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.
 c t i on
t rod u
In
Upper GI bleeding
originates 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 food
 Abdominal pain at night
 Blood in vomit
 Nausea  May be relieved by
 Anorexia antacids or milk
 Black stools  Abdominal
 Fatigue indigestion
 Breathlessness  Vomiting, especially
vomiting blood
 Abdominal pain
 Blood in stools or
 Lack of sleep
black, tarry stools
 Worsened on  Unintentional weight
eating loss
 Treatment
 Symptomatic relief: antacid preparations
 Anti-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
 a l D ata
r ap hi c
Bi og
Name: Ms. M. Z. Admitting Date:
Age: 79 y/o April 22, 2010
Gender: Female Attending Physician:
Dr. Macalalag

Address: Admitting Diagnosis:

Cupang, Muntinlupa Urosepsis; Metabolic
Chief Complaint: Encepalopathy
Change in sensorium Final Diagnosis:
and general body UGIB secondary to Multiple
weakness Gastric Ulcers.
 s t r a ct
C ase Ab
 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.
 at om y
An
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 Tract
The 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.
Pharynx
The 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 Tract
The 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 Intestine
Also 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 Organs
Accessory 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.