DUODENAL ULCER

Presented By:
Nabina Paudyal
Pooja Bhandari
PBNS 1st Year
CONTENTS

1. Anatomy 10. Medical management

2. Introduction 11. Surgical management
3. Definition 12. Nursing management
4. Epidemiology 13. Complication
5. Causes 14. Prevention
6. Risk factor 15. Prognosis
7. Pathophysiology 16. References
8. Signs and symptoms
9. Diagnostic evaluation
Anatomy of Gastro intestinal
system
Introduction

➢ A duodenal ulcer is a sore that forms in the lining of the

duodenum. The duodenum is the first part of our small
intestine, the part of our digestive system that food travels
through straight after it leaves our stomach.

➢ It can get an ulcer in our stomach as well as in our

duodenum. Stomach ulcers and duodenal ulcers are both
types of peptic ulcers.
Definition

➢ Ulcers that occur in the upper

area of the small intestine,which
is called the duodenum, are
called duodenal ulcers.
Epidemiology

Peptic ulcer disease;

Prevalance: 12% of men and 10% in women in United States.

Doudenal ulcer:
■ 6-15% of the western population
■ Duodenal ulcers usually first occur the between the ages of 30-
50 years and are twice of common in men as in women.
■ Gastric or stomach ulcer
■ Usually occurs in people older than 60 years are more common
in women.
 Causes
➢ Duodenal ulcers are a common cause of abdominal pain.
➢ Helicobacter Pylori 90%
➢ Use of anti-inflammatory drugs
➢ Zollinger-Ellison syndrome(increase hormonal stimulation)
➢ Stress
➢ Diet caffine, alcohol and highly spicy food and sour food
➢ Hepatic billiary disease, crons disease
>Other Factors
➢ Such as smoking, stress and drinking heavily may possibly increase the risk of
having a duodenal ulcer.

➢ However, these are not usually the underlying cause of duodenal ulcers.
Risk Factors

➢ Long term use of anti-inflammatory drugs

➢ Liver disease
➢ COPD
➢ Trauma such as sever burn, brain injury
➢ Age (more common in people over the age of 50)
➢ Alcohol use
➢ Family history
➢ Blood group O,COPD,Chronic renal
failure,Smoking,Stress,Cirrhosis
Pathophysiology

Due to etiological factor

Erosion occurs which is caused by the increased

concentration or activity of acid pepsin or by
decreased resistance of mucosa.

A damage mucosa cannot secretes enough mucus to act

as a barrier against HCL
 Contd.
Patient with duodenal ulcer disease secrets more acid
then normal

Damage to the gastro duodenal mucosa allows

for decrease resistance to bacteria

Thus infection occurs from h-pylori which causes duodenal ulcer

Sign and Symptoms

➢ Abdominal distension,
➢ Abdominal pain
➢ Nausea
➢ Vomiting (less likely to vomiting)
➢ Weight gain
➢ Feeling tired and weak
➢ Bleeding
➢ Hemorrage is less likelybut if present melena more common than
hematemesis
 Diagnostic Evaluation
1. History taking
2. Physical examination( Epigastric tenderness , abdominal
distention, bowel sound may be absent)
3. Blood Investigation (serum pepsinogen , serum gastrine
normal, CBC for anemia )
4. Stool test for occult blood
5. Testing of H.Pylori through the urea test end serum anti body
for H.Pylori
6. Esophagostractomy with biopsy
7. Upper GI X-ray
8. Gastric Analysis to determine the presence of zollinger Ellison
syndrome (elevated serum gastrin level and acid secretion )
➢ A test to detect the H.pylori germ (bacterium)
is usually done If we have a duodenal ulcer.
➢ If H. pylori is found then it is likely to be the
cause of the ulcer.
➢ Briefly, (faces), or in a breath test, or from a
blood test, or from a biopsy sample taken
during an endoscopy.
Duodenal versus gastric ulcers
>Gastric ulcer
■ Normal / hyposecreation of gastric acid
■ Pain 1 / 2 hours meals
■ Food aggravates pain
■ Vomiting common
■ More likely to hemorrhage manifests as hematemesis
>Duodenal ulcer
■ Hyper secretion
■ Pain 2 / 4 hours meals
■ Food may relive pain
■ Vomiting not common
■ Less likely to hemorrhage but if occurs likely to manifest as
melena
 Medical Management
➢Physical examination (epigastric tenderness, abdominal
distention)
➢ Endoscopy (upper gastrointestinal (GI) )
■ Acid-suppressing medication – The most common use
medication is proton pump inhibitor For example –
esomeprazole, lansoprazole, omeprazole, pantoprazole and
rabeprazole.
■ If ulcer was caused by H.pylori-Antibiotic should also be give
with acid suppressing medicine
■ Antibiotics ;Assist in eradiating h – pylori bacteria.
■ If causative organism is h – pylori bacteria antibiotic is
given necessary (Clarithromycin) (Mixaxin) or
Ampicilline and metronidazole are mostly used
antibiotics.(Two antibiotics+proton pump inhibitor for
14 days is considered for the treatment.
■ Frequent food should be given avoid hot and spicy food.
■ Prevent and manage reaction of drugs and
complications.
Surgical Management

➢ If recommended ,surgery is usually for intractable

ulcers (particularly with zollinger Ellison syndrome)
,lifethreatening hemorrhage, perforation, or
obstruction.Surgical procedures include vagotomy,
vagotomy with pyloroplasty.
Types of Surgery

1. Gastastro duodelostomy (billroth I) partial

gasterectomy with removal of antrum and pylorous of
the stomach and anastomosis of gastric stump with
the duodenum.
■ Gastrojejunostomy (Billroth II) Partil gastrectomy
with removal of antrum and pylorous of the stomach
and anastomosis of gastric stump with the jejunum.
Antrectomy

■ Gastric resection with cut off the pylorous , antrum

and duodenum.
Total gastrectomy

■ Removal of the stomach and the anastomosis of the

esophagus with the duodenum or jejenum.
Pyloroplasty

■ Longitudinal incision is made in the pylorous and is

closed transversely to permit the muscle to relax and
to make enlarge outlet.
 Vagotomy
■ To eliminate the impulses that stimulate the vagus
nerve that help in secreting the HCL
 Complication of surgery
■ Hemorrhage-(UGI bleeding)
■ Acute Gastric dialtation
■ Nutritional problems
■ Dumping syndrome
■ Pyloric obstruction (Gastric outlet obstruction)
Nursing Management

■ Assesement
– Psychological assessment: family history of ulcer
ingestion of medication that causes gastric
irritation.
– Smoking ,alcohol intake , stressors and copping
patterns lifestyles occupation work and leisure
activities.
– Assessment for description of pain.
– Assessment of the characteristics of the vomitus.
– Assessment of relief measures to relieve the pain.
➢ Ask how expresses anger (especially at work
and with family), and determine whether
patient is experiencing occupational stress or
family problems.
➢ Obtain a family history of ulcer disease.
➢ Assess vital signs for indicators of anemia
(tachycardia, hypotension)
 Nursing Diagnosis
➢ Acute pain related to the effect of gastric acid
irritation of stomach mucosa
➢ Imbalanced nutrition related to changes in diet
➢ Deficient knowledge about preventing symptoms
and managing the condition
➢ Anxiety related to coping with an acute disease.
 Acute pain related to the effect of gastric acid ,
irritation of stomach mucosa
▪ Instructing patient to avoid foods and beverages that
may irritates gastric mucosa
■ Investigate complaints of pain , note the location ,
intensity of pain and pain scale
■ Use prescribed medications to reduce pain
■ Instruct the client to avoid NASIDs such as aspirin
■ Avoid smoking
■ Imbalanced nutrition related to changes in diet
■ Keep patient NPO untill the acute symptoms have
subsided
■ Introduce solid food as soon as possible
■ Provide small frequent meal which are not irritating to
gastric mucosa
■ If pain or nausea interferes appetite , administer pain
relief medications or antiemetic should be provided
one hour before meal
■ Avoided the caffeniated breverages , smoking and
alcohol
 Knowledge deficit about Prevention of
symptoms management of the condition

➢ Give the client a list of irritating foods to avoid

spicy alcohol and caffeinated and cessation of
smoking

➢ Teach him or her stress reduction technique

➢ Instruct the client in what sign and symptoms to

report the health care provider
➢ Anxiety related to coping with an acute
disease
■ Encourage to express fears openly
■ Use simple language when giving instruction to client
■ Answer all question as completely as possible
■ Decrease sensory stimuli by mantaining a quite environment
 Planning and goals
■ Relief of pain and reduce anxiety
■ Maintenance of nutritional requirements
■ Knowledge about the management and prevention of ulcer
recurrence
■ Maintain fluid volume
■ Absence of complications
NURSING INTERVENTION

■ Reliving pain
■ Administration of prescribed medications.
■ Teach the patient to avoid asprin ,foods and
beverages that contain caffeine, and
decaffeniated coffee and mealsshould be
eaten at regular intervals in relaxed setting.
■ Encourage relaxation technique.
.Reducing anxiety
. The nurse assesses the patient level of pain.Explain
diagnostic tests and administering medications on
shedule.
. The patient family is also encourage to participate in
care and to provide emotional support
Maintaining optimal nutritional status

.The nurse assesses the patient for malnutrition and

weight loss
. The nurse provides information about medications to
be taken at home ,continuing medication even after
signs and symptoms have been decreased or subsided
. It is important counsel the patient to eat meals at
regular times and over eating
. If gastric surgery is done take precaution to prevent
dumping syndrome.
■ Monitoring and managing
complications
■ If hemorrhage is a concern
■ Assess for faintness or dizziness and nausea, before or
with bleeding.
■ Test stool for occult or gross blood, monitor vitals signs
frequently(Tachycardia,Hypotension,and Tachypnea)
■ Monitor laboratory values(Hemoglobin and Hematocrit.)
■ Insert and maintain Nasogastric tube and monitor drianage
,provide lavage as ordered.
■ Monitor oxygen therapy , saturation, treat hypovolemic
shock as indicated.
■ If perforation and penetration are
concerns;
■ Note and report symptoms of penetration (back
and epigastric pain not relived by medications)
■ Note and report symptoms of perforation (sudden
abdominal pain, vomiting and collapse,extremely
tender and rigid abdomen, hypotension and
tachycardia or other sign of shock.
Complications

➢ Gastrointestinal bleeding
➢ Cancer (helicobacter pylori as the etiological factor
making it 3-6 times likely to develop stomach cancer)
➢ Perforation (hole in the wall]
➢ Iron deficency anemia
Prevention

➢ Lifestyle adjustment :- avoid tobacco and alcohol

from our life can help to reduce irritation to the ulcer.
➢ medication :- Depending on case proton pump
inhibitors or antibiotics can help to treat ulcers
➢ Proton pump inhibitors help reduce acid levels and
antibiotics help treat a helicobacter pylori infection.
➢ Don’t ignore the ulcer symptoms.
➢ Protect self from infections by washing hands
regularly and consuming foods that have been cooked
thoroughly.
Prognosis
➢ When the underlying cause of duodenal ulcer disease
is addressed, the prognosis is excellent. Most patients
are treated successfully with the eradication of H
pylori infection avoidance of nonsteroidal anti-
inflammatory agents(NSAIDS), and the appropriate
use of antisecretory therapy.
Take Home Messages

■ Patient will land-up in serious complications if it is

not detected and managed timely.
■ Hurry, worry and curry remain the main culprit
behind this disease.
■ Life style modification plays an important role for the
prevention this disease.
■ Prescribed Triple therapy should be started in cases of
H.Pylori if identified.
 References
1. Mandal, GN.(2015) medical surgical nursing 4th
edition.Dillibazzar, Kathmandu. Makalu Publication
house.
2. Brunner and Suddarth’s,Textbook of Medical
Surgical nursing Volume-I(13th edition),published by
wolters Kluwer (India)Pvt.Ltd.New Delhi.
3. (RAI 1(2015),Nursing Concept theories and
principles (3rd edition).MR.Nabin Kumar Rai
Pvt,Ltd..Basaha1 Udhayapur.PP 306-323.
4. https://www.mayoclinic.org.duodenalulcer

5. https://en.m.wikipedia.org.duodenalulcer

6. https://emedicine.medscape.com1