PEPTIC ULCERS
Peptic Ulcer refers to the ulceration in the mucosa of the lower oesophagus, stomach or duodenum.
The erosion may extend as deeply as the muscle layers or through the muscle to the peritoneum.
They occur singly, but there may be a number of them present at one time. Chronic gastric ulcers tend to occur in the lesser curvature of the stomach near the pylorus.
Risk Factors - Drugs, family history, Zollinger-Ellison syndrome, cigarette, stress, blood group 0, lower socio-economic status.
Incidence occurs between ages 40 and 60. More men than women are affected (3:1). After menopause, the incidence in females is almost equal to males.
Causes
It is multifactorial. H. Pyloric infection present in most patient with peptic ulcer disease. Ulcerogenic drugs-such as NSAIDs. Zollinger-Ellison syndrome and other hypersecretory syndrome.
Pathophysiology: The erosion is due to an increase in the concentration or activity of acid pepsin or a decrease in the normal resistance of the mucosa. A damaged mucosa is unable to secrete enough mucus to act as a barrier against hydrochloric acid.
Clinical Manifestation
· Gnawing or burning epigastric pain occurring 1-3 hrs. after a meal | meal
· Nocturnal epigastric, abdominal pain or burning.
· Early satiety, anorexia, weight loss, heart burn, belching
· Dizziness, syncope, hematemesis, or melena.
Diagnostic Evaluation
1. Upper Gl Endoscopy with possible biopsy and cytology
2. Upper G! Radiographic examination(barium study).
3. Serial stool specimens to detect occult blood
4. Gastric acid secretion test and serum gastric level rest elevated in Zollinger-Ellison syndrome.
5. Serology to test for H.Pylori antibodies
6. C-Urea breath test to diagnose H Pylori
Management
· Gastric acidity can be managed with appropriate sedation and neutralization of the gastric juice at frequent and regular intervals with drugs, non-irritating foods and antacids.
· Sometimes antispasmodics are given to reduce pylorospasm and intestinal motility.
· The patient needs to identify situations that are stressful or exhausting
· A rushed lifestyle and an irregular schedule may aggravate symptoms and interfere with regular meals and regular administration of medication.
· Regular rest periods during the day at least during acute phase of the disease.
· Eliminate cigarette smoking
· Bland diets are beneficial. Avoid extremes of temperature and over-stimulation by meat extracts, alcohol, seasonings and coffee.
· Three regular meals a day helps to neutralize acid.
· If the patient tolerates a particular food he may eat it. If it produces pain he should avoid it
· Antacids can be divided into those that contain magnesium or magnesium and aluminium and those contain aluminium alone. Those that contain magnesium tends to cause diarrhoea and those contain aluminium cause constipation. A recommended schedule is 1-2 table spoons, 1-3 hrs. of each meal and at bed time.
· Anticholinergics blocks acetylcholine, which is a major stimulant of acid secretion.
· H₂ receptor Antagonists
· Cimetidine lowers acid secretion in the stomach. It's given orally with each meal and at bed time. It relieves ulcer pain and thus decreases the need for antacids
· Ranitidine Usually given twice a day. Causes fewer side effects than cimetidine.
· Famotidine (Pepcid)
· Other Drugs Sucralfate It forms an adherent barrier over the ulcer. This barrier is acid resistant. The acid is prevented from passing through to the ulcer, but the acid is net neutralized.
Surgical Management
Surgical interventions may be indicated for haemorrhage, obstruction, perforation and acid reduction. Surgery may also be indicated with ulcer disease of long duration or severity or difficulty with medical regimen compliance,
1. Gastroduodenostomy (Billroth I)
a. Partial gastrectomy with removal of antrum and pylorus of stomach.
b. The gastric stump is anastomosed with the duodenum.
2. Gastrojejunostomy (Billroth II)
a. Partial gastrectomy with removal of antrum and pylorus of stomach.
b. The gastric stump is anastomosed with the jejunum.
3. Antrectomy, Removal of the antral (lower) portion of the stomach as well as a small portion of the duodenum and pylorus. The duodenal stump is closed, and the jejunum is anastomosed to the stomach.
4. Total gastrectomy/Oesophagojejunostomy. Removal of the stomach with attachment of the oesophagus to the jejunum or duodenum.
5. Pyloroplasty.
a. A longitudinal incision is made in the pylorus, and it is closed-transversely to permit the muscle to relax and to establish an enlarged outlet.
b. Often, a vagotomy is performed at the same time.
6. Vagotomy.
a. The surgical division of the vagus nerve to eliminate the impulses that stimulate HCL secretion.
b. There are 3 types.
Selective vagotomy with severs only the branches that interrupt acid secretion.
Truncal Vagotomy severs both anterior & posterior trunks to decrease acid secretion and gastric motility.
Parietal Vagotómy Severs only the part of vagus that innervates the parietal acid-sccreting cells.
Complications
Haemorrhage, ulcer perforation, gastric outlet obstruction, intractability (An intractable ulcer is one that continues to give problems and is resistant to all forms of treatment).
Nursing Management
1. Administer prescribed medications for pain relief
2. Avoid aspirin and foods and beverages that contain caffeine (Cola, tea, coffee, chocolate) and are spicy.
3. Advise the client to eat regular spaced meals slowly and in, a relaxed atmosphere.
4. Encourage the client to learn relaxation techniques to help lim cope with stress and pain and to stop smoking.
5. Avoid ulcerogenic over-the-counter drugs.
6. Instruct patient to increase intake of water 6-8 glasses/day.
7. Instruct patient to eat slowly and chew small pieces of food.
8. The patient is helped to identify stressful situations and to learn effective coping mechanisms and relaxation techniques.
9. Energy-saving techniques (sit to cook, sit on a chair in the shower) are taught.
10. He is encouraged to become
aware of signs of over activity (excessive fatigue, dizziness) and, to take his
medication on time so that he can sleep uninterrupted through the night.
11. The patient is allowed to express his fears openly.
12. Teach patient the signs and symptoms of complications.
Haemorrhage- cool skin, confusion, increased heart rate, laboured breathing, blood in the stool.
Perforation- severe abdominal pain, rigid and tender abdomen, vomiting, elevated temperature, increased heart rate.
Pyloric obstruction- nausea, vomiting, distended abdomen, abdominal pain.
Intractability- persistent pain and discomfort related to stress, food intake, or drug regimen.
