PEPTIC ULCER A peptic ulcer is a defect in the lining of the stomach or the first part of the small intestine,

an area called the duodenum. A peptic ulcer in the stomach is called a gastric ulcer. An ulcer in the duodenum is called a duodenal ulcer. A peptic ulcer is an excavation formed in the mucosal wall of the stomach, pylorus, duodenum, or esophagus. It is frequently referred to as a gastric, duodenal, or esophageal ulcer, depending on its location. It is caused by the erosion of a circumscribed area of mucous membrane. Peptic ulcer has been associated with bacterial infection, such as Helicobacter pylori. The greatest frequency is noted in people between the ages of 40 and 60 years. After menopause, the incidence among women is almost equal to that in men. Predisposing factors include family history of peptic ulcer, blood type O, chronic use of nonsteroidal antiinammatory drugs (NSAIDs), alcohol ingestion, excessive smoking, and, possibly, high stress. Esophageal ulcers result from the backward ow of hydrochloric acid from the stomach into the esophagus. Clinical Manifestations

relieved by ejection of the acid gastric contents. Constipation or diarrhea may result from diet and medications. Bleeding (15% of patients with gastric ulcers) and tarry stools may occur; a small portion of patients who bleed from an acute ulcer have only very mild symptoms or none at all.

Assessment and Diagnostic Methods

Physical examination (epigastric tenderness, abdominal distention). Endoscopy (preferred, but upper gastrointestinal [GI] barium study may be done). Diagnostic tests include analysis of stool specimens for occult blood, gastric secretory studies, and biopsy and histology with culture to detect H. pylori (serologic testing, stool antigen tests, or a breath test may also detect H. pylori).

Medical Management

The goals of treatment are to eradicate H. pylori and manage gastric acidity.

Pharmacologic Therapy

Symptoms of an ulcer may last days, weeks, or months and may subside only to reappear without cause. Many patients have asymptomatic ulcers. Dull, gnawing pain and a burning sensation in the mid epigastrium or in the back are characteristic. Pain is relieved by eating or taking alkali; once the stomach has emptied or the alkali wears off, the pain returns. Sharply localized tenderness is elicited by gentle pressure on the epigastrium or slightly right of the midline. Other symptoms include pyrosis (heartburn) and a burning sensation in the esophagus and stomach, which moves up to the mouth, occasionally with sour eructation (burping). Vomiting is rare in uncomplicated duodenal ulcer; it may or may not be preceded by nausea and usually follows a bout of severe pain and bloating; it is

Antibiotics combined with proton pump inhibitors and bismuth salts to suppress H. pylori. H2receptor antagonists (in high doses in patients with ZollingerEllison syndrome) to decrease stomach acid secretion; maintenance doses of H2receptor antagonists are usually recommended for 1 year. Proton pump inhibitors may also be prescribed. Cytoprotective agents (protect mucosal cells from acid or NSAIDs). Antacids in combination with cimetidine (Tagamet) or ranitidine (Zantac) for treatment of stress ulcer and for prophylactic use.

Lifestyle Changes

Stress reduction and rest are priority interventions. The patient needs to identify situations that are stressful or exhausting (eg, rushed lifestyle and

irregular schedules) and implement changes, such as establishing regular rest periods during the day in the acute phase of the disease. Biofeedback, hypnosis, behavior modication, massage, or acupuncture may also be useful. Smoking cessation is strongly encouraged because smoking raises duodenal acidity and signicantly inhibits ulcer repair. Support groups may be helpful. Dietary modication may be helpful. Patients should eat whatever agrees with them; small, frequent meals are not necessary if antacids or histamine blockers are part of therapy. Oversecretion and hypermotility of the GI tract can be minimized by avoiding extremes of temperature and over stimulation by meat extracts. Alcohol and caffeinated beverages such as coffee (including decaffeinated coffee, which stimulates acid secretion) should be avoided. Diets rich in milk and cream should be avoided also because they are potent acid stimulators. The patient is encouraged to eat three regular meals a day.

(NSAIDs), and level of tension or nervousness. Ask how patient expresses anger (especially at work and with family), and determine whether patient is experiencing occupational stress or family problems. Obtain a family history of ulcer disease. Assess vital signs for indicators of anemia (tachycardia, hypotension). Assess for blood in the stools with an occult blood test. Palpate abdomen for localized tenderness.

Diagnosis Nursing Diagnoses

Surgical Management

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 Decient knowledge about preventing symptoms and managing the condition

With the advent of H2receptor antagonists, surgical intervention is less common. If recommended, surgery is usually for intractable ulcers (particularly with ZollingerEllison syndrome), lifethreatening hemorrhage, perforation, or obstruction. Surgical procedures include vagotomy, vagotomy with pyloroplasty, or Billroth I or II.

Collaborative Problems/Potential Complications

Hemorrhage: upper GI Perforation Penetration Pyloric obstruction (gastric outlet obstruction)

Planning and Goals

Nursing Process Assessment

Assess pain and methods used to relieve it; take a thorough history, including a 72hour food intake history. If patient has vomited, determine whether emesis is bright red or coffee ground in appearance. This helps identify source of the blood. Ask patient about usual food habits, alcohol, smoking, medication use

The major goals of the patient may include relief of pain, reduced anxiety, maintenance of nutritional requirements, knowledge about the management and prevention of ulcer recurrence, and absence of complications.

Nursing Interventions Relieving Pain and Improving Nutrition

prevent hypotension, or place the patient on the left side to prevent aspiration from vomiting. Treat hypovolemic shock as indicated.

Administer prescribed medications. Avoid aspirin, which is an anticoagulant, and foods and beverages that contain acidenhancing caffeine (colas, tea, coffee, chocolate), along with decaffeinated coffee. Encourage patient to eat regularly spaced meals in a relaxed atmosphere; obtain regular weights and encourage dietary modications. Encourage relaxation techniques.

If perforation and penetration are concerns

Reducing Anxiety

Assess what patient wants to know about the disease, and evaluate level of anxiety; encourage patient to express fears openly and without criticism. Explain diagnostic tests and administering medications on schedule. Interact in a relaxing manner, help in identifying stressors, and explain effective coping techniques and relaxation methods. Encourage family to participate in care, and give emotional support.

Note and report symptoms of penetration (back and epigastric pain not relieved by medications that were effective in the past). Note and report symptoms of perforation (sudden abdominal pain, referred pain to shoulders, vomiting and collapse, extremely tender and rigid abdomen, hypotension and tachycardia, or other signs of shock).

Promoting Home and Community Based Care TEACHING PATIENTS SELF CARE

Monitoring and Managing Complications

If hemorrhage is a concern

Assess for faintness or dizziness and nausea, before or with bleeding; test stool for occult or gross blood; monitor vital signs frequently (tachycardia, hypotension, and tachypnea). Insert an indwelling urinary catheter and monitor intake and output; insert and maintain an IV line for infusing uid and blood. Monitor laboratory values (hemoglobin and hematocrit). Insert and maintain a nasogastric tube and monitor drainage; provide lavage as ordered. Monitor oxygen saturation and administering oxygen therapy. Place the patient in the recumbent position with the legs elevated to

Assist the patient in understanding the condition and factors that help or aggravate it. Teach patient about prescribed medications, including name, dosage, frequency, and possible side effects. Also identify medications such as aspirin that patient should avoid. Instruct patient about particular foods that will upset the gastric mucosa, such as coffee, tea, colas, and alcohol, which have acidproducing potential. Encourage patient to eat regular meals in a relaxed setting and to avoid overeating. Explain that smoking may interfere with ulcer healing; refer patient to programs to assist with smoking cessation. Alert patient to signs and symptoms of complications to be reported. These complications include hemorrhage (cool skin, confusion, increased heart rate, labored breathing, and blood in the stool), penetration and perforation (severe abdominal pain, rigid and tender abdomen, vomiting, elevated temperature, and increased heart

rate), and pyloric obstruction (nausea, vomiting, distended abdomen, and abdominal pain). To identify obstruction, insert and monitor nasogastric tube; more than 400 mL residual suggests obstruction. CONTINUING CARE

Teach patient that followup supervision is necessary for about 1 year. Tell patient that the ulcer could recur; advise patient to seek medical assistance if symptoms recur. Inform patient and family that surgery is no guarantee of cure. Discuss possible postoperative sequelae, such as intolerance to dairy products and sweet foods.

Evaluation Expected Patient Outcomes

Remains free of pain between meals Experiences less anxiety Complies with therapeutic regimen Maintains weight Experiences no complications