CASE STUDY:UGIB with Multiple Large Gastric Ulcers

GROUP 6:Bulatao, Lesley Charmaine C. Cabudoc, Maricar G.Comilang, Janielle Lyn M.Constante, Quolette M. Dela Cruz, Rhealyn N.Ebuenga, Allysa O.Espanueva, Gaylen C.Fabon, Yvette Stephanie Nichol B. Franco, Ma. Eliza Joy L.Fuentes, Racquel F.

Introduction

Upper GI bleedingoriginates in the GI tract from the

mouth to the ligament of Treitz where the duodenum, the first part of the small intestine, ends. Bleeding from the esophagus may occur from esophageal varices, dilation of the veins in the esophagus. This can occur with liver cirrhosis, because blood from the GI tract to the liver backs up when it has difficulty getting through the liver.

For the stomach and duodenum, bleeding in these areas can often occur from tumors and ulcers, the latter of which can be due to certain medications (e.g., nonsteroidal anti-inflammatory drugs) or the bacterium Helicobacter pylori. These causes do not comprise a complete list but do represent common causes.

Symptoms and Signs

One of the symptoms of upper GI bleeding is vomiting of blood (hematemesis). If the blood travels through the GI tract, the stool may appear tarry and black (melena) because of digested blood, though the stool can still be stained with red blood (hematochezia).

Otherwise, bleeding over time results in anemia, characterized by lower than normal blood hemoglobin and hematocrit with symptoms like weakness, fatigue, and fainting.

Evaluation and Treatment

The most important step to evaluate upper GI bleeding is upper endoscopy. During this procedure, performed by a gastroenterologist, a tube with a camera (endoscope) is passed into the mouth and down the esophagus. The gastroenterologist can proceed to the stomach and duodenum and localize the source of the bleeding, if possible.

Any active bleeding can be stopped at the site or sites of origin using mechanical methods (e.g., banding for esophageal varices), thermal methods, or chemical methods (e.g., vasopressin). The necessary tools, including biopsy instruments if necessary to take tissue samples, are brought to the site through the tube portion of the endoscope.

The remainder of treatment addresses the underlying causes of the bleeding. For example, upper GI bleeding due to a large stomach tumor requires surgery, and for patients with stomach and duodenal ulcers, medications like proton-pump inhibitors to halt acid production can slow progression of the ulcer.

Gastric Ulcer

An ulcer is a sore or hole in the lining of the stomach or duodenum (the first part of the small intestine). It is a break in the normal tissue that lines the stomach.

SIGNS AND SYMPTOMS

Recurrent abdominal pain - dull and burning type pain usually located in epigastric area (area between belly button and rib cage)

Abdominal pain after foodAbdominal pain at nightBlood in vomit

NauseaAnorexiaBlack stoolsFatigueBreathlessnessAbdominal painLack of sleepWorsened on

eating

May be relieved by antacids or milk

Abdominal indigestion

Vomiting, especially vomiting blood

Blood in stools or black, tarry stools

Unintentional weight loss

TreatmentSymptomatic relief: antacid

preparationsAnti-acid medications: "Proton-Pump"

inhibitors (eg omeprazole, lansoprazole), H2 antagonists (eg ranitidine, cimetidine)

Eradication of Helicobacter pylori infection: oral antibiotics, proton pump inhibitor

• Avoidance of NSAID medications (aspirin, ibuprofen (Nurofen, Brufen etc)

• Surgical partial gastrectomy - only performed if ulcer will not heal using medications or if there is acute haemorrhage or perforation of ulcer

Biographical

Data

Name: Ms. M. Z.Age: 79 y/o Gender: Female

Address:Cupang, Muntinlupa

Chief Complaint: Change in sensorium and general body weakness

Admitting Date: April 22, 2010

Attending Physician: Dr. Macalalag

Admitting Diagnosis: Urosepsis; Metabolic Encepalopathy

Final Diagnosis: UGIB secondary to Multiple Gastric Ulcers.

Case Abstract

This is the case of Patient M. Z., a 79 year old female who came to Medical Center Muntinlupa with a chief complaint of general body weakness and who manifested a change in sensorium. She was admitted on April 22, 2010 under the service of Dr. Macalalag.

1 week prior to admission, the patient had experienced a sudden loss of appetite and body weakness. 4 days prior to admission, Ms. M. Z. had her laboratory check up which revealed that she has a urinary tract infection and was prescribed with Ceftriaxone which she received via heplock. 3 days prior to admission, patient reported to have noticed the appearance of black, tarry stool.

1 day prior to admission, patient was noted by her relatives to be talkative but was not oriented to person, place or time. She was also unable to sleep the previous night.

On April 23, 2010, the physician ordered for a CT Scan and an ECG test. The following day, April 24, 2010, the patient was inserted with a Central Venous Pressure line via cutdown of her right arm and was subject for a urinalysis. On April 25, 2010, the patient had her chest X-ray, BUN and Creatinine tests

On April 26, 2010, the patient was subject for a blood test (Hgb and CBC) and a gastroscopy which revealed a result of multiple gastric ulcers and a Hiatal Hernia.

Anatomy

Anatomy of Gastrointestinal Tract

The Human gastrointestinal tract is the system by which ingested food is acted upon by physical and chemical means to provide the body with nutrients it can absorb and to excrete waste products; in mammals the system includes the alimentary canal extending from the mouth to the anus, and the hormones and enzymes assisting in digestion.

In an adult male human, the gastrointestinal (GI) are 5 metres (20 ft) long in a live subject, or up to 9 metres (30 ft) without the effect of muscle tone, and consists of the upper and lower GI tracts. The tract may also be divided into foregut, midgut, and hindgut, reflecting the embryological origin of each segment of the tract.

The GI tract releases hormones as to help regulate the digestion process. These hormones, including gastrin, secretin, cholecystokinin, and grehlin, are mediated through either intracrine or autocrine mechanisms, indicating that the cells releasing these hormones are conserved structures throughout evolution.

The major functions of the GI tract are categorized as four distinct processes:

Ingestion is the consumption of food and other substances through the mouth, as they pass by chewing and swallowing into the GI tract.

Digestion is the process of metabolism by which ingested substances are mechanically and chemically converted for use by the body.

Digestion is further categorized into three distinct phases: the cephalic phase in which taste and smell stimulate the nervous system to prepare the body for eating and digestion; the gastric phase in which passage of food into the stomach stimulates the release of gastric juices and pH balancing mechanisms throughout the system; the intestinal phase in which excitatory and inhibitory reflexes control the passage of partially digested food into and through the intestines.

Absorption is the movement of metabolized nutrients and water from the digestive system into the circulatory and lymphatic capillaries by osmosis, active transport, and diffusion through the cells in the walls and surrounding layers of the intestines and their supporting circulatory systems.

Excretion is the elimination of undigested, mostly solid material from the GI tract by defecation. Fluid products of metabolism throughout the body are also excreted by organ systems not directly part of the GI tract and digestive system, such as the kidneys, skin, and lungs.

In addition to processing nutrients as the principal pathway of the digestive system, the GI tract is also a prominent part of the immune system, providing various levels of defense against pathogenic microorganisms and potentially toxic substances throughout the path of digestion.

Dysfunction anywhere in the GI tract, whether by disease, trauma, or anatomical anomaly, can result in symptoms or conditions affecting the well-being of the entire individual. Many diseases and disorders of the GI tract can result in feeding difficulties in children and infants.

Upper GI TractThe upper GI

tract consists of the mouth, pharynx, esophagus, and stomach. This is where ingestion and the first phase of digestion occur.

The mouth includes the tongue, teeth, and buccal mucosa or mucous membranes containing the ends of the salivary glands, continuous with the soft palate, floor of the mouth and underside of the tongue. Chewing (mastication) is the mechanical process by which food, constantly repositioned by muscular action of the tongue and cheeks, is crushed and ground by the teeth through the muscular action of the lower jaw (mandible) against the fixed resistance of the upper jaw (maxilla).

Saliva excreted in the oral cavity by three pairs of exocrine glands (parotid, submandibular, and sublingual) is mixed with chewed food to form a bolus, or ball-shaped mass. There are two types of saliva: a thin watery secretion that wets the food and a thick mucous secretion that lubricates and causes the food particles to stick together to form the bolus.

Digestive enzymes in saliva begin the chemical breakdown of food, primarily starches at this point, almost immediately.

PharynxThe pharynx is contained in the neck and throat and functions as part of both the digestive system and the respiratory system. The human pharynx is divided into three sections: the nasopharynx behind the nasal cavity and above the soft palate;

The oropharynx behind the oral cavity and including the base of the tongue, the tonsils, and the uvula; the hypopharynx or laryngopharynx includes the junction with the esophagus and the larynx, where respiratory and digestive pathways diverge. The swallowing reflex is initiated by touch receptors in the pharynx as the bolus of chewed food is pushed to the back of the mouth.

Swallowing automatically closes down the respiratory or breathing pathway as an anti-choking reflex. Failure or confusion of reflexes at this point can result in aspiration of solid or liquid food into the trachea and lungs.

Esophagus The esophagus is the hollow muscular tube through which food passes from the pharynx to the stomach. It is also lined with mucous membrane continuous with the mucosa of the mouth and into which open the esophageal glands.

The esophagus is surrounded by relatively deep muscles that move the swallowed bolus of masticated food through peristaltic action, piercing the thoracic diaphragm to reach the stomach.

Stomach The stomach is a hollow muscular organ, located below the diaphragm and above the small intestine that receives and holds masticated food to begin the next phase of digestion. Two smooth muscle valves, the esophageal sphincter above and the pyloric sphincter below, keep stomach contents contained.

The stomach is surrounded by stimulant (parasympathetic) and inhibitor (orthosympathetic) nerve plexuses which regulate both secretory and muscular activity during digestion. With a volume of as little as 50 mL when empty, the adult human stomach may comfortably contain about a liter of food after a meal, or uncomfortably as much as 4 liters of liquid

Lower GI TractThe lower GI tract includes the small intestine and large intestine, beginning after the stomach and terminating at the anus. Its function is to complete the digestion and absorption of nutrients and to prepare waste products for elimination from the digestive system.

Small Intestine

The small intestine is where most digestion takes place. It is structurally divided into three parts: the duodenum, the jejunum, and the ileum. Among humans over five years old, the small intestine tends to vary in length from 4-7 meters (13 to 23 feet).

The duodenum consists of four parts, with the first three forming a “C” shape. The first or superior part of the duodenum begins at the pylorus, passing laterally for a short distance before curving into the superior duodenal flexure. The second or descending part the duodenum passes from the superior into the inferior duodenal flexure, and is where the pancreatic and common bile ducts enter the GI tract.

The third or inferior horizontal part of the duodenum passes from the inferior flexure, crossing the aorta (major artery) and inferior vena cava (major vein), as well as the spinal. The fourth or ascending part of the duodenum passes over the aorta, and curves past the pancreas to the duodenojejunal flexure. The duodenum is where most of the breakdown of food in the small intestine occurs.

It is here that Brunner’s glands produce an alkaline secretion to protect the duodenum from acidic chyme entering from the stomach and to activate intestinal enzymes enabling digestion and absorption.

The jejunum begins at the ligament of Treitz in the duodenojejunal flexure and continues to the ileum. The inner surface or mucous membrane of the jejunum is covered by villi (small finger-like structures) much longer than found in the duodenum or ileum, contained in many large circular folds (plicae circulares) which provide extensive surface area for absorption of nutrients.

The villi can increase intestinal absorptive surface area by a factor of 30; the microvilli extensions of the villi increase surface area by an additional factor of 600. Villus capillaries collect amino acids and simple sugars. Villus lacteals or lymphatic capillaries absorb dietary fats.

The ileum is the final and longest section of the small intestine. Both the jejunum and the ileum are suspended by mesentery, a double layer of peritoneum that allows these parts of the intestine to move more freely within the abdomen. Like the jejunum, the wall of the ileum has many folds and villi to increase both adsorption of enzymes and absorption of nutrients.

It also has an increasing number of goblet cells. The ileum is responsible for the final stages of protein and carbohydrate digestion, as contents are pushed along by peristaltic waves of smooth muscle contractions. There is no absolute demarcation between the jejunum and the ileum, but the ileum tends to have more fat inside the mesentery and has a relatively decreasing diameter.

Unlike the rest of the small intestine, the ileum has abundant Peyer’s patches, lymphoid follicles similar to lymph nodes, which function as an important component of the immune system response to pathogenic organisms in the GI tract.

Large IntestineAlso commonly referred to by the name of its longest component, the colon, the large intestine is the last part of the digestive system. Its principal function is to absorb remaining water from the waste products of digestion as it compact the accumulated waste for periodic elimination by defecation.

While food is not broken down further at this stage, the fluid absorption function of the large intestine does act to gather in vitamins created by beneficial bacteria or flora inhabiting the colon. Instead of the predominance of evaginations of villi found in the small intestine, the large intestine has increased invaginations of glands and an abundance of goblet cells. The large intestine is structurally divided into three parts: cecum, colon, and rectum.

The cecum is a pouch at the beginning of the large intestine, separated from the ileum of the small intestine by the ileocecal valve and joining the colon at the cecocolic junction in the lower right quadrant of the abdomen. The cecum is host to a large number of bacteria which aid in the final enzymatic processing of material not completely digested in the small intestine.

The vermiform appendix is a worm-like cul-de-sac attachment of the cecum, until recently considered entirely vestigial in humans, but now thought to have a role as a haven for the beneficial gut flora, as well as a site of infection-fighting lymphoid cells.

The colon consists of four parts named for their relative orientation in the abdomen: (1) the ascending colon, (2) the transverse colon, (3) the descending colon, and the (4) sigmoid colon. By the time chyme has reached the colon, almost all nutrients and most of the water have already been absorbed by the body. It is here that the chyme is mixed with mucus and bacteria to become feces.

The waste products of bacterial metabolism include some nutrients used by the cells lining the colon for their own nourishment. The colon ends at the junction of the sigmoid colon and (5) the rectum.

The rectum is the last part of the large intestine, beginning at and continuous with the colon, and terminating at anus. The rectum provides temporary storage for feces. Stretch receptors of the nervous system located in the rectal walls stimulate the desire to defecate. As peristaltic waves propel the feces into the anal canal, external and internal sphincters allow the final exit of waste material from the GI tract.

Accessory OrgansAccessory to the alimentary canal of the GI tract is various secretory, storage, and waste filtering organs and related hormonal glands. Principal among these are the liver, gallbladder, and pancreas.

The liver secretes bile, produced by its hepatocytes, into the duodenum of the small intestine via the biliary system. Bile acts as a kind of detergent, emulsifying fats to promote enzyme action in the intestines. Epithelial cells in the liver add a watery solution rich in bicarbonates that act to dilute and neutralize acids at this stage of digestion.

Cholesterol is also released with the bile and is important for the metabolism of fat soluble vitamins as well as maintenance of normal cell membranes throughout the body. Consistent with its major role in metabolism, the liver has a number of functions not strictly related to digestion, such as decomposition of red blood cells, plasma protein synthesis, and detoxification.

The liver is the largest gland in the human body and performs or regulates a wide variety of high-volume reactions involving very specialized tissues.