Peptic Ulcer Disease

INTRODUCTION
Peptic Ulcer is a lesion in the lining
(mucosa) of the digestive tract, typically in the stomach or duodenum, caused by the
digestive action of pepsin and stomach acid.

Lesion may subsequently occur into the lamina
propria and submucosa to cause bleeding. – Most of peptic ulcer occur either in the duodenum, or in the stomach – Ulcer may also occur in the lower esophagus due to reflexing of gastric content – Rarely in certain areas of the small intestine

PATHOPHYSIOLOGY

Under normal conditions, a physiologic balance exists between gastric acid secretion and gastroduodenal mucosal defense. Mucosal injury and, thus, peptic ulcer occur when the balance between the aggressive factors and the defensive mechanisms is disrupted. Aggressive factors, such as NSAIDs, H pylori infection, alcohol, bile salts, acid, and pepsin, can alter the mucosal defense by allowing back diffusion of hydrogen ions and subsequent epithelial cell injury.

ETIOLOGY/ RISK FACTORS
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Lifestyle
Smoking
Acidic drinks
Medications
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H. Pylori infection
90% have this bacterium
Passed from person to person (fecal-oral route or oral-oral route)
Age
Duodenal 30-40
Gastric over 50
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Gender
Duodenal: are increasing in older women
Genetic factors
More likely if family member has Hx
Other factors: stress can worsen but not the cause

TYPES
GASTRIC PEPTIC ULCER
DUODENAL PEPTIC ULCER

Gastric and Duodenal Ulcers

INVESTIGATION
Stool examination for fecal occult blood.
Complete blood count (CBC) for decrease in blood cells.

DIAGNOSTIC TEST
Esophagogastrodeuodenoscopy (EGD)
Endoscopic procedure
Visualizes ulcer crater
Ability to take tissue biopsy to R/O cancer and diagnose
H. pylori
Upper gastrointestinal series (UGI)
Barium swallow
X-ray that visualizes structures of the upper GI tract
Urea Breath Testing
Used to detect H.pylori
Client drinks a carbon-enriched urea solution
Exhaled carbon dioxide is then measured

In all patients with “Alarming symptoms” endoscopy is required.
Dysphagia.
Weight loss.
Vomiting.
Anorexia.
Hematemesis or Melena

Complications of Peptic Ulcers
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Hemorrhage
Blood vessels damaged as ulcer erodes into the muscles of stomach or duodenal wall
Coffee ground vomitus or occult blood in tarry stools
Perforation
An ulcer can erode through the entire wall
Bacteria and partially digested food spill into peritoneum=peritonitis
Narrowing and obstruction (pyloric)
Swelling and scarring can cause obstruction of food leaving stomach=repeated vomiting

MANAGEMENT
LIFE STYLE MODIFICATION
HYPOSECRETORY DRUG THERAPY
H. pylori ERADICATION THERAPY
SURGERY

Hyposecretory Drugs
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Proton Pump Inhibitors
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Suppress acid production Prilosec, Prevacid
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H2-Receptor Antagonists
Block histamine-stimulated gastric secretions
Zantac, Pepcid, Axid
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Antacids
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– Neutralizes acid and prevents formation of pepsin (Maalox, Mylanta)
Give 2 hours after meals and at bedtime
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Prostaglandin Analogs
Reduce gastric acid and enhances mucosal resistance to injury
Cytotec
Mucosal barrier fortifiers
Forms a protective coat
Carafate/Sucralfate
– cytoprotective

H. pylori Eradication Therapy:

Indications:
Failure of medical treatment.
Development of complications
High level of gastric secretion and combined duodenal and gastric ulcer.
Principle:
Reduce acid and pepsin secretion.

Types of Surgical Procedures
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GASTROENTEROSTOMY
Creates a passage between the body of stomach to small intestines.
Allows regurgitation of alkaline duodenal contents into the stomach.
Keeps acid away from ulcerated area

Types of Surgical Procedures
VAGOTOMY
Cuts vagus nerve
Eliminates acid- secretion stimulus

Types of Surgical Procedures
PYLOROPLASTY
– Widens the pylorus to guarantee stomach emptying even without vagus nerve stimulation

Types of Surgical Procedures
ANTRECTOMY/ SUBTOTAL GASTRECTOMY
Lower half of stomach (antrum) makes most of the acid
Removing this portion (antrectomy) decreases acid production
SUBTOTAL GASTRECTOMY
Removes ½ to 2/3 of stomach
Remainder must be reattached to the rest of the bowel
Billroth I
Billroth II

Billroth I
Distal portion of the stomach is removed
The remainder is anastomosed to the duodenum

Billroth II
The lower portion of the stomach is removed and the remainder is anastomosed to the jejunum

Postoperative Care
NG tube – care and management
Monitor for post-operative complications