Peptic Ulcer

 

Acute peptic ulcer

Acute ulcers are often multiple and may be due to;

 

Shock especially burns - local ischaemia, increased histamine release increases gastric juice secretion

 

Drugs   eg. aspirin, NSAIDS

 

Uraemia           Acute ulcers usually heal rapidly

 

Chronic peptic ulcer

 

Aetiology

HP (helicobacter pylori), stimulates gastrin secretion and damages mucosa.

NSAIDs

Familial tendency

Smoking

Psychological stress raises acid levels

Gastric -  Men : women  2 : 1

DU,     -  Men : women  4   : 1

More in blood group O, (for DU)

More common in elderly

Alteration in mucus production

Mucosal ischaemia

Intake of methylxanthines, eg tea coffee, cola, chocolate

 

Pathophysiology

DU are 10 times more common than gastric

Gastric juices contain hydrochloric acid and digestive enzymes.

Acidity of stomach (HCl) may be as low as pH 1

Peptic ulcers occur at sites where there are peptic juices

Up to 15% of individuals may have DU at some time in their life.

Ulceration extends through the lining mucosa into the muscle layer of the gut.

Craters up to 5 cm in diameter occur.

A sharply "punched out" edge with a smooth clean floor.

Often local thickening occurs due to fibrous tissue.

Fibrous tissue often contract causing folding of the gut wall.

Most gastric ulcers are singular and occur on the lesser curve of the stomach

Duodenogastric reflux, (bile damage to gastric mucosa)

Prostaglandins increase mucus production and vasodilate so are cytoprotective

 

Sites

Stomach                                               Oesophagus

Duodenum (most common)                   Meckel`s diverticulum, (ectopic gastric mucosa)

Jejunum (after anastomosis)

 

Signs and Symptoms

Exacerbations of several days or weeks

Remissions may last for months or years

Pain or tenderness in the epigastrium probably with Pointing sign

Pain is burning or gnawing

Usually worse at night

Occasional vomiting occurs in 40% of cases

Pain is relieved by vomiting and antacids

Anorexia and nausea

Dyspepsia (pain or upper abdominal discomfort)

Weight loss

Flatulence

Heartburn

Some ulcers are `silent` and present with complications

 

Complications

Haemorrhage - coffee grounds, melaena, haematemesis

Perforation -  peritonitis

Stenosis, pyloric or gastric

Perforation of the pancreas

Deficiencies, haemorrhage and poor diet.

Malignant changes

 

Investigations

Gastroscopy (always exclude malignancy)          Biopsy

Barium meal                                                      Blood profiling

FOBs                                                               

 

Treatment

Decreasing the amount of acid present

Giving alkali tablets

Stop NASIDs

PPIs e.g. omperazole, lansoprazole

H2 receptor antagonists, e.g. ranitidine

Stop smoking

No bed rest

No special diets

Combat obesity

Indications for surgery are haemorrhage, perforation, gastric outflow obstruction, recurrence of ulcer following gastric surgery

 

Pharmacology

H2-receptor antagonists            Cimetidine, ranitidine

Inhibit action of histamine at H2 receptor sites on parietal cells

Reduce volume and acidity of gastric juice

Accelerates ulcer healing, reduces relapse rate

 

Proton pump inhibitors            Esomeprazole, omeprazole

Inhibit gastric parietal cell H+/K+-ATPase

Work faster and heal ulcers faster than H2 blockers

Also improve symptoms and heal GORD

 

Cytoprotectants            Sucralfate, bismuth

 

Helicobacter pylori infection

Confirm diagnosis with culture, 13C-urea breath test or antibodies.

Eradication can achieve rapid and long term healing of peptic ulcers.

Acid inhibition combined with antibiotics.

One week triple therapy, PPI, amoxicillin and either clarithromycin or metronidazole gives 90% eradication rates

 

Nursing assessment

History

Locality of pain

How pain is relieved, eating antacids, vomiting etc

Time of day of pain

Foods which increase symptoms

Psychological profiling

Type A personality

Neurotic illness

Intake of drugs or other gastric irritants

Smoker

Vomit/ stool specimen

Level of patient anxiety about the condition

Sleep disturbances

Patients understanding of the condition

Potential for the development of complications

Situation of significant others

 

Patient Education

Adequate rest                                      

Relaxation advice

Smoking          

Adequate balanced diet

Drug education to improve compliance

Alert to possible gastric irritants, eg aspirin

Avoid cola

Observation for haemorrhage, anaemia

Chew food thoroughly, eat in a leisurely manner

Ovoid over large meals