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Treatments for Ulcer
Treatments of Ulcer: Online Medical Books
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Corneal ulcers:
Treatment
(Professional Guide to Diseases (Eighth Edition))
Prompt treatment is essential for all forms of corneal ulcer to prevent complications and permanent visual impairment. Treatment usually consists of systemic and topical broad-spectrum antibiotics until culture results identify the causative organism. The goals of treatment are to eliminate the underlying cause of the ulcer and to relieve pain:
❑ Fungi — topical instillation of natamycin for Fusarium, Cephalosporium, and Candida.
❑ Herpes simplex type 1 virus — topical application of trifluridine drops or vidarabine ointment. Corneal ulcers resulting from a viral infection often recur, requiring further treatment with trifluridine.
❑ Hypovitaminosis A — correction of dietary deficiency or GI malabsorption of vitamin A.
❑ Infection by P. aeruginosa — polymyxin B and gentamicin, administered topically and by subconjunctival injection, or carbenicillin and tobramycin I.V. Because this type of corneal ulcer spreads so rapidly, it can cause corneal perforation and loss of the eye within 48 hours. Immediate treatment and isolation of hospitalized patients are required.
❑ Neurotropic ulcers or exposure keratitis — frequent instillation of artificial tears or lubricating ointments and use of a plastic bubble eye shield.
❑ Varicella-zoster virus — topical sulfonamide ointment applied three to four times daily to prevent secondary infection. These lesions are unilateral, following the pathway of the fifth cranial nerve, and are typically quite painful. Give analgesics as ordered. Associated anterior uveitis requires cycloplegic eyedrops. Watch for signs of secondary glaucoma (transient vision loss and halos around lights).
Experts recommend treating the patient with antibiotics to eradicate H. pylori. The patient taking NSAIDs may take a prostaglandin analog (misoprostol) to suppress ulceration (or the patient may take the analog with NSAIDs to prevent ulceration). Histamine-2 (H2) receptor antagonists or proton pump inhibitors may reduce acid secretion. A coating agent or bismuth may be administered to the patient with a duodenal ulcer to protect the lining.
If GI bleeding occurs, emergency treatment begins with passage of a nasogastric (NG) tube to allow for iced saline lavage, possibly containing norepinephrine. Gastroscopy allows visualization of the bleeding site and coagulation by laser or cautery to control bleeding. This type of therapy allows postponement of surgery until the patient’s condition stabilizes. Surgery is indicated for perforation, unresponsiveness to conservative treatment, and suspected malignancy. Surgery for peptic ulcers may include:
❑ vagotomy and pyloroplasty: severing one or more branches of the vagus nerve to reduce hydrochloric acid secretion and refashioning the pylorus to create a larger lumen and facilitate gastric emptying
❑ distal subtotal gastrectomy (with or without vagotomy): excising the antrum of the stomach, thereby removing the hormonal stimulus of the parietal cells, followed by anastomosis of the rest of the stomach to the duodenum or the jejunum
❑ pyloroplasty: surgical enlargement of the pylorus to provide drainage of gastric secretions.
Successful treatment must relieve pressure on the affected area, keep the area clean and dry, and promote healing. (See Special aids for preventing and treating pressure ulcers.)
The goals of treatment are to control inflammation, replace nutritional losses and blood volume, and prevent complications. Supportive treatment includes bed rest, I.V. fluid replacement, and a clear-liquid diet. For patients awaiting surgery or showing signs of dehydration and debilitation from excessive diarrhea, total parenteral nutrition (TPN) rests the intestinal tract, decreases stool volume, and restores positive nitrogen balance. Blood transfusions or iron supplements may be needed to correct anemia.
Immunomodulators or 5-aminosalicylates may be used to decrease the frequency of attacks. Drug therapy to control inflammation includes steroids. Antispasmodics and antidiarrheals are used only in patients whose ulcerative colitis is under control but who have frequent, loose stools.
Surgery is the last resort if the patient has toxic megacolon, fails to respond to drugs and supportive measures, or finds symptoms unbearable. A common surgical technique is proctocolectomy with ileostomy. Another procedure, the ileoanal pull-through, is being performed in more cases. This procedure entails performing a total proctocolectomy and mucosal stripping, creating a pouch from the terminal ileum, and anastomosing the pouch to the anal canal. A temporary ileostomy is created to divert stool and allow the rectal anastomosis to heal. The ileostomy is closed in 2 to 3 months, and the patient can then evacuate stool rectally. This procedure removes all the potentially malignant epithelia of the rectum and colon. Total colectomy and ileorectal anastomosis isn’t as common because of its mortality rate (2% to 5%). This procedure removes the entire colon and anastomoses the terminal ileum to the rectum; it requires observation of the remaining rectal stump for any signs of cancer or colitis.
Pouch ileostomy (Kock pouch or continent ileostomy), in which the surgeon creates a pouch from a small loop of the terminal ileum and a nipple valve from the distal ileum, may be an option. The resulting stoma opens just above the pubic hairline and the pouch is emptied periodically through a catheter inserted in the stoma. In ulcerative colitis, a colectomy may be performed after 10 years of active disease because of the increased incidence of colon cancer in these cases. Performing a partial colectomy to prevent colon cancer is controversial.
Advise the patient to eat frequent small meals and to avoid foods known to cause symptoms as well as coffee, tea, chocolate, alcohol, and tobacco.
Prompt treatment is essential for all forms of corneal ulcer to prevent complications and permanent visual impairment. Treatment aims to eliminate the underlying cause of the ulcer and to relieve pain.
Until culture results identify the causative organism, treatment consists of topical broad-spectrum antibiotics. Once the causative agent is identified, specific treatments vary.
❑ P. aeruginosa infection is treated with ciprofloxacin, gentamicin, or tobramycin, administered topically. This type of corneal ulcer can cause corneal perforation and loss of the eye very rapidly if left untreated. Immediate treatment and isolation of hospitalized patients are required.
A corneal ulcer should never be patched because patching creates the dark, warm, moist environment ideal for bacterial growth. However, it should be protected with a perforated shield.
❑ Herpes simplex type 1 virus is treated with hourly topical applications of idoxuridine or vidarabine. Corneal ulcers resulting from this viral infection commonly recur. Trifluridine is the treatment of choice.
❑ Fungi are treated with topical instillation of natamycin for Fusarium, Cephalosporium, and Candida.
❑ Hypovitaminosis A requires correction of dietary deficiency or GI malabsorption of vitamin A.
❑ Neurotropic ulcers or exposure keratitis is treated with frequent instillation of artificial tears or lubricating ointments and use of a plastic bubble eye shield or by a tarsorrhaphy (suturing the eyelids together).
H. pylori can be treated with a combination of agents and eradicated with antibiotics. Pharmacologic treatments include antisecretory agents, such as proton pump inhibitors and histamine-2 (H2)-receptor antagonists. Proton pump inhibitors work by binding to hydrogen-potassium adenosine triphosphatase, located at the surface of gastric parital cells to block formation of gastic acid. H2-receptor antagonists inhibit histamine binding to H2 receptors on the gastric parietal cell, which in turn decreases acid secretion. Drug therapy, which protects the mucosa, includes prostaglandin analogs and antacids. Prostaglandin analogs may be given to patients taking NSAIDs to suppress ulceration.
GI bleeding may be treated by giving H2-receptor antagonists I.V. as a continuous infusion. Upper endoscopy is preferred as a diagnostic tool when GI bleeding is present because an injection of epinephrine or saline (to surround the ulcer) can be performed to stop the bleeding during the procedure; cautery may also be used for hemostasis.
Surgery is indicated for perforation of the ulcer, continued bleeding despite medical treatment, and suspected malignancy. Surgical procedures for peptic ulcers and gastric outlet obstruction include:
❑ vagotomy and pyloroplasty: severing one or more branches of the vagus nerve to reduce hydrochloric acid secretion and refashioning the pylorus to create a larger lumen and facilitate gastric emptying
❑ distal subtotal gastrectomy (with or without vagotomy): excising the antrum of the stomach, thereby removing the hormonal stimulus of the parietal cells, followed by anastomosis of the remainder of the stomach to the duodenum or the jejunum.
Treatment should relieve pressure on the affected area, keep the area clean and dry, and promote healing. (See Special aids for preventing and treating pressure ulcers.)
The goals of treatment are to relieve symptoms of the acute attack and prevent recurrent attacks, to replace nutritional losses and blood volume, and to prevent complications.
Supportive treatment includes I.V. fluid replacement and a clear-liquid diet. For patients awaiting surgery or showing signs of dehydration and debilitation from excessive diarrhea, total parenteral nutrition rests the intestinal tract, decreases stool volume, and restores positive nitrogen balance. Blood transfusions or iron supplements may be necessary to correct anemia.
Medications to control inflammation include corticotropin and adrenal corticosteroids, such as prednisone, prednisolone, and hydrocortisone; sulfasalazine, which has antiinflammatory and antimicrobial properties, may also be used. Options to decrease attacks include 5-aminosalicylates such as mesalamine and immunomodulators such as azathioprine, 6-mercaptopurine.
UNDER STUDY: Dehydroepiandrosterone is a steroid hormone that’s marketed as an over-the-counter drug in the United States. In pilot studies, it was proven safe to use in patients with ulcerative colitis. Dosage adjustments may further improve treatment outcomes.
Patients with mild to moderate disease may eat a regular diet, excluding caffeinated beverages and gas-producing foods. Anticholinergics and a low-roughage diet without milk or milk products may be used to reduce bowel movement frequency. Fiber supplementation may be used to control diarrhea and rectal symptoms. Antidiarrheal agents should be used only in patients with mild symptoms, not in those with the acute phase of this illness.
Patients with disease primarily affecting the rectum or rectosigmoid should be managed with topical agents such as mesalamine. Topical steroids may be used, but they may be less effective.
Patients with mild to moderate disease extending above the sigmoid colon who fail to improve after 2 to 3 weeks on sulfasalazine or mesalamine should have a corticosteroid added to their regimen.
Severe colitis is usually managed with nothing-by-mouth status and parenteral alimentation. Volumizers and blood should be provided as needed. Surgical consultation should be obtained in all patients with severe disease.
Surgery is recommended for patients who have toxic megacolon or who fail to respond to drugs and supportive measures.
The ileoanal restorative proctocolectomy with ileoanal pouch anastomosis is being performed more frequently. This procedure entails performing a total proctocolectomy, creating a pouch from the terminal ileum, and anastomosing the pouch to the anal canal. A temporary ileostomy is created to divert stools and allow the rectal anastomosis to heal. This technique is now more common than total proctocolectomy with ileostomy. The ileostomy is closed in 2 to 3 months.
Total proctocolectomy (with ileostomy) provides complete cure of disease. However, the patient’s self-image and social interactions may be affected by wearing an external appliance.
Pouch ileostomy (Kock pouch or continent ileostomy), in which the surgeon creates a pouch from a small loop of the terminal ileum and a nipple valve from the distal ileum, may be an option. The resulting stoma opens just above the pubic hairline, and the pouch empties periodically through a catheter inserted in the stoma. Patients may experience six or more bowel movements per day. A low-residue diet should be maintained to promote pouch adaptation. Patients may also need bulking agents or antidiarrheals to slow stool output. This procedure is performed less often now than in the past.
A colectomy may be performed after 10 years of active ulcerative colitis because of the increased incidence of colon cancer in these patients. Performing a partial colectomy to prevent colon cancer is controversial.
Advise patients to eat frequent, small meals. Also, tell them to avoid foods known to cause symptoms as well as coffee, tea, chocolate, alcohol, and tobacco. Explain all diagnostic tests and procedures. Discuss other ways to deal with stress, such as deep breathing and guided imagery. Provide the patient with a calm environment to reduce stress, and make sure the patient gets plenty of rest. In addition, prepare the patient for endoscopy to evaluate the cause of dyspepsia.
▪ Give an antacid 30 minutes before or 1 hour after a meal.
▪ Provide food to relieve dyspepsia.
▪ Because various drugs can cause dyspepsia, give these after meals or with food, if possible.
▪ Provide a calm environment to reduce stress, and make sure that the patient gets plenty of rest.
▪ Prepare the patient for endoscopy to evaluate the cause of dyspepsia.
▪ Discuss stress reduction techniques, such as deep breathing and guided imagery.
▪ Discuss the importance of small, frequent meals.
▪ Explain to the patient his diagnosis and the treatment plan.
▪ If breast cancer is suspected, provide emotional support and encourage the patient to express her feelings.
▪ Prepare her for diagnostic tests, such as ultrasonography, thermography, mammography, nipple discharge cytology, and breast biopsy.
▪ If a Candida infection is suspected, prepare her for skin or blood cultures.
▪ Teach the patient how to apply a topical antifungal or antibacterial ointment or cream.
▪ Instruct her to keep the ulcer dry to reduce chafing and to wear loose-fitting undergarments.
▪ Explain the importance of clinical breast examination and mammography following the American Cancer Society guidelines.
▪ Teach the patient about the cause of the breast ulcer and the treatment plan after a diagnosis is established.
Note:You must always seek professional medical advice about any treatment
or change in treatment plans.
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Medical Articles:
Peptic ulcers:
Treatment
(Professional Guide to Diseases (Eighth Edition))
Pressure ulcers:
Treatment
(Professional Guide to Diseases (Eighth Edition))
Ulcerative colitis:
Treatment
(Professional Guide to Diseases (Eighth Edition))
Dyspepsia:
Patient counseling
(Professional Guide to Signs & Symptoms (Fifth Edition))
Corneal ulcers:
Treatment
(Handbook of Diseases)
Peptic ulcers:
Treatment
(Handbook of Diseases)
Pressure ulcers:
Treatment
(Handbook of Diseases)
Ulcerative colitis:
Treatment
(Handbook of Diseases)
Drug therapy
Surgery
Dyspepsia:
Patient counseling
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Dyspepsia:
Nursing considerations
(Nursing: Interpreting Signs and Symptoms)
Patient teaching
Breast ulcer:
Nursing considerations
(Nursing: Interpreting Signs and Symptoms)
Patient teaching
Medications used to treat Ulcer:
Medical news summaries about treatments for Ulcer:
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