Peptic Ulcer

Peptic Ulcer

Definition

Break in the epithelium & Excavation formed in the mucosal wall of the oesophagus, stomach, pylorus or duodenum.

Aetiology

H.pylori infection (70% 95%) (gram negative bacteria)

Excessive acidity (Zollinger-Ellison Syndrome)

Stress

Caffeinated beverages

Smoking

Alcohol

Familial tendency

Blood type 'O'

NSAID

Gastrin

Gasro-oesophageal reflux

Pathophysiology

Ingestion of food - acetylcholine, gastrin and histamine bind to specific receptors of the parietal cells in the fundus of the stomach & secrete hydrochloric acid.

The parietal cells with the the assistance of the hydrogen - potassuum adenosine triphosphatase (H+, K+ - ATPase) pump (Proton Pump) transport the hydrochloric acid to the stomach lumen

Chief cells in the stomach secrete pepsinogen, which converts to pepsin in the presence of hydrochloric acid.

Pepsin breakdowns the food

Mucous barrier from duodenal cells in the gastric epithelium protects the lining of the gastroduodenal area.

Increased action of acid-pepsin or decreased resistance of the mucosa.

Damaged mucosa cannot produce enough mucus barrier against acid

NSAID inhibits secrerion of this mucus

ZES gastrinomas (islet cell tumours ) in the pancreas - gastrin - increased secretion of acid - multiple ulcers or ulcer intractable.

Stress ulcers are different from Cushing's ulcers and Curling's ulcers

Cushing's ulcers - trauma to the brain

Curling' ulcers - extensive burns

Stressful conditions like burns, shock, severe sepsis, multiple organ trauma - post surgical conditions ' multiple erosions. Shock - decreased blood flow to stomach mucosa., reflux of duodenal contents into the stomach. Large quantities of pepsin released. Combination of ischaemia, acid and pepsin - ulceration

Clinical Manifestations

Dull gnawing pain or a burning sensation in the midepigastrium or in the back.

Pain relieved by eating

Night pain morning relief

periodicity

Sharply localized tenderness in the epigastrium slightly to the right of the midline

Heartburn (pyrosis)

Vomiting

Constipation

Diarroea

Bleeding

Melena (altered blood in the stool) black tarry stools

Haematemesis (ground coffee coloured vomitus)

Vomiting of food which was consumed two to three days earlier in pyloric stenosis. (gastric outflow obstruction)

Asymptomatic ulcers

Asymptomatic ulcers which perforate

Differential Diagnosis

Amoebiasis

Gall stones

Cholecystitis

Pancreatitis

Investigations

Hb , TC, DC, ESR

Upper GI endoscopy (Choice)

Gastroscopic biopsy in appropriate cases and histopathological examination and tests to detect H.pylori infection : culture,

Barium meal

Stool for occult blood

Breath test that detects H.pylori

Serological tests to detect antibodies against H.pylori

Medical Management

Inform that remissions and recurrences are common

Eradication of H.pylori - an antibiotic, a proton pump inhibitor and metronidazole (Ulcikit, Zovanta Kit, H.pylori kit)

Histamine receptor antagonists (H2 receptor antagonists), cimatidine - ranitidine - famotidine

Proton pump inhibitors which also decrease acid secetion from acid or NSAIDs - omeprazole, pantoprazole, rameprazole, rabeprazol

Antacids - gelusil, ulgel, mucaine gel, etc containing aluminium hydroxide

Cytoprotective Medicationss - misoprostol, sucralfate

Rest, sedatives, and tranquilizers

Maintenance dosages of H2 receptors antagonists ae usually recommended for one year

ZES - H2 receptor antagonists. Twice the normal dose. Octreotide (sandostatin, a medication that suppresses gastrin levels )

Stress - IV H2 receptor antagonists and cytoprotective agents

Change of life style

Stop smoking

Dietary modification bland diet and avoidance of offending food.

Surgical Management

Has become rare with the arrival of newer drugs

Procedures which were use in the past are

1. Gastrojejunostomy

antrectomy with gastroduodenostomy - Billroth I

o Antrectomy with gastrojejunostomy - Billroth II

o GJ Vagotomy - truncal, selective, highly selective

o GJ Vagotomy with pyloroplasty

Complications of Peptic Ulcer

Haemorrhage

Perforation

Penetration

Pyloric obstruction (gastric outlet obstruction)

Perforated peptic ulcer - gas under diaphragm

University Questions

Thiru.Somanath aged 35 years is a business executive. He is admitted with acute abdominal pain. Hi is diagnoses as peptic ulcer with perforation.

o How do you prepare the patient for emergency surgery?

o Describe the post-operative nursing management of the patient for the 1st 24 hours.

Preparation for Emergency Surgery

Patient need not be rushed to the O.T. though it is an emergency surgery - upto 6 hours can be spent on improving the general condition

Make the patient comfortable in bed

Start IV fluids to correct fluid and electrolyte imbalance

Do investigations : CBC, ESR, Blood urea, serum creatinine, BT, CT, Serum electrolyte estimation, Plain X-ray Chest to look for air under diaphragm, plain X-ray abdomen

Monitor vital signs : TPR frequently

Monitor Abdominal girth 4 hourly

Monitor SpO2 by pulse oxymetry

Start Pain relieving drugs - if needed narcotics

Start antibiotics and imidazole derivatives (Ciprofloxacin/Ofloxacin + Metronidazole/ornidazole Or Cefaperazone + Sulbactum (inj.Magnex) +Metronidazole)

Insert Ryle's tube and start continuous or freuent nasogastric suction

Administer Inj.TT and Lidocaine sensitivity test

Clean and prepare the abdomen for surgery Laparoscopic / open

Post operative management for the first 24 hours

Semi-Fowler's position to relax incision

Pain relief with Narcotics or Tramadol

Maintain fluid and electrolyte balance

Continous Nasogastric suction

Monitor abdominal girth

Cough : support the incision with hands

Antibiotics and other medications, Proton pump inhibitors

Watch for bleeding from the site of surgery