Gastric and Duodenal Ulcer

Dr. Belal M. Hijji, PhD, RN

April 30 & May 04, 2011
 Learning Outcomes
By the end of this lecture, students will be able to:
1. Define peptic ulcer and identify the risk factors for its
formation.
2. Describe the pathophysiology and clinical manifestations of
peptic ulcer.
3. Describe assessment and diagnostic findings of a patient with
peptic ulcer.
4. Discuss the medical management of peptic ulcer.
5. Discuss the nursing management of a patient with peptic
ulcer.

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Deep peptic ulcer. From Porth, C. (2002). Pathophysiology:
Concepts of altered health states (6th ed). Philadelphia:
Lippincott Williams & Wilkins. 3
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 ?What is a Peptic Ulcer

It is a hole that forms in the mucosal wall of the stomach, in

the pylorus (opening between stomach and duodenum), in the
duodenum (first part of small intestine), or in the esophagus.

It is frequently referred to as a gastric, duodenal, or esophageal

ulcer, depending on its location, or as peptic ulcer disease.

It is more likely to be in the duodenum than in the stomach.

Chronic gastric ulcers tend to occur in the lesser curvature of

the stomach, near the pylorus.
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 Risk Factors For Peptic Ulcers
Infection with bacteria "Helicobacter pyloricus" (H. pylori).
Gastritis, alcohol, smoking, use of NSAIDs, and stress.
Familial tendency may be a significant predisposing factor.
People with blood type O are more susceptible to peptic ulcers
than are those with other types.
Rarely, ulcers are caused by excessive amounts of the
hormone gastrin, produced by tumors. This Zollinger-Ellison
syndrome (ZES) consists of severe peptic ulcers, extreme
gastric hyperacidity, and gastrin-secreting benign or malignant
tumors of the pancreas.

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 Pathophysiology

Peptic ulcers occur mainly in the tissue of gastroduodenal

mucosa because it cannot withstand the digestive action of
gastric acid (HCl) and pepsin.

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.

Stress ulcer refers to the acute mucosal ulceration of the

duodenal or gastric area that occurs after physiologically
stressful events, such as burns, shock, severe sepsis, and
multiple organ traumas. Stress ulcer is usually preceded by
shock; this leads to decreased gastric mucosal blood flow and
to reflux of duodenal contents into the stomach. In addition,
large quantities of pepsin are released. The combination of
ischemia, acid, and pepsin creates an ideal climate for
ulceration. 7
 Clinical Manifestations
Many people have symptomless ulcers, and in 20% to 30%
perforation or hemorrhage may occur without any preceding
manifestations.
Dull, gnawing [persistent & troubling] pain or a burning
sensation in the midepigastrium. The pain may occur when the
increased acid content of the stomach and duodenum erodes
the lesion and stimulates the exposed nerve endings. Pain is
usually relieved by eating, or by taking alkali.
Sharply localized tenderness can be elicited by applying gentle
pressure to the epigastrium at or slightly to the right of the
midline.

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 Pyrosis (heartburn), vomiting, and bleeding. Pyrosis is a
burning sensation in the esophagus and stomach that moves up
to the mouth.
Heartburn is often accompanied by sour eructation, which is
common when the patients stomach is empty.
Fifteen percent of patients with gastric ulcers experience
bleeding, as evidenced by the passage of tarry stools.

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 Assessment and Diagnostic Findings
A physical examination may reveal pain, epigastric tenderness,
or abdominal distention. Pain that is relieved by ingesting food
or antacids and absence of pain on arising are also highly
suggestive of an ulcer.

Endoscopy is useful procedure because it allows direct

visualization of inflammatory changes, ulcers, and lesions. A
biopsy of the gastric mucosa and of any suspicious lesions can
be obtained. Biopsy and histology with culture can determine
H. Pylori.

Stools may be tested for occult blood (OB).

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 Medical Management
The purpose of medical management of peptic ulcer is to
eradicate H. pylori and to manage gastric acidity. This is
achieved through pharmacologic therapy, lifestyle changes,
and surgical intervention. These are described next.

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 Pharmacologic Therapy
A combination of antibiotics (clarithromycin & amoxicillin),
proton pump inhibitors (omeprazole), and bismuth salts
(bismuth subsalicylate) that suppresses or eradicates H. pylori;
Antibiotics assist in eradicating H. pylori bacteria.
Histamine 2 (H2) receptor antagonists (Ranitidine) and proton
pump inhibitors are used to treat NSAID-induced and other
ulcers not associated with H. pylori ulcers.
Bismuth salts suppress H. pylori bacteria in the gastric mucosa
and assists with healing of mucosal lesions.
H2 receptor antagonists inhibit acid secretion by blocking the
action of the histamine on the histamine receptors in the
stomach.

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 Life Style Changes
Stress reduction and rest
The patient may need avoid situations that are stressful or
exhausting. A rushed lifestyle and an irregular schedule may
aggravate symptoms and interfere with regular meals taken in
relaxed settings and with the regular administration of
medications.
The patient may benefit from regular rest periods during the day,
at least during the acute phase of the disease.
Smoking cessation
Smoking decreases the secretion of bicarbonate from the
pancreas into the duodenum, resulting in increasing its acidity.
Smoking may significantly inhibit ulcer repair. Therefore, the
patient is strongly encouraged to stop smoking.

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 Dietary modification
Dietary modification is required to avoid oversecretion of acid
and hypermotility in the GI tract. Therefore, avoiding extremes
of temperature and overstimulation from consumption of meat
extracts, alcohol, coffee and other caffeinated beverages, and
diets rich in milk and cream.
In addition, an effort is made to neutralize acid by eating three
regular meals a day.
Surgery
Surgery is usually recommended for patients with intractable
ulcers (those that fail to heal after 12 to 16 weeks of medical
treatment), life-threatening hemorrhage, perforation, or
obstruction.

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 Nursing Management of Peptic Ulcer
Assessment
The nurse asks the patient to describe the pain (burning or
gnawing) and the methods used to relieve it (e.g., food,
antacids). Pain occurs about 2 hours after a meal and frequently
awakens the patient between midnight and 3 AM. Taking
antacids, eating, or vomiting often relieves the pain.
The nurse asks about history of vomiting and characteristics of
the vomitus: Is it bright red, does it resemble coffee grounds?
Has the patient noted any bloody or tarry stools?
The nurse assess life style and habits such as drinking coffee
and/ or alcohol, and smoking. Does the patient take NSAIDs?
Any anxiety or stress?
The nurse records vital signs and reports any tachycardia and
hypotension. Is there any tenderness of abdomen?

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 Nursing diagnoses
Acute pain related to the effect of gastric acid secretion on
damaged tissue
Anxiety related to coping with an acute disease
Imbalanced nutrition related to changes in diet
Deficient knowledge about prevention of symptoms and
management of the condition
Planning and goals
Relief of pain and reduced anxiety,
Maintenance of nutritional requirements,
Knowledge about the management and prevention of ulcer
recurrence.

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 Nursing interventions
Relieving pain: Administration of prescribed medications. The
patient should avoid aspirin, foods and beverages that contain
caffeine, and decaffeinated coffee, and meals should be eaten at
regularly paced intervals in a relaxed setting.
Reducing anxiety: The nurse assesses the patients level of
anxiety. Appropriate information and explanation are provided at
the patients level of understanding, all questions are answered,
and the patient is encouraged to express fears openly. The
patients family is also encouraged to participate in care and to
provide emotional support.
Maintaining optimal nutritional status: The nurse assesses the
patient for malnutrition and weight loss. The patient is advised
about the importance of complying with the medication regimen
and dietary restrictions.

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 Knowledge about the management and prevention of ulcer
recurrence. The nurse instructs the patient about the factors that
will help or aggravate the condition. The nurse provides
information about medications to be taken at home, 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. It is important to counsel the patient to eat meals at
regular times and in a relaxed setting, and to avoid overeating. If
relevant, the nurse also informs the patient about the irritant
effects of smoking on the ulcer.

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 Evaluation
Reports freedom from pain between meals
Feels less anxiety by avoiding stress
Complies with therapeutic regimen
Avoids irritating foods and beverages
Eats regularly scheduled meals
Takes prescribed medications as scheduled
Uses coping mechanisms to deal with stress
Maintains weight

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