Management of

patient with peptic

ulcer and upper
gastrointestinal
bleeding
Prepared by:SAFAR ALOTAIBI
MOHAMAD ALSHAMMRI
MOHAMAD ALMUTIRY
SULIMAN ALATAWI
Supervised by: Dr.NAJWA
Outlines:
 Introduction for peptic ulcer
 Classification of peptic ulcer
 Signs and symptoms
 Causes
 Risk factors
 Diagnostic tests
 Complication
 Treatment
 Nursing management
 Introduction for gastrointestinal bleeding (upper and lower)
 Signs and symptoms
 Causes ( upper and Lower )
 Diagnostic tests
 GI bleeding management
 Treatment
 Complications
 Prevention
 Nursing management
 Case study
Peptic Ulcer

 Is a break in the lining of the stomach , first part of the

small intestine or occasionally the lower esophagus.
 Peptic ulcers are produced by an imbalance between
the gastroduodenal mucosal defense mechanisms and
damaging forces of gastric acid and pepsin, combined
with superimposed injury from environmental or
immunologic agents
Peptic Ulcer Cont.

 Contrary to general belief, more peptic ulcers arise in

the duodenum than in the gastric, four times more
common than gastric ulcers
 Duodenal ulcers usually first occur between the ages of
30-50 years and are twice as common in men as in
women.
 Gastric ulcers usually occur in people older than 60
years and are more common in women.
Calcification:

 1. Esophagus (called esophageal ulcer)

 2. Stomach (called gastric ulcer)
 3. Duodenum (called duodenal ulcer)
Symptoms

 Duodenal ulcer
 burning, aching, or hunger-like pain, primarily in the
upper middle region of the abdomen below the
breastbone (the epigastric region).
 Pain may occur or worsen when the stomach is empty,
usually two to five hours after a meal.
 Symptoms may occur at night between 11 PM and 2 AM,
when acid secretion tends to be greatest.
 Feel better when you eat or drink and then worse 1 or 2
hours later .
Symptoms Cont.

 Gastric ulcer
 pain soon after eating.
 Symptoms are sometimes not relieved by eating or
taking antacids.
 Feel worse when you eat or drink.
Causes

 Peptic ulcers occur when acid in the digestive tract

eats away at the inner surface of the stomach or small
intestine or backward to the esophagus.
 The acid can create a painful open sore that may bleed.
Causes

 1. Bacterium
 2. Regular use of certain pain relievers (NSAIDs)
Causes Cont.

 1. A bacterium. Helicobacter pylori bacteria commonly

live in the mucous layer that covers and protects tissues
that line the stomach and small intestine. Often, the H.
pylori bacterium causes no problems, but it can cause
inflammation of the stomach's inner layer, producing an
ulcer.
Causes Cont.

 2. Regular use of certain pain relievers. NSAIDs inhibit

production of an enzyme (cyclooxygenase) that
produces prostaglandins.
 These hormone-like substances help protect stomach
lining from chemical and physical injury. Without this
protection, stomach acid can erode the lining, causing
bleeding and ulcers
Risk factors

 1. Smoke
 2. Drink alcohol.
 3. Have untreated stress.
 4. Eat spicy foods.
 5. Caffeine.
Test and diagnosis

 1. Noninvasive
 a) Urea Breath Test (UBT)
 b) Blood test
 2. Invasive
 a) Histology
 b) Biopsy Urease Test
Complications

 1. Internal bleeding
 2. Infection.
 3. Obstruction.
Treatment

 1. Antibiotic medications
 2. Acid blockers
Nursing diagnosis

 Pain related to the wound in the stomach, primary to HCl

secretion.
 Vomiting related to indigestion of food.
 Loss appetite related to ulceration of the stomach.
 Loss of weight related decreased nutrients intake secondary to
peptic ulcer.
 Stress and anxiety related to disease process.
Nursing interventions.

 Support the patient emotionally.

 Administer prescribed medications.
 Provide small meals a day or small hourly meals as ordered.
 Schedule care so that the patient gets plenty of rest.
 Monitor the effectiveness of administered medications, and
also watch for adverse reactions.
 Assess the patient’s nutritional status and the effectiveness of
measures used to maintain it.Weigh him regularly.
Gastrointestinal
(GI) bleeding
Introduction:
Gastrointestinal (GI) bleeding is a
symptom of a disorder in the digestive
tract. The blood often appears in stool
or vomit but isn't always visible, though
it may cause the stool to look black or
tarry. The level of bleeding can range
from mild to severe and can be life-
threatening.
Signs & Symptoms
Signs and symptoms of GI bleeding can be either obvious (overt) or
hidden (occult). Signs and symptoms depend on the location of the
bleed, which can be anywhere on the GI tract, from where it starts —
the mouth — to where it ends — the anus — and the rate of bleeding.

Overt bleeding might show up as:

 Hematemesis is vomiting blood that is either bright red or has
coffee grounds appearance, indicating UGI bleeding. Coffee
grounds appearance is caused when blood is mixed with digestive
juices, and it usually indicates that bleeding has slowed or
stopped.
 Melena is the passage of black tarry colored stool with a very
characteristic foul odor and it usually suggest UGI bleed.
 Hematochezia is the passage of bright red blood from the rectum.
It may or may not be mixed with stool. It suggests an LGI bleed.
Signs of bleeding in the digestive tract depend where it is
and how much bleeding there is.
Signs of bleeding in the upper digestive tract include:
 Bright red blood in vomit
 Vomit that looks like coffee grounds
 Black or tarry stool
 Dark blood mixed with stool
Signs of bleeding in the lower digestive tract include
 Black or tarry stool
 Dark blood mixed with stool
 Stool mixed or coated with bright red blood
With occult bleeding :

Lightheadedness

Difficulty breathing

Fainting

Chest pain

Abdominal pain
Symptoms of shock

If the bleeding starts abruptly and progresses rapidly, it

could go into shock. Signs and symptoms of shock include:

Drop in blood pressure

Not urinating or urinating infrequently, in small amounts

Rapid pulse

Unconsciousness
Upper gastrointestinal (GI)
bleeding
 Is bleeding in the esophagus, stomach or duodenum is
characterized by frank, bright red bleeding in emesis or
dark, grainy digested blood (”coffee grounds”) in stool.
Causes of Upper GI bleeding
Esophageal causes
 Esophageal varices:
are extremely dilated sub-mucosal veins in the lower
third of the esophagus. They are most often a
consequence of portal hypertension, commonly due
to cirrhosis; people with esophageal varices have a
strong tendency to develop severe bleeding which
left untreated can be fatal
 Esophagitis
 Esophageal cancer
 Esophageal ulcers
 Mallory-Weiss teargastro-esophageal laceration
syndrome:
refers to bleeding from a laceration in the mucosa at
the junction of the stomach and esophagus. This is
usually caused by severe vomiting because of
alcoholism or bulimia.
Causes of Upper GI bleeding
Gastric causes:
 Gastric ulcer
 Gastric cancer
 Gastritis
 Gastric varices: are dilated submucosal veins in the
stomach, which can be a life-threatening cause of
bleeding in the upper gastrointestinal tract. They are
most commonly found in patients with portal
hypertension, or elevated pressure in the portal vein
system, which may be a complication of cirrhosis.
 Gastric antral vascular ectasia:(GAVE) is an uncommon
cause of chronic gastrointestinal bleeding or iron
deficiency anemia. The condition is associated with
dilated small blood vessels in the pyloric antrum, which
is a distal part of the stomach.
 Dieulafoy's lesions: is a medical condition characterized
by a large tortuous arteriole most commonly in the
stomach wall (submucosal) that erodes and bleeds. It
can present in any part of the gastrointestinal tract .It
can cause gastric hemorrhage but is relatively
uncommon.
Causes of Upper GI bleeding:
Duodenal causes
 Duodenal ulcer
 Vascular malformation, including aorto-enteric fistulae:
Fistulae are usually secondary to prior vascular surgery and usually
occur at the proximal anastomosis at the third or fourth portion of
the duodenum where it is retroperitoneal and near the aorta.
 Hematobilia, or bleeding from the biliary tree
 Hemosuccus pancreaticus, or bleeding from the
pancreatic duct :is a rare cause of hemorrhage in the
gastrointestinal tract. It is caused by a bleeding source in the
pancreas, pancreatic duct, or structures adjacent to the pancreas,
such as the splenic artery, that bleed into the pancreatic duct,
which is connected with the bowel at the duodenum, the first part
of the small intestine.
 Severe superior mesenteric artery syndrome: is a digestive
condition that occurs when the duodenum is compressed
between two arteries (the aorta and the superior mesenteric
artery). This compression causes partial or complete blockage
of the duodenum
Lower gastrointestinal (GI)
bleeding
 Bleeding from small intestine (jejunum or ileum), colon,
or rectum.
Lower GI bleeding
Causes can include:
 Diverticular disease. This involves the
development of small, bulging pouches in the
digestive tract (diverticulosis). If one or more
of the pouches become inflamed or infected,
it's called diverticulitis.
 Inflammatory bowel disease (IBD). This
includes ulcerative colitis, which causes
inflammation and sores in the colon and
rectum, and Crohn's disease, and inflammation
of the lining of the digestive tract.
 Tumors. Noncanerous (benign) or cancerous
tumors of the esophagus, stomach, colon or
rectum can weaken the lining of the digestive
tract and cause bleeding.
 Causes can include:
 Colon polyps. Small clumps of cells that form on the
lining of your colon can cause bleeding. Most are
harmless, but some might be cancerous or can become
cancerous if not removed.
 Hemorrhoids. These are swollen veins in your anus or
lower rectum, similar to varicose veins.
 Anal fissures. These are small tears in the lining of the
anus.
 Proctitis. Inflammation of the lining of the rectum can
cause rectal bleeding.
Proctitis. Colon polyps
Diagnostic tests
 Blood tests. a complete blood count, a test to
see how fast the blood clots, a platelet count
and liver function tests.
 Stool tests. Analyzing the stool can help
determine the cause of occult bleeding.
 Nasogastric lavage. A tube is passed through the
nose into the stomach to remove the stomach
contents. This might help determine the source
of the bleed.
Diagnostic tests

 Upper endoscopy. This procedure uses a tiny camera on

the end of a long tube, which is passed through the
mouth to enable the doctor to examine the upper
gastrointestinal tract.
 Capsule endoscopy. In this procedure, the patient
swallow a vitamin-size capsule with a tiny camera
inside. The capsule travels through the digestive tract
taking thousands of pictures that are sent to a recorder
the wear on a belt around the waist. This enables the
doctor to see inside the small intestine
 https://www.youtube.com/watch?v=Zxrykg-9bok
 Colonoscopy. This procedure uses a tiny camera on the end of a
long tube, which is passed through the rectum to enable the
doctor to examine the large intestine and rectum.
 Flexible sigmoidoscopy. A tube with a light and camera is placed
in the rectum to look at the rectum and the last part of the large
intestine that leads to the rectum (sigmoid colon).
 Balloon-assisted enteroscopy. A specialized scope inspects parts
of the small intestine that other tests using an endoscope can't
reach. Sometimes, the source of bleeding can be controlled or
treated during this test.
 Angiography. A contrast dye is injected into an artery, and a
series of X-rays are taken to look for and treat bleeding vessels
or other abnormalities.
 Imaging tests. A variety of other imaging tests, such as an
abdominal CT scan, might be used to find the source of the
bleed.
 Labs :Chemistries,CBC (cycle perhaps ~q8hrs) PT, PTT, Fibrinogen
 Type & cross-match ,Cirrhotic patients: thromboelastography
(TEG) is useful for patients with elevated INR
Management

 Resuscitation and initial assessment

 Localization of the bleeding site
 Therapeutic intervention to stop bleeding at the site
Treatments
 GI bleeding stops on its own. If it doesn't, treatment depends on
where the bleed is from. In many cases, medication or a procedure
to control the bleeding can be given during some tests. For example,
it's sometimes possible to treat a bleeding peptic ulcer during an
upper endoscopy or to remove polyps during a colonoscopy.

 For upper GI bleed, IV drug known as a proton pump inhibitor (PPI) to

suppress stomach acid production.

 Depending on the amount of blood that is being lost and whether or

not the patient continues to bleed, this might require fluids through
a needle (IV) and, possibly, blood transfusions. If the patient takes
blood-thinning medications, including aspirin or nonsteroidal anti-
inflammatory medications, that might need to discontinued.
medications
 Proton Pump Inhibitor: If upper GI hemorrhage
possible, give IV proton pump inhibitor. There's no
evidence that a continuous infusion is superior to
intermittent IV bolus therapy (e.g. 40 mg pantoprazole IV
q12hr).
 Octreotide: If variceal hemorrhage is possible, give
octreotide (50 microgram bolus followed by 50 mcg/hr
infusion). This is safe, when in doubt just give it.
 Antibiotic: Cirrhosis plus GI bleeding equals antibiotics
(usually ceftriaxone 1 gram daily).
 coagulopathy management
 The indication for anticoagulation must be weighed against
the severity of the bleed to determine how aggressively to
reverse anticoagulation.
 Antiplatelet agents, uremia, or thrombocytopenia: platelet
transfusion.
Complications

 hepatic encephalopathy.
 Shock
 Anemia
 Death
Prevention

To help prevent a GI bleed:

 Limit the use of nonsteroidal anti-inflammatory drugs.
 Limit the use of alcohol.
 Quit smoke.
 Follow the doctor instructions for treating GERD.
Nursing management
 Assess severity of GI bleeding and stabilize
 Maintaining safety
The nurse will frequently monitor the patient’s:
• Respiratory status
• Hemodynamic status: stability of vital signs
• Level of consciousness: mental status, ability to follow commands, lethargy
• Hematemesis: presence, frequently, amount
 Take a patient history
• Has the patient had previous GI bleeding? Up to 60% of patients with a history
of an upper GI bleed are bleeding from the same lesion.
• Ask the patient about medications. Non-steroidal anti-inflammatory drugs and
acetylsalicylic acid can predispose the patient to peptic ulcer disease;
antiplatelets and anticoagulants can promote bleeding; and bismuth and iron
can cause stool to appear black.
• Liver cirrhosis can indicate varices.
• Aortic stenosis and renal disease can indicate angioectasia.
• Tobacco abuse, alcohol abuse, and Helicobacter pylori can indicate a
malignancy.
 Perform a physical exam
• Signs of hypovolemia include tachycardia, orthostatic hypotension, and
supine hypotension.
• Examining stool color may provide a clue to the location of the bleeding.
• Abdominal pain may be a sign of perforation.
 Perform a risk assessment
• Perform a complete blood count, comprehensive metabolic panel, and
coagulation studies.
• Cardiac enzymes and electrocardiogram can determine if a patient as a high
risk of cardiovascular disease.
• Predict the need for hospitalization and intervention.
• Assessment of fluid volume status.
 Treat the source of the bleeding
• Determine the need for pre-endoscopy medications.
• Perform endoscopy based on risk.
• If a patient undergoes hemodynamic resuscitation, they may need to
undergo endoscopy, computed tomography, angiography, or push
enteroscopy.
 Providing nutrition
The patient experiencing a UGI bleed will typically remain NPO until he
undergoes the necessary diagnosis test, most often an upper
endoscopy. NPO status is maintained for visualization and safety.
The decision to feed patients with LGI bleeding or patients not in the
low risk for UGI re-bleeding category will be made according to the
individual patient’s clinical status.
Maintain Hemodynamic
Stability and Normovolemia
 Fluid resuscitation
Aggressive fluid resuscitation for both mild and severe disease is
the most critical therapeutic intervention. Fluid that is third
spaced is difficult to estimate and hypovolemia is frequently
underestimated. Choice of fluid is reflective of the patient’s
hematocrit, albumin, and electrolytes. Unless hemorrhage is
evident, the nurse should expect to provide the patient with fluid
boluses of normal saline. The volume of the boluses is determined
by the assessment data. It is not unusual to initially bolus with 1 to
2 liters of saline rapidly followed by between 250 and 500 ml per
hour for 24 to 48 hours.
 Successful fluid resuscitation will be evident by the
following changes:
• Normalization of BP
• Decreased/ normal resting heart rate
• Increased urine output greater than 0.5 cc/kg/hour,
approximately 30 cc per hour.
• Normalization of advance hemodynamic monitoring
(pulmonary artery pressure, cardiac output and index).
• If the hematocrit was initially hemoconcentrated,
adequate fluid resuscitation would result in decreasing the
hematocrit.
• Normal capillary refill with warm, dry skin.
Case study
 CHIEF COMPLAINT: "I'm passing black stool" and lightheadedness - 3 days.
 HISTORY OF PRESENT ILLNESS: Mr. Murphy is a 45 year old advertising
executive who presents to the emergency room complaining of the passage of
black stools x 3 days and an associated lightheadedness. He also relates that he
cannot keep up with his usual schedule because of fatigability. Upon further
questioning he states that his stools are not only black, but are sticky and
malodorous. He further complains of recent worsening of a chronic epigastric
burning which had been a problem off/on for years. He had doubled his usual
dose of turns without significant relief of the burning. He takes NSAIDS as
needed for back pain and recently started on one aspirin per day for cardiac
prophylaxis. He smokes two packs of cigarettes per day. He was told of an ulcer
in the distant pas at but had no specific evaluation or treatment for same.
 Mr. Murphy has been treated for hypertension for eight years but denies any
known cardiac history. His weight is stable to increased and he claims to have
an excellent appetite. He has a normal bowel habit and has not had prior black
stools. He has had no abdominal surgery and denies bleeding tendencies or prior
transfusion.
 PHYSICAL EXAMINATION: Examination reveals an alert, oriented, overweight
male. He appears anxious and somewhat restless. Vital signs are as follows.
Blood Pressure 120/80 mmHg, Heart Rate 110/min - Supine; BP 90/60
mmHg; HR Thready - Standing (Patient complains of dizziness upon
standing). Respiratory Rate - 20 /minute; Temperature 36.6 C.

 SKIN: Facial pallor and cool, moist skin are noted.

 CHEST: Lungs are clear to auscultation and percussion. The cardiac exam
reveals regular rhythm. No murmur is appreciated. Peripheral pulses are
present but are rapid and weak.

 ABDOMEN: The abdomen reveals a rounded abdomen. Bowel sounds are

hyperactive. There is moderate tenderness in the epigastrium.
 LABORATORY TESTS: Hemoglobin 9gm/dL, Hematocrit 27%,
MCV 90. WBC 13,000/mm. PT/PTT - normal. BUN 45mg/dL,
Creatinine 1.0 mg/dL. Chest x-ray - normal. X-ray of abdomen
(kidney, ureter, bladder - KUB) is unremarkable.
 What is the major clinical problem (not the diagnosis)?
Melena (tarry, black stools) is the major clinical problem

 What is most likely cause for the black stools based on

the information?
Acute GI bleeding
Nursing diagnosis
 Deficit Fluid Volume related to active blood loss as evidence by
BP 90/60, HR 110, Hgb 9, abdominal pain, and frequent dark
tarry stools.
 Acute pain related to mucosal irritation
 Nausea related to GI bleeding d
 Ineffective tissue perfusion
 Decreased cardiac output
 Anxiety related to health status
 Risk for falls

Nursing Outcomes:
• Pt’s HGB will be greater or equal to 14 as evidence by lab values
within 48 hours.
• Pt’s input will be equal to output as evidence by shift I & O reports
within 72 hours.
Nursing intervention
 Check for the appearance of vomiting, stool, or drainage
 Monitor vital signs
 Administer blood products, Pt will be transfused 2 units of Packed
Red Blood Cells per MD order and HGB will be rechecked 1 hour
after transfusion has completed.
 Obtain 12 lead ECG
 Strictly monitor fluid intake and output
 Administer IV fluid for 24 hours per MD order and mucous
membranes will be reassessed within 24 hours.
 Monitor laboratory findings
 Administer PPI Potential surgical intervention to stop the bleeding
 Fall precautions
Amount of blood loss is required to produce each of the
following:
 Occult positive stool. 3 cc (hemoccult).
 Melena =100-200 cc
 Orthostasis=20% loss of circulating volume or about
1000 cc.
References

-Brunner & Suddarth's Canadian Textbook of Medical-

Surgical Nursing.14 Edition. Philadelphia. Walters Kluwer.
2018