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MARTINEZ MEMORIAL COLLEGES

198 A. Mabini St., Maypajo Caloocan City

UPPER GASTRO INTESTINAL BLEEDING PROBABLY SECONDARY TO BENIGN PEPTIC ULCER DISEASE

Ms. Josephine S. Sagun RN Submitted to

Dagumboy, Loren S. Submitted by

BSN III A Yr. & Sec.

November 28, 2012 Date Submitted

I.

INTRODUCTION What is gastrointestinal tract? It is the stomach, small intestine and large intestine. It

often used as a synonym of digestive tract. The stomach (gastro) is an organ between the esophagus and the small intestine. The stomach has three tasks. It stores swallowed food, it mixes the food with stomach acids, and then it sends the mixture to the small intestine. The intestines are a long, continuous tube running from the stomach to the anus. Most absorption of nutrients and water happen in the intestines. The intestines include the small intestine, large intestine, and rectum. The small intestine (small bowel) is about 20 feet long and about an inch in diameter. Its job is to absorb most of the nutrients from what we eat and drink. Velvety tissue lines the small intestine, which is divided into the duodenum, jejunum, and ileum. The large intestine (colon or large bowel) is about 5 feet long and about 3 inches in diameter. The colon absorbs water from wastes, creating stool. As stool enters the rectum, nerves there create the urge to defecate. So, why the presentor discussed above the gastrointestinal tract? Its because GI tract is related to the patient, that the researcher chose to present. Patient is suffering from Upper Gastrointestinal Bleeding (UGIB) secondary to Benign Peptic Ulcer Disease (BPUD). UGIB originate in the first part of the GI tract the esophagus, stomach or duodenum (first part of the small intestine) that is caused by one of the following like Peptic ulcer that is present in the chosen patient, other causes are Gastritis, Esophageal Varices, Mallory Weiss tears, GI cancers and Inflammation of the GI lining from ingested materials.

Peptic Ulcers are localized erosions of the mucosal lining of the GI tract. Ulcers usually occur in the stomach or duodenum. Breakdown of mucosal lining results in damage to blood vessels, causing bleeding. Acute gastrointestinal bleeding first will appear as vomiting of blood, bloody bowel movements, or black, tarry stools. Vomited blood may look like "coffee grounds." Symptoms associated with blood loss can include Fatigue, Weakness, Shortness of breath, Abdominal pain, Pale appearance, Vomiting of blood usually originates from an upper GI source, bright red or maroon stool can be from either a lower GI source or from brisk bleeding from an upper GI source. Long-term GI bleeding may go unnoticed or may cause fatigue, anemia, black stools, or a positive test for microscopic blood.

II.

ICEBERG

The presentor noticed that the patient got his UGIB due to his lifestyle. Patient also has Asthma, and as we all know cigarette smoking is one of the leading causes of asthma attack. So whats the connection of asthma to the patients condition now? Going back to the patients history. Mr. RT has an asthma that he got from his mother. As childhood up to teen age years Mr. RT often experienced asthma attack and used nebulizer as his medical treatment. But when his early adult years comes and he got his job as baradero, he experienced a moderate asthma attack every-time at work, thats why his boss send him to the companys clinic to have a checked up. The companys clinic doctor prescribed him a Prednisone for his asthma. Mr. RT took Prednisone every-time he experienced asthma and didnt follow doctors orders and prescriptions right. As we all know, Prednisone can weaken immune system making it easier to get an infection or worsening an infection you already have or have recently had. Other side

effects of Prednisone that relates the situation of Mr. RT is bloody or tarry stool, and due to a long term therapy that Mr. RT did, he got Peptic Ulcer disease that make him suffer until now. Prednisone is NSAIDs that work by inhibiting two enzymes, substances that cause chemical changes in the body, called COX-1 and COX-2. Both enzymes produce prostaglandinschemicals produced in the body's cellsthat promote pain, inflammation, and fever. However, unlike COX-2, COX-1 produces another type of prostaglandin that protects the stomach lining from stomach acid and helps control bleeding. By inhibiting COX-1, NSAIDs increase the risk of a peptic ulcer developing and bleeding, and another thing smoking and drinking alcohol can worsen ulcers and prevent healing.

III.

PATIENTs PROFILE A. DEMOGRAPHIC PROFILE : : : : : : : : : Mr. RT Tangos, Malabon City 58 y/o August 24, 1954 Nueva Ecija Filipino Male -noneCatholic November 23, 2012

Name Address Age Date of Birth Birthplace Nationality Sex Occupation Religion

Date of Admission :

Time of Admission : Chief Complain :

10:30 pm Abdominal pain, black tarry stool UGIB probably secondary to BPUD

Clinical Diagnosis :

B.

History of Present Illness A day PTA patient suddenly experienced dizziness and 2 consecutive black tarry

stool. No consult was done, self-medicated with Esomeprazole 40mg. Few hour PTA patient still with another episode of black tarry stool. Prompted consult at E.R, hence admission.

C.

Past Medical History Medical 2012 November Mr. RT went to ER of Tondo Medical Center due to UGIB and dizziness. Administered Omeprazole 40mg/amp 1amp TIV OD. Doctor suggested to undergo CBC test. 2005 October Mr. RT went back to ER of TMC due to UGIB. Patient admitted at TMC Philhealth Ward for 3 days. 2001 July Mr. RT went to ER of TMC due to Hematemesis, abdominal pain and with black tarry stool. Patient diagnosed with Upper

Gastrointestinal Bleeding (UGIB) probably secondary to Benign Peptic Ulcer Disease (BPUD), and admitted at the TMC Philhealth Ward for 5 days.

Surgical According to patient, there is no surgical procedure done to him.

Psychiatric Patient denied history of depression.

D.

FAMILY HISTORY

Illnesses Cardiac Disease HPN DM Cancer Asthma Others:

Paternal Side -

Maternal Side -

According to pt., they had no history of any diseases on both paternal and maternal side.

IV.

PHYSICAL ASSESSMENT Upon observation patients development is appropriate to his gender and age. Patients gait is balanced, and relaxed while sitting and lying on his bed. At the time of assessment patient is coordinated and established good eye contact upon conversation and responds to questions appropriately. His voice is clear, facial expression is appropriate in the conversation. As of 2pm, his vital signs are as follows; BP= 110/70 mmHg, RR=14cpm, PR=90 bmp, and a To of 35.5oC. A. Head & Face INSPECTION: Upon inspection, the patients head round and is symmetrical in shape, located at the center of the neck. Necks movement is smooth and in controlled, his thyroid cartilage moves occasionally upon drinking.

PALPATION: Upon palpation, patients head is smooth & hard, no lesions and non-tender. His neck is non-tender; trachea is located at the midline.

B. EYES INSPECTION: Upon inspection, eyes move symmetrically eye balls are also symmetrical in shape. No lesions on both sides of his eyes. Sclera appears white & moist. C. EARS INSPECTION: Upon inspection, both ears are symmetrical in shape and color, no redness or rashes seen on both side. PALPATION: Upon palpation, there is no tenderness on both side.

D. NOSE INSPECTION: Upon inspection, nose color is same as face, smooth in & symmetrical in appearance, no lesions, septum is midline. PALPATION: Upon palpation, patients external nose is non-tender.

V.

REVIEW OF SYSTEM GENERAL: Patient has peripheral edema on his right side of hand. Patient has no other complaint of his condition. His vital signs are as follows; BP= 110/70 mmHg, RR=14cpm, PR=90 bmp, and a To of 35.5oC. SKIN: She has no dermatologic complaints at this time and specifically denies any rash and significant pruritus. HEENT: No auditory, no tinnitus and no sinus congestion, no dysphagia, but he had a history of sore throat.

NECK: No reports of pain on the neck area or stiff neck. RESPIRATORY: No complaints of DOB, CARDIOVASCULAR: No chest pain, no history of CHF and other heart problems. GASTROINTESTINAL: Patient denied any history of colon cancer. Patient is experiencing UGIB probably secondary to BPUD. GENITOURINARY: No complaints of burning, urgency and frequency on urinating MUSKULOSKELETAL: patient has no joint or muscle pain, no back pain and no recent trauma. PSYCHIATRIC: He denies history of depression, no change in sleep pattern. No noted changes in mood or cognitive function. HEMATOLOGIC: According to her they have no history of anemia, easy bruising, bleeding or clotting disorders. According to lab results his Hematocrit & Hemoglobin and RBC are low probably due to melena. ENDOCRINE: Patient has no Diabetes. Patient says that they have no history of thyroid disease or goiter, and reported patient that, theres no any significant changes in his weight.

VI.

ANATOMY

The gastro-intestinal system is essentially a long tube running right through the body, with specialized sections that are capable of digesting material put in at the top end and extracting any useful components from it, then expelling the waste products at the bottom end. The whole system is under hormonal control, with the presence of food in the mouth triggering off a cascade of hormonal actions; when there is food in the stomach, different hormones activate acid secretion, increased gut motility, enzyme release etc. etc. Nutrients from the GI tract are not processed on-site; they are taken to the liver to be broken down further, stored, or distributed.

Pharynx a muscular tube, lined with mucous membrane, that extends from the beginning of the esophagus (gullet) up to the base of the skull. It is divided into the nasopharynx, and hypopharynx, and it communicates with the posterior nares, Eustachian tube, the mouth larynx, and esophagus. Pharynx acts as a passageway for food from mouth to the esophagus, and as an air passage from the nasal cavity and mouth to the larynx. It also acts as a resonating chamber for the sounds produced in the larynx.

Esophagus (Gullet) a muscular tube about 23cm long that extends from the pharynx to the stomach. It is lined with mucous membrane, whose secretions lubricate food as it passes from the mouth to the stomach.

Liver - is a large, meaty organ that sits on the right side of the belly. Weighing about 3 pounds, the liver is reddish-brown in color and feels rubbery to the touch. Normally you can't feel the liver, because it's protected by the rib cage. The liver has two large sections, called the right and the left lobes. The gallbladder sits under the liver, along with parts of the pancreas and intestines. The liver and these organs work together to digest, absorb, and process food. The liver's main job is to filter the blood coming from the digestive tract, before passing it to the rest of the body. The liver also detoxifies chemicals and metabolizes drugs. As it does so, the liver secretes bile that ends up back in the intestines. The liver also makes proteins important for blood clotting and other functions

Stomach

- is

an

expanded

section

of

the

digestive

tube

between

the esophagus and small intestine. Its characteristic shape is well known. The right side of the stomach is called the greater curvature and the left the lesser

curvature. The most distal and narrow section of the stomach is termed the pylorus - as food is liquefied in the stomach it passes through the pyloric canal into the small intestine. Gall bladder a pear shaped sac (7-10 cm long), lying underneath the right lobe of the liver, in which bile is stored. Bile passes (via the common hepatic duct) to the gall bladder from the liver where it is formed and is released into the duodenum. Duodenum is the first three parts of the small intestine. It extends from the pylorus of the stomach to the jejunum. The duodenum receives bile from the gall bladder and pancreatic juice from the pancreas. Pancreas a compound gland, about 15cm long that lies behind the stomach. One end lies in the duodenum; the other end touches the spleen. It is composed of clusters (acini) of cells that secrete pancreatic juice. Transverse Colon - The transverse colon is the large part of the colon that attaches the ascending colon to the descending colon by crossing the abdominal cavity. Jejunum part of the small intestine. It comprises about two-fifths of the whole small intestine and connects the duodenum to ileum. Ascending Colon - one of four portions of the large intestine. It extends from the cecum superiorly along the right abdominal wall to the inferior surface of the liver and bends sharply at a right angle to the left at a curve called the hepatic flexure. From there, it crosses the abdominal cavity as the transverse colon to the left abdominal wall at the splenic flexure and begins the descending colon which traverses inferiorly along the left abdominal wall to the pelvic region.

Descending Colon transverse inferiorly along the left abdominal wall to the pelvic region.

Cecum is the pouch where the large intestine begins.it is where the ileum opens from one side and continues with the colon.

Ileum the lowest of the three portions of the small intestine. It runs from the jejunum to the ileocaecal valve.

Vermiform Appendix the short thin-ended tube, 7-10cm long that is attached to the end of caecum. It has no known function in human and is liable to become infected an inflamed, especially in young adult.

Sigmoid Colon / Flexure part of the colon that forms an angle medially from the pelvis to form an S shaped curve.

Rectum the terminal part of the large intestine, about 12cm long which runs from the sigmoid colon to the anal canal. Faeces are stored in the rectum before defecation.