PEPTIC ULCER DISEASE

Hyperacidity (Acid Rebound) Peptic Ulcer Disease (PUD) Bleeding Peptic Ulcer Disease (BPUD) Classic Symptom: Epigastric Pain

Types of PUD 1. 2. Duodenal PUD: Main Problem: Increased HCL S/S: Right Epigastric Pain 2 3 hours after meals and usually relieved by eating. Gastric PUD : Main Problem: Weak Gastric Mucosa S/S: Left Epigastric pain 30 mins 1 hr after meals and usually relieved by vomiting.

Predisposing Factors 1. 2. 3. Stress / Tension (Emotional, Activity) body is forced to release more acid and stimulates vagal nerve. Lifestyle (Ex. Stressful Lifestyle, Heavy Drinking, Smoking) Food Intake a. Spicy Foods b. Too hot and too cold foods c. Gas forming foods that can cause flatulence (abdominal gas) High fiber foods or too much fiber can cause flatulence and diarrhea Ex. Vegetables (Cabbage, Celery, Beans, Eggplant, Onion, Wheat) Fruits (Apple, Cherries, Coconut, Melon) Irregular Eating Pattern (ex. Improper Eating Time) Medications a. Antihistamines b. Bronchodilators c. Anti Cancer or Anti Neoplastic d. Steroids e. Stimulant Xanthine Group Caffeine colas, coffee (may add creamer), tea (can give weak tea), energy drinks Nicotine tobacco Acrid or Acidic Breath (Acid Odor) Associated with Halitosis, Fetid (Odor of Necrotic Tissue) (+) HELICOBACTER PYLORI BACTERIA causes sloughing action (leads to perforation) and releases histamine (too much histamine is irritating to stomach)

4. 5.

6.

Treatment: 1. 2. Based on Predisposing Factors Surgery: Gastrectomy Surgical removal of acid producing portion of the stomach Decreases stomach capacity = double workload of stomach = increase release of acid Secondary to TB

Zollinger Ellisen Syndrome Uncontrollable hypersecretion of HCL and Pepsin triggered by Vagus Nerve No medications can treat this Treatment: Stop the activity of the Vagus Nerve

ANTACIDS
Mechanism of Action: Neutralizes (balances) acid with its primary goal to Relieve Pain Antacids are Alkaline

(3) Divisions of Antacids 1. Systemic Antacid Flows in the Blood Circulation Soluble (can be dissolved) in gastric acid. Once dissolved, they are readily absorbed Rapid Onset but short duration of action May cause Fluid and Electrolyte Imbalance May cause Hyperacidity (Acid Rebound) due to its short duration of action

Examples: Sodium Bicarbonate, Alkaseltzer, Novaluzid (sachet; mix it by hand prior cutting the tip then client will sip it directly; dont add liquid) 2. Non Systemic Antacid Most useful for long term therapy Small portion of antacid is absorbed in systemic circulation and the rest remains in GIT (sticks in the stomach)

Ex. a. b. c. d. Aluminum Hydroxide CONSTIPATION astringent effect is the GI Aluminum Phosphate Calcium Carbonate or Precipitated Chalk ex. Cosmetic Peeling Agent Ingredient; Always drink a full glass of water Magnesium Hydroxide Magenesium Trisilicate Magnesium Carbonate or DIARRHEA draws out water; binds water Milk of Magnesia Magmas suspension; liquid dosage form that contains solid particles suspended in liquid medium; must be shaken to assume uniformity Sometimes called MILK for they are WHITE in color.

a. b. c.

Aluminum Magnesium Hydroxide (Al Mg Hydroxide) antacid; usual prescription of a Physician to prevent diarrhea and constipation. 3. Antacids with Non Antacid Ingredients Improves therapeutic response of the product to relieve gas distention and flatulence found in Hyperacidity Simethicone Dimethicone Ingredients dimethicone absorbs gas and has a soothing effect a. Gascon c. Biopan b. Gelusil MPS d. Mucilan anesthetic Maalox has dimethicone; relieves gas distention & pain; Adult dose is 30ml not >90ml; Child Dose is 4 5 ml not >20ml

Nursing Considerations 1. 2. 3. Generally taken 1 hour after meals because their neutralizing last for 3 4 hours If given on an empty stomach, effect lasts only for 30 minutes to 1 hour Observe complicated related conditions a. Hemmorhage b. Obstruction c. Perforation (sloughing, holes in the stomach; damage) d. Peritonitis (Abdomial Guarding and Rigidity, Melena (blood in stool, upper GIT bleeding), Hematochizea (Rectal Bleeding or Blood Flecked Anal Fissure; Upper GIT Bleeding) Alternate Magnesium and Aluminum Antacids Health Teaching based on Predisposing Factors

4. 5.

ANTI-CHOLINERGICS
Antispasmodics; Vagolytic; Drying Agent Mechanism of Action: a. Inhibits the release of acid in the stomach via the vagus nerve ending. b. Blocks the action of Parasympathic Nervous System a. Parasympathetic = increases gastric secretions and lowers cardiac rate b. Sympathetic decreases gastric secretions and increases cardiac rate Atropine Sulfate* Belladona Banthine* d. e. Probanthine* Daricon

a. b. c.

Nursing Considerations 1. Take Note the Side Effects a. Dry mouth & tongue hydrate frequently but not fast; helps produce Apocrine Gland b. Blurring of Vision avoid tasks that requires acute vision c. Tachycardia d. Nausea e. Constipation f. Urinary Retention weakens bladder contraction g. Muscle Cramps h. Vertigo (dizziness) All patient should be screened for any Eye Disorder especially, CLOSED ANGLE GLAUCOMA (increased pressure of the eye) If given in large dosage = PSYCHOTIC DISTURBANCE Hallucinations, Confusion, Disorientation (Always Orient Client in Person, Environment, Place, Time) Drug Interaction = Increases Confusion, Hallucination a. Tricyclic Antidepressants (Increases reuptake of norephinephrine) Tofranil tachycardia & palpitation Norpramine Elavil Moprotiline Vivactil

2.

3.

4.

b.

Anti- Psychotic Drugs Haldol Thorazine causes hypotension Compazine

Stelazines Phenothiazines Mellaril

H2 Receptor Antagonist (Histamine Antagonist)

H1 respiratory and skin; H2 - GIT Mechanism of Action: Inhibit the action of histamine at histamine sensitive receptor sites of parietal cells in the stomach Side Effects: a. Galactorrhea (women) increased production of breastmilk in lactating mothers; breasts are pumped up and painful on non nursing mothers); tingling sensations on the nipples and areola; Galactose is a milk sugar found in lactose b. Gynecomastia (men) enlarges breast even; stimulates hormones for 2ndary Sex Characteristics, anti adrogenic Ex. CIMEtidine (Tagamet) * RANItidine (Zantac) * FAMOtidine (H2 Blocker, Pepcid) NIZOtidine (Axid)

MUCOSAL PROTECTIVE AGENTS: Cytoprotective Agents or Coating Agents

New Agent Chemical derivative of SUCROSE that produces a GUM GEL substance once absorbed Primary Action a. act locally or at the ulcer site witch coats crater like or perforated areas and protect it from acid secretion b. speeds healing process c. brings back normal mucosal tone

Ex SUCRALFATE (Carafate, Sulcrate) Iselpin For SHORT TERM THERAPY (Only up to 8 weeks) Should be given 30 min 1 hour prior meals or antacids: a. Decreases sucralfate binding to perforated areas b. Interferes with the absorption of ADEK if given >8 weeks

Note: Take Sucralfate 30 1 hr prior meals MEALS Take Antacid 1 hour after meals.

HIDDEN DANGERS FOR PATIENTS WITH PUD

Drug Addiction Antacids or Anti-secretory May impede absorption of Folate (B Complex), Iron, Vitamin B12 (Cyanocobalamin) Elderly Patients with undiagnosed anemia or at risk for iron deficiency anemia, particulary if they take OTC Antacids or H2 Antagonist for long time Sucralfate interferes with the absorption of Fat Soluble Vitamins (ADEK) Antacids containing Magnesium interferes with VITAMIN A (Retinol) absorption Nursing Consideration Advise patient to have PERIODIC BLOOD COUNT, especially if theres UNUSUAL FATIGUE Remind patient to inform their Health Care Providers of OTC drug use Tell patient to take this drug on an EMPTY STOMACH and NOT WITH VITAMIN SUPPLEMENTS Tell patient to take this drug on an EMPTY STOMACH and NOT WITH VITAMIN SUPPLEMENTS

PROTON PUMP INHIBITORS (PPI)

Mechanism of Action 1. 2. Blocks final step of acid production Inhibits gastric secretions and concentration more than the effect of H2 Receptor Antagonist Inhibit the enzyme H+ K+ ATPase H+ is irritant and appears on the last stage of secretions Short term Therapy (4 8 weeks with interval of 2 3 weeks then continue. PULSE TREATMENT) Increases Alkalinity environment of stomach Drug of Choice a. (+) Duodenal CA b. Gastroesophageal Reflux or Reflex Disorder (GERD) c. (+) Helicobacter Pylori Bacteria Used as adjunctive treatment (can be combined with others) to AMOXICILLIN and CLARITHROMYCIN to eradicate H. Pylori

3. 4. 5.

6.

Ex. 1. 2. 3. 4. 5. PANTOprozole (Pantoloc / Protonix) LANZOprazol (Prevacid) OMEprazole (Prisolec, Losec) * ESOMEprazole (Nexium) RABEprazole (Aciphex)

Drug Interaction 1. 2. Diazepam (anti - convulsant) Theophylline (bronchodilator) 3. 4. Warfarin (anticoagulant) Phenytoin Derivative (Anti convulsant)

Nursing Considerations 1. 2. 3. 4. Give BEFORE meals Dont crush or chew and client should swallow it whole Assess Gastric Ph (Acidic 1 5 ; Alkaline 7) Assess Frequent Side Effects a. Headache b. Nausea c. Abdominal Pain d. Diarrhea e. ASTHENIA (always defecating; leads to dehydration and loss of strength)

A. PROSTAGLANDIN ANALOGS Has E1 (Ester); From natural Prostaglandins Prostaglandins is a stomach protectant Ex. Misoprostol (Cytotec) Dont give with NSAIDS (Non Steroidal Inflammatory Drugs) ex. ASA or Aspirin ( Acetyl Salicylic Acid) Nursing Considerations 1. 2. 3. Check Patient if Pregnant Can be taken if used as an antacid; take it whole with a full glass of water Assess: a. Asthenia b. Chilling c. Cold, Clammy Perspiration d. Uncontrolled, Profuse Bleeding e. Assess 2x if with powerful diarrheal stools. Refer asap.

B. TRANQUILIZERS downers, relaxants, induces sleep, anti anxiety, sedative, has hypnotic effect a. Librax b. Librium c. Quarzan anti-cholinergic clidinium d. Valium diazepam *Stillnox ,Unison for insomniacs, sleep inducing e. Tranxene XR clorazepate C. GIS GASTROINTESTINAL STIMULANT Serotonin 4 Receptor Antagonist (serotonin is a nerve balancer; enhances sleep) Action: Restores and balances motility of GIT and Relaxes Stomach Contraindicated for PT with Cardiac Problems. May cause TACHYCARDIA, DYSRRHYTHMIAS, ISCHEMIC HEART DISEASE, CONGESTIVE HEART FAILURE (CHF) Associated with Fluid and Electrolyte Ex CISAPRIDE (PROPULSID) drug of choice for GERD

COMMON PUD DRUG INTERACTIONS PUD Drugs interfere with the absorption, metabolism, and excretion of other drugs. Even recurrent references are inconsistent when listing PUD drug interactions. This chart lists some interactions that are clinically significant, although not intended to be all inclusive. Consult a current drug reference or Pharmacist when in doubt or to be safe, separate the dosages of PUD from other drugs at LEAST 1 HR. DRUG ANTACID Absorption H2 Antagonist Isioniazid (antituberculous) Quinolones Tetracyclines Penicillamine Ketacomazole (Anti-fungal) Lincosamides Iron Product Absorption Quinidine (anti arrhythmic; BN: Kinin Durules) Valporic Acid (anticonvulsant; BN: Depakine) Levadopa (antiparkinsonism ; Sinemet) Warfarin (anticoagulant) Lidocaine (local anesthetic) Tricyclic Antidepressants Benzodiazepines (antiemetic) (anti anxiety) (anti convulsant) Nifedipine (anti hypertensive; Darat, Adalat) Benzodiazepines Clarithromycin (antibiotic; macrolide) Tetracycline Ranitidine (Zantac; H2 Antagonist) Theophylline (bronchodilator) Plasma Excretion Quinidines Excretion Salicylates Blood thinner Common in patients with kidney problems Ex. NSAIDS (ex. ASA)

H2 Antagonist (Esp. Cimetidine Tagamet)

Ketaconazole Iron Products

Proton Pump Inhibitors

Ketaconazole

Cytoprotective Agent (Sucralfate)

Quinolones Phenytoin (anticonvulsant) Penicillin Digoxin (cardiac glycoside; digitalis prep; for angina pectoris)

GIS CISAPRIDE (Propulsid)

Antibiotic Anti fungal Macrolides Ritonavir (antiviral) Nefazodone (antidepressant)

CONSTIPATION
< 3 Bowel Movement per week Interferes the passage of dry, hard stool, or the passage of no stool Occurs when the movement of feces thru Large Intestine is SLOW, thus allowing time for additional reabsorption of fluid from the Large Intestine

Predisposing Factors 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Fiber Intake Fluid Intake Lack of Activity / Immobility (ex. Confined to bed, lack of exercise) Irregular Defecation Habits Lack of Privacy Poor Motility Pelvic Floor Dysfunction or Muscle Damage Chronic Use of Laxatives and Enemas Neurological Conditions (Stroke, Paralysis, Parkinsons) Emotional Disturbances (Depression, Confusion) Irritable Bowel Syndrome (IBS) Intussusceptions Imperforated Anus Positioning Medications Antacids Antihistamines Anti-cholinergic Anti-depressants Iron Supplements Opiods

Constipation Producing Foods 1. 2. 3. 4. 5. Pasta Eggs Lean Meat Cheese Caffeine

Nutrition 1. 2. 3. Increase fluid intake Increase Fiber Intake (wheat, cereals, bread, bran, etc) Drink PRUNE JUICE

LAXATIVES
A. Contact / Irritant / Stimulant Laxatives Acts directly in the intestine particularly in INTRAMURAL SENSORY NERVE PELXI ENDING (lumen of intestine) in the mucosa that causes IRRITATION and PROMOTES PERISTALSIS EVACUATION. Produce watery or diarrheal stools If given Orally acts within 6 12 hrs If given Rectally acts within 60 90 mins (faster action) 3 Subdivisions of Laxatives 1. Anthracene Stimulant Laxative or Anthraquinonone Acts directly to small and large intestines that produces Cramping Like Effect Ex. Senna Products Senokot (Effect is 6 12 hrs); may give @ night before sleeping Cascara Sagrada Cas Evac (Effect is 6 10 hrs) Danthron Modane, Dorbane (Effect is 6 10 hrs) Diphenylmethanes a. Phenolpthaleim (Phenol derivative powerful acid) White powder thats insoluble in water and soluble in intestinal juices where it exerts a mild intestinal irritation. Ex. Alophen Ex Lax, Phenolax, Feen a Mint, Doxidan Bisacodyl Evacuation effect: 6 10 hours Enteric Coated Tablet not to be taken 1 hr after ingestion of antacid or milk to prevent premature dissolution of the drug (do not also give milk) Ex. Dulcola, Bisco lax

2.

b.

3.

Ricinoleic Acid Laxative Bland, colourless, emollient glyceride that passes into stomach unchanged but like other fatty acids, it retards emptying of the stomach. Ex. Neoloid, Alphamul Caster Oil Not for <8 y/o because of Risk of Aspiration; can lead to Aspiration Pneumonia Dose: 8yo above = 15 ml / Adult = 30ml Drawback: Vomiting (d/t to oiliness) When administering, cover nose and drink water Use soap solution and warm water to wash out excess oil Produces a frothy and oily stool Bulk Forming Laxatives From GUMS (Methycellulose, Psyllium Seeds Psyllium C) Ex. Metamucil effervescent form, strong, effect is 12 24 hrs up to 48 hours, safe for pregnant (ex.Fibrosine made of fruits and veggies; not for daily intake; drink during the afternoon) Karacil Cologel

4.

5.

Saline Laxatives Has Unpleasant Taste Soluble salts of Hypertonic (easily mix with H20) compound that attracts water into the intestine, thus increases water content of FECES resulting to: a. Bowel Distention b. Promotes Peristalsis Dont crush or chew, just mix it with water. It will produce Bubble Contraindicated: a. Children d/t unpleasant taste b. Hypertensive Patients / Heart Problems c. Kidney Problems d. Malabsorption Problems Complication: Impedes ADEK absorption Ex. MOM (Milk of Magensium) or MgOHmixture Magnesium Sulfate (Epsom Salt) Magnesium Citrate Effervescent Sodium Phosphate Lubricant or Emollient Laxatives Lubricate stools in the intestine (so stools will slide) For poor nerve function and decreased peristalsis / (-) Peristalsis Evacuation Effect: 6 8 hrs Ex. Mineral Oil, Caster oil Stool Softeners / Wetting / Surfactant Laxatives No Irritation, No Toxicity (-) Peristalsis Exerts detergent like effect Evacuation Effect: 12 72 hrs (slow) Ex. Dialose, Kasof, Surfak Colace

6.

7.

Oil lubricant if stool is super impacted (hard) Oil Retention Enema Higher than 18 20 inches Allow patient to contract buttocks (baka lumabas un oil) Position: Can position in FULL SIDELYING After defecation, use soap solution and warm water

Enema Length or Height: 18 20 inches distance Position: Left Lateral, Right Lateral

Cholera plain diarrhea; painful; rice watery stool

10