Peptic Ulcer Disease
The initial phase occurs _____ - ____ hours after perforation. This includes _______, _____ pain that quickly spreads through the _____. Pain radiates to the ____ and is not relieved by _____ or ______. The abdomen appears _____ and ____. Respirations become ____ and ____. _____ and ____ pulse occur. Bowel sounds are ______. _____ and _____ may occur.
0-2 hours sudden, severe; abdomen back; antacids or food rigid & board-like shallow & rapid Tachycardia & weak pulse absent Nausea & vomiting
The onset of action for H2-receptor blockers is ____ hour(s).
1
Quadruple drug therapy for treating h. pylori: ___-___ days ____% eradication rate ____, _____, _____, & _____ (_____)
10-14 days 85% PPI, bismuth, tetracycline, and metronidazole (Flagyl)
Therapeutic effects of H2-receptor blockers can last for up to _____ hour(s)
12
If perforation is suspected, take vital signs every ___-___ min.
15-30
Symptoms of dumping syndrome start ___-___ minutes after eating. They include... and usually last _____ after eating
15-30 min Weakness Sweating Palpitations Dizziness Abdominal Cramps Borborygmi Urge to defacate; less than 1 hour
In duodenal PUD, symptoms generally occur ____-____ hours after meals. The pain is usually described as ____ or _____ _____.
2-5 hours; burning or cramp-like
Antacids neutralizing effects may last as long as ___-____ hours after meals.
3-4 hours
After treatment of PUD, pain disappears after ___-___ days; complete ulcer healing may take ___-___ weeks. Follow up endoscopic evaluation is performed ___-___ months after diagnosis and treatment. No aspirin and nonselective NSADS for ___-___ weeks.
3-6 days; 3-9 weeks 3-6 months; 4-6 weeks
At pH _____ or more _____ has no ____ activity.
3.5, pepsin, proteolytic
There is a high incidence of duodenal ulcers in people between the ages of ____ and ____
35-45
After surgery the color of the gastric aspirate changes to yellow-green within ____-____ hours
36-48
Peak incidence of gastric ulcers is in people ____ yrs +
50 years +
Triple drug therapy for treating h. pylori: ____-____ days ___-____% eradication rate ______, _____, and _______ (_______)
7-14 days 70-85% PPI, amoxicillin, and clarythromycin (Biaxin)
______ ulcers account for ~____% of all peptic ulcers.
80%
If pH is _____ intermittent suction may be used on a patient with an NG tube.
<5
Nursing interventions for PUD
Adequate Rest Drug Therapy Elimination of smoking Dietary modifications Long Term follow up care
_______ may occur within 6-12 hours if a perforation is untreated
Bacterial peritonitis
____ ____ ____ is used to diagnose GI outlet obstruction or ulcer detection for patients who cannot undergo ____.
Barium contrast study; endoscopy
High risk patient groups for duodenal ulcers
Chronic Obstructive Pulmonary Disease (COPD) Cirrhosis of liver Chronic pancreatitis Hyperparathyroidism Chronic kidney disease Zollinger-Ellison Syndrome
_______ PUD is more common than ______ PUD.
Chronic is more common than acute
Post Prandial Hypoglycemia definition Symptoms occur _____
Considered a variant of dumping syndrome, bolus is high in carbs, results in hyperglycemia so the body releases excessive amounts of insulin. ~2 hours after eating
______ affect mucosal cell renewal and decrease its protective effects
Corticosteroids
____, _____, and _____ increase the risk of ulcer development
Corticosteroids, anticoagulants, and SSRIs
H. pylori is not related to _____ or ____ _____.
Crohn's or ulcerative colitis
In _____ PUD, food helps buffer the acid
Duodenal
______ PUD can also produce back pain
Duodenal
_______, ______, & ______ are H2-receptor blockers that are available orally or IV
Famotidine, ranitidine, & cimetidine
Discomfort/pain is worse toward the end of the day for this as the stomach fills and dilates.
Gastric Outlet Obstruction
____ _____ _____ can result from acute and chronic PUD
Gastric Outlet Obstruction
For some patients the earliest symptoms of _____ PUD are due to _____ _____.
Gastric PUD; serious complications
Locations of PUD
Gastric Ulcers (stomach) usually antrum Duodenal = duodenum
______ ulcers are less common than _____ ulcers
Gastric are less common than duodenal
~ 2/3 of the world's population is infected with _______.
H. pylori
_______ is the most common factor associated with the development of duodenal ulcers. It is found in ___-____% of patients with duodenal ulcers.
H. pylori 90-95%
Risk factors for gastric ulcers
H. pylori Medications Smoking Bile reflux
Nizatidine (an ___-_____ _____) is only available ____.
H2-receptor blocker; orally
Back diffusion of ____ _____ into the ____ ____ causes ____ ____ & _____. This causes a release of ______. The release of this causes ______ and _____ ______ _____, which continues the cycle by initiating further secretion of ______ and _____.
HCl acid, gastric mucosa, cellular destruction & inflammation. Histamine. Vasodilation and increased capillary permeability, acid and pepsin.
Intensity of peritonitis IS or IS NOT proportional to the amount and duration of spillage
IS
The presence or absence of symptoms IS or IS NOT directly related to the size of the ulcer or the degree of healing?
IS NOT
______ are responsible for the majority of non-H. pylori peptic ulcers
NSAIDS
______ in the presence of H. pylori increase the risk for PUD.
NSAIDS
If aspirin must be continued, it should be co-administered with a ___ (____-_____ ____) or ______ (______) may be prescribed.
PPI (H2-receptor blocker) misoprostol (Cytotec)
_____ are more effective than ______ in reducing gastric acid secretion and promoting ulcer healing.
PPIs (proton pump inhibitors); H2-receptor blockers
Perforation results in spillage of gastric or duodenal contents into the ______ _____.
Peritoneal cavity
Ulcerogenic drugs inhibit the synthesis of ______, increase ____ _____ _____, and reduce integrity of the _____ _____.
Prostoglandins, gastric acid secretion, mucosal barrier
This test is considered the "gold standard" for diagnosis of an h. pylori infection.
Rapid Urease Testing
Nutritional interventions for post-operative complications include:
Reduce meal sizes Reduce fluid intake at meals Dry foods with low carb and moderate protein Limit sugar consumed with each meal
Bile Reflux Gastritis
Reflux of bile into stomach, vomiting relieves distress temporarily.
_______ ____ test differentiates between gastrinoma and other causes of hypogastrinemia
Secretin stimulation
Diagnostic tests to confirm ACTIVE infection of h. pylori
Stool or breath testing Urea breath test stool antigen tests (not as accurate) Biopsy of the antral mucosa & testing for urease
Clinical Manifestations: ____ and _____ onset
Sudden & dramatic
______ drugs are associated with risk for PUD.
Ulcerogenic (aspirin, NSAIDS)
_______ activates the immune response with _____ production and release of ______ ______.
Urease; antibody production; inflammatory cytokines
Dumping Syndrome
When a large bolus of hypertonic fluid enters the intestine which results in fluid being drawn into the bowel lumen. This decreases plasma volume and causes distention and rapid intestinal transit.
Peptic ulcers develop only in a(n) ______ environment
acid
Alcohol stimulates _____ _____.
acid secretion
Food tends to _____ pain if ulcer has eroded through the _____ ____. This is a clinical manifestation of _____ PUD.
aggravate; gastric mucosa; Gastric PUD
_____ increase gastric pH by neutralizing HCl acid
antacids
With Duodenal ulcers _____ and/or ___-_______ blocker, and/or _____ provides relief by neutralizing acid.
antacids, H2-receptor blocker, food
Patients with h. pylori infection are treated with ____ and ____.
antibiotics and a PPI
Gastric ulcers are most commonly found in the _____.
antrum
After surgery the patient begins oral feedings of clear liquids _____ NG tube is removed to determine ____ ____.
before; tolerance level
Relief of gastric outlet obstruction is obtained by ______ or _____ ____ ______.
belching or self induced vomiting
Administration of _____ has successfully treated Bile Reflux Gastritis
cholestryramine
H. pylori is found in most patients with _____ ____
chronic gastritis
In Gastric Outlet Obstruction ________ occurs due to dehydration and reduced diet intake secondary to ______.
constipation; anorexia
Duodenal ulcers have a tendency of occurring _____ for _____, and then disappear for a time, only to recur some ______ later.
continuously, a few weeks/months, months
After surgery observe for signs of ____ ____.
decreased peristalsis
______ ulcers account for more upper GI bleeds
duodenal
Chronic PUD has a long ______ and erodes through the ______ ______ with ____ _____.
duration; muscular wall with fibrous tissue
Obstruction in the distal stomach & duodenum is caused by _____, _____, or ______ & ______ ____ _____ formation.
edema, inflammation, pylorospasm & fibrous scar tissue formation.
_____ is the most accurate diagnostic study for PUD
endoscopy
Spontaneous sealing results from _____ production in response to perforation. This can lead to _____ _____ of the _____ or _____ _____ to adjacent tissue & strictures that can .....
fibrin; fibrinous fusion of the duodenum or gastric curvature; ... obstruct the flow of intestinal contents and stool
______ ulcers are more likely to results in obstruction
gastric
Symptoms of duodenal PUD occur when the ....
gastric acid comes into contact with the ulcers
Coffee stimulates _____ _____ _____.
gastric acid secretion
H. pylori survives a long time by colonizing the _____ ____ ____ within the ____ _____.
gastric epithelial cells; mucosal layer
H. pylori alters ____ ____ and produces ____ ___, leading to PUD
gastric secretion, tissue damage
Elevated fasting serum gastrin levels indicates presence of a possible _____ (_____-_____ _____)
gastrinoma (Zollinger-Eillison syndrome)
Tissue samples can be obtained with an endoscopy to ID ______ and rule out ____ _____.
h. pylori; stomach cancer
After surgery if the tube must be replaced call the ____ ____ to perform this task.
healthcare provider
______ is most common complication of PUD
hemorrhage
Development of duodenal ulcers is often associated with...
high HCl acid secretion
Clinical Manifestations of PUD (Gastric): Discomfort _____ _____ ____, ____-____ hours after meals. Described as a ____ or ____ pain.
high in the epigastrum, 1-2 hours burning or gaseous pain
After an acute phase of bleeding, antacids are generally administered ______.
hourly
H. pylori can lead to _____ _____ in the stomach, resulting in _____ _____ ____ and in some cases ____ ____.
intestinal metaplasia, chronic atrophic gastritis, stomach cancer
Treatment for perforation includes having blood volume replaced with ___ ___ and ____ ____.
lactated ringers and albumin solutions
Perforation is commonly seen in _____, ____ _____ ulcers.
large, penetrating, duodenal
Duodenal PUD is most often located in the ______ _____ beneath the _____ _____.
midepigastric region; xiphoid process
Antacids high in sodium need to be used with caution in ____ ____ and patients with ___ ___, ____, ___ ___, and ____ ___.
older adults, liver cirrhosis, hypertension, heart failure, and renal disease
Silent peptic ulcers are more likely to occur in _____ _____ and those taking _____
older adults; NSAIDS
Serum amylase determination is used to determine _____ function when ______ duodenal ulcer penetration of the _______ is suspected.
pancreatic; posterior; pancreas
______ is the most LETHAL complication of PUD
perforation
There is a higher mortality rate with ______ because patients are usually _____ and have _____ medical problems.
perforation; older; concurrent
Gastric outlet obstruction is most likely to occur when the ulcer is located close to the _____. There is a ____ onset of symptoms.
pylorus; gradual
Do not prescribe/administer magnesium preparations for patients with ____ ____ because of the risk of magnesium toxicity.
renal failure
Lare perforations usually ....
require immediate surgical closure
Small perforations usually ____ _____.
seal themselves
_______ tests do not distinguish between past and current infection
serum or whole blood antibody
Zollinger-Ellison syndrome is a rare condition characterized by...
severe peptic ulceration and HCl hypersecretion
Over time in Gastric Outlet Obstruction, dilation of the _____ and visible swelling of the _____ ____ may appear.
stomach; upper abdomen
Acute PUD is associated with ______ _____ and ______ ________
superficial erosion and minimal inflammation
CBC may indicate anemia secondary to ___ ____.
ulcer bleeding
Endoscopy can be used to determine the degree of_____ ______ & to confirm the _____ _____ ______.
ulcer healing; absence of malignancy
Urease metabolizes ______-producing _____ ____ and other damaging chemicals
urea; ammonium chloride
H. pylori produces _______
urease
Gastric ulcers are more prominent in _____ and _____ _____.
women and older adults
