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01.05 Nursing Care and Pathophysiology for Peptic Ulcer Disease (PUD)

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Pathophysiology: Peptic ulcer disease (PUD) consists of open sores in the protective lining of the stomach and upper small intestine. Gastric ulcers occur on the inside of the stomach and duodenal ulcers occur on the inside of the upper portion of the small intestine (duodenum).

Overview

  1. Break in mucosal lining of stomach, pylorus, duodenum, or esophagus that come in contact with gastric secretions
  2. Irritation by gastric secretions may cause bleeding

Nursing Points

General

  1. Causes
    1. Helicobacter pylori
    2. Frequent use of NSAIDs, Aspirin
    3. Smoking
    4. Alcohol Use
  2. Diagnosis
    1. Upper GI Series x-rays
    2. EGD – Esophagogastroduodenoscopy

Assessment

  1. Nausea/Vomiting
  2. Abdominal Pain
    1. Usually upper abdominal pain
    2. Often burning or sharp pain
    3. Gastric Ulcer
      1. Gnawing, sharp 30-60 minutes after a meal
    4. Duodenal Ulcer
      1. 1.5 to 3 hours after eating
      2. Pain may be relieved by eating
  3. Hematemesis (gastric)
  4. Melena (duodenal)

Therapeutic Management

  1. Avoid aspirin and NSAIDs
  2. Monitor H&H and assess for bleeding
  3. Medications
    1. H2 receptor antagonists
    2. Proton pump inhibitors
    3. Antacids
    4. Sucralfate (Carafate) – take 30-60 minutes  before meals
  4. Surgical options
    1. Vagotomy
      1. Cut Vagus nerve
      2. ↓ Parasympathetic = ↓ gastric acid secretion
    2. Gastric resection / Gastrectomy
      1. Remove all or part of stomach to remove ulcerated tissue
    3. Billroth I, Billroth II
      1. Remove a portion of the stomach and reattach to duodenum (I) or jejunum (II)
    4. Post-Op:
      1. HOB 45°
      2. Clear Liquids x 3-7 days
      3. Assess Bowel sounds
      4. Risk for  Dumping Syndrome (rapid influx of gastric contents into small intestine)
        1. Avoid sugar or fatty foods
        2. Smaller meals
        3. No fluids with meal

Nursing Concepts

  1. Nutrition
    1. Avoid foods that cause irritation
      1. Coffee
      2. Soda
      3. Tea
      4. Chocolate
      5. High sodium
      6. Spicy foods
    2. Small, frequent meals
  2. Comfort
    1. Administer medications as ordered
    2. Encourage nutrition compliance

Patient Education

  1. Smoking Cessation
  2. Adhere to dietary restrictions
  3. Take medications as prescribed

Reference Links

Study Tools

Video Transcript

So let’s talk about Peptic Ulcer Disease.

Peptic Ulcer Disease is when there is a break in the mucosal lining of the stomach or the duodenum. Now, if you remember from Anatomy the stomach has a mucosal lining, and that mucus helps to protect the tissue in the muscle of the stomach from that stomach acid. Remember the pH of of the stomach acid could be as low as 2, which is very acidic. And so we have to have that mucosal lining to protect the muscle and tissue from that acid. So if there’s a break in that mucosal lining, that stomach acid is going to come in and irritate that spot. It’s going to cause an ulceration and eventually that ulceration could potentially bleed. Some of the things that cause peptic ulcer disease include the bacteria helicobacter pylori. H. pylori is a bacteria that everybody has in their gut, but sometimes it becomes overactive and sometimes it can get into these breaks in the mucosa and cause even further irritation. Some other things that can cause peptic ulcers are NSAIDs, like ibuprofen, and aspirin. Frequent use of those is definitely a risk factor for developing ulcers within the stomach and the duodenum. And then of course smoking because of the effects on our vascular system and alcohol abuse because it is just really hard on our GI tract.

To diagnose peptic ulcer disease we can use an upper GI series of x-rays to look for signs of ulceration, but the best diagnostic tool we have is an EGD. EGD stand for esophagogastroduodenoscopy. So we know that oscopy means camera or scope – so they’re going to insert the scope to take pictures of the esophagus, stomach, and duodenum. The most common presentation of symptoms for these patients is severe abdominal pain. This is a sharp, gnawing pain, that is especially worse after meals. Depending on where the ulcer is in their system it could be anywhere from 30 minutes after a meal, if it’s in the stomach, to two hours after a meal if it’s farther down in the duodenum. Patients will often have nausea and vomiting, and as I mentioned before these ulcerations can begin to bleed. When that happens we will either see hematemesis which is vomiting blood, or we will see Melena which is when their stools are dark red or bloody. Typically gastric ulcers will present with hematemesis, while duodenal ulcers will present with melena. you could also see what’s called coffee ground emesis, which is when their vomit literally looks like it has coffee grounds in it because the blood has been partially digested by the stomach acid.

When we are managing peptic ulcer disease, the most important thing we can do is to avoid things that are going to irritate the ulcers or make it worse. So we don’t give NSAIDs or aspirin to these patients, and we educate them not to take these at home either. Here in South Carolina we have something called goody powders. it’s basically a powdered form of aspirin that people take when they have a headache. These patients will take this stuff like candy and they’ll come in with a ridiculous GI bleed and multiple gastric ulcers. So we also want to make sure that we are assessing for bleeding and monitoring their hemoglobin and hematocrit. As far as medications, the goal is to decrease the level of irritation on those breaks in the mucosal lining. So we’re going to give H2 receptor antagonist and proton pump inhibitors to decrease the overall secretion of acid, we can give antacids to help neutralize it, and we also give something called sucralfate. sucralfate or Carafate is given about 30 to 60 minutes before a meal, and actually coats the stomach with a protective lining so that the acid can’t cause irritation.

We also have a few surgical options for severe cases of Peptic Ulcer Disease. One of those is a vagotomy. We’ll actually cut the vagus nerve at the level of the stomach. That decreases parasympathetic impulses which will decrease the amount of gastric acid secretion in the stomach. We also have options for a full or partial gastrectomy. If it’s severe enough, sometimes cutting out and removing the ulcerated portion of the stomach is the best option. Billroth I and Billroth II are two examples of this. We’ll remove a portion of the stomach and reattach the rest to the duodenum in Billroth I or the jejunum in Billroth II. Now after any type of gastrectomy, we need to make sure we keep the HOB elevated, the patient may be NPO for a day and then will be on clear liquids for 3-7 days, and then they’ll advance as tolerated or as instructed from there. But the big thing to keep an eye out for is Dumping Syndrome. This occurs when there’s a rapid influx of food or fluids into the small intestine and it will make the patient very sick. Nausea, vomiting, diarrhea, severe abdominal cramping – it’s really awful. So we have them avoid sugar and fried or fatty foods and they need to eat smaller meals and eat slower. We also encourage them not to drink while they eat, because that fluid just flushes the food right out of their stomach.

So our priorities for a patient with peptic ulcer disease will include nutrition, comfort, and safety. We need to encourage them to avoid foods that irritate the mucosa like coffee, tea, soda, chocolate, high sodium foods, and spicy foods. We want to give analgesics and antacids as ordered, and we want to keep them safe from complications like GI bleeds or dumping syndrome if they’re post-op. Be sure to check out the care plan attached to this lesson for more detailed nursing interventions and rationales.

So let’s recap – Peptic Ulcer Disease is when there’s a break in the mucosal lining that can get irritated by the stomach acid and could eventually bleed. Think about that mucosal lining like icing on a cake. If you put a hole in the icing, you’ll be able to get down and get a bite of the cake. Many causes of Peptic Ulcer Disease are preventable so we want to limit the use of NSAIDs and Aspirin, and promote smoking cessation and limited alcohol use. Patients typically present with severe abdominal pain that is worse with eating and they could present with a GI bleed as well. We focus on reducing the acid level in the stomach to decrease the irritation, or we could actually remove all or part of the stomach. We need to make sure the patients avoid irritating foods/beverages like coffee and spicy foods, and encourage small, frequent meals.

That’s it for Peptic Ulcer Disease. Make sure you check out the resources attached to this lesson to learn more! Now, go out and be your best selves today! And, as always, happy nursing!

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