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Peptic Ulcer Disease Nursing Case Study

  • Is a lesion in the mucosa of the lower esophagus, stomach, pylorus, or duodenum.
  • also known as ulcus pepticum, PUD or peptic ulcer disease, is an ulcer (defined as mucosal erosions equal to or greater than 0.5 cm) of an area of the gastrointestinal tract that is usually acidic and thus extremely painful
  • Causative factors include mucosal infection by the bacterium Helicobacter pylori (mechanism unclear).
  • Use of non-steroidal anti-inflammatory drugs (NSAIDs), especially aspirin.
  • Genetic factors such as cigarette smoking, stress, and lower socio-economic status may play a role.
  • Complications include GI hemorrhage, perforation, and gastric outlet obstruction.

Classification

  • Stomach (called gastric ulcer)
  • Duodenum (called duodenal ulcer)
  • Oesophagus (called Oesophageal ulcer)
  • Meckel’s Diverticulum (called Meckel’s Diverticulum ulcer)

Types of peptic ulcers

  • Type I: Ulcer along the lesser curve of stomach
  • Type II: Two ulcers present – one gastric, one duodenal
  • Type III: Prepyloric ulcer
  • Type IV: Proximal gastroesophageal ulcer
  • Type V: Anywhere along gastric body, NSAID induced

Assessment

  1. Abdominal pain
    • Occurs in the epigastric area radiating to the back; described as dull, aching, and gnawing.
    • Pain may increase when the stomach is empty, at night, or approximately 1 to 3 hours after eating. Pain is relieved by taking antacids (common with duodenal ulcers).
  2. Nausea, anorexia, early satiety (common with gastric ulcers), belching.
  3. Dizziness, syncope, hematemesis, melena with GI hemorrhage:
    • Positive fecal occult blood
    • Decreased hemoglobin and hematocrit, indicating anemia.
    • Orthostatic blood pressure and pulse changes.
  4. Peptic ulcer disease may be asymptomatic in up to 50% of persons affected
  5. Differentiating Gastric and Duodenal Ulcers:
Gastric UlcerDuodenal Ulcer
Gnawing epigastric pain occurring 30 minutes to 1 hour after mealsGnawing epigastric pain occurring 2-3 hours after meals
Aggravated by eating (because acid secretion increase at meal time) leads to weight lossRelieved by food (because the pyloric sphincter, at the junction of stomach and duodenum, closes upon eating to concentrate food in the stomach) causes weight gain
Relieved by vomiting (because acid is expelled out)Not relived
No pain at hours of sleep (HCl production decreases at hours of sleep)Pain at hours of sleep (because gastric emptying continuous at hours of sleep)
More common in persons older than age 50More common between ages 25 and 50

Diagnostic Evaluation

  1. Upper GI series usually outlines ulcer or area of inflammation.
  2. Endoscopy (esophagogastroduodenoscopy) visualizes duodenal mucosa and helps identify inflammatory changes, lesions, bleeding sites, and malignancy (through biopsy and cytology).
  3. Gastric secretory studies ( gastric acid secretion test, serum gastrin level tst) are elevated in Zollinger-Ellison syndrome.
  4. H. pylori antibody titer may be positive, especially in recurrent ulcers; however, there is high rate of false positive results; C-urea breath test or biopsy testing is more definitive test for H. pylori.

Pharmacologic Interventions

  1. Histamine2 (H2) receptor antagonists such as ranitidine to reduce gastric acid secretions.
  2. Antisecretory or proton-pump inhibitor, such as omeprazole, to help ulcer heal quickly in 4 to 8 hours.
  3. Cytoprotective drug sucralfate, which protects ulcer surface against acid, bile, and pepsin.
  4. Antacids to reduce acid concentration and help reduce symptoms.
  5. Anti-biotic as part of a multi-drug regimen to eliminate H. pylori to prevent reoccurrence.

Surgical Interventions

Surgery is indicated for hemorrhage, perforation, obstruction, and when unresponsive to medical therapy. Procedures include:

  1. Gastroduodenostomy (Billroth I)
    • Partial gastrectomy with removal of antrum and pylorus; gastric stump is anastomosed to duodenum.
  2. Gastrojejunostomy (Billroth II)
    • Partial gastrectomy with removal of antrum and pylorus; gastric stump is anastomosed to jejunum.
  3. Antrectomy
    • Antrum (lower half of stomach), pylorus and small cuff of duodenum are resected; stomach is anastomosed to jejunum and duodenal stump is closed.
  4. Total gastrectomy
    • Removal of stomach with anastomosis of esophagus to jejunum or duodenum.
  5. Pyloroplasty
    • Longitudinal incision is made in the pylorus, and closed transversely to permit the muscle to relax and established an enlarged outlet; often performed with vagotomy.

Nursing Interventions

  1. Monitor the patient for signs of bleeding through fecal occult blood, vomiting, persistent diarrhea, and change in vital signs.
  2. Monitor intake and output.
  3. Monitor the patient’s hemoglobin, hematocrit, and electrolyte levels.
  4. Administered prescribed I.V. fluids and blood replacements if acute bleeding is present.
  5. Maintain nasogastric tube for acute bleeding, perforation, and postoperatively, monitor tube drainage for amount and color.
  6. Perform saline lavage if ordered for acute bleeding.
  7. Encourage bed rest to reduce stimulation that may enhance gastric secretion.
  8. Provide small, frequent meals to prevent gastric distention if not actively bleeding.
  9. Watch for diarrhea caused by antacids and other medications.
  10. Restrict foods and fluids that promote diarrhea and encourage good perineal care.
  11. Advise patient to avoid extremely hot or cold food and fluids, to chew thoroughly, and to eat in a leisurely fashion to reduce pain.
  12. Administer medications properly and teach patient dose and duration of each medication.
  13. Advise patient to modify lifestyle to include health practices that will prevent recurrences of ulcer pain and bleeding.

Peptic Ulcer Nursing Care Plan

Daisy Jane Antipuesto RN MN

Currently a Nursing Local Board Examination Reviewer. Subjects handled are Pediatric, Obstetric and Psychiatric Nursing. Previous work experiences include: Clinical instructor/lecturer, clinical coordinator (Level II), caregiver instructor/lecturer, NC2 examination reviewer and staff/clinic nurse. Areas of specialization: Emergency room, Orthopedic Ward and Delivery Room. Also an IELTS passer.

What Do You Think?

 

Peptic Ulcer

A peptic ulcer may be referred to as a gastric, duodenal, oresophageal ulcer, depending on its location. A person who has a pepticulcer has peptic ulcer disease. A peptic ulcer is an excavation(hollowed-out area) that forms in the mucosal wall of the stomach, inthe

pylorus

(the opening between the stomach and duodenum), or inthe esophagus. Erosion of a circumscribed area of mucous membraneis the cause. This erosion may extend as deeply as the muscle layersor through the muscle to the

peritoneum

.Peptic ulcers are more likely to be in the duodenum than inthe stomach. As a rule they occur alone, but they may occur inmultiples. Chronic gastric ulcers tend to occur in the lesser curvatureof the stomach, near the pylorus. Esophageal ulcers occur as a resultof the backward flow of HCl from the stomach into the esophagus( gastroesophageal reflux disease [GERD] ).

Peptic ulcer disease occurs with the greatest frequency inpeople between 40 and 60 years of age. It is relatively uncommon inwomen of childbearing age, but it has been observed in children andeven in infants. After menopause, the incidence of peptic ulcers inwomen is almost equal to that in men. Peptic ulcers in the body of thestomach can occur without excessive acid secretion.

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