localized infection
(increased temperature, abdominal pain, paralytic ileus,
increased or absent bowel sounds, abdominal distention).
Antibiotic therapy is administered parenteral as prescribed
Immediate surgical repair and haemodynamic stabilisation
49. Pyloric Obstruction
insert an NG tube to decompress the stomach. Confirmation that
obstruction is the cause of the discomfort is accomplished by
assessing the amount of fluid aspirated from the NG tube.
A residual of more than 400 mL strongly suggests obstruction .
Usually an upper GI study or endoscopy is performed to confirm
gastric outlet obstruction.
Decompression of the stomach and management of extracellular fluid
volume and electrolyte balances may improve the patient’s condition
and avert the need for surgical intervention.
A balloon dilatation of the pylorus via endoscopy may be beneficial.
If the obstruction is unrelieved by medical management, surgery (in
the form of a vagotomy andantrectomy or gastrojejunostomy and
vagotomy) may be required.
50. FOLLOW-UP CARE
Recurrence within 1 year may be prevented with the
prophylactic use of H2 receptor antagonists given at a
reduced dose.
all patients require maintenance therapy; it may be
prescribed only for those with two or three recurrences
per year,
The likelihood of recurrence is reduced if the patient
avoids smoking, coffee (including decaffeinated coffee)
and their caffeinated beverages, alcohol, and ulcerogenic
medications (eg, NSAIDs) etc