The case study deliberates about Dr. S., a male in the middle adulthood period of the life cycle (Jarvis, 2008), with complaints of persistent upper abdominal pain for the last two months, now seeking medical advice. He reveals a history of smoking, irregular eating habits, more intense pain immediately after eating, a pain-antacid-relief pattern, recent weight loss, and the use of aspirin for pain relief of headaches and rheumatoid stiffness. Family history is unremarkable. Based on these symptoms presented, it appears this patient has a gastric ulcer, a type of peptic ulcer disease, which is a gastrointestinal disorder. By incorporating the discussion of the developmental process of the digestive system and its effects in the diagnosis of peptic ulcer disease, focus will include a plan of care by use of assessment, interventions, plan, and evaluation. Normal Function and Structure of the Gastrointestinal System The gastrointestinal system is comprised of the mouth, esophagus, stomach, small and large intestine, rectum and anus. This process includes food ingestion, peristalsis, mechanical and chemical breakdown, captivation of nutrients, and evacuation of waste products. After food mixed with saliva activates carbohydrate breakdown, it reaches the end of the esophagus, and enters the stomach through a muscular valve called the lower esophageal sphincter. This sphincter prevents stomach regurgitation which may cause corrosive damage to the esophagus (Huether and McCance, 2008). The stomach is a hollow, muscular organ, located on the left side of the upper abdomen. Three functional areas of the stomach include the fundus (upper portion), body (middle portion), and antrum (lower portion). The stomach accumulates food after mastication, secreting digestive acidic fluids and enzymes and mixes food with these digestive acidic fluids and enzymes. Digestive fluids consist of an acid that liquefies food, kills microorganisms, and transforms pepsinogen to pepsin, pepsin that breaks down protein, mucus that protects stomach mucosa, intrinsic factor that is needed for B12 absorption and gastroferrin that is needed for iron absorption in the small intestine.
Crests of muscle tissue called rugae line the stomach (Huether and McCance, 2008). The stomach has a rich arterial and venous blood supply and is supplied by both the sympathetic and parasympathetic divisions of the autonomic nervous system. Stimulation of the sympathetic response causes peristaltic reduction and stimulation of the parasympathetic response causes increased motility and secreted gastric juices. Gastric motility is influenced by enteric hormones such as gastrin (gastric acid secretion aid) and cholecystokinin (pancreatic enzymes and bile secretion stimulator), which acts to relax the proximal stomach and enhance contractions in the distal stomach. The stomach muscles contract periodically, and by peristaltic wave action, partially digest food into a thick semifluid mass of partially digested food called chyme. Chyme then passes through the pyloric sphincter, another muscular valve that opens, allowing food to pass from end to end through the pylorus, (via osmotic pressure) the duodenum, and into the small intestine, where nutrients are absorbed (Huether and McCance, 2008). The small intestine is comprised of the duodenum absorbing iron, calcium, fats, sugars, water, proteins, vitamins, magnesium, and protein, the jejunum absorbing sugars and proteins and the ileum absorbing bile salts, vitamin B12 and chloride (Huether and McCance, 2008).good Dysfunctions of the Gastrointestinal System Peptic ulcer disease affects mostly the stomach and duodenum. However, when gastric acids become altered, ulcerations of the mucosal lining occur, and may affect the lower esophagus, the stomach and duodenum in peptic ulcer disease. Erosion of the outer smooth muscle layer begins and ulcerations can extend into the inner smooth muscle layer. This damage can cause blood vessels to hemorrhage or the gastric wall to perforate, which can be life threatening (Huether and McCance, 2008).
An excess of secretions of hydrochloric acid (secreted from the parietal cell) erode away the protective properties of mucus secretion and acid neutralization. Normally, the stomach protects itself from damage with mucus that coats and protects the stomach lining. When damaging substances make it through this wall and the repair mechanisms are in place, this produces the symptoms of gastric ulcer. Infection and medication weaken the mucosal layer, most commonly in the lesser curvature of the antral region of the stomach, allowing acidic fluid in the stomach to irritate and wear down its lining, which in turn forms ulcers of various sizes in the lining. Helicobacter pylori bacteria, the most common cause of peptic ulcers, increase acid production in the stomach. Smoking tobacco, alcohol, and stress also produce acid volume and contribute to peptic ulcer disease (Kinney, 2010). Nonsteroidal anti-inflammatory drugs (NSAIDs), like aspirin and ibuprofen, can erode the stomach lining and are the second most common cause of ulcers (Kalloo, 2011).
Risk factors such as smoking, advanced age, habitual use of nonsteroidal anti-inflammatory drugs, alcohol, chronic diseases such as rheumatoid arthritis and infection of the gastric mucosa contribute to alteration of acid balances. As a result of this alteration increased acid causes thinning and ulceration of the mucosal lining (Huether and McCance, 2008). Labs and Diagnostic Tests Ordered Based on this case study, a complete history, physical examination and a referral to a gastroenterologist who specializes in digestive diseases may confirm the diagnosis of a gastric ulcer after performing an endoscopy (Hynnelli, 2010). An endoscopy involves a thin tube with a tiny camera on the end fed through the mouth down to the duodenum (Smith, 2010). Discovery of an ulcer crater and sharp, spastic contractions narrowing the stomach in proximity of the ulcer is indicative of a gastric ulcer during endoscopy (Kalloo, 2011). An organism called Helicobacter pylori, the alleged cause of gastric ulcers, is also a precursor of gastric carcinoma. Per a biopsy, gastric analysis also detects organisms, antibodies (IgG), gastric acid, blood, and bile.
A physician may also perform an upper gastrointestinal (UGI) series, an x-ray exam of the esophagus and stomach, even though this test is now being used less frequently because of inaccuracy in defining the exact nature of the disease, or distinguishing benign from malignant ulcer disease (Hynnelli, 2010). Other important tests significant to this case and presented symptoms are a complete comprehensive metabolic panel, a complete blood count, and a stool (guiac test) exam for blood. Over-the-counter antacids such as Sodium Bicarbonate products can alter the gastric and intestinal environment, alter normal acid-base balance (alkalosis) and sodium can increase blood pressure. Calcium products can cause kidney stones and kidney damage, acid-base imbalances (alkalosis) and constipation. Magnesium products can cause electrolyte imbalances related to its effect of diarrhea. Aluminum products can cause constipation. A complete blood count reveals bleeding or anemia. A stool exam tests for blood in the stool, detecting bleeding (Kalloo, 2011). Nursing Interventions Nursing interventions using multidisciplinary team approach are necessary for consistent management of this patient with peptic ulcer disease. Education includes teaching about peptic ulcer disease including signs and symptoms.
The importance of prescribed medications and the effectiveness of the medications as prescribed, avoiding aspirin-containing medications, avoiding alcohol, spicy foods, and caffeine, which irritate the mucosal lining of the stomach. Nutritional education includes six small meals per day or small hourly meals and weekly weights. Teaching also includes the importance of rest, and stress management. Exercise, including yoga, massage therapy, or other activities are significant in stress reduction. These important interventions are crucial in compliancy with care. The significance of follow-up care is essential in the proper management and maintenance of this disease (Barba, 2007). Discussion This case study demonstrates the normal and abnormal structure of the digestive system as it relates to the case study of peptic ulcer disease, as well as key diagnostic tests and the important factors of a gastric ulcer and its management. Collaboration of a multidisciplinary team, consistent nursing interventions, and coordination of care provides optimal compliance. This can ensure favorable outcomes with peptic ulcer disease. Changes to diet and lifestyle can be achieved by following a regimen with proper medication, nutrition, exercise, and stress reduction. As a health care provider, the importance of continual assessment, support, education and follow-up care is necessary for vital management of this disease (Barba, 2007).