Peptic Ulcers/Dumping Syndrome

What is the pathophysiology of an ulcer?
excavation of more than half a cm in the mucosal wall
Where are peptic ulcers located?
esophagus, stomach, or duodenum
Why do peptic ulcers form?
tissue cannot withstand the gastric acids HCl/pepsin and/or there is a decreased amount of protective mucous (often comes from NSAIDs)
What does the damage to mucosa do?
decreases resistance to bacteria
What are the causes of peptic ulcers?
alcohol, stress, medications (ASA, NSAIDs, steroids), smoking, gastritis, H. pylori infection
What are the two types of peptic ulcers?
gastric and duodenal
Why are gastric ulcers more dangerous?
associated with gastric cancer
What are the clinical manifestations of gastric ulcers?
onset of dull, gnawing epigastric pain 0.5-1 hrs pc (rarely at night), eating doesn’t help and can increase pain
Which type of ulcer is more likely to have associated hemorrhage?
gastric ulcer
Is hematemesis or melena more common?
hematemesis
What does LGI bleeding usually look like?
frank red blood
Are gastric or duodenal ulcers more common?
duodenal
What are duodenal ulcers caused by?
hypersecretion of stomach HCl
What are the clinical manifestations of duodenal ulcers?
onset of pain 2-3 hrs pc, often awakened by pain around 1-2 AM when stomach is empty and irritating tissue, eating relieves the pain because food neutralizes acid
What are the risk factors for duodenal ulcers?
chronic H. pylori, alcohol, tobacco, cirrhosis, stress
What is triple therapy?
10-14 days of 2 antibiotics and 1 proton pump inhibitor
What is quadruple therapy?
10-14 days of 2 antibiotics, 1 proton pump inhibitor, bismuth
What are the classes of drugs used to treat H. pylori?
antibiotics, H2 blockers, PPIs, cytoprotective agents
How is H. pylori diagnosed?
endoscopy with biopsy, blood, stool/breath test
What are potential life threatening complications of ulcers?
hemorrhage, perforation, pyloric obstruction
What are symptoms of hemorrhage?
increased heart rate, blood in stool, hematemesis, confusion, dizziness, cool and clammy skin, thirst
What is the treatment for hemorrhage?
IV fluids, blood transfusion, emergent endoscopy/surgery
What are the symptoms of perforation?
severe abdominal pain, rigid/tender abdomen, vomiting, fever
What is the treatment for perforation?
emergent surgery
What is pyloric obstruction caused by?
scar tissue
What are the symptoms of pyloric obstruction?
N/V, abdominal bloating, distention, feeling of fullness, abdominal pain
What is the treatment for pyloric obstruction?
gastric decompression with nasogastric tube, IV fluids, electrolytes, EGD with pyloric dilitation
What do prostaglandins in gastric mucosa do?
increase resistance to acid
What should the patient avoid because they reduce prostaglandins? (drugs)
aspirin containing drugs, NSAIDs
What should the patient avoid because they stimulate gastric secretion?
smoking, milk products
What are surgeries done to treat peptic ulcers?
vagotomy, antrectomy, pyloroplasty
vagotomy
procedure that involves cutting parts of the vagus nerve to interrupt messages sent through it, which reduces acid secretion
antrectomy
removes lower part of stomach (antrum) which produces a hormone that stimulates stomach to secrete digestive juices, may also remove adjacent part of stomach that secretes pepsin and acid
What are antrectomies and pyloroplasties usually done with?
vagotomy
pyloroplasty
opening into duodenum and small intestine (pylorus) are enlarged, enabling contents to pass more freely from the stomach
What is dumping syndrome?
common complication of gastric resection when pylorus is bypassed; rapid emptying of gastric contents into jejunum after meals without proper mixing and duodenal digestion
When do signs and symptoms of dumping syndrome appear?
15-30 mins after meals
What is dumping syndrome caused by?
rapid shift of ECF into bowel to dilute hypertonic chyme causing a decrease in blood volume
What are symptoms of dumping syndrome?
N/V, abdominal cramping, feeling of fullness, diarrhea, palpitations, tachycardia, hypotension, diaphoresis, weakness, dizziness, dehydration
What type of diet should a pt with dumping syndrome follow?
low carb, high protein
What foods should be avoided with dumping syndrome?
sweets, candies, fruit juice, soda, high fat meats, fried foods
How many meals should a pt with dumping syndrome eat?
6 small evenly spaced meals per day
When should pts with dumping syndrome drink fluids?
between meals
How should a pt with dumping syndrome position themselves after eating?
recline in semi-Fowlers after eating
What drugs may delay gastric emptying?
antispasmodics/sedatives