PUD A. PUD- lesion of GI mucosa characterized by erosion from HCL & pepsin 1.

Stomach protected by prostaglandins- increase stomachs resistance to ulceration B. ETIOLOGY 1. Disruption mucosal barrierback diffusion HCL & pepsininflammation & cellular destruction-->histamine release more HCL & pepsin release 2. Inflammatory agents- bile salts, NSAIDS, H. Pylori, acids, ischemia, & corticosteroids C. GASTRIC ULCER 1. Decrease/N HCL & delayed gastric emptying 2. Females 55-60 3. Burning, gaseous pain high epigastrum, pain empty stomach, 1-2hrs after eating, aggravated by food D. DUODENAL ULCER 1. 2. 3. 4. High HCL and increased gastric emptying Males 34-45 Muscularis layer, scar Burning, cramp like pain mid-epigastrum, 90min-3hrs after eating, mid-morning, afternoon, and @ nite (1-2a.m) 5. Relief w/ antacids & H2 blockers E. DEFINITIVE DX: EGD F. RISK FACTORS 1. NSAIDS 2. Smoking 3. Alcohol 4. H. Pylori 5. Caffeine 6. Genetic predisposition 7. Psychologic stress 8. Altered gastric acid & serum gastric levels G. DIAGNOSTICS 1. UPPER GI ENDOSCOPY-r/o gastric cancer 2. H. Pylori testing blood, breath, urine, tissues-IgG, IgM 3. CBC 4. Serum amylase 5. Urinalysis 6. Barium swallow 7. Liver enzymes: AST, ALT, bilirubin 8. Serum e-lytes 9. Gastric analysis- Zollinger-ellison syndrome 10. Guaiac stool

H. S/S PUD 1. Gastric/duodenal pain 2. Melena 3. Vomiting 4. Orthostatic VS 5. Deficient fluid volume 6. Decreased HgB & HCT 7. Dyspepsia 8. Anorexia & weight loss I. COMPLICATIONS PUD 1. Hemorrhage 2. Obstruction-long hx ulcer pain, worsens as day progresses, relieved by vomiting/belching (foul odour), weight loss, thirst, unpleasant taste mouth, constipation, swelling upper abdomen, loud & visible peristalsis 3. Perforation- rigid board like, guarding, absent bowel sounds, N&V 4. Intractable dx J. MEDICAL/SURGICAL 1. ADEQUATE REST 2. DIETARY THERAPY i. Avoid foods cause pain including milk & creams ii. 6 meals daily, decrease roughageraw fruits & veggies iii. No aspirin or NSAIDS 3. Smoking cessation 7 avoid alcohol consumption 4. DRUG THERAPY i. Antacids ii. H2 blockers or PPIs iii. Antibiotic therapy 1. Metronidazole (Flagyl) 2. Tertracycline 3. Amoxicillin iv. Cholinergics- Metoclopranamide (Reglan) v. Cytoprotective- Bismuth Subsalicylate (Pepto-bismol), Carafate (Sulcralfate) vi. Tricyclic antidepressants 5. STRESS MANAGEMENT 6. ACUTE INTERVENTIONS i. No complications 1. NPO 2. NG w/ sxn 3. Adequate rest 4. Smoking cessation 5. IV fluids 6. Drug therapy ii. w/ complications 1. NPO 2. NG sxn- cont aspiration obstruction 3. Bed rest 4. IV fluids: albumin, ringers lactate, PRBC- perforation & hemorrhage maintain or increase rate 5. Gastric lavage (ice NS) 6. Repair perforation

7. SURGERY i. Gastroenterostomy ii. Closure w/ omentum graft iii. Vagotomy w/without pyloroplasty iv. BilrothI/II 1. Post-op a. Patency NG tube b. Fluid & e-lyte balance c. Assess acute gastric dilation d. Assess dumping syndrome e. Manage dumping syndrome i. Decrease amt food given ii. High protein & fat iii. Admin pectin powder iv. Admin semi-recumbant/recumbent v. Lay flat after eating vi. Admin sedative & antispasmotic f. Check alkaline reflux gastritis g. Assess delayed gastric emptying h. Assess afferent loop syndrome i. Admin vit B12, folic acid, Fe3+ supps K. POST-OP COMPLICATIONS 1. Dumping syndrome 2. Postpranadial hypoglycemia 3. Bile reflux gastritis L. NURSING INTERVENTIONS 1. HEALTH PROMOTION i. Id those at risk ii. Encourage pts take drug w// milk or food iii. Teach report s/s gastric irretation 2. Acute interventions i. Approach in calm manner ii. VSq15-30min iii. NPO (stop all oral when perforation/hemorrhage) iv. NG w/ sxn 1. Hemorrhage & decompression- cont sxn & decompression 2. Obstruction- cont aspiration, clamp <200mL 7 resume feeding. Assess shock, give oral & nasal care v. Admin IV fluids 1. E-lytes for obstruction 2. Ringers & PRBC for hemorrhage vi. REST vii. Gastric lavage if indicated viii. Antibiotics for perforation ix. HOB elevated x. Assess bloody stools xi. Monitor HgB, HCT, q4-6, BUN, creatinine xii. O2 therapy

3. HOME CARE i. Explain dietary modification ii. Smoking cessation, avoidance alcohol iii. Avoid OTC substitutions of meds iv. Take all meds as prescribed v. Teach report: N&V, increased epigastric pain, bloody emesis or tarry stools