Peptic Ulcer Disease (PUD): Nursing Study Guide

Peptic ulcer disease (PUD) is a high-yield GI topic on the NCLEX. This guide reviews the balance between aggressive and protective mucosal factors, distinguishes gastric from duodenal ulcers, and outlines the drug therapy, complications, and nursing priorities you must know.

What Is Peptic Ulcer Disease?

• Peptic ulcer disease (PUD) is the development of open sores in the stomach, duodenum, or lower esophagus.
• Ulcers form when aggressive factors overwhelm the protective factors of the GI mucosa.

Aggressive vs Protective Factors

Aggressive factors (cause damage):

• Gastric acid
• Pepsin
• H. pylori infection
• NSAIDs (ibuprofen, naproxen, aspirin)
• Smoking
• Alcohol
• Physiologic stress

Protective factors (prevent damage):

• Mucus secretion
• Bicarbonate production
• Prostaglandins
• Mucosal blood flow
• Epithelial cell regeneration
• Tight cell junctions
• Growth factors

Causes and Risk Factors

• H. pylori infection causes 60–90% of duodenal ulcers and 40–70% of gastric ulcers.
• NSAIDs are the second most common cause.
• Additional risk factors: smoking, alcohol, stress, and older age.

Clinical Presentation

• Epigastric pain is the hallmark symptom — typically burning or gnawing.
• Pain timing depends on ulcer location (gastric vs duodenal).
• Bloating, belching, and nausea may occur.

Alarm Symptoms (Require Immediate Evaluation)

• Hematemesis (vomiting blood)
• Melena (black, tarry stools)
• Unexplained weight loss
• Severe, persistent pain
• Dysphagia

Gastric vs Duodenal Ulcers

Gastric ulcer:

• Pain 30–60 minutes after meals
• Night pain uncommon
• Relief with vomiting or antacids
• Weight loss
• Increased cancer risk

Duodenal ulcer:

• Pain 2–4 hours after meals (hunger pain)
• Night pain common
• Relief with food or antacids
• Weight gain
• No increased cancer risk

Exam trick: Gastric = pain after eating; Duodenal = pain when hungry.

Diagnostic Tests

• Upper endoscopy (EGD): direct visualization with biopsy to check for H. pylori or cancer. Indicated for patients over 60 or with alarm symptoms.
• Urea breath test: non-invasive; positive when labeled CO₂ is detected. H. pylori produces urease, which breaks down labeled urea into ammonia and labeled CO₂ that the patient exhales.
• Stool antigen test: positive bacterial antigen indicates active infection.
• Barium swallow: contrast study that visualizes an ulcer crater on X-ray.

H. pylori Treatment

• First-line: triple therapy for 10–14 days.
• Triple therapy = PPI + two antibiotics.
• Common regimen: PPI + amoxicillin + clarithromycin.
• Confirm eradication with urea breath test or stool antigen test 4 weeks after treatment.
• H. pylori testing should be done off PPIs and antibiotics for 2–4 weeks to avoid false negatives.

Medications for PUD

• Proton pump inhibitors (PPIs) — omeprazole, pantoprazole: most effective; take 30–60 minutes before breakfast.
• H2 blockers — famotidine: less effective than PPIs.
• Antacids — calcium carbonate: symptom relief only; do not heal ulcers.
• Sucralfate (Carafate): coats the ulcer; take on an empty stomach.
• Misoprostol (Cytotec): prostaglandin analog that increases protective factors; prevents NSAID-induced ulcers; contraindicated in pregnancy (causes uterine contractions).
• Antibiotics — amoxicillin, clarithromycin: for H. pylori eradication.

Complications

• Upper GI bleeding — most common complication; presents with hematemesis or melena.
• Perforation — ulcer erodes through the entire wall; sudden severe pain with a rigid, board-like abdomen; surgical emergency.
• Penetration — ulcer erodes into an adjacent organ (pancreas, liver); pain radiates to the back.
• Gastric outlet obstruction — swelling/scarring blocks gastric emptying; vomiting of undigested food and metabolic alkalosis.

Bleeding Ulcer Management

• Assess ABCs and establish two large-bore IV lines.
• Administer IV fluids for resuscitation.
• Transfuse packed RBCs if hemoglobin < 7 g/dL.
• Give IV PPI (pantoprazole) to reduce rebleeding risk — not oral.
• Perform endoscopy to identify and treat the bleeding site.

Perforated Ulcer Management

• Surgical emergency.
• Sudden, severe epigastric pain spreading to the entire abdomen.
• Free air under the diaphragm on upright chest X-ray.
• Treatment: IV fluids, IV antibiotics, and emergency surgery.

Nursing Assessment

• Assess epigastric pain — timing and relation to meals.
• Monitor for alarm symptoms: hematemesis, melena, weight loss.
• Watch for signs of bleeding: hypotension, tachycardia.
• Watch for signs of perforation: sudden severe pain, rigid abdomen.
• Review medication history, especially NSAID and aspirin use.

Nursing Interventions

• Give PPIs 30–60 minutes before breakfast.
• Give sucralfate on an empty stomach, 1 hour before meals.
• Separate antacids from other medications by 1–2 hours.
• Educate the patient to avoid NSAIDs, smoking, and alcohol.
• Encourage small, frequent meals.

Patient Teaching

• Take PPIs 30–60 minutes before breakfast, not with food.
• Complete the full course of antibiotics for H. pylori.
• Avoid NSAIDs, aspirin, smoking, and alcohol.
• Report black tarry stools, coffee-ground vomit, or severe abdominal pain immediately.

Common NCLEX Traps

• Duodenal = hunger pain; gastric = pain after meals.
• H. pylori testing requires being off PPIs and antibiotics for 2–4 weeks.
• Misoprostol prevents NSAID-induced ulcers but is contraindicated in pregnancy.
• Sucralfate must be taken on an empty stomach.
• Perforation = free air under the diaphragm on upright chest X-ray.
• Bleeding ulcer requires IV PPI, not oral.

Key Takeaways

• PUD occurs when aggressive factors (acid, H. pylori, NSAIDs) overwhelm protective factors (mucus, bicarbonate, prostaglandins, blood flow).
• Duodenal ulcers cause hunger pain relieved by food; gastric ulcers cause pain 30–60 minutes after meals.
• H. pylori is the leading cause; first-line therapy is triple therapy (PPI + amoxicillin + clarithromycin) for 10–14 days.
• PPIs are the most effective acid suppressants — take 30–60 minutes before breakfast.
• Major complications: bleeding (most common), perforation (surgical emergency with free air on X-ray), penetration (pain radiating to back), and gastric outlet obstruction (vomiting undigested food).
• Misoprostol prevents NSAID-induced ulcers but is contraindicated in pregnancy.