peptic ulcer disease
a group of upper GI disorders characterized by varying degrees of erosion of the gut wall
•Name two complications of PUD
hemorrhage and perforation
•Name two locations where peptic ulcers are most common
lesser curvature of the stomach and duodenum
•When do peptic ulcers develop?
when there is an imbalance between mucosal defensive factors and aggressive factors.
•Name the two major defensive factors against ulceration.
mucus and bicarbonate
•Name the four major aggressive factors for ulceration
H. pylori, NSAIDs, gastric acid, and pepsin
•Name the two most important agents that can weaken defenses against ulceration
H. pylori, NSAIDs
•Explain how prostaglandins play an important role in maintaining defenses.
stimulate secretion of mucus and bicarbonate; promote vasodilation, which helps maintain submocosal blood flow; and suppress secretion of gastric acid
a gram negative bacillus that can colonize the stomach and duodenum
•Explain how NSAIDs are the underlying cause of many gastric ulcers and some duodenal ulcers.
inhibit the biosynthesis of prostaglandins
•True or False? Patients with gastric ulcers produce an increased amount of gastric acid.
•Name one life-style habit that delays ulcer healing and increases the risk of recurrence.
•Name the first and second most common causes of gastric and duodenal ulcers.
H. pylori, NSAIDs
•Name four goals of drug therapy for PUD.
(1) alleviate symptoms, (2) promote healing, (3) prevent complications, and (4) prevent recurrence.
•Name the five classes of antiulcer drugs.
antibiotics, antisecretory agents, mucosal protectants, antisecretory agents that enhance mucosal defenses, and antacids
•Name the three basic ways drugs used for PUD act to promote ulcer healing. Identify classes of drugs that perform each action.
(1) eradicate H. pylori (anitbiotics), (2) reduce gastric acidity (antisecretory agents, misoprostol, and antacids), and (3) enhance mucosal defenses (sucralfate and misoprostol)
•Name the 2 preferred drug options for prevention of NSAID-Induced Ulcers.
misoprostol and the proton pump inhibitors
•Name the 2 preferred drug options for treatment of NSAID-Induced Ulcers
histamine2-receptor blockers and proton pump inhibitors
•What common diet restrictions have not been shown to accelerate healing of PUD? What is one dietary change that may be beneficial?
"ulcer diet"-bland foods together with milk or cream; eating pattern of 5 or 6 small meals a day may be beneficial
•What life-style habit should be avoided by patients with PUD?
•What group of patients with PUD may continue to take aspirin? Why?
use of aspirin to prevent cardiovascular disease
•What restriction should be placed on alcohol consumption by patients with PUD?
stop if patient notes a temporal relationship between consumption and exacerbation of symptoms
•What invasive procedure is necessary to obtain a biopsy to conduct tests for H. pylori?
an endoscopically obtained biopsy sample
•Name three types of noninvasive tests used in the United States to test for H. pylori.
breath, serologic and stool tests
•Name the five antibiotics used to treat PUD caused by Helicobacter pylori. Which ones can be used alone?
amoxicillin, clarithromycin, bismuth, metronidazole, and tetracycline.
•List the antibiotics used in order of least resistance to most resistance (not including Bismuth).
tetracycline (<1%), amoxicillin (3%), clarithromycin (10%), metronidazole (>40%)
•Name one common side effect that Amoxicillin and Clarithromycin have in common. Name two additional side effects of Clarithromycin.
nausea, and distortion of taste
•What is one common brand name of bismuth subsalicylate?
•What effect can Bismuth have on the tongue and stool? What serious symptom may be difficult to assess because of this side effect?
•Why should Tetracycline not be used by pregnant women or young children?
stain developing teeth
•What is disulfiram? (You will need to do look up elsewhere) What would be a disulfiram-like reaction?
Disulfiram [Antabuse] is a drug used in the treatment of alcoholism by causing unpleasant effects if alcohol is ingested.
Reaction includes nausea, copious vomiting, flushining, palpitations, headache, sweating, thirst, chest pain, weakness, blurred vision, and hypotension, and sharp decline in BP.
•Which of the 5 antibiotics used to treat PUD can cause a disulfiram-like reaction if is used with alcohol?
•To minimize emergence of resistance, how many different antibiotics should be used to treat PUD caused by Helicobacter pylori?
at least two, and preferably three
•What other type of medication should be included along with the antibiotics?
an antisecretory agent
•For how many days should the antibiotic regimen last?
•List some reasons why compliance with antibiotic therapy can be difficult.
complex regimen, side effects, and expensive
The health care provider is treating a patient with complaints of severe abdominal pain and confirmed infection with H. pylori. Which of the following medication combinations would the nurse expect the health care provider to order?
a. amphotericin B, cimetidine (Tagamet), and bismuth (Pepto-Bismol)
b. cimetidine (Tagamet) and metronidazole (Flagyl)
c. cimetidine (Tagamet), tetracycline, and cefuroxime (Ceftin)
d. clarithromycin (Biaxin), amoxicillin (Amoxil), and esomeprazole (Nexium)
A patient is placed on a multidrug regimen that includes bismuth for treatment of peptic ulcer disease (PUD). The nurse should include which of the following points when providing patient education?
a. A single-antibiotic regimen is preferable to a multi-antibiotic regimen whenever possible.
b. One week of therapy should heal ulcers, relieve symptoms, and eradicate H. pylori.
c. Resolution of pain indicates that the ulcer has healed.
d. The tongue and stool may turn black.
When metronidazole (Flagyl) is a component of the H. pylori treatment regimen, the patient must be instructed to
a. avoid any alcoholic beverages.
b. avoid foods containing tyramine.
c. take the drug on an empty stomach.
d. take the drug with food
•How do histamine2-receptor antagonists (H2RAs) promote ulcer healing?
suppressing secretion of gastric acid
•Name the four H2RAs that are available. Which one(s) are most effective?
cimetidine, ranitidine, famotidine, and nizatidine. All four are equally effective.
•What is the brand name of cimetidine?
•What is the mechanism of action of cimetidine and the other H2RAs
Inhibits the action of histamine at the H2-receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion
•What will be the effect if cimetidine is taken orally with meals?
food decreases the rate of absorption but not the extent
•How long must cimetidine be taken to heal duodenal and gastric ulcers?
duodenal: 4-6 weeks
gastric: 8-12 weeks
•Name four other conditions besides PUD for which cimetidine might be used
GERD; Zollinger-Ellison Syndrome; aspiration pneumonitis; heartburn, acid indigestion, and sour stomach
•Describe antiandrogenic effects.
Cimetidine binds to androgen receptors, producing receptor blockade. This causes gynecomastia, reduced libido, and impotence.
•What patients are most at risk for CNS effects during the use of cimetidine? What type of effects may occur?
elderly who have renal or hepatic impairment.
confusion, halluciantions, CNS depresssion, and CNS excitation
•If a patient is taking both cimetidine and antacids how should the drugs be scheduled?
administered 1 hr apart
•What is the brand name of ranitidine?
•How does food effect the absoption of ranitidine?
•How common are antiandrogenic effects with ranitidine?
•How do antacids effect ranitidine?
small effect on absorption
•What is the brand name of famotidine?
A patient on antiulcer therapy complains of reduced libido and impotence. The nurse identifies a knowledge deficit in the patient. During teaching, the nurse informs the patient that _______ has been shown to cause reduced libido and impotence.
a. cimetidine (Tagamet)
b. famotidine (Pepcid)
c. nizatidine (Axid)
d. ranitidine (Zantac)
The nurse is providing education to a patient who has been prescribed both an antacid and ranitidine (Zantac). Which instruction should the nurse give the patient about taking the medications?
a. "Take the antacid 1 hour after the ranitidine."
b. "Take the antacid 15 minutes before the ranitidine."
c. "Take the antacid 30 minutes after the ranitidine."
d. "The antacid and ranitidine should be taken at the same time for better effect."
•What are proton pump inhibitors (PPIs) most effective at doing?
suppressing secretion of gastric acid
•What is the brand name of omeprazole?
•Explain in very simple terms the mechanism of action of omeprazole.
Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into the gastric lumen
•Name two ways omeprazole is formulated to protect it from being destroyed by stomach acid
a capusle that contains protective enteric-coated granules; a powdered mixture of omeprazole with sodium bicarbonate, an antacid that elevates gastric pH
•When should omeprazole be taken in relation to meals?
before the first meal of the day
•What is the brand name of esomeprazole?
•What is the brand name of lansoprazole?
•What is the brand name of pantoprazole?
The nurse is discussing the mechanism of action of omeprazole (Prilosec) with a group of nursing students. Which statement by a student would best indicate understanding of the mechanism of action of omeprazole?
a. "Absorption occurs in the stomach when the pH is greater than 5."
b. "It irreversibly inhibits the enzyme needed to produce stomach acid."
c. "The complete return of acid production occurs 24 hours after discontinuation."
d. "The duration of action is short, because the drug has a short half-life."
•What is the brand name of sucralfate?
•Describe in simple terms how sucralfate works to promote ulcer healing.
creating a protective barrier against acid and pepsin
•What is the most significant side effect of sucralfate?
•Since sucralfate may impede the absorption of some drugs, what would be an appropriate nursing action to minimize this effect?
administered 30 minutes to 2 hours apart
•How should sucralfate be administered in relation to meals?
1 hour before meals
•What form of the drug may be used if a patient finds the large tablets difficult to swallow?
The nurse is providing patient education to an elderly patient being treated for duodenal ulcers. The prescriber has ordered sucralfate (Carafate). The patient asks the nurse how sucralfate helps heal ulcers. Select the correct explanation given by the nurse.
a. "It creates a protective barrier against pepsin and acid."
b. "It enhances prostaglandin production."
c. "It inhibits the enzyme that generates gastric acid."
d. "It irreversibly suppresses gastric acidity."
The nurse is preparing to administer medications to a patient taking sucralfate (Carafate) and ciprofloxacin (Cipro). The drugs are ordered for 0900. In what manner should the nurse proceed to administer the drugs?
a. The nurse should administer the ciprofloxacin 15 minutes before the sucralfate.
b. The nurse should administer the drugs with a full glass of water.
c. The nurse should administer the two drugs at same time with food.
d. The nurse should ask the prescriber to change the times to prevent concurrent administration
•What is the brand name of misoprostol?
•What is misoprostol?
an analog of prostaglandin E1
•In the United States what is the only approved GI use for misoprostol?
prevention of gastric ulcer caused by long-term therapy with NSAIDs
•For what other use(s), unrelated to GI problems, is misoprostol used for?
promote cervical ripening and induce abortion
•In normal individuals, how does prostaglandins help protect the stomach?
(1) suppressing secretion of gastric acid, (2) promoting secretion of bicarbonate and cytoprotective mucus, and (3) maintaining submucosal blood flow (by promoting vasodilation).
•How do aspirin and other NSAIDs cause gastric ulcers?
inhibiting biosynthsis of prostaglandin
•How does misoprostol prevents NSAID-induced ulcers?
serving as a replacement for endogenous prostagladins
•Why is misoprostol is contraindicated during pregnancy? What is the FDA Pregnancy Risk Category?
causes partial or complete explusion of fetus; Category X
•When is misoprostol administered in relation to meals?
A 30-year-old female patient is to be started on misoprostol (Cytotec) for treatment of a gastric ulcer secondary to long-term ibuprofen (Motrin) use. Which of the following must the nurse include in the patient education?
a. "Perform a breast self-examination weekly while on the medication."
b. "Start taking the drug at the end of your next menstrual period."
c. "Take the medication 1 hour before meals."
d. "Use a reliable method of birth control."
•True or False: Antacids neutralize acid and decrease destruction of the gut wall
•True or False: Antacids may also enhance mucosal protection by stimulating production of prostaglandins
•True or False: Antacids coat the ulcer crater to protect it from acid and pepsin.
•Because the objective of peptic ulcer therapy is to promote healing, and not simply to relieve pain how often should antacids be administered?
regular schedule, 7 times a day: 1 and 3 hours after each meal and at bedtime.
•What are the two most common adverse effects of antacids?
constipation and diarrhea
•Since antacids can influence the dissolution and absorption of many other drugs how should antacids be scheduled in relation to other drugs?
1 hour apart
•Which of the 2 most common antacids causes diarrhea?
•Which of the 2 most common antacids causes constipation?
aluminum hydroxide, calcium carbonate