Adult-Gerontology Acute Care Practice Guidelines
Definition
A.An ulcer that forms in the lining of the esophagus, stomach, or small intestine.
Incidence
A.10% of the population is thought to have evidence of peptic ulcer disease (PUD).
B.Similar occurrence in males and females.
C.Mortality rate due to hemorrhagic ulcer is approximately 5%.
Pathogenesis
A.Defect of mucosal lining of digestive tract; frequently occurs when there is an imbalance between gastric acid secretion and degradation of the mucosal defense mechanism caused by use of anti-inflammatory drugs, Helicobacter pylori infection, alcohol, acid, and pepsin.
B.H. pylori infection can colonize the gastric mucosa and cause inflammation.
C.Nonsteroidal anti-inflammatory drug (NSAID) use can disrupt the mucosal barrier.
D.Alcohol is a gastric mucosal irritant.
E.Stress ulceration can occur and is associated with serious systemic illnesses.
F.Brain injury or tumors are associated with high gastric acid output.
G.Hypersecretory states can also cause PUD, most notably Zollinger–Ellison syndrome.
H.Three types of ulcers (location based).
1.Gastric ulcers.
2.Esophageal ulcers.
3.Duodenal ulcers.
I.Major risk of perforation, which carries a mortality rate of up to 30%.
Predisposing Factors
A.Taking NSAIDs including ibuprofen, aspirin.
B.Smoking.
C.Excessive alcohol.
D.Excess stress.
E.Obesity.
F.Zollinger–Ellison disease.
Subjective Data
A.Common complaints/symptoms.
1.Gnawing or burning sensation that occurs shortly after meals (gastric ulcers) or at 2 to 3 hours (duodenal ulcers).
2.Heartburn.
3.Belching.
4.Bloating.
5.Distention.
B.Common/typical scenario.
1.Gastric and duodenal ulcers typically cannot be differentiated with history alone, but there are some differences.
a.Most patients regardless of type of PUD complain of epigastric pain.
b.Patients with gastric ulcers typically complain of pain shortly after meals.
c.In patients with duodenal ulcers:
i.Antacid use commonly ineffective.
ii.Complaints of pain 2 to 3 hours after a meal.
iii.Frequent night waking.
C.Family and social history.
1.Ask about smoking and alcohol use.
2.Ask about family history of any type of gastric cancer.
D.Review of systems.
1.Evaluate for dysphagia, nausea, vomiting, or blood in stool.
2.Evaluate pain intensity, timing, and duration.
3.Inquire about back pain (which may indicate gallstones or pancreatitis).
Physical Examination
A.Gastrointestinal focus.
1.Epigastric tenderness.
2.Typically pain will be vague and nonlocalizing.
3.Melena may be present.
B.If the ulcer perforates.
1.Sudden onset of severe abdominal pain that is generalized and worsens with movement.
2.Rebound abdominal tenderness.
3.Guarding.
4.Rigidity.
5.May have signs of shock including:
a.Tachycardia.
b.Hypotension.
c.Anuria.
Diagnostic Tests
A.Obtain complete blood count (CBC) and liver function tests (LFTs) in all suspected cases of PUD.
B.Use amylase or lipase to rule out other causes of epigastric pain.
C.Test for H. pylori.
D.Upper gastrointestinal (GI) endoscopy is the preferred diagnostic test in PUD.
1.Differentiates gastric and duodenal ulcers.
2.Allows for biopsy if indicated.
E.Angiography may be needed in cases with massive GI bleeding.
F.If Zollinger–Ellison syndrome is suspected, obtain serum gastrin level: If inconclusive, order secretin stimulation test.
G.Biopsy if concern for cancer.
Differential Diagnosis
A.Gastritis.
B.Gastroesophageal reflux disease (GERD).
C.Inflammatory bowel disease.
D.Cholecystitis.
E.Coronary artery disease.
F.Esophageal rupture.
G.Diverticulitis.
H.Pancreatitis.
I.Viral hepatitis.
Evaluation and Management Plan
A.General plan.
1.Gastric ulcers can be staged according to Johnson classification.
a.Type I—normal or decreased gastric acid secretion.
b.Type II—combination of stomach and duodenal ulcers with normal or increased gastric acid secretion.
c.Type III—prepyloric associated with normal or increased gastric acid secretion.
d.Type IV—near gastroesophageal junction with normal or decreased gastric acid secretion.
2.Treatment plans vary on the location of the peptic ulcer and clinical presentation.
3.Typical treatment options include:
a.Empiric antisecretory therapy.
b.Triple therapy for H. pylori infection.
c.Endoscopy 6 to 8 weeks after diagnosis to document healing of ulcers.
d.Document H. pylori cure with noninvasive test.
i.Urea breath test.
ii.Fecal antigen test (complicated ulcers).
B.Patient/family teaching points.
1.Avoid NSAIDs and aspirin.
2.Reduce or eliminate alcohol.
3.Smoking cessation.
4.Reduce or eliminate caffeine from diet.
5.Weight loss.
6.Stress reduction.
C.Pharmacotherapy.
1.H. pylori infection.
a.Option 1—10 to 14 days of quadruple therapy.
i.Bismuth.
ii.Proton pump inhibitor.
iii.Tetracycline.
iv.Nitroimidazole.
b.Option 2—10 to 14 days.
i.Proton pump inhibitor.
ii.Clarithromycin.
iii.Amoxicillin.
iv.Nitroimidazole.
c.Option 3—10 to 14 days of triple therapy (no previous macrolide exposure and clarithromycin resistance low).
i.Clarithromycin.
ii.Proton pump inhibitor.
iii.Amoxicillin or metronidazole.
d.Other suggested options per guidelines.
2.H. pylori infection persists.
a.Avoid previously used antibiotics.
b.Choose a new option from the aforementioned list.
D.Discharge instructions.
1.Follow-up with primary care provider for long-term monitoring and further evaluation.
Follow-Up
A.Follow-up routinely with primary care provider to assure proper maintenance therapy is initiated and symptoms are controlled.
B.If H. pylori eradication is not achieved, antisecretory therapy should be recommended.
Consultation/Referral
A.Consult to gastroenterology for bleeding (hematemesis or melena), anemia, unexplained weight loss, associated vomiting, or family history of gastrointestinal cancer.
B.Surgical consultation for all bleeding ulcers or suspected perforations.
C.Urgent referral for sudden and severe onset of symptoms, which may indicate perforation.
D.Failure of medical management.
Special/Geriatric Considerations
A.NSAID-induced PUD may not be overtly symptomatic in elderly patients.
B.Elderly patients may also present with significantly less profound signs and symptoms of shock in the case of perforated ulcers.
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