Bleeding Peptic Ulcer Disease Case Study 123c50

ANATOMY AND PHYSIOLOGY

Mouth The mouth is the starting point in the digestive system. Both mechanical and chemical digestion can occur here. The teeth grind food for mechanical digestions while the salivary gland break down for chemically for chemical digestion. Salivary Glands The salivary glands release saliva. The saliva breaks down food chemically. You have three major salivary glands. One on the top of your mouth, one on the bottom and one that covers both sides. Saliva breaks up food using the enzyme salivary amylas Esophagus (also Oesophagus) The esophagus, a muscular tube through which partially digested food travels, connects the mouth and the stomach. Food goes down the esophagus using peristalsis, a pattern of muscular movements, contracting and expanding. Stomach The stomach's job is to break down large food molecules into smaller pieces, so that they are more easily absorbed into the blood. The stomach can give off two or three liters of gastric juices per day. This juice can even destroy the inner liner of the stomach. This is why the inner lining of the stomach is replaced every two to three days. Liver, Pancreas, and Gallbladder The liver puts bile into the small intestine through the biliary system, using the gallbladder as a container to hold the extra bile. The pancreas puts off a fluid containing bicarbonate and several juices, including trypsin, chymotrypsin, lipase, and pancreatic amylase, as well as nucleolytic juices, into the small intestine. Both these organs help in the process of digestion. Small Intestine The small intestine connects the stomach and the colon or large intestine. It has three parts. They are the duodenum, jejunum, and the ileum. The walls of the small intestine are lined with villi. Villi help absorb nutrients and put them into the blood. This is the main purpose of the small intestine.

Large Intestine (Colon) The large intestine is used to remove water from solid waste. It is 1.5 meters in length. It also absorbs some vitamins such as vitamin k.

Human Digestive System

The human digestive system is a complex series of organs and glands that processes food. In order to use the food we eat, our body has to break the food down into smaller molecules that it can process; it also has to excrete waste. Most of the digestive organs (like the stomach and intestines) are tube-like and contain the food as it makes its way through the body. The digestive system is essentially a long, twisting tube that runs from the mouth to the anus, plus a few other organs (like the liver and pancreas) that produce or store digestive chemicals. The Digestive Process: The start of the process - the mouth: The digestive process begins in the mouth. Food is partly broken down by the process of chewing and by the chemical action of salivary enzymes (these enzymes are produces by the salivary glands and break down starches into smaller molecules). On the way to the stomach: the esophagus - After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube that runs from the mouth to the stomach. It uses rhythmic, wave-like muscle movements (called peristalsis) to force food from the throat into the stomach. This muscle movement gives us the ability to eat or drink even when we're upside-down. In the stomach - The stomach is a large, sack-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed with stomach acids is called chyme. In the small intestine - After being in the stomach, food enters the duodenum, the first part of the small intestine. It then enters the jejunum and then the ileum (the final part of the small intestine). In the small intestine, bile (produced in the liver and stored in the gall bladder), pancreatic enzymes, and other digestive enzymes produced by the inner wall of the small intestine help in the breakdown of food.

In the large intestine - After ing through the small intestine, food es into the large intestine. In the large intestine, some of the water and electrolytes (chemicals like sodium) are removed from the food. Many microbes (bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli, and Klebsiella) in the large intestine help in the digestion process. The first part of the large intestine is called the cecum (the appendix is connected to the cecum). Food then travels upward in the ascending colon. The food travels across the abdomen in the transverse colon, goes back down the other side of the body in the descending colon, and then through the sigmoid colon. The end of the process - Solid waste is then stored in the rectum until it is excreted via the anus. Digestive System Glossary: anus - the opening at the end of the digestive system from which feces (waste) exits the body. appendix - a small sac located on the cecum. ascending colon - the part of the large intestine that run upwards; it is located after the cecum. bile - a digestive chemical that is produced in the liver, stored in the gall bladder, and secreted into the small intestine. cecum - the first part of the large intestine; the appendix is connected to the cecum. chyme - food in the stomach that is partly digested and mixed with stomach acids. Chyme goes on to the small intestine for further digestion. descending colon - the part of the large intestine that run downwards after the transverse colon and before the sigmoid colon. duodenum - the first part of the small intestine; it is C-shaped and runs from the stomach to the jejunum. epiglottis - the flap at the back of the tongue that keeps chewed food from going down

the windpipe to the lungs. When you swallow, the epiglottis automatically closes. When you breathe, the epiglottis opens so that air can go in and out of the windpipe. esophagus - the long tube between the mouth and the stomach. It uses rhythmic muscle movements (called peristalsis) to force food from the throat into the stomach. gall bladder - a small, sac-like organ located by the duodenum. It stores and releases bile (a digestive chemical which is produced in the liver) into the small intestine. ileum - the last part of the small intestine before the large intestine begins. jejunum - the long, coiled mid-section of the small intestine; it is between the duodenum and the ileum. liver - a large organ located above and in front of the stomach. It filters toxins from the blood, and makes bile (which breaks down fats) and some blood proteins. mouth - the first part of the digestive system, where food enters the body. Chewing and salivary enzymes in the mouth are the beginning of the digestive process (breaking down the food). pancreas - an enzyme-producing gland located below the stomach and above the intestines. Enzymes from the pancreas help in the digestion of carbohydrates, fats and proteins in the small intestine. peristalsis - rhythmic muscle movements that force food in the esophagus from the throat into the stomach. Peristalsis is involuntary - you cannot control it. It is also what allows you to eat and drink while upside-down. rectum - the lower part of the large intestine, where feces are stored before they are excreted. salivary glands - glands located in the mouth that produce saliva. Saliva contains enzymes that break down carbohydrates (starch) into smaller molecules. sigmoid colon - the part of the large intestine between the descending colon and the rectum.

stomach - a sack-like, muscular organ that is attached to the esophagus. Both chemical and mechanical digestion takes place in the stomach. When food enters the stomach, it is churned in a bath of acids and enzymes. transverse colon - the part of the large intestine that runs horizontally across the abdomen. The digestive system carries out six basic processes: ingestion secretion propulsion digestion absorption defecation Ingestion is taking food into the mouth. Secretion is the act of expelling a liquid. The cells lining the GI tract secrete about 9 liters (9.5 quarts) of water, acid, buffers, and enzymes each day to lubricate the canal and aid in the process of digestion. Propulsion consists of alternating contraction and relaxation of smooth muscle in the walls of the GI tract to squeeze food downwards. Digestion has two parts, mechanical and chemical. Mechanical digestion is chewing up the food and your stomach and smooth intestine churning the food, while chemical digestion is the work the enzymes do when breaking large carbohydrate, lipid, protein and nucleic acid molecules down into their subcomponents -these and others are the nutrients-. Absorption occurs in the digestive system when the nutrients move from the gastrointestinal tract to the blood or lymph. Defecation is the process of expelling what the body couldn't use.

PATHOPHYSIOLOGY OF BLEEDING PEPTIC ULCER DISEASE

Helicobacter Pylori

Non-Steroidal AntiInflammatory

Release of cytokines, lipopolysaccharides, heat-shock protein enzymes, etc.

Inflammatory cascade initiated (cytokines, lymphocytes, neutrophils, etc.)

Hydrogen ions and pepsin

Topical and systemic effects

Mucosal damage and ulceration

Decreased mucus production, Decreased blood flow, Increased neutrophils, Decreased bicarbonate,

Bleedin g

Decreased cell restitution

Melena Hemateme sis Abdominal Pain

DRUG STUDY

Name of drug Metronidazole

Pharmacodynamics Direct-acting trichomonacide and amebicide that works inside and outside the intestines. It is thought to enter the cells of microorganisms that contain nitroreductase, forming unstable compounds that bind to DNA and inhibit synthesis, causing cell death.

Dosage

Adverse effects

Contraindications

Nursing Responsibilities

Rationale

CNS: headache, dizziness, seizures GI: abdominal pain, anorezia, nausea, diarrhea, dry mouth, furry tongue, glossitis, unpleasant taste vomiting Skin: rashes, urticaria Hematologic: leucopenia Local: phlebitis at IV site Neuro: peripheral neuropathy Other: superinfection

- patients with hypersensitivity to metronidazole or other nitroimidazoles. - use cautiously in patients with history of blood dyscrasia, CNS disorder, or retinal or visual changes. Patients - use cautiously in patients who take hepatotoxic drugs or have hepatic disease or alcoholism.

- ister with food or milk. Tablets may be crushed for patients with difficulty swallowing.

- to minimize gastric irritation.

- instruct patient to take medication exactly as directed evenly spaced times between dose, even if feeling better. Do not skip doses or double up on missed doses. Id a dose is missed, take as soon as ed if not almost time for the next dose.

- altering the dosage of the medication may cause untoward effects.

- drug may cause - caution patient about dizziness or lightactivities that may be headedness. requiring mental awareness until response to medication is known. - caution patient that medication may cause an unpleasant metallic taste. - inform patient that medication may cause urine to turn dark. - advise patient to consult - this may indicate occurrence of a health care professional if there is no superinfection. improvement after a few days or if signs such as black furry overgrowth in tongue, or foul-smelling stools develop. - monitor patient for

MEDICAL MANAGEMENT •

Given the current understanding of the pathogenesis of PUD, most patients with PUD are treated successfully with cure of H pylori infection and/or avoidance of NSAIDs, along with the appropriate use of antisecretory therapy.

•

A number of treatment options exist for patients presenting with symptoms suggestive of PUD or ulcerlike dyspepsia, including empiric antisecretory therapy, empiric triple therapy for H pylori infection, endoscopy followed by appropriate therapy based on findings, and H pylori serology followed by triple therapy for patients who are infected. Breath testing for active H pylori infection may be used.

•

Computer models have suggested that obtaining H pylori serology followed by triple therapy for patients who are infected is the most cost-effective approach; however, no direct evidence from clinical trials provides confirmation.

•

Perform endoscopy early in patients older than 45-50 years and in patients with associated so-called alarm symptoms, such as dysphagia, recurrent vomiting, weight loss, or bleeding.

SURGICAL TREATMENT With the success of medical therapy, surgery has a very limited role in the management of PUD. •

Potential indications for surgery include refractory disease. Complications of PUD include the following: o

Refractory, symptomatic peptic ulcers, though rare with the cure of H pylori infection and the appropriate use of antisecretory therapy, are a potential complication of PUD.

o

Perforation usually is managed emergently with surgical repair. However, this is not mandatory for all patients.

o

Obstruction can complicate PUD, particularly if PUD is refractory to aggressive antisecretory therapy, H pylori eradication, or avoidance of NSAIDs. Obstruction may persist or recur despite endoscopic balloon dilation.

o

Penetration, particularly if not walled off or if a gastrocolic fistula develops, is a potential complication of PUD.

o

Bleeding can complicate PUD, particularly in patients with massive hemorrhage and hemodynamic instability, recurrent bleeding on medical therapy, and failure of therapeutic endoscopy to control bleeding.

•

The appropriate surgical procedure depends on the location and nature of the ulcer. o

Many authorities recommend simple oversewing of the ulcer with treatment of the underlying H pylori infection or cessation of NSAIDs for bleeding PUD.

o

Additional surgical options for refractory or complicated PUD include vagotomy

and

pyloroplasty,

vagotomy

and

antrectomy

with

gastroduodenal reconstruction (Billroth I) or gastrojejunal reconstruction (Billroth II), or a highly selective vagotomy.

IF NOT TREATED Complications of Bleeding Peptic Ulcer Disease

Bleeding from granulation tissue

Erosion of ulcer into an artery or vein

HEMORRH AGE Sudden onset of weakness

Dizziness

Thirst

Cold and moist skin

age of loose, tarry, or even red stools and coffee-ground emesis

Excessive blood loss

Circulatory shock

Desire to defecate

Edema, spasm or contraction of scar tissue

OBSTRUCTION

Interference with the free age of gastric contents through the pylorus or adjacent areas

Feeling of epigastric fullness And heaviness after meals

SEVERE OBSTRUCTION Vomiting of undigested food

Ulcer erodes through all the layers of the stomach or duodenum

PERFORATIO N Gastrointestinal contents enter the peritoneum

Symptoms: Radiation of pain into the lower back Severe night distress

PERITONIT IS

Penetrate adjacent

Bowel obstruction

Nausea and vomiting

Translocation of fluid into peritoneal cavity and into bowel

Further losses of fluid

Hypovolemia and shock

Inadequate pain relief from eating food or taking antacids

PERITONITIS

Reflex muscle guarding

Vomiting Fever

Irritation of phrenic nerve

Elevated WBC count Abdomen is rigid, often described as board-like

Tachycardia Hypotension

Hiccups

Breathing is shallow

PARALYTIC ILEUS

ABDOMINAL DISTENTION

Note: if peritonitis progresses and is left untreated, it leads to toxemia and shock, and eventually death.