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