A case presentation on a patient with

1. A case presentation on a patient with UPPER GASTROINTESTINAL BLEEDING

2. DEMOGRAPHIC DATA • Case no. 195*** • Name: Patient X • Age: 72 y.o • Sex: Male • Nationality: Syrian • Marital Status: Married • Date of Admission: February 4,2013 • Date of Discharge: February 7,2013

3. PHYSICAL ASSESSMENT: • GCS: 15/15 E: Opens eyes spontaneously V: Oriented and converses normally M:Obeys commands Dizziness and nausea upon assessment • VITAL SIGNS: BP:100/70MMHG T: 37 c HR: 125CPM RR: 25BPM SpO2:91% • GRBS: 190mg/dl • WT: 116kgs • Skin: Light complexion, Warm to touch,smooth, hair evenly distributed • EYES: slightly sunken eyeballs,no redness, no discharges, pupils reactive to light and accommodation

4. MOUTH: oral cavity is pale in color, buccal mucosa is dry but no ulcers,lips are pale and dry • THORAX: thorax is symmetric, slight retraction of theIntercostal muscles during inspiration • MUSCULOSKELETAL: generalized weakness with residual Left SidedWeakness • GASTROINTESTINAL:moderate-severe epigastic pain (PS:8/10) Passage of soft, black stool

5. LABORATORY FINDINGS: (Feb 4, 2013)

6. Past medical history 3 months prior to consult, the patient experienced left sided weakness and had hypertension recorded a 190/100mmhg BP, sought consult and was diagnosed of CVA, treated medically started medications of Valsartan (Diovan) 160 mg OD to control elevation of his BP, Aspirin 80 mg OD, Plavix 75 mg OD, Simvastatin 20 mg OD and Piracetam 800mg OD. Also the patient has a long diagnosed type 2 DM (non insulin dependent diabetes mellitus) and continuously taking Glimipride 1mg BID. Long been diagnosed of degenerative arthritis and chronically took Diclofenac 50 mg BID since many years ago. Same incident of suspected GI bleeding,wherein the patient passed soft blakstool,happened 10 years ago as stated by the relative but endoscopy was not done.Only prescribed with medications. He is a known smoker and consumes caffeine containing drinks on a regular basis.

7. Present medical history Patient was brought to the Emergency Department, presenting with symptoms of dizziness, body weakness and epigastric pain for 2 days, passed black colored loose stool 3-4 times. Patient was conscious and oriented but with obvious body weakness. Upon interview, reveals that morning prior to consult, he had passage of black loose stool moderate to large amount as observed. In the emergency department, patient was immediately given IV Infusion of NSS 500 ml, and given Omeprazole 80 mg TIV STAT as ordered by the treating physician. Blood sample was collected, sent to laboratory, reveals a low HGB level of 8.2. ECG was done and noted sinus tachycardia. Also Chest xray done no significant finding as explained by the physician. Gastroenterology consult was done and advised for admission for monitoring and correction of blood loss. Patient was admitted in Surgery Ward. Started omeprazole infusion 8 mg/hr and continuous IV fluid infusion and was put on NPO. Then after a series of investigations, later that day, was shifted to ICU (4/2/13)due to rapid decrease of blood pressure to 60/ 40 regardless of continuous fluid replacement, Voluven infusion given and was scheduled for an urgent Upper GI Endoscopy on OR , alongside blood transfusion of PRBC was done. Endoscopy shows duodenal ulcer on the anterior wall of the bulb and a large amount of black material (digested blood) inside the stomach cavity. 15 ml of Adrenaline was injected around the ulcer to control bleeding. Patient was monitored in ICU w/ regular checking of RBS and CBC.Oral anticoagulants and other medications are withheld. After stabilization and a total of 4 units PRBC transfusion was transferred back to ward (5/2/13). Omeprazole infusion was then shifted to Omperazole 40 mg TIV BID, started soft diabetic diet.Patient was discharged last 7/2/13 with home medications of Nexium, Amoxicillin, Clarithromycin, Amlor, Simvastatin and Panadol. Instructed to avoid aspirins and NSAIDs.

8. Actual image of ulcer seen after endoscopy Digested blood Ulcer

9. Topic presentation Gastrointestinal bleeding is not just a gastroduodenal disorder but may occur anywhere along the alimentary tract. Bleeding is a symptom of an upper or lower GI disorder. It may be obvious in emesis or stool or it may be occult or hidden.Upper gastrointestinal (GI) bleeding refers to hemorrhage in the gastrointestinal tract.Patients with upper GI hemorrhage often present with hematemesis,coffee ground vomiting, and melena. The presentation of bleeding depends on the amount and location of hemorrhage. Melena refers to the black, "tarry" feces that are associated with gastrointestinal hemorrhage. The black color is caused by oxidation of the iron in hemoglobin during its passage through the ileum and colon. Bleeding may be caused by a lot of factors. One of which is a peptic ulcer which is an erosion in the gastronintestinal lining wherein lining is exposed to acid secretion causing inflammation, it may be seen as a small, red crater on the inside lining of the gut. Peptic ulcer is classified according to its origin It may be classified as gastric wherein ulcer develops in the stomach lining and duodenal if it arise on the duodenum. In this case the duodenum which is the most common site of peptic ulcer. Peptic ulcer is the end result of an imbalance between digestive fluids in the stomach and duodenum.. It is estimated that between 5% and 10% of adults globally are affected by peptic ulcers at least once in their lifetimes.

10. anatomy Upper gastrointestinal tract The upper gastrointestinal tract extend from the mouth,esophagus, stomach, until the duodenum.The exact demarcation between "upper" and "lower" can vary.

11. Mouth, oral cavity, and pharynx The mouth leads to the oral cavity, which has a vestibule lying between the lips, the cheeks and gums (gingivae), and the teeth. The main oral cavity also lies between the hard and soft palate above, the tongue below, and the alveoli and teeth. The oral cavity leads to the pharynx through the fauces, which contain pharyngeal tonsils (adenoids) and palatine tonsils. Salivary glands (parotid, submandibular, and sublingual) open into the oral cavity. The pharynx extends from the base of the skull above to the cricoid cartilage (at the level of C6) below. It has 3 parts: the nasopharynx (from the base of the skull above to the soft palate below), the oropharynx (from the soft palate above to the hyoid bone below), and the laryngopharynx (from the hyoid bone above to the cricoid cartilage below). The nasal cavity, oral cavity, and larynx open into the nasopharynx, oropharynx, and laryngopharynx, respectively. The laryngopharynx also has a piriformfossa on either side.

12. esophagus The esophagus (gullet) is one of the few organs traversing 3 regions of the body--namely, the neck, thorax, and abdomen. Accordingly, it is divided into 3 parts: cervical, thoracic, and abdominal. The esophagus is a 25-cm-long vertical muscular tube that which normally remains collapsed and that runs from the laryngopharynx (throat or hypopharynx) in the neck through the thorax (chest) to the stomach in the abdomen.

13. stomach The stomach is a muscular, hollow, dilated part of the digestion system located between the esophagus and the small intestine. It secretes protein-digesting enzymes called protease and strong acids to aid in food digestion, (sent to it via esophageal peristalsis) through smooth muscular contortions (called segmentation) before sending partially digested food (chyme) to the small intestines.

14. duodenum The duodenum is the first section of the small intestine and is the shortest part of the small intestine, where most chemical digestion takes place. The duodenum is largely responsible for the breakdown of food in the small intestine, using enzymes. The duodenum also regulates the rate of emptying of the stomach via hormonal pathways

15. Lower gastro intestinal tract The lower gastrointestinal tract includes most of the small intestine and all of the large intestine. According to some sources, it also includes the anus.

16. Small intestine • Duodenum: Here the digestive juices from the pancreas (digestive enzymes) and hormones and the gall bladder (bile) mix. The digestive enzymes break down proteins and bile and emulsify fats into micelles. The duodenum contains Brunner's glands which produce bicarbonate. In combination with bicarbonate from pancreatic juice, this neutralizes HCl of the stomach. • Jejunum: This is the midsection of the intestine, connecting the duodenum to the ileum. It contains the plicaecirculares, and villi to increase the surface area of that part of the GI Tract. Products of digestion (sugars, amino acids, fatty acids) are absorbed into the bloodstream. • Ileum: Has villi and absorbs mainly vitamin B12 and bile acids, as well as any other remaining nutrients.

17. Large intestine • Caecum: The Vermiform appendix is attached to the caecum. • Colon: Includes the ascending colon, transverse colon, descending colon and sigmoid Flexure: The main function of the Colon is to absorb water, but it also contains bacteria that produce beneficial vitamins like vitamin K. • Rectum

18. physiology The major processes occurring in the GI system are that of motility, secretion, regulation, digestion and circulation. The function and coordination of each of these actions is vital in maintaining GI health, and thus the digestion of nutrients for the entire body. In the uppermost portion, the teeth begin the process of digestion by grinding food into small fragments. The esophagus delivers the food to the stomach where strong acid further breaks up and degrades the swallowed material. Small amounts of the liquified food called chyme are then delivered in spurts from the stomach into the duodenum where they are mixed with bile from the liver (via the bile ducts) and pancreatic juice (via the pancreatic duct). Bile aids in the breakdown and digestion of fat, while the pancreatic enzyme amylase fragments starches into smaller molecules. The pancreas also releases a fluid into the duodenum, which neutralizes the acidic stomach contents. This neutral bile/amylase/fragmented food substance passes to the upper small intestine for the next phase of digestion. It is moved along by peristalsis, worm-like contractions of the intestine.

19. The small intestine is so named because its calibre is small, about one inch in diameter. The term small creates some confusion because, in terms of length, it is not small at all. In fact, it normally measures nearly 23 feet in length! The small intestine's job is absorption of food. The body gains access to the food that we consume by means of absorption of microscopic particles of food through the wall of the small intestine. Vitamins and minerals and large amounts of fluid are also absorbed by the small intestine and pass into the bloodstream for distribution to the rest of the body. Small amounts of the liquified food called chyme are then delivered in spurts from the stomach into the duodenum where they are mixed with bile from the liver (via the bile ducts) and pancreatic juice (via the pancreatic duct). Bile aids in the breakdown and digestion of fat, while the pancreatic enzyme amylase fragments starches into smaller molecules. The pancreas also releases a fluid into the duodenum, which neutralizes the acidic stomach contents. This neutral bile/amylase/fragmented food substance passes to the upper small intestine for the next phase of digestion. It is moved along by peristalsis, worm-like contractions of the intestine. By the time the intestinal contents reach the large intestine, most of its nutritional value has been extracted, leaving a watery waste product. The role of the large intestine is fluid absorption from the remaining waste and compaction and storage of what is left. Expulsion of the waste (feces, stool) is generally under voluntary control and is undertaken when socially convenient

21. etiology There are many possible causes of bleeding, Causes are usually anatomically divided into their location in the upper gastrointestinal tract. It may be a result of trauma anywhere along the GI tract, rupture of an enlarged vein such as a varicosity (esophageal or gastric varices),inflammation such as esophagitis,gastritis,inflammatory bowel disease and bacterial infection. Alcohol and drugs (aspirin-containing compounds,NSAIDS, anticoagulants,corticosteroids), cancers, or even anal disorders, and erosions and ulcers.

23. Bleeding may be classified as: -massive: it may be acute, wherein there is bright red hematemesis or large amount of melena with clots in the stool, rapid pulse,drop in BP, hyppovolemia and shock -subacute:intermittentmelena or coffe ground emesis,hypotension,weakness and dizziness -chronic:intermittent appearance of bleed,increasedweakness,paleness or shortness of breath,occult blood and iron deficiency anemia. Upper gastrointestinal bleeding is a result of the ulceration of the mucosal lining of the stomach. This is due to infection with a bacterium (germ) called H. pylori or chronic use of Anti-inflammatory medicines used to treat various medical conditions. The diagnosis of upper GI bleeding is assumed when there is the presence of at least two factors among: black stool, age > 50 years, and high blood urea nitrogen/creatinine ratio.

24. Signs and symptoms emphasized items are those noted in the patient) • fatigue, weakness, or lack of energy • Lightheadedness may occur if a person stands too quickly, since the body isn't able to pump oxygen-carrying red blood cells fast enough to the brain • abdominal pain/burning pain, classically epigastric strongly correlated to mealtimes. In case of duodenal ulcers the pain appears about three hours after taking a meal; • bloating and abdominal fullness; • nausea, and copious vomiting; • loss of appetite and weight loss; • hematemesis (vomiting of blood); this can occur due to bleeding directly from a gastric ulcer, or from damage to the esophagus from severe/continuing vomiting • melena (tarry, foul-smelling feces due to oxidized iron from hemoglobin); • Pallor of oral and nasal mucosa due to blood loss • Low blood hemoglobin level (8.6) • Breathing difficulties and low O2 saturation • Decreased Blood pressure • Tachycardia

25. PREDISPOSING FACTORS: Medications(aspirin,NSAIDs,anticoagulants) Cigarette smoking Alcohol and caffeine consumption Stress H. Pylori infection DAMAGED MUCOSAL BARRIER Dec function of mucosal cells Dec quality of mucus back diffusion of acid into gastric mucosa pathophysiology

26. Formation and liberation of antihistamine Increased acid production Further mucosal erosion-uleration Acute, massive GI bleeding Compensatory constriction of peripheral arteries-pallor of skin and nail beds Blood volume depletion Dec cardiac output –hypotension and tachycardia

27. Interventions and treatment • The initial focus is on resuscitation beginning with airway management and fluid resuscitation using either intravenous fluids and or blood transfusion. Based on evidence from people with other health problems crystalloid and colloids are believed to be equivalent for peptic ulcer bleeding. • Bowel rest: Bed rest and clear fluids with no food at all for a few days. This gives the ulcer a chance to start healing without being irritated. • Also endoscopy is the priority management, both a diagnostic and a treatment for GI bleeding, wherein after seeing the area where bleeding is originating, adrenalin can be injected to control the bleeding. • Acid suppressing medication following a 4-8 week course of a medicine that greatly reduces the amount of acid that your stomach makes is usually advised. The most commonly used medicine is a proton pump inhibitor (PPI). These are a class (group) of medicines that work on the cells that line the stomach, reducing the production of acid. Proton pump inhibitors may reduce mortality in those with severe disease as well as the risk of re-bleeding and the need for surgery. They include: esomeprazole, lansoprazole, omeprazole, pantoprazole and rabeprazole, and come in various brand names. • Sometimes another class of medicines called H2 blockers is used. They are also called histamine H2-receptor antagonists but are commonly called H2 blockers. H2 blockers work in a different way on the cells that line the stomach, reducing the production of acid. They include: cimetidine, famotidine, nizatidine and ranitidine, and come in various brand names. As the amount of acid is greatly reduced, the ulcer usually heals. • Surgical Interventions may also be indicated for hemorrhage caused by ulcer.

28. Upper gi endoscopy Upper endoscopy is a procedure that enables the examiner (usually a gastroenterologist) to examine the esophagus (swallowing tube), stomach, and duodenum (first portion of small bowel) using a thin, flexible tube through which the lining of the esophagus, stomach, and duodenum can be viewed using a TV monitor

29. complications • Prolonged bleeding detectable in a microscopic study can lead to the loss of iron in the individual. This can cause anemia. Red blood cells contain a protein called hemoglobin. It is required to carry oxygen to the tissues of the body. A lack of hemoglobin and a lack of red blood cells can occur during constant GI bleeding, causing anemia. Symptoms of anemia include chest pain, dizziness, fatigue, weakness, headaches, shortness of breath and lack of mental clarity. • Hypovolemia may occur as a complication of GI bleeding. Due to a severe loss of blood and fluid in acute GI bleeding, the heart finds it difficult to pump enough blood to the body. It is a life-threatening condition since it can cause the body's organs to stop working. Symptoms of this condition include cool, clammy skin; confusion; agitation; decreased urine output; weakness; pale skin; quick breathing; and loss of consciousness. • Acute and massive bleeding from the gastrointestinal tract can lead to a lack of blood flow to the body. This can damage the different organs of the body, causing organ failure. Shock is an emergency condition and if it is not treated immediately, it can worsen quickly, causing irreversible damage to the organs or even death. Symptoms of shock include an extremely low blood pressure, bluish lips and fingernails, chest pain, confusion, dizziness, anxiety, pale skin, decreased or no urine output, racing but weak pulse rate, shallow breathing, and unconsciousness.

30. Prioritization of nursing problems • Acute pain related to inflammation of gastric mucosa • Fluid volume deficit related to active bleeding or fluid loss • Decreased cardiac output due to active bleeding • Fatigue related to decreased oxygen in blood • Knowledge Deficit related to lifestyle modification and drug regimen

31. Nursing care plan 1

32. Nursing care plan 2

33. Nursing health teaching • Prevention of recurrence of bleeding due to duodenal ulcer is the priority health teaching by: • Instructing patient in taking gastric irritating medications on full stomach • Advising to limit or quit smoking • Having a well balanced diet with meals at regular intervals and avoiding dietary irritants. • Religiously following medication regimen for duodenal ulcer • Avoiding aspirins and NSAIDs instead using Paracetamol for pain • Taking adequate amount of rest to prevent stress • Advise to drink alcohol only in moderation, or avoid drinking alcohol. Limit alcohol to 2 drinks a day for men and 1 drink a day for women. Drinking too much alcohol and other caffeine containing beverages may make an ulcer heal more slowly and may make your symptoms worse.

34. conclusion Early detection is important in the management of any disease. In this case, the patient developed a complication of his past medical condition which is CVA due to his medication treatment and other causes. The Upper Gastrointestinal Bleeding was already a complication of the duodenal ulcer which may be caused by the medication he took and his lifestyle and started months prior to hospitalization. And this case when not prompted early may cause death. Improvement was seen upon discharge as evidenced by laboratory results and the patients overall condition. But it is possible that the condition may recur if the patient will follow dietary and health regimens advised.

35. Thank you! Maria Beverly A. Centeno,RN Emergency Department staff