1. PEPTIC ULCER DISEASE

2. INTRODUCTION

3. PREVELENCE
 In India, the prevalence of peptic ulcers is estimated to
be 4-10 per1000 population

4. INCIDENCE
 Age 30–60
 Male: female–3:1

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

6. Types
 Acute
 Chronic

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

9. Another classification
 Gastric
 duodenal

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.

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

17. MEDICAL MANAGEMENT
 Antibiotics
 Eradicate H. pylori
 Rest
 sedatives
 Tranquilizers
 Octreotide (decrese gastric activity)
 cytoprotective agents (sucralfate)

18. PHARMACOLOGIC THERAPY
 proton pump inhibitors
 antibiotics
 bismuth salts
 histamine 2 antagonist
 proton pump inhibitors

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

24. Truncal

25. VAGOTOMY WITH
PYLOROPLASTY

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

27. ANTRECTOMY

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

31. BILROTH 1

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

33. BILROTH II

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

41. NURSING INTERVENTIONS
 RELIEVING PAIN
 REDUCING ANXIETY
 MAINTAINING OPTIMAL NUTRITIONAL STATUS
 MAINTAINING OPTIMAL NUTRITIONAL STATUS
 TEACHING PATIENTS SELF-CARE

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

46. POTENTIAL COMPLICATIONS
 Hemorrhage
 Perforation and Penetration
 Pyloric Obstruction

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

51. Evidence based practice
Conclusion

52. Bibliography

53. Thank you