Peptic Ulcer Disease, Hinkle Ch. 47

Recommended therapy for 10 to 14 days includes triple therapy with two antibiotics ______ plus a proton pump inhibitor______, or quadruple therapy with two antibiotics ______ plus a proton pump inhibitor and bismuth salts (Pepto-Bismol).

(e.g., metronidazole [Flagyl] or amoxicillin [Amoxil] and clarithromycin [Biaxin]); (e.g., lansoprazole [Prevacid], omeprazole [Prilosec], or rabeprazole [AcipHex]); (metronidazole and tetracycline)

A residual of more than ______ suggests obstruction.

400 mL

Those who are ______ years and older present to both outpatient and inpatient settings for treatment of peptic ulcers more than any other age group

65

What is included in "triple therapy" for peptic ulcers? A. A proton-pump inhibitor (PPI) and two antibiotics. B. An H2 receptor antagonist, sucralfate (Carafate), and an antacid. C. A PPI, an antacid, and an anibiotic. D. An H2 receptor antagonist, antacids, and a PPI.

A. A proton-pump inhibitor (PPI) and two antibiotics.

What other instructions should the nurse give the patient? Select all that apply. A. Avoid taking ibuprofen, aspirin, and related medications like naproxen (Advil). B. Avoid drinking alcohol. C. Avoid smoking tobacco. D. Decrease caffeine intake. E. Consume 8 ounces of milk whenever the heartburn begins.

A. Avoid taking ibuprofen, aspirin, and related medications like naproxen (Advil). B. Avoid drinking alcohol. C. Avoid smoking tobacco. D. Decrease caffeine intake.

The patient tells the nurse that his uncle had surgery for ulcers "30 or 40 years ago" and asks if he will need surgery too. What is the best response for the nurse to make? A. Surgery used to be common treatment for ulcers, but with the medications we have now, surgery is rarely needed. B. It's too early to tell if you'll need surgery for the ulcer, but many people do. C. Surgery is the best treatment for ulcers. D. Don't worry; I'm sure you won't need surgery.

A. Surgery used to be common treatment for ulcers, but with the medications we have now, surgery is rarely needed.

Initial H. pylori therapy (Second line):

Bismuth subsalicylate 2 tabs qid plus tetracycline 250 mg qid plus metronidazole 250 mg qid (optional: add PPI daily) for 14 days

The nurse is instructing the patient about the famotidine. Which statement should the nurse include in the teaching? A. Famotidine prevents acid from the stomach from backing up into the esophagus. B. Famotidine neutralizes acid in the stomach. C. Famotidine works to reduce the production of acid in the stomach. D. Famotidine is an analgesic; it will help your pain.

C. Famotidine works to reduce the production of acid in the stomach.

______ ulcers tend to occur in the lesser curvature of the stomach, near the pylorus.

Chronic gastric

______ ulcer is frequently observed about 72 hours after extensive burns and involves the antrum of the stomach or the duodenum.

Curling's

Specific types of ulcers that result from stressful conditions include ______ ulcers and ______ ulcers.

Curling's; Cushing's

______ ulcers are common in patients with head injury and brain trauma. They may occur in the esophagus, stomach, or duodenum and are usually deeper and more penetrating than typical stress ulcers.

Cushing's

Which aspect of the patient's symptoms do you think are of greatest concern? A. Location of the pain B. Recurrence of the pain 2 to 3 hours after antacids C. Being awakened by pain D. Black, sticky stools

D. Black, sticky stools

Patient reports to the ED. They report epigastric pain has worsened and they are feeling fatigued and weak. Stools are now maroon in color. BP 88/52mm Hg, Pulse 121 bpm, and respiration 20. What intervention is the highest priority? A. Prepare the patient for an EGD. B. Position the patient in a semi-Folwer's position. C. Obtain a list of the patient's current medications. D. Insert a large-bore IV line.

D. Insert a large-bore IV line.

What blood type is more susceptible to peptic ulcer? A. A B. B C. AB D. O

D. O

Three hours after the patient is admitted to the medical/surgical unit, he complains of increased abdominal pain. The nurse notes that his abdomen is rigid and tender. What is the most likely explanation of the assessment finding? A. The findings are to be expected in a peptic ulcer. B. The bleeding from the ulcer has worsened. C. The findings are a reaction to the pain. D. The ulcer has most likely perforated.

D. The ulcer has most likely perforated.

Proximal (parietal cell) gastric vagotomy without drainage

Denervates acid-secreting parietal cells but preserves vagal innervation to the gastric antrum and pylorus.

______ ulcers occur as a result of the backward flow of HCl from the stomach into the esophagus (gastroesophageal reflux disease [GERD]).

Esophageal

______ occurs when the area distal to the pyloric sphincter becomes scarred and stenosed from spasm or edema or from scar tissue that forms when an ulcer alternately heals and breaks down.

Gastric outlet obstruction

In the past, stress and anxiety were thought to be causes of ulcers, but research has documented that most peptic ulcers result from infection with the gram-negative bacteria ______, which may be acquired through ingestion of food and water.

H. pylori

For patients with ZES, hypersecretion of acid may be controlled with high doses of ______. These patients may require twice the normal dose, and dosages usually need to be increased with prolonged use.

H2 blockers

Recurrence of peptic ulcer disease within 1 year may be prevented with the prophylactic use of ______ taken at a reduced dose.

H2 blockers

______ and ______ that reduce gastric acid secretion are used to treat ulcers not associated with H. pylori infection.

H2 blockers and proton pump inhibitors

Excessive secretion of ______ in the stomach may contribute to the formation of peptic ulcers, and stress may be associated with its increased secretion.

HCl

Pyloroplasty

Longitudinal incision is made into the pylorus and transversely sutured closed to enlarge the outlet and relax the muscle; usually accompanies truncal and selective vagotomies.

In treating the patient with gastric outlet obstruction, the first consideration is to insert an ______ to decompress the stomach.

NG tube

(peritonitis) During surgery and postoperatively, the stomach contents are drained by means of an ______. The nurse monitors ______ and assesses the patient for localized infection or peritonitis (increased temperature, abdominal pain, paralytic ileus, increased or absent bowel sounds, abdominal distention). ______ is administered parenterally as prescribed.

NG tube; fluid and electrolyte balance; Antibiotic therapy

The use of ______ inhibits the secretion of mucus that protects the mucosa.

NSAIDs

_______, a medication that suppresses gastrin levels, also may be prescribed. (ZES)

Octreotide (Sandostatin)

Ulcer healing H2 PPI's:

Omeprazole 20 mg daily Lansoprazole 30 mg daily Rabeprazole 20 mg daily Pantoprazole 40 mg daily Esomeprazole 40 mg daily

Initial H. pylori therapy (First line):

PPI bid plus clarithromycin 500 mg bid plus amoxicillin 1,000 mg bid or metronidazole 500 mg bid for 10—14 days

Prophylactic therapy for NSAID ulcers:

Peptic ulcer healing doses of PPIs (above) Misoprostol 200 mcg bid

______ is the erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning. It is an abdominal emergency and requires immediate surgery.

Perforation

______ is a burning sensation in the stomach and esophagus that moves up to the mouth. It is often accompanied by sour eructation (burping), which is common when the patient's stomach is empty.

Pyrosis

Ulcer healing H2 receptor antagonists:

Ranitidine 150 mg bid or 300 mg at bedtime Cimetidine 400 mg bid or 800 mg at bedtime Famotidine 20 mg bid or 40 mg at bedtime Nizatidine 150 mg bid or 300 mg at bedtime

Billroth II (gastrojejunostomy)

Removal of lower portion (antrum) of stomach with anastomosis to jejunum. Dotted lines show portion removed (antrectomy). A duodenal stump remains and is oversewn.

Antrectomy Billroth I (gastroduodenostomy)

Removal of the lower portion of the antrum of the stomach (which contains the cells that secrete gastrin) as well as a small portion of the duodenum and pylorus. The remaining segment is anastomosed to the duodenum. May be performed in conjunction with a truncal vagotomy.

Therapy for retreatment of H. pylori therapy failure:

Repeat first-line therapy, substitute metronidazole for amoxicillin (or vice versa) for 14 days; may add Bismuth subsalicylate. Add second-line H. pylori therapy.

Vagotomy

Severing of the vagus nerve. Decreases gastric acid by diminishing cholinergic stimulation to the parietal cells, making them less responsive to gastrin. May be performed via open surgical approach, laparoscopy, or thoracoscopy. May be performed to reduce gastric acid secretion. A drainage type of procedure (see pyloroplasty) is usually performed to assist with gastric emptying (because there is total denervation of the stomach).

Truncal vagotomy

Severs the right and left vagus nerves as they enter the stomach at the distal part of the esophagus; most commonly used to decrease acid secretions.

Selective vagotomy

Severs vagal innervation to the stomach but maintains innervation to the rest of the abdominal organs.

______ ulcer is the term given 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

______ is the preferred diagnostic procedure because it allows direct visualization of inflammatory changes, ulcers, and lesions.

Upper endoscopy

______ is suspected when a patient has several peptic ulcers or an ulcer that is resistant to standard medical therapy.

ZES

The ______ consists of severe peptic ulcers, extreme gastric hyperacidity, and gastrin-secreting benign or malignant tumors of the pancreas.

Zollinger-Ellison syndrome (ZES)

Small, frequent feedings are not necessary as long as an ______ is taken.

antacid or a H2 blocker

Currently, the most commonly used therapy for peptic ulcers is a combination of ______ that suppress or eradicate H. pylori.

antibiotics, proton pump inhibitors, and bismuth salts

The introduction of _______ to eradicate H. pylori and of ______ as treatment for ulcers has greatly reduced the need for surgical intervention

antibiotics; H2 blockers

Smoking decreases the secretion of ______ from the pancreas into the duodenum, resulting in increased acidity of the duodenum.

bicarbonate

There also is an association between peptic ulcers and ______ or ______.

chronic pulmonary disease or chronic kidney disease

The patient who has a bleeding peptic ulcer may require periodic ______ to determine the extent of blood loss and whether or not blood transfusions are advisable.

complete blood counts (CBCs)

Patients with ______ ulcers are more likely to express relief of pain after eating or after taking an antacid than patients with gastric ulcers.

duodenal

Person-to-person transmission of the bacteria (H. pylori) also occurs through close contact and exposure to ______.

emesis

The most common symptom is ______.

epigastric pain

A peptic ulcer is an ______ (hollowed-out area) that forms in the mucosal wall of the stomach, in the pylorus (the opening between the stomach and duodenum), in the duodenum (the first part of the small intestine), or in the esophagus.

excavation

Seventy-five percent of tumors are found in the "______," which encompasses the cystic and common bile ducts, the second and third portions of the duodenum, and the junction of the head and body of the pancreas.

gastric triangle

A peptic ulcer may be referred to as a ______, depending on its location.

gastric, duodenal, or esophageal ulcer

Peptic ulcers are found in rare cases of patients with tumors that cause secretion of excessive amounts of the hormone ______.

gastrin

Peptic ulcers occur mainly in the ______ because this tissue cannot withstand the digestive action of gastric acid (HCl) and pepsin.

gastroduodenal mucosa

Fifteen percent of patients with peptic ulcer experience bleeding. Patients may present with GI bleeding as evidenced by ______.

hematemesis or the passage of melena

The patient may have coexisting parathyroid adenomas or hyperplasia and may therefore exhibit signs of ______.

hypercalcemia

The use of NSAIDs such as _____ and ______ is also a major risk factor for peptic ulcers.

ibuprofen and aspirin

Surgery is usually recommended for patients with ______ ulcers (those failing to heal after 12 to 16 weeks of medical treatment), life-threatening ______, perforation, or obstruction and for those with ZES that is ______.

intractable; hemorrhage; unresponsive to medications

The combination of ______ creates an ideal climate for ulceration.

ischemia, acid, and pepsin

Most gastrinomas grow slowly; 60% to 90% of these are ______.

malignant

The goals are to eradicate H. pylori as indicated and to manage gastric acidity. Methods used include:

medications, lifestyle changes, and surgical intervention.

As a rule, the patient with an ulcer complains of dull, gnawing pain or a burning sensation in the ______.

midepigastrium or the back

Patients at risk for stress ulcers (e.g., patients with head injury or extensive burns) may be treated prophylactically with IV H2 blockers and cytoprotective agents (e.g., ______) because of the risk of upper GI tract hemorrhage.

misoprostol, sucralfate

Patients with duodenal ulcers secrete ______ acid than normal, whereas patients with gastric ulcers tend to secrete ______ levels of acid.

more; normal or decreased

Stools may be tested periodically until they are ______. Gastric secretory studies are of value in diagnosing achlorhydria and ZES.

negative for occult blood

The intent of dietary modification for patients with peptic ulcers is to avoid ______.

oversecretion of acid and hypermotility in the GI tract.

Symptoms of ______ include back and epigastric pain not relieved by medications that were effective in the past. Like perforation, penetration usually requires surgical intervention.

penetration

Other nonspecific symptoms of either gastric ulcers or duodenal ulcers may include:

pyrosis (heartburn), vomiting, constipation or diarrhea, and bleeding.

It is believed that ______ and ______ consumption may be risks, although the evidence is inconclusive.

smoking and alcohol

The likelihood of recurrence is reduced if the patient avoids:

smoking, coffee (including decaffeinated coffee) and other caffeinated beverages, alcohol, and ulcerogenic medications (e.g., NSAIDs).

Diarrhea and ______ (i.e., fat in the stool) may be evident.

steatorrhea

Infection with H. pylori and concomitant use of NSAIDs are ______ risks.

synergistic

Surgical procedures for ulcers include ______, with or without pyloroplasty and ______.

vagotomy; antrectomy

Stress ulcers are most common:

ventilator-dependent patients after surgery or trauma

Signs and symptoms of perforation include the following:

• Sudden, severe upper abdominal pain (persisting and increasing in intensity); pain may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm • Vomiting • Collapse (fainting) • Extremely tender and rigid (boardlike) abdomen • Hypotension and tachycardia, indicating shock