ANATOMY AND PHYSIOLOGY

Mouth
The mouth is the starting point in the digestive system. Both mechanical and chemical
digestion can occur here. The teeth grind food for mechanical digestions while the
salivary gland break down for chemically for chemical digestion.

Salivary Glands
The salivary glands release saliva. The saliva breaks down food chemically. You have
three major salivary glands. One on the top of your mouth, one on the bottom and one
that covers both sides. Saliva breaks up food using the enzyme salivary amylas

Esophagus (also Oesophagus)

The esophagus, a muscular tube through which partially digested food travels, connects
the mouth and the stomach. Food goes down the esophagus using peristalsis, a pattern
of muscular movements, contracting and expanding.

Stomach
The stomach's job is to break down large food molecules into smaller pieces, so that
they are more easily absorbed into the blood.

The stomach can give off two or three liters of gastric juices per day. This juice can
even destroy the inner liner of the stomach. This is why the inner lining of the stomach
is replaced every two to three days.

Liver, Pancreas, and Gallbladder

The liver puts bile into the small intestine through the biliary system, using the
gallbladder as a container to hold the extra bile.

The pancreas puts off a fluid containing bicarbonate and several juices, including
trypsin, chymotrypsin, lipase, and pancreatic amylase, as well as nucleolytic juices, into
the small intestine. Both these organs help in the process of digestion.

Small Intestine
The small intestine connects the stomach and the colon or large intestine. It has three
parts. They are the duodenum, jejunum, and the ileum. The walls of the small intestine
are lined with villi. Villi help absorb nutrients and put them into the blood. This is the
main purpose of the small intestine.
Large Intestine (Colon)
The large intestine is used to remove water from solid waste. It is 1.5 meters in length. It
also absorbs some vitamins such as vitamin k.

Human Digestive System

The human digestive system is a complex series of organs and glands that processes
food. In order to use the food we eat, our body has to break the food down into smaller
molecules that it can process; it also has to excrete waste.

Most of the digestive organs (like the stomach and intestines) are tube-like and contain
the food as it makes its way through the body. The digestive system is essentially a
long, twisting tube that runs from the mouth to the anus, plus a few other organs (like
the liver and pancreas) that produce or store digestive chemicals.

The Digestive Process:

The start of the process - the mouth: The digestive process begins in the mouth. Food is
partly broken down by the process of chewing and by the chemical action of salivary
enzymes (these enzymes are produces by the salivary glands and break down starches
into smaller molecules).

On the way to the stomach: the esophagus - After being chewed and swallowed, the
food enters the esophagus. The esophagus is a long tube that runs from the mouth to
the stomach. It uses rhythmic, wave-like muscle movements (called peristalsis) to force
food from the throat into the stomach. This muscle movement gives us the ability to eat
or drink even when we're upside-down.

In the stomach - The stomach is a large, sack-like organ that churns the food and
bathes it in a very strong acid (gastric acid). Food in the stomach that is partly digested
and mixed with stomach acids is called chyme.

In the small intestine - After being in the stomach, food enters the duodenum, the first
part of the small intestine. It then enters the jejunum and then the ileum (the final part of
the small intestine). In the small intestine, bile (produced in the liver and stored in the
gall bladder), pancreatic enzymes, and other digestive enzymes produced by the inner
wall of the small intestine help in the breakdown of food.
In the large intestine - After passing through the small intestine, food passes into the
large intestine. In the large intestine, some of the water and electrolytes (chemicals like
sodium) are removed from the food. Many microbes (bacteria like Bacteroides,
Lactobacillus acidophilus, Escherichia coli, and Klebsiella) in the large intestine help in
the digestion process. The first part of the large intestine is called the cecum (the
appendix is connected to the cecum). Food then travels upward in the ascending colon.
The food travels across the abdomen in the transverse colon, goes back down the other
side of the body in the descending colon, and then through the sigmoid colon.

The end of the process - Solid waste is then stored in the rectum until it is excreted via
the anus.

Digestive System Glossary:

anus - the opening at the end of the digestive system from which feces (waste) exits the
body.

appendix - a small sac located on the cecum.

ascending colon - the part of the large intestine that run upwards; it is located after the
cecum.

bile - a digestive chemical that is produced in the liver, stored in the gall bladder, and
secreted into the small intestine.

cecum - the first part of the large intestine; the appendix is connected to the cecum.

chyme - food in the stomach that is partly digested and mixed with stomach acids.
Chyme goes on to the small intestine for further digestion.

descending colon - the part of the large intestine that run downwards after the
transverse colon and before the sigmoid colon.

duodenum - the first part of the small intestine; it is C-shaped and runs from the
stomach to the jejunum.

epiglottis - the flap at the back of the tongue that keeps chewed food from going down
the windpipe to the lungs. When you swallow, the epiglottis automatically closes. When
you breathe, the epiglottis opens so that air can go in and out of the windpipe.

esophagus - the long tube between the mouth and the stomach. It uses rhythmic
muscle movements (called peristalsis) to force food from the throat into the stomach.

gall bladder - a small, sac-like organ located by the duodenum. It stores and releases
bile (a digestive chemical which is produced in the liver) into the small intestine.

ileum - the last part of the small intestine before the large intestine begins.

jejunum - the long, coiled mid-section of the small intestine; it is between the duodenum
and the ileum.

liver - a large organ located above and in front of the stomach. It filters toxins from the
blood, and makes bile (which breaks down fats) and some blood proteins.

mouth - the first part of the digestive system, where food enters the body. Chewing and
salivary enzymes in the mouth are the beginning of the digestive process (breaking
down the food).

pancreas - an enzyme-producing gland located below the stomach and above the
intestines. Enzymes from the pancreas help in the digestion of carbohydrates, fats and
proteins in the small intestine.

peristalsis - rhythmic muscle movements that force food in the esophagus from the
throat into the stomach. Peristalsis is involuntary - you cannot control it. It is also what
allows you to eat and drink while upside-down.

rectum - the lower part of the large intestine, where feces are stored before they are
excreted.

salivary glands - glands located in the mouth that produce saliva. Saliva contains
enzymes that break down carbohydrates (starch) into smaller molecules.

sigmoid colon - the part of the large intestine between the descending colon and the
rectum.
stomach - a sack-like, muscular organ that is attached to the esophagus. Both chemical
and mechanical digestion takes place in the stomach. When food enters the stomach, it
is churned in a bath of acids and enzymes.

transverse colon - the part of the large intestine that runs horizontally across the
abdomen.

The digestive system carries out six basic processes:

ingestion
secretion
propulsion
digestion
absorption
defecation

Ingestion is taking food into the mouth.

Secretion is the act of expelling a liquid. The cells lining the GI tract secrete about 9
liters (9.5 quarts) of water, acid, buffers, and enzymes each day to lubricate the canal
and aid in the process of digestion.

Propulsion consists of alternating contraction and relaxation of smooth muscle in the

walls of the GI tract to squeeze food downwards.

Digestion has two parts, mechanical and chemical. Mechanical digestion is chewing up
the food and your stomach and smooth intestine churning the food, while chemical
digestion is the work the enzymes do when breaking large carbohydrate, lipid, protein
and nucleic acid molecules down into their subcomponents -these and others are the
nutrients-.

Absorption occurs in the digestive system when the nutrients move from the
gastrointestinal tract to the blood or lymph.

Defecation is the process of expelling what the body couldn't use.

 PATHOPHYSIOLOGY OF BLEEDING PEPTIC ULCER DISEASE

Helicobacter Release of cytokines, Inflammatory cascade initiated

Pylori lipopolysaccharides, heat-shock (cytokines, lymphocytes,
protein enzymes, etc. neutrophils, etc.)

Hydrogen ions Mucosal damage and

and pepsin ulceration
Non-Steroidal
Anti-
Inflammatory

Topical and systemic Decreased mucus production,

effects Decreased blood flow,

Increased neutrophils,
Bleedin
Decreased bicarbonate, g
Decreased cell restitution

Melena

Hemateme
sis

Abdominal
Pain
DRUG STUDY
 Name of drug Pharmacodynamics Dosage Adverse effects Contraindications Nursing Responsibilities Rationale

Metronidazole Direct-acting CNS: headache, - patients with - administer with food or - to minimize
trichomonacide and dizziness, seizures hypersensitivity to milk. Tablets may be gastric irritation.
amebicide that GI: abdominal pain, metronidazole or crushed for patients with
works inside and anorezia, nausea, other difficulty swallowing.
outside the diarrhea, dry mouth, nitroimidazoles.
intestines. It is furry tongue, glossitis, - use cautiously in - instruct patient to take - altering the
thought to enter the unpleasant taste patients with medication exactly as dosage of the
cells of vomiting history of blood directed evenly spaced medication may
microorganisms Skin: rashes, urticaria dyscrasia, CNS times between dose, cause untoward
that contain Hematologic: leucopenia disorder, or retinal even if feeling better. Do effects.
nitroreductase, Local: phlebitis at IV site or visual changes. not skip doses or double
forming unstable Neuro: peripheral Patients up on missed doses. Id a
compounds that neuropathy - use cautiously in dose is missed, take as
bind to DNA and Other: superinfection patients who take soon as remembered if
inhibit synthesis, hepatotoxic drugs not almost time for the
causing cell death. or have hepatic next dose.
disease or
alcoholism. - caution patient about - drug may cause
activities that may be dizziness or light-
requiring mental headedness.
awareness until response
to medication is known.

- caution patient that

medication may cause an
unpleasant metallic taste.

- inform patient that

medication may cause
urine to turn dark.

- advise patient to consult - this may indicate

a health care occurrence of
professional if there is no superinfection.
improvement after a few
days or if signs such as
black furry overgrowth in
tongue, or foul-smelling
stools develop.

- monitor patient for

 MEDICAL MANAGEMENT

• Given the current understanding of the pathogenesis of PUD, most patients with
PUD are treated successfully with cure of H pylori infection and/or avoidance of
NSAIDs, along with the appropriate use of antisecretory therapy.
• A number of treatment options exist for patients presenting with symptoms
suggestive of PUD or ulcerlike dyspepsia, including empiric antisecretory
therapy, empiric triple therapy for H pylori infection, endoscopy followed by
appropriate therapy based on findings, and H pylori serology followed by triple
therapy for patients who are infected. Breath testing for active H pylori infection
may be used.
• Computer models have suggested that obtaining H pylori serology followed by
triple therapy for patients who are infected is the most cost-effective approach;
however, no direct evidence from clinical trials provides confirmation.
• Perform endoscopy early in patients older than 45-50 years and in patients with
associated so-called alarm symptoms, such as dysphagia, recurrent vomiting,
weight loss, or bleeding.

SURGICAL TREATMENT

With the success of medical therapy, surgery has a very limited role in the management
of PUD.

• Potential indications for surgery include refractory disease. Complications of PUD

include the following:
o Refractory, symptomatic peptic ulcers, though rare with the cure of H
pylori infection and the appropriate use of antisecretory therapy, are a
potential complication of PUD.
o Perforation usually is managed emergently with surgical repair. However,
this is not mandatory for all patients.
o Obstruction can complicate PUD, particularly if PUD is refractory to
aggressive antisecretory therapy, H pylori eradication, or avoidance of
NSAIDs. Obstruction may persist or recur despite endoscopic balloon
dilation.
o Penetration, particularly if not walled off or if a gastrocolic fistula develops,
is a potential complication of PUD.
o Bleeding can complicate PUD, particularly in patients with massive
hemorrhage and hemodynamic instability, recurrent bleeding on medical
therapy, and failure of therapeutic endoscopy to control bleeding.
• The appropriate surgical procedure depends on the location and nature of the
ulcer.
o Many authorities recommend simple oversewing of the ulcer with
treatment of the underlying H pylori infection or cessation of NSAIDs for
bleeding PUD.
o Additional surgical options for refractory or complicated PUD include
vagotomy and pyloroplasty, vagotomy and antrectomy with
gastroduodenal reconstruction (Billroth I) or gastrojejunal reconstruction
(Billroth II), or a highly selective vagotomy.
 IF NOT TREATED

Complications of Bleeding Peptic Ulcer Disease

Bleeding from granulation Erosion of ulcer into an artery

tissue or vein

HEMORRH
AGE
Sudden onset of Dizziness Thirst Cold and Desire to
weakness moist skin defecate

Passage of loose, tarry,

or even red stools and
coffee-ground emesis

Excessive blood loss

Circulatory shock
Edema, spasm or contraction
of scar tissue

OBSTRUCTION

Interference with the free

passage of gastric contents
through the pylorus or
adjacent areas

Feeling of epigastric fullness

And heaviness after meals

SEVERE
OBSTRUCTION

Vomiting of undigested food

 Ulcer erodes through all the
layers of the stomach or
duodenum

PERFORATIO
N

Gastrointestinal Symptoms:
contents enter the
peritoneum Radiation of pain into
the lower back

Severe night distress

Inadequate pain relief

Penetrate
PERITONIT adjacent
from eating food or
taking antacids

IS

Bowel Nausea and

obstruction vomiting

Translocation
of fluid into
peritoneal Further losses of
cavity and into fluid
bowel

Hypovolemia and
shock
 PERITONITIS

Reflex muscle guarding Vomiting Irritation of

phrenic nerve
Fever

Elevated WBC
count

Abdomen is rigid, often Tachycardia

described as board-like
Hypotension Hiccups

Breathing is shallow

PARALYTIC ILEUS ABDOMINAL

DISTENTION

Note: if peritonitis progresses and is left untreated, it leads to toxemia and shock, and
eventually death.