10.2 Upper GI Disorders: H. pylori, Peptic Ulcer, Gastroscopy & Coffee-Ground Vomiting
Key Takeaways
- RCSI lists H. pylori, gastroscopy and coffee-ground vomiting in its gastrointestinal reading group, and pairs H. pylori ulcer with gastroscopy as a teaching the junior student nurse example.
- Helicobacter pylori is the commonest cause of peptic ulcer disease, and is diagnosed non-invasively by urea breath test or stool antigen test, both of which require the patient to stop proton pump inhibitors for about two weeks and antibiotics for four weeks beforehand.
- Coffee-ground vomitus is altered blood from an upper gastrointestinal bleed and is a medical emergency requiring ABCDE assessment, a full observation set with INEWS, large-bore intravenous access, group and crossmatch and urgent escalation.
- Nursing care after gastroscopy centres on keeping the patient nil by mouth until the gag reflex has returned after throat spray, and observing for bleeding, perforation and sedation-related complications.
- Peptic ulcer perforation presents with sudden severe epigastric pain, a rigid board-like abdomen and signs of shock, and is a surgical emergency.
Upper GI Disorders: H. pylori, Peptic Ulcer, Gastroscopy & Coffee-Ground Vomiting
RCSI's Gastrointestinal reading group includes H. pylori, gastroscopy and coffee-ground vomiting, and its teaching the junior student nurse examples open with Helicobacter pylori ulcer and gastroscopy. This is therefore a topic you may need to explain to someone else under examination conditions - which is a higher bar than knowing it yourself.
Peptic Ulcer Disease
A peptic ulcer is a break in the mucosa of the stomach (gastric ulcer) or duodenum (duodenal ulcer) extending through the muscularis mucosae. Ulceration occurs when aggressive factors - acid, pepsin, H. pylori, NSAIDs - overwhelm the mucosal defences of mucus, bicarbonate, mucosal blood flow and prostaglandins.
| Cause | Mechanism |
|---|---|
| Helicobacter pylori | A Gram-negative spiral bacterium that colonises gastric mucosa, produces urease to neutralise local acid, and causes chronic inflammation. The commonest cause of peptic ulceration |
| NSAIDs and aspirin | Inhibit COX-1, reducing protective prostaglandin synthesis. Risk rises with age, dose, duration, concurrent corticosteroids, anticoagulants or SSRIs |
| Smoking and alcohol | Impair healing and mucosal defence |
| Severe physiological stress | Stress ulceration in critical illness, burns and head injury |
| Zollinger-Ellison syndrome | Rare gastrin-secreting tumour causing profound acid hypersecretion |
Presentation. Epigastric pain is the cardinal symptom. Classically, duodenal ulcer pain eases with food and returns some hours later, often waking the patient at night, while gastric ulcer pain is aggravated by eating. That distinction is soft in practice, and older patients or those on NSAIDs may have no pain at all and present first with bleeding or perforation. Other features include nausea, early satiety, bloating, belching, and weight loss.
Complications: bleeding (haematemesis, coffee-ground vomiting, melaena), perforation, gastric outlet obstruction, and - with chronic H. pylori infection - gastric malignancy.
Helicobacter pylori: Testing and Eradication
Non-invasive tests
- Urea breath test. The patient swallows labelled urea; if H. pylori is present, its urease splits the urea and labelled carbon dioxide appears in the breath.
- Stool antigen test. Detects H. pylori antigen in faeces.
The preparation rule that gets missed. Both tests are affected by acid suppression and antibiotics. The patient must generally stop a proton pump inhibitor for about two weeks and antibiotics for four weeks before testing, otherwise a false negative is likely. Checking and explaining this is a nursing responsibility, and a patient who takes their omeprazole the morning of the test has wasted it.
- Serology detects antibodies but cannot distinguish current from past infection, so it is not used to confirm eradication.
- Endoscopic biopsy with a rapid urease test or histology is used when gastroscopy is being performed anyway.
Eradication therapy
Standard eradication combines a proton pump inhibitor with two antibiotics - commonly amoxicillin with clarithromycin or metronidazole - for 7 to 14 days, with the exact regimen determined by local resistance patterns and antimicrobial guidance.
Nursing education points that determine whether it works:
- Complete the full course. Partial treatment fails and drives clarithromycin resistance.
- Expect side effects: metallic taste, nausea, diarrhoea, and with metronidazole a disulfiram-like reaction with alcohol, so alcohol must be avoided during and for a period after the course.
- Warn that clarithromycin and metronidazole interact with warfarin, raising the INR.
- Stop NSAIDs where possible; if they must continue, gastroprotection is required.
- Confirm eradication with a repeat urea breath test or stool antigen test, observing the same washout rules.
Coffee-Ground Vomiting and Upper GI Bleeding
Coffee-ground vomitus is blood. Haemoglobin exposed to gastric acid is converted to brown haematin, producing granular brown-black material resembling coffee grounds. It signals bleeding that has been in the stomach for some time.
| Sign | Meaning |
|---|---|
| Fresh haematemesis | Active, brisk bleeding |
| Coffee-ground vomitus | Blood altered by gastric acid - bleeding may be slower or have stopped, but it is still bleeding |
| Melaena | Black, tarry, offensive stool - digested blood from an upper GI source |
| Fresh rectal bleeding with shock | Can indicate a very brisk upper GI bleed with rapid transit |
Common causes: peptic ulcer, oesophageal or gastric varices (in liver disease), Mallory-Weiss tear after forceful vomiting, oesophagitis, gastritis and malignancy.
Immediate Nursing Management
- ABCDE. Protect the airway - a vomiting patient with a reduced conscious level is at high aspiration risk; position appropriately and have suction ready.
- Full observation set and INEWS. Tachycardia usually precedes hypotension; a young patient can lose a large volume before the blood pressure falls, and a patient on beta-blockers may not mount a tachycardia at all.
- Escalate immediately - a significant upper GI bleed meets emergency response criteria and needs medical review without delay.
- Two large-bore IV cannulae; bloods for full blood count, urea and electrolytes, coagulation screen, liver profile and group and crossmatch. A raised urea with normal creatinine is a classic marker of an upper GI bleed, from absorbed blood protein.
- Nil by mouth in anticipation of endoscopy.
- Fluid resuscitation and blood products as prescribed; strict fluid balance and hourly urine output.
- Review anticoagulants, antiplatelets and NSAIDs with the medical team; anticipate proton pump inhibitor therapy and, where varices are suspected, terlipressin and antibiotics as prescribed.
- Endoscopy is both diagnostic and therapeutic and is usually arranged urgently.
- Keep the patient and family informed - vomiting blood is frightening, and calm explanation is part of the care.
Perforation
Sudden, severe, constant epigastric pain with a rigid, board-like abdomen, absent bowel sounds, a patient lying completely still, and signs of shock indicates perforation. This is a surgical emergency: nil by mouth, large-bore access, fluids, analgesia and antiemetics as prescribed, urgent escalation, and preparation for theatre.
Gastroscopy (Upper GI Endoscopy)
Gastroscopy - oesophagogastroduodenoscopy - passes a flexible endoscope through the mouth to visualise the oesophagus, stomach and duodenum, allowing biopsy, H. pylori testing and therapeutic intervention such as clipping or banding a bleeding point.
| Phase | Nursing care |
|---|---|
| Before | Confirm valid informed consent. Confirm fasting per local policy - typically no food for around 6 hours and clear fluids stopped a set period before. Check anticoagulants, antiplatelets and diabetic medication and whether instructions were followed. Record baseline observations. Remove dentures. Establish IV access. Explain the throat spray and, if used, sedation. Ask about allergies and about previous sedation reactions |
| During | Position in the left lateral position; a mouth guard protects the scope and teeth. Monitor saturations, pulse and conscious level. Offer reassurance and reposition the patient's head to allow saliva to drain |
| After | Observations until stable. Strictly nil by mouth until the gag reflex has fully returned after throat spray, then test with sips of water. Observe for haematemesis, melaena, abdominal or chest pain, surgical emphysema in the neck, breathlessness and fever - any of which may indicate bleeding or perforation. Expect some bloating and a sore throat. Give written discharge advice and a results plan |
If sedation was given, the patient must not drive, operate machinery, drink alcohol or sign legal documents for the rest of the day, and must be accompanied home by a responsible adult and not left alone.
Teaching a Junior Student: A Model Explanation
RCSI's teaching stations are marked on how well you teach, not only on what you know. A workable structure:
- Check what they already know, and pitch from there.
- Explain the condition in plain language: "An ulcer is a sore in the stomach or duodenal lining. The commonest cause is a bacterium called Helicobacter pylori."
- Explain the investigation and why it is being done: what a gastroscopy is, what it can show, and that a biopsy can be taken painlessly.
- Cover the nursing responsibilities: consent, fasting, dentures out, IV access, observations, position, and - the point students most often miss - nil by mouth until the gag reflex returns.
- Name the complications to watch for: bleeding, perforation, and sedation-related respiratory depression.
- Check understanding using teach-back: ask the student to tell you in their own words what they would monitor after the procedure, rather than asking "does that make sense?".
- Signpost the evidence: local policy, the endoscopy unit's patient information, and national guidance.
A patient attending for a urea breath test to check for Helicobacter pylori mentions they took their omeprazole this morning as usual. What should the nurse do?
A 63-year-old man on long-term diclofenac vomits a large amount of brown granular material resembling coffee grounds. His pulse is 116 and his systolic BP is 96 mmHg. What is the priority?
A patient has just returned from gastroscopy performed with throat spray and sedation. Which instruction is most important in the immediate recovery period?