Sunday, January 15, 2006

ulcer, peptic (gastric ulcer)

A peptic ulcer is an ulceration of the mucosa and deeper structures of the upper gastrointestinal tract. Ulcers may be acute or chronic. An acute peptic ulcer is usually superficial, involving only the mucosal layer. It usually heals within a short time but may bleed, perforate, or become chronic. A chronic peptic ulcer involves both the mucosa and submucosa.
Duodenal ulcers (ulceration located in the uppermost portion of the small intestine) are more frequent in people 25 to 50 years of age, where peptic ulcers occur more frequently in people over 50 years of age. Peptic ulcers are caused by the digestive action of the acidic gastric juices and pepsin on the mucosa.
Symptoms include pain such as a "burning" or "gnawing" in the epigastric region, usually occurring within several hours after meals. Bleeding may be the fist sign of the ulcer, presented as hematemesis (vomiting of blood) or melena (dark tarry stools due to blood altered by intestinal juices). Diagnosis is made by the history and the gastrointestinal X-ray series.
Duodenal ulcers are always benign, whereas gastric ulcers may be either benign or malignant. The combined use of X-ray, gastric analysis, gastric washings, and gastroscopy are helpful in differentiating between benign and malignant lesions. Failure to heal, which may indicate a malignancy, is the usual reason to operate. Neutralizing the acid so that it does not irritate the ulcer and decreasing the hypermotility (spastic movement) and secretions of the stomach are treatment objectives. A bland diet may be recommended, omitting spicy foods, alcoholic beverages, coffee, or other foods that cause gastric distress. Drugs such as aspirin can also be irritating to the gastric mucosa.
Antacids are given to neutralize hydrochloric acid. Cholinergic blocking agents such as tincture of belladonna and atropine may be given to decrease the gastric motility. Adverse effects of these drugs include dilation of the pupils, blurring of the vision, and difficulty voiding. Cholinergic blocking agents are avoided in persons with narrow angle glaucoma or prostatic enlargement. Cimetedine, which decreases the production of hydrochloric acid, is used in the treatment of duodenal ulcers. Ulcers usually heal within eight weeks with the use of Cimetedine therapy.
Carafate® has been introduced as an alternative to Cimetidine. Rest and relaxation are important, thus sedatives may be prescribed to promote rest.
Hemorrhage is a frequent complication. Bleeding occurs when a blood vessel is eroded by the ulcer. Examining the stool for occult blood may detect bleeding. Faintness, weakness, and dizziness may result from large losses of blood. When bleeding cannot be controlled, immediate surgical intervention is necessary.
The ulcer may penetrate the tissues and perforate, resulting in the gastrointestinal tract contents seeping out, causing peritonitis. The abdomen becomes rigid, extremely painful, and tender. This is an emergency condition requiring immediate surgical closure. Peptic ulcers that do not respond to medical treatment may require gastric surgery. This consists of subtotal gastrectomy with gastroenterostomy. Vagotomy (division of the vagus nerve) is done to decrease the secretions of hydrochloric acid and gastric motility. Nutritional problems that follow gastric resection are related to the amount of the stomach removed.
The dumping syndrome can be a complication of gastric surgery. Sensations of weakness and faintness are accompanied by profuse perspiration and palpitations. This is due to rapid emptying of large amounts of food and fluid through the gastroenterostomy into the jejunum.
See also DUMPING SYNDROME; GASTRITIS; VITAMIN B12 DEFICIENCY.
Phipps, W. 1. Essentials of Medical-Surgical Nursing. St. Louis: C. V. Mosby Co., 1985.
Reichel, W. M. Clinical Aspects of Aging. Baltimore: The Williams & Wilkins Co., 1979.

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