CASE STUDY REPORT:

PEPTIC ULCER

Submitted by:
(GROUP 1)
Vrix Andrada
Joan Claire Alcazaren
Aliyah Joy Andrada
Justine Angeles
Khrizlynne Soberano

Submitted to:
Mrs. Elyza D. Catahay
Instructor

BSN 1- STEM B
Anatomy and Physiology of the Organs Involved

Stomach
- The stomach is located in the upper part of the abdomen just beneath the diaphragm. The stomach is
distensible and on a free mesentery, therefore, the size, shape, and position may vary with posture and
content. An empty stomach is roughly the size of an open hand and when distended with food, can fill
much of the upper abdomen and may descend into the lower abdomen or pelvis on standing.
- The stomach has 3 main functions:
 Temporary storage for food, which passes from the esophagus to the stomach where it
is held for 2 hours or longer.
 Mixing and breakdown of food by contraction and relaxation of the muscle layers in the
stomach.
 Digestion of food.
Esophagus
- The esophagus is a muscular tube connecting the throat (pharynx) with the stomach. The
esophagus is about 8 inches long, and is lined by moist pink tissue called mucosa. The esophagus
runs behind the windpipe (trachea) and heart, and in front of the spine.
- It forms an important piece of the gastrointestinal tract and functions as the conduit for food
and liquids that have been swallowed into the pharynx to reach the stomach.
Duodenum
- The duodenum extends from the pylorus to the ligament of Treitz in a sharp
curve that almost completes a circle. It is so named because it is about equal in length to the
breadth of 12 fingers, or about 25 cm. It is largely retroperitoneal and its
position is relatively fixed.
- The duodenum is the first segment of the small intestine. It's largely responsible for the
continuous breaking-down process.

Assessment: Signs and Symptoms Present: Pathognomonic Signs/Symptoms

- A dull or burning pain in your stomach is the most common symptom of a peptic ulcer. You
may feel the pain anywhere between your belly button and breastbone. The pain most often
• happens when your stomach is empty—such as between meals or during the night
• stops briefly if you eat or if you take antacids
• lasts for minutes to hours
• comes and goes for several days, weeks, or months
- Less common symptoms may include
• bloating
• burping
• feeling sick to your stomach
• poor appetite
• vomiting
• weight loss
- Even if your symptoms are mild, you may have a peptic ulcer. You should see your doctor to
talk about your symptoms. Without treatment, your peptic ulcer can get worse.

Pathophysiology of the Disease

H.pylori Induced Ulcer

Gram negative bacteria produced heat shock proteins

Secretes urease (generates ammonia), protease (breaks down

glycoprotein in the gastric mucus) or phospholipases
 Bacterial lipopolysaccharides attracts inflammatory cells to the
mucosa. Neutrophils release myeloperoxide.

A bacterial platelet-activating factor promotes thrombotic

occlusion of surface capillaries

Mucosal damage allows leakage of tissue nutrients in the surface

microenvironment, sustaining the bacillus.

Ulcer occurs

Drug Induced Ulcer

Arachidonic acid

Prostaglandins

Controls gastric juice secretions

Damage mucosal lining lead to ulcer

Stress Induced Ulcer

In stress energy consumption increase, so increase glycolysis

which is usually done by cortisol hormone

This hormone inhibit phospholipase A2

No arachidonic acid formation no prostaglandin increase gastric

juice secretions

Cause Ulcer
Steroids Induced Ulcer

Steroids acts on cell membrane (phospholipid)

Inhibit phospholipase

Inhibits arachidonic acid no prostaglandins and damaging of

mucosal lining that leads to ulcer

Ulcer Due to Genetic Defect

Rare genetics occurs some time having blood group O positive

the size of parietal cell is increase

Increase cell demand as HCL secretions increase

Cause destruction of mucosal lining leading towards ulcer

ZES (Zollinger-Ellison Syndrome)

Secretes urease (generates ammonia), protease (breaks down

glycoprotein in the gastric mucus) or phospholipases

Abnormal mucus secretions (gastrin acts on parietal cells)

Increase secretions of gastric juice

Mucosal lining Damage cause ulcer

Diagnostic Procedures

Radiological Diagnosis
Barium x-ray or upper GI series is a widely available and accepted method to establish a
diagnosis of peptic ulcer in the stomach or duodenum.
Though less invasive than endoscopy, the barium x-ray is limited by being less sensitive
and accurate at defining mucosal disease, or distinguishing benign from
malignant ulcer disease (Figure 9). In patients who have anatomic deformities from previous
gastric surgery or scarring from chronic inflammation, barium x-rays may be difficult to
interpret. Generally, these x-rays have up to a 30% false negative and a 10% false positive rate.
Until 1970, peptic ulcers were diagnosed almost exclusively by radiological methods. The most
common inaccuracies of radiological diagnosis include the failure to recognize true ulcers, or the
misdiagnosis of a scar or a deformed duodenal bulb as a true ulcer. Since the 1970s, increasing
numbers of peptic ulcers are diagnosed by endoscopy.
Laboratory Testing
Patients who respond to optimal therapy for peptic ulcer disease do not require
specialized testing. However, those with refractory (not healed after 8 weeks of therapy) or
recurrent disease should have serum gastrin and serum calcium measured to screen for
gastrinoma and multiple endocrine neoplasia (MEN). These patients should also undergo gastric
acid analysis to determine whether the ulcer is caused by gastric acid hypersecretion (basal acid
output exceeding 10 mEq/hr) or decreased mucosal protection.
Patients with refractory or recurrent peptic ulcer disease may have an underlying
Helicobacter pylori (H. pylori) infection. Histological examination of biopsies of the gastric
antrum, obtained during endoscopy, is the gold standard for diagnosis of H. pylori. Routinely, H.
pylori is not cultured because of the difficulty growing the organism. Serologic tests are
available, but unfortunately, positive test results indicate only past exposure and are not useful
for determining if the infection has been cured.
Urea breath tests are simple and noninvasive, and have been used to diagnose H. pylori
infection. Because H. pylori produces large quantities of the enzyme urease, these breath tests
have the potential to be quite useful. 13C- and 14C-urea breath tests offer excellent diagnostic
yield. Patients ingest a solution containing 13C- or 14C-labeled urea and an exhaled breath is
sampled for isotope-labeled CO2 released by intragastric H. pylori urease activity. The test can
be completed within 20 minutes and is highly sensitive and specific.
Serologic testing is an accepted method for detection of H. pylori. Mean levels of IgG
and IgA ELISA tests (enzyme-linked immunosorbent assay) are significantly higher in H. pylori
positive than in H. pylori-negative patients. Sensitivity of this serum assay is generally in the
range of 80–95% and specificity in the range of 75–95%.
More recently, stool antigen testing has emerged as an alternative non-invasive means of
detecting the presence of H. pylori. These fecal assays have become a useful test, and recent
studies have shown a sensitivity value of 94% with specificity between 86-92%. Furthermore, it
may be used to easily document eradication of an H. pylori infection if performed at least four
weeks after treatment.
Endoscopic Diagnosis
Gastrointestinal endoscopy allows the physician to visualize and biopsy the upper
gastrointestinal tract including the esophagus, stomach and duodenum. The enteroscope (a longer
endoscope) allows visualization of at least 50% of the small intestine, including most of the
jejunum and different degrees of the ileum. During these procedures, the patient is given a
numbing agent to help prevent gagging. Pain medication and a sedative may be administered
prior to the procedure. The patient is placed in the left lateral position.
An endoscope (a thin, flexible, lighted tube) is passed through the mouth and pharynx
and into the esophagus. The forward-viewing scope transmits an image of the esophagus,
stomach and duodenum to a monitor visible to the physician. Air may be introduced into the
stomach, expanding the folds of tissue, and enhancing examination of the stomach.
Esophagogastroduodenoscopy (EGD) is the most direct and most accurate method of
establishing the diagnosis of peptic ulcer disease. In addition to identifying the ulcer, its location
and size, EGD also provides an opportunity to detect subtle mucosal lesions and to biopsy
lesions to establish histopathological basis. Endoscopic biopsies are indicated for all gastric
ulcers at the time of diagnosis, whereas duodenal ulcers are almost always benign, not requiring
biopsy in usual circumstances.
Endoscopic biopsy also appears the best and most accurate diagnostic method for H.
pylori. Histological examination with standard hematoxylin and eosin staining provides an
excellent means of diagnosis.
In an effort to speed up the diagnosis of H. pylori following a biopsy of the gastric
mucosa, urease activity has been used. Biopsy specimens are placed in a urea and phenol red
solution or gel. If urease from H. pylori is present in the specimen, urea is hydrolyzed to release
ammonia, increasing pH in the solution and giving a pink color to the gel or solution. At 3 hours,
this test has a sensitivity of 90%. Using this technique, the diagnosis can be made sooner than
standard histopathological examination.

Treatment or Management and Prevention

Treatment for peptic ulcers depends on the cause. Usually treatment will involve killing
the H. pylori bacterium if present, eliminating or reducing use of NSAIDs if possible, and
helping your ulcer to heal with medication.
Medications can include:
 Antibiotic medications to kill H. pylori. If H. pylori is found in your digestive tract,
your doctor may recommend a combination of antibiotics to kill the bacterium. These
may include amoxicillin (Amoxil), clarithromycin (Biaxin), metronidazole (Flagyl),
tinidazole (Tindamax), tetracycline and levofloxacin.
The antibiotics used will be determined by where you live and current antibiotic
resistance rates. You'll likely need to take antibiotics for two weeks, as well as additional
medications to reduce stomach acid, including a proton pump inhibitor and possibly
bismuth subsalicylate (Pepto-Bismol).
 Medications that block acid production and promote healing. Proton pump inhibitors
— also called PPIs — reduce stomach acid by blocking the action of the parts of cells
that produce acid. These drugs include the prescription and over-the-counter medications
omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole
(Nexium) and pantoprazole (Protonix).
Long-term use of proton pump inhibitors, particularly at high doses, may increase your
risk of hip, wrist and spine fracture. Ask your doctor whether a calcium supplement may
reduce this risk.
  Medications to reduce acid production. Acid blockers — also called histamine (H-2)
blockers — reduce the amount of stomach acid released into your digestive tract, which
relieves ulcer pain and encourages healing.
Available by prescription or over the counter, acid blockers include the medications
famotidine (Pepcid AC), cimetidine (Tagamet HB) and nizatidine (Axid AR).
 Antacids that neutralize stomach acid. Your doctor may include an antacid in your
drug regimen. Antacids neutralize existing stomach acid and can provide rapid pain
relief. Side effects can include constipation or diarrhea, depending on the main
ingredients.
Antacids can provide symptom relief but generally aren't used to heal your ulcer.
 Medications that protect the lining of your stomach and small intestine. In some
cases, your doctor may prescribe medications called cytoprotective agents that help
protect the tissues that line your stomach and small intestine.
Options include the prescription medications sucralfate (Carafate) and misoprostol
(Cytotec).
Follow-up after initial treatment
Treatment for peptic ulcers is often successful, leading to ulcer healing. But if your
symptoms are severe or if they continue despite treatment, your doctor may recommend
endoscopy to rule out other possible causes for your symptoms.
If an ulcer is detected during endoscopy, your doctor may recommend another endoscopy
after your treatment to make sure your ulcer has healed. Ask your doctor whether you should
undergo follow-up tests after your treatment.
Ulcers that fail to heal
Peptic ulcers that don't heal with treatment are called refractory ulcers. There are many reasons
why an ulcer may fail to heal, including:
 Not taking medications according to directions
 The fact that some types of H. pylori are resistant to antibiotics
 Regular use of tobacco
 Regular use of pain relievers — such as NSAIDs — that increase the risk of ulcers
Less often, refractory ulcers may be a result of:
 Extreme overproduction of stomach acid, such as occurs in Zollinger-Ellison syndrome
 An infection other than H. pylori
 Stomach cancer
 Other diseases that may cause ulcerlike sores in the stomach and small intestine, such as
Crohn's disease
Treatment for refractory ulcers generally involves eliminating factors that may interfere with
healing, along with using different antibiotics.
If you have a serious complication from an ulcer, such as acute bleeding or a perforation, you
may require surgery. However, surgery is needed far less often now than previously because of
the many effective medications available.
Prevention
 Avoid foods that irritate your stomach. Use common sense: If it upsets your stomach
when you eat it, avoid it. Everyone is different, but spicy foods, citrus fruits, and fatty
foods are common irritants.
 Stop smoking. Heavy smokers are more likely to develop duodenal ulcers than
nonsmokers.
 Practice moderation. Heavy consumption of alcohol and has been shown to contribute to
the development of ulcers, so keep your intake to a minimum.
 Take non steroidal anti-inflammatory drugs (NSAIDS including aspirin and ibuprofen)
with food, as this may decrease your risk of irritating the lining of your stomach
 Learn how to control your stress levels. Regular exercise and mind-body relaxation
techniques (such as guided imagery and yoga or tai chi) are often helpful.