GI

• What is peptic ulcer disease?

  Focal defects (ulceration) of the gastrointestinal mucosa (the innermost layer of the GI tract that comes in contact with digested food chyme)
• Peptic ulcer disease affects the stomach and/or duodenum (first part of the small intestine)
• Causes of peptic ulcer disease

  • Worldwide and affects 5-10% of the population
  • H. pylori (bacteria)
  • Medications (NSAIDs, Corticosteroids)
  • Smoking (impairs healing)
  • Alcohol (irritates gastric mucosa)
  • Chronic stress
  • Vascular insufficiency
• Helicobacter pylori


  H. pylori burrow into the stomach lining, where they proliferate. Shielded by urease, an enzyme they secrete that produces ammonia, which neutralizes stomach acids.
• Stressors/Vascular insufficiency

  Can be a cause of ischemia to the lining of the stomach/duodenum or overreaction of the Vagus nerve (increases gastric acidity)
• NSAIDs

  Inhibit COX-1 enzyme, which reduces prostaglandin synthesis. Prostaglandins have a protective effect in the gastrointestinal mucosa.
• Diagnosing peptic ulcer disease

  • EGD (esophagogastroduodenoscopy)
  • Assess for H. pylori Infection
  • Blood test
  • Stool Antigen (presence does not mean infection; just at one time they had it)
  • Urea Breath Test
• Urea breath test


  You swallow a pill that contains tagged carbon molecules. If you have H. pylori infection, carbon is released when the solution comes in contact with H. pylori in your stomach.
• EGD is the gold standard for diagnosing peptic ulcer disease
• Reducing acids in the GI tract

  • Antacids
  • PPI's
  • H2 Blockers
  • Mucosal Protectant
• Treatment and drug classifications for peptic ulcer disease

  • Proton-Pump Inhibitor
  • Treat H. pylori (Triple Therapy - Clarithromycin, Amoxicillin, PPI)
  • Antibiotics
  • Histamine2-receptor antagonist
  • Mucosal Protectant
  • Antacids
  • Prostaglandin E analog
• Histamine 2 - receptor antagonists

  Blocks H2 receptors, which suppresses the secretion of gastric acid and lowers the concentration of hydrogen ions in the stomach
• Cimetidine (Histamine 2 - receptor antagonist)


  Blocks androgen receptors (sex hormones) - resulting in decreased sex drive, gynecomastia (males get enlarged breasts), and impotence (infertility)
• Cimetidine is Pregnancy Risk Category B
• Older adult clients are more likely to experience adverse CNS effects from Histamine 2 - receptor antagonists and can require a decreased dosage
• Histamine 2 receptor antagonists decrease gastric acidity, which promotes bacterial colonization of the stomach and the respiratory tract
• Histamine 2 receptor antagonists should be used cautiously in clients who are at high risk for pneumonia, including clients who have COPD
• Dosages of Histamine 2 receptor antagonists should be reduced in clients with moderate to severe kidney impairment
• Cimetidine can inhibit medication


  Increases the levels of warfarin, phenytoin, theophylline, and lidocaine
• When clients are taking warfarin, monitor for bleeding, monitor INR and PT levels
• When clients are taking phenytoin, theophylline, and lidocaine, monitor blood levels
• Concurrent use of Antacids can decrease absorption of Histamine 2 receptor antagonists
• Client education for Histamine 2 - receptor antagonists

  • Do not take an antacid WITHIN 1 hr before, or after, taking a histamine2 receptor antagonist
  • Space administering of antacids to one hour before/after taking
  • Smoking can decrease the effectiveness of histamine 2 receptor antagonists. Nicotine is a vasoconstrictor that reduces blood flow to the skin, thereby resulting in tissue ischemia and impaired healing of injured tissues
• Treatment of peptic ulcer disease

  Usually started on an oral dose twice a day until the ulcer is healed, followed by a maintenance dose, which is usually taken once a day
• Coffee-ground emesis is an indication of GI bleeding
• Proton pump inhibitors

  Blocks basal (occurs independently of eating and maintains at 1.5 to 3.5) and stimulated (the thought, smell, or taste of food effects vagal stimulation of the gastrin-secreting G cells located in the distal one-third [antrum] of the stomach) acid production and reduces gastric acid secretion by irreversibly inhibiting the enzyme that produces gastric acid
• Therapeutic uses of proton pump inhibitors

  • Short-term therapy for gastric and duodenal ulcers, erosive esophagitis, and GERD. Treatment should be limited to 4 to 8 weeks.
• PPIs can interfere with the absorption of magnesium and other vitamins. Monitor magnesium for long term use
• Report fever, diarrhea, abdominal cramping, or bloody stools immediately to the provider, as these may indicate Clostridium difficile-associated diarrhea.
• Proton pump inhibitors are Pregnancy Risk Category C
• Use proton pump inhibitors cautiously with clients who have dysphagia or liver disease
• Proton pump inhibitors increase the risk for pneumonia.
• Digoxin, Methotrexate, Diazepam, Tacrolimus, Antifungal Agents, and Phenytoin levels


  Can increase when used concurrently with omeprazole
• Absorption of ketoconazole, itraconazole, and atazanavir is decreased when taken concurrently with a proton pump inhibitor. Avoid concurrent use. If necessary to administer concurrently, separate administering of the medications by 2 to 12 hours.
• The beneficial effects of clopidogrel (anti-platelet) can decrease with concurrent use of a proton pump inhibitor. Monitor for thrombotic events.
• Mucosal protectant (Sucralfate)


  The acidic environment of the stomach and duodenum changes sucralfate into a protective barrier that adheres to an ulcer. This protects the ulcer from further injury from acid and pepsin. This viscous substance can stick to the ulcer for up to 6 hours.
• Sucralfate protects the esophageal lining
• Therapeutic uses of sucralfate

  Treatment of acute duodenal ulcers and maintenance therapy. Neutralizes or reduces the acidity of gastric acid; can reduce pepsin activity if the pH is raised above 5.
• Sucralfate can interfere with the absorption of

  phenytoin, digoxin, warfarin, and ciprofloxacin
• Maintain 2–3-hour interval between these medications and sucralfate to minimize the interaction