Anatomy and Physiology

Esophagus
The esophagus or oesophagus, sometimes known as the gullet,is an organ in vertebrates which consists of a muscular tube throughwhich food passes from the pharynx to the stomach. The wordesophagus is derived from the Latin sophagus, which derives fromthe Greek word oisophagos, lit. "entrance for eating." In humans theesophagus is continuous with the laryngeal part of the pharynx at thelevel of the C6 vertebra. The esophagus passes through a hole in thediaphragm at the level of the tenth thoracic vertebrae (T10). It isusually about 2530 cm long and connects the mouth to the stomach.It is divided into abdominal parts. Diaphragm A thin dome-shaped skeletal muscle that separates the thoracicand abdominal cavities. The diaphragm plays an important role inbreathing: it contracts with each inspiration, becoming flatteneddownward and increasing the volume of the thoracic cavity so that airis drawn into the respiratory tract, and then, with expiration, it relaxesand is restored to its dome shape.

Liver
The liver is a vital organ present in vertebrates and some otheranimals. It has a wide range of functions, including detoxification,protein synthesis, and production of biochemicals necessary

fordigestion. The liver is necessary for survival; there is currently no wayto compensate for the absence of liver function.This organ plays a major role in metabolism and has a numberof functions in the body, including glycogen storage, decomposition of red blood cells, plasma protein synthesis, hormone production, anddetoxification. It lies below the diaphragm in the thoracic region of theabdomen. It produces bile, an alkaline compound which aids indigestion, via the emulsification of lipids. It also performs andregulates a wide variety of high-volume biochemical reactionsrequiring highly specialized tissues, including the synthesis andbreakdown of small and complex molecules, many of which arenecessary for normal vital functions.

Stomach
The stomach is a muscular organ of the digestive tract. It islocated between the esophagus and the small intestine. The stomachis hollow and sac-shaped. It is involved in the second phase of digestion, following mastication (chewing). The stomach releases aprotein-digesting enzyme (protease) and hydrochloric acid, which killor inhibit bacteria and provide the acidic pH for the protease to work. The word stomach is derived from the Latin stomachus which isderived from the Greek word stomachos, ultimately from stoma,"mouth". The words gastro- and gastric (meaning related to thestomach) are both derived from the Greek word gaster. The stomachchurns food before it moves on to the rest of the digestive system. Thestomach lies between the esophagus and the duodenum (the first partof the small intestine). It is on the left upper part of the abdominalcavity. The top of the stomach lies against the diaphragm. Lyingbehind the stomach is the pancreas. The greater omentum hangsdown from the greater curvature.Two smooth muscle valves, or sphincters, keep the contents of the stomach contained. They are the esophageal sphincter (found inthe cardiac region) dividing the tract above, and the Pyloric sphincterdividing the stomach from the small intestine.The stomach is surrounded by parasympathetic (stimulant) andorthosympathetic (inhibitor) plexuses (networks of blood vessels andnerves in the anterior gastric, posterior, superior and inferior, celiacand myenteric), which regulate both the secretions activity and themotor (motion) activity of its muscles.Like the other parts of the gastrointestinal tract, the stomach walls aremade of the following layers, from inside to outside: Mucosa The first main layer. This consists of an epithelium, thelamina propria composed of loose connective tissue and whichhas gastric glands in it underneath, and a thin layer of smoothmuscle called the muscularis mucosae. Submucosa This layer lies over the mucosa and consists of fibrous connective tissue, separating the mucosa from the nextlayer. The Meissner's plexus is in this layer. Muscularis Externa Over the submucosa, the muscularisexterna in the stomach differs from that of other GI organs inthat it has three layers of smooth muscle instead of two. inner oblique layer: This layer is responsible for creatingthe motion that churns and physically breaks down thefood. It is the only layer of the three which is not seen inother parts of the digestive system. The antrum hasthicker skin cells in its walls and performs more forcefulcontractions than the fundus.

middle circular layer: At this layer, the pylorus issurrounded by a thick circular muscular wall which isnormally tonically constricted forming a functional (if notanatomically discrete) pyloric sphincter, which controls the movement of chyme into the duodenum. This layer isconcentric to the longitudinal axis of the stomach. outer longitudinal layer: Auerbach's plexus is foundbetween this layer and the middle circular layer.

Serosa This layer is over the muscularis externa, consisting of layers of connective tissue continuous with the peritoneum. Spleen The spleen is an organ found in virtually all vertebrate animalswith important roles in regard to red blood cells and the immunesystem.[1] In humans, it is located in the left upper quadrant of theabdomen. It removes old red blood cells and holds a reserve in case of hemorrhagic shock, especially in animals like horses (not in humans),while recycling iron.[2] It synthesizes antibodies in its white pulp andremoves, from blood and lymph node circulation, antibody-coatedbacteria along with antibodycoated blood cells.[2][3] Recently, it hasbeen found to contain, in its reserve, half of the body's monocytes,within the red pulp, that, upon moving to injured tissue (such as theheart), turns into dendritic cells and macrophages while aiding "woundhealing", or the healing of lacerations.[4][5][6] It is one of the centersof activity of the reticuloendothelial system and can be consideredanalogous to a large lymph node as its absence leads to apredisposition toward certain infections. Pancreas The pancreas is a gland organ in the digestive and endocrinesystem of vertebrates. It is both an endocrine gland producing severalimportant hormones, including insulin, glucagon, and somatostatin, aswell as an exocrine gland, secreting pancreatic juice containingdigestive enzymes that pass to the small intestine. These enzymeshelp in the further breakdown of the carbohydrates, protein, and fat inthe chyme. Gallbladder The gallbladder (or cholecyst or gall bladder) is a small non-vitalorgan that aids in the digestive process and stores bile produced in theliver. The gallbladder is a hollow organ that sits in a concavity of theliver known as the gallbladder fossa. In adults, the gallbladdermeasures approximately 8 cm in length and 4 cm in diameter whenfully distended.[2] It is divided into three sections: fundus, body, andneck. The neck tapers and connects to the biliary tree via the cystic duct, which then joins the common hepatic duct to become thecommon bile duct.The adult human gallbladder stores about 50 millilitres (1.8 impfl oz; 1.7 US fl oz) of bile, which is released when food containing fatenters the digestive tract, stimulating the secretion of cholecystokinin(CCK). The bile, produced in the liver, emulsifies fats in partly digestedfood.

Small intestine
The small intestine is the part of the gastrointestinal tract (gut)following the stomach and followed by the large intestine, and is wherethe vast majority of digestion and absorption of food takes place. Ininvertebrates such as worms, the terms "gastrointestinal tract" and"large intestine" are often used to describe the entire intestine.The small intestine in an adult human measures on averageabout 5

meters (16 feet), with a normal range of 3 - 7 meters; it canmeasure around 50% longer at autopsy because of loss of smoothmuscle tone after death. It is approximately 2.5-3 cm in diameter.Although the small intestine is much longer than the large intestine(typically around 3 times longer), it gets its name from itscomparatively smaller diameter. Although as a simple tube the lengthand diameter of the small intestine would have a surface area of onlyabout 0.5m2, the surface complexity of the inner lining of the smallintestine increase its surface area by a factor of 500 to approximately200m2, or roughly the size of a tennis court.The small intestine is divided into three structural parts:* Duodenum 26 cm (9.8 in) in length* Jejunum 2.5 m (8.2 ft)* Ileum 3.5 m (11.5 ft).

Large intestine
The large intestine is the second to last part of the digestivesystemthe final stage of the alimentary canal is the anus invertebrate animals. Its function is to absorb water from the remainingindigestible food matter, and then to pass useless waste material fromthe body.[1] This article is primarily about the human gut, though theinformation about its processes are directly applicable to mostmammals.The large intestine consists of the cecum and colon. It starts inthe right iliac region of the pelvis, just at or below the right waist,where it is joined to the bottom end of the small intestine. From hereit continues up the abdomen, then across the width of the abdominalcavity, and then it turns down, continuing to its endpoint at the anus. The large intestine is about 1.5 metres (4.9 ft) long, which isabout one-fifth of the whole length of the intestinal canal.AppendixDigestion takes place almost continuously in a watery, slushyenvironment. The large intestine absorbs water from its inner contentsand stores the rest until it is convenient to dispose of it. Attached tothe first portion of the large intestine is a troublesome pouch called the(veriform) appendix. The appendix has no function in modern humans;however it is believed to have been part of the digestive system in ourprimitive ancestors.

Rectum
The rectum (from the Latin rectum intestinum, meaning straightintestine) is the final straight portion of the large intestine in somemammals, and the gut in others, terminating in the anus. The humanrectum is about 12 cm long.[citation needed] Its caliber is similar tothat of the sigmoid colon at its commencement, but it is dilated nearits termination, forming the rectal ampulla.

Care Plan to the Client with a Peptic Ulcer

Assessment 1. Assess for chronic use of certain medications (such as aspirin, steroids). 2. Collect information of complaints that brought client to the hospital. 3. Obtain history of onset and progression of symptoms. 4. Obtain information of diet, use of alcohol and tobacco, ingestion of irritating foods, previous diseases or infections of GI tract, emotional stress. 5. Assess connection of pain attacks to meals, certain drugs, ingestion of coffee, alcohol. 6. Perform complete physical assessment including weight, vital signs, signs of GI bleeding, and acute abdomen. 7. Assess diagnostic tests and procedures for abnormal values.

Diagnosis 1. Increased risk of GI bleeding and perforation of stomach, related to gastric or intestinal wall erosion. 2. Increased risk of pyloric obstruction as complication of the peptic ulcer. 3. Increased risk of anemia due to acute or chronic GI bleeding, related to ulcer. 4. Pain and heartburn, related to diagnosis of peptic ulcer. 5. Appetite changes and weight changes due to symptoms of the ulcer. 6. Increased risk of aspiration due to vomiting, related to ulcer. 7. Anxiety related to the symptoms of disease and fear of the unknown. Plan and Interventions Goals 1. Reduce or completely eliminate contributing factors. 2. Assist with stress management. 3. Promote adequate nutrition. 4. Prevent avoidable injury. 5. Then surgical intervention prescribed, prevent postoperative complications. 6. Relief or diminish symptoms. 7. Decreased anxiety with increased knowledge of disease, it treatment, way of prevention and followup.

Interventions 1. Assess, report , and record signs and symptoms and reactions to treatment. 2. Monitor fluids input and output closely. 3. Administer antacid agents, analgesics, H2-receptors antagonists, anticholinergics, sedatives as prescribed, monitor for side effects. 4. Monitor clients vital signs and signs of possible GI bleeding or perforation closely. 5. Monitor laboratory tests results (CBC, electrolytes, Hb levels) for abnormal values. 6. Undertake appropriate intervention in case of GI bleeding, vomiting, or perforation. 7. Provide prescribed diet avoid irritating foods, coffee, etc. 8. Prepare client and his family for surgical intervention if required for recurrent ulcer, hemorrhage, or perforation. 9. For client after surgical intervention provide postoperative care and inform about possible postoperative complications, such as dumping syndrome. 10. Provide emotional support to client, explain all procedures to decrease anxiety and to obtain cooperation. 11. Instruct client regarding disease progress, diagnostic procedures, treatment and its complications, home care, daily activities, diet, restrictions and follow-up. Evaluation 1. Reports increased comfort, decreased anxiety. 2. Verbalizes absence of heartburn and pain. 3. No evidence of nausea, vomiting, GI bleeding, or acute abdomen.

4. Maintains stable vital signs, fluid balance, and body weight. 5. Laboratory tests results shows no abnormalities. 6. No postoperative complications. 7. Demonstration of understanding of disease progress, diagnostic and treatment procedures, prevention, and need for follow-up.

Pathophysiology
Peptic ulcers result from an imbalance between factors that can damage the gastroduodenal mucosal lining and defense mechanisms that normally limit the injury. Aggressive factors include gastric juice (including hydrochloric acid, pepsin, and bile salts refluxed from the duodenum), H pylori, and NSAIDs. Mucosal defenses comprise a mucus bicarbonate layer secreted by surface mucus cells forming a viscous gel over the gastric mucosa; the integrity of tight junctions between adjacent epithelial cells; and the process of restitution, whereby any break in the epithelial lining is rapidly filled by adjacent epithelial and mucosal stromal cells migrating and flattening to fill the gap. Mucosal defenses depend on an adequate blood supply and on formation within the gastric mucosa.

In general, duodenal ulcers are the result of hypersecretion of gastric acid related to H pylori infection (the majority of cases), whereas secretion is normal or low in patients with gastric ulcers. In duodenal ulcers, chronic H pylori infection confined mainly to the gastric antrum leads to impaired secretion of somatostatin and consequently increased gastrin release, resulting in gastric acid hypersecretion. In Zollinger-Ellison syndrome, a gastrin-secreting neuroendocrine tumour is the stimulus for high rates of gastric acid secretion. In gastric ulcers, longstanding H. pylori infection throughout the stomach accompanied by severe inflammation results in gastric mucin degradation, disruption of tight junctions between gastric epithelial cells, and the induction of gastric epithelial cell death. NSAIDs cause injury directly (involving trapping hydrogen ions) and indirectly (a systemic effect involving the inhibition of cyclo-oxygenases, especially COX-1) and increase bleeding risk through antiplatelet actions. Chronic gastric ischaemia underlies the stress ulcers of patients in intensive care.