Peptic Ulcer Disease

Risk Factors for Gastric and Duodenal ulcers:

-Bacterial infection - H. pylori most common (mainly in duodenal though?) -Medication induced injury (NSAIDs, aspirin, corticosteroids, anticoagulants, SSIs like prozac) -Lifestyle - alcohol and smoking, stress, coffee

Clinical manifestation of gastric

-epigastric pain -1-2 hrs after meals -pain is burning or gaseous in nature (and worse with food bc you are secreting acid)

Clinical Manifestations of duodenal ulcerations

-mid epigastric/sub-xiphoid/radiates to back -2-4 hours after a meal (bc it takes a while to get to the duodenum -pain is burning and cramp-like in nature (but gets BETTER WITH FOOD bc of alkaline secretions from liver and pancreas and will buffer that pain)

3 major complications of both gastric and duodenal ulcers:

1) Hemorrhage - higher incidence in duodenal and can cause upper GI bleed, so may see bright red blood or coffee ground emesis ( means bloods come in contact with stomach acid); watch for symptoms of shock (tachycardia, hypotension, cool and clammy skin, dyspnea, decreased urine output); look at NG tube contents; also can have blood in stool - occult stool testing needs to be done 2) Perforation - sudden severe abd pain radiating to the shoulder, rigid abdomen, increasing distention (bacterial peritonitis can happen within 6-12 hours of a perforation) ; increased incidence with duodenal, but mortality increased with gastric (due to age and co-morbidities; with the ulcer penetrates the serosal surface with spillage of gastric of duodenal contents into the peritoneal cavity; small perforations may heal on own, large ones require immediate surgical closure 3) Gastric Outlet Obstruction - obstruction of distal stomach and duodenum from edema, inflammation and scarring. The pain gets worse late in the day as the stomach fills, and usually seen with PROJECTILE vomiting that is malodorous bc its old stomach contents

Duodenal Ulcers are more common in the first ___-____ cm of the duodenum, more prevalent in ______, more middle age (35-45), are most commonly caused by __________ which is a bacteria, most often caused associated with high HCl acid secretion, and groups of people at high risk for this type of ulcer are people with COPD, cirrhosis, chronic pancreatitis, chronic ________ __________, and Zollinger-Ellison Syndrome.

1-2 men H.pylori renal disease

HCL pH is normally ____ to _____, so it's very acidic

1.5, 2

Complications of PPI's would be decreased digestions of fat, bacteria won't be killed as much and _________ infection can develop.

C. diff

Carbonic acid reaction is where H2CO3 is then dissociated into H2O and _______. This helps to free up our hydrogen ion that is used to secrete our hydrochloric acid. So our hydrogen ion in this situation used for hydrochloric acid, when our bicarbonate then changes the pH in our blood. (?????)

CO2

Parietel cells in the stomach secrete _________.

HCL

Upper GI bleeding is our most common complication of _______. This happens more often in DUODENAL than gastric, and 60% of these happen over age of 65, mortality is between 6 and 13%. Esophageal bleed caused by a varices (enlarged vein at the base of the esophageous due to hepatomegaly and build up of blood flow, portal hypertension and alcohol). Bleeding severity depends on our bleeding origin: artieral is worse than venous and capillary is intermediate.

PUD

Jobs of the stomach:

Storage Breaks down food - by secreting our gastric juice Absorption - certain drugs, water, alcohol, and some butter and milk fat (lipophilic molecules)

The MOA of H2 blockers is the block the H2 receptor on parietal cells, which decreases ______ production

acid

Amylase can be drawn look into pancreatic involvement . Amylase is produced in _______ cells of the pancreas. Amylase is used for catabolism of ______________. A penetrating ulcer in the pancreas can increase our amylase levels, but amylase is also produces in out ___________ glands. This test is sensitive to this but not specific.

acinar carbohydrates salivary

Other things that are lipophilic that the stomach absorbs is aspirin and _________.

alcohol

Acinar cells produce ___________ in the pancreas to aid in catabolism of _________.

amylase carbohydrates

H1 blockers are used in an allergic reaction, where as H2 Blockers are used in our stomach acid. H2 receptor blockers such as phemotidine or pepsin, block our histamine which decreases our acid secretion. These medications are RAPIDLY absorbed, ____ minute onset of action, and a half life of __ to __ hours. These are not affected by food. Do not take with other ___________ because they decrease the absorption of H2 blockers.

antacids 30 1 to 4

Gastric Ulcers happen more commonly in the _________, is more prevalent in women over age of _____ yr old, higher _________ than duodenal, and more likely to result in an __________ than a duodenal.

antrum 50 mortality obstruction

CBC test can be done, and we will check for ___________, and this should be trended if we have someone with a chronic ulceration because this can lead to a ________ bleed.

bleeding chronic

Pyloric sphincter allows chyme to move through slowly. When our pyloric sphincter is no longer there or working, pt is a risk for ______

dumping syndrome

Peptic Ulcer Disease can be defined by ________ and ________ ulcers, but they differ in etiology and incidence.

gastric duodenal

A peptic ulcer can be considered acute or chronic, where acute is _________ and is superficial erosion that does not break into the muscularis at all, versus chronic happens in the _________, which is penetrating and breaks through muscularis damaging blood vessels and causing a chronic or acute bleed (can start chronic and turn quickly into acute).

gastric duodenum

In Zollinger-Ellison Syndrome is characterized by severe peptic ulceration (usually duodenal) and overall HCl hypersecretion and create tumors. This can also happen in the pancreas, where the tumors are called ___________. Gastrinomas then secrete too much ________, increasing gastric secretions from ______ cells in the stomach secreting _____ and creating more ulcerations. In addition, chief cells convert pepsinogen into pepsin rapidly. Treatment includes _______ therapy or surgical removal of tumor.

gastrinomas gastrin parietal HCl PPI

*Upper Endoscopy is the ______ standard, and looks at esophagus, lining of all stomach and duodenum. Will tell you what type of ulcer you have and whether it is _______ or ________.

gold acute, chronic

What things can nurse do to figure out the patient's risk factors?

history and physical (what is stress level, how do you deal with your stress)

Secretion of gastric juices helps to turn our food, breaking into small particles. Parietal cells secrete ___________ which helps absorb vitamin _________. Parietal cells produce hormone ___________, which regulates our digestive functions, and it produces _________ which is our hormone that tells us we are hungry. Other jobs of our gastric juices is to help decrease and kill bacteria that is ingested off of foods. D

intrinsic factor B12 gastrin ghrelin

PPI MOA

irreversible block H/K ATPase pump in parietal cells

Another test we can do is for ________ enzymes. Our ALT testing is more more specific to liver cells, also called _____________. Our AST is there for any highly metabolic tissues, including cardiac muscle, skeletal tissues, and liver tissues. While our AST is drawn with ALT, it as not as secific to the liver.

liver hepatocellular/hepatocytes

Our goal of drug therapy is to eradicate the ________ that can be causing this erosion.

microorganism

Duodenum is the first 25 cm of the small bowel and considered the ________ bowl. Receives our acidic chyme and basic secretion from pancreas and liver, of which all go into duodenum. Absorption of _______ and _______ happens here.

mixing iron and calcium

Pepsinogen is used to convert to _________ once it combines with HCL from chief cells

pepsin

Chief cells secrete _________

pepsinogen

After the upper endoscopy, we will do a H. pylori test to find out the reason why. H. Pylori tests can be through biopsy of the _______ lining or duodenal lining, _______ test, or a breathing test. We are looking for bacteria.

stomach blood

what is the gold standard for diagnosing a gastric or duodenal ulcer?

upper endoscopy because it will look at the esophagus, the lining of the stomach and the whole duodenum

In the stomach, the bacteria can survive a long time by colonizing the gastric epithelial cells within the mucosal layer. The bacteria produce _________, which metabolizes urea-producing ammonium, carbon dioxide, and bicarb (book says chloride) and other damaging chemicals. The ammonia erodes the mucosa which can lead to an intestinal metaplasia (change in the tissue to form abnormal cells) and then body starts producing more and more abnormal cells. Or it can produce tissue damage leading to peptic ulcer disease. 66% of the world is infected with H. pylori and will never know.

urease

Zollinger-Ellison syndrome

usually happens with duodenal ulcers. It is severe peptic ulcerations that cause HCL hypersecretion caused by one or more tumors in the duodenum. These tumors can also occur in the pancreas called gastrinomas. Gastrinomas then secrete too much gastrin, causing too much acid and ulcerations. When gastrin is stimulated we have an increase in secretion of HCL by parietel cells, an increase of our conversion of pepsinogen to pepsin by the chief cells. To treat this, we control our gastric acid hypersecretion with a PPI, and then we can surgically remove the tumor if it's possible