PANGASINAN STATE UNIVERSITY BAYAMBANG CAMPUS INTSTITUTE OF NURSING BAYAMBANG, PANGASINAN

Submitted by: Joa a Pau!a G" Jo#o BSN II$A Submitted to: M#" Naomi Rebo % C!i i&a! I #t'u&to'

(ite'a!!y mea # )*ate' i #ide t+e ,id ey) - 'e.e'# to di#te #io a d di!atio o. t+e 'e a! /e!0i# a d &a!y&e#, u#ua!!y &au#ed by ob#t'u&tio o. t+e .'ee .!o* o. u'i e .'om I. INTRODUCTION t+e ,id ey" U t'eated, it !ead# to /'o%'e##i0e at'o/+y o. t+e ,id ey" I &a#e# of hydroureteronephrosis, t+e'e i# di#te tio o. bot+ t+e ureter a d t+e 'e a! /e!0i# a d &a!i&e#"

II. SIGNS AND SYMPTOMS

T+e #i% # a d #ym/tom# o. +yd'o e/+'o#i# de/e d u/o *+et+e' t+e ob#t'u&tio i# a&ute o' &+'o i&, /a'tia! o' &om/!ete, u i!ate'a! o' bi!ate'a!" 1yd'o e/+'o#i# t+at o&&u'# a&ute!y *it+ #udde o #et 2a# &au#ed by a ,id ey #to e3 &a &au#e intense pain in the flank area (between the hips and ribs). 1i#to'i&a!!y, t+i# ty/e o. /ai +a# bee de#&'ibed a# )Dietl's crisis") Co 0e'#e!y, +yd'o e/+'o#i# t+at de0e!o/# %'adua!!y *i!! %e e'a!!y &au#e no pain or attacks of a dull discomfort" Nausea and vomiting may also occur. A ob#t'u&tio t+at o&&u'# at t+e u'et+'a o' b!adde' out!et &a &au#e /ai a d /'e##u'e 'e#u!ti % .'om di#te #io o. t+e b!adde'" B!o&,i % t+e .!o* o. u'i e *i!! &ommo !y 'e#u!t i u'i a'y t'a&t i .e&tio # *+i&+ &a !ead to t+e de0e!o/me t o. additional stones, fever, and blood or pus in the urine. If complete obstruction occurs, kidney failure may follow" B!ood te#t# may #+o* im/ai'ed ,id ey .u &tio 2e!e0ated u'ea o' &'eati i e3 o' e!e&t'o!yte imba!a &e# #u&+ a# +y/o at'emia o' +y/e'&+!o'emi& metabo!i& a&ido#i#" U'i a!y#i# may i di&ate a e!e0ated /1 due to t+e #e&o da'y de#t'u&tio o. e/+'o # *it+i t+e a..e&ted ,id ey" P+y#i&a! e4ami atio may dete&t a /a!/ab!e abdomi a! o' .!a , ma## &au#ed by t+e e !a'%ed ,id ey" Predisposing factors T+e .o!!o*i % .a&to'# i &'ea#e you' &+a &e# o. de0e!o/i % +yd'o e/+'o#i#: 5e.e&t i t+e u'i a'y #y#tem t+at i# /'e#e t at bi't+ Ca &e'# i t+e /e!0i& a'ea Pe!0i& #u'%e'y B!ood$&!otti % di#o'de'# Re&u''e t u'i a'y t'a&t i .e&tio # E !a'%ed /'o#tate Neu'o%e i& B!adde' P'e% a &y Causes 1yd'o e/+'o#i# i# t+e 'e#u!t o. #e0e'a! ab o'ma! /at+o/+y#io!o%i&a! o&&u''e &e#" St'u&tu'a! ab o'ma!itie# o. t+e 6u &tio # bet*ee t+e ,id ey, u'ete', a d b!adde' t+at !ead to +yd'o e/+'o#i# &a o&&u' du'i % .eta! de0e!o/me t" Some o. t+e#e &o %e ita! de.e&t# +a0e bee ide ti.ied a# i +e'ited &o ditio #, +o*e0e' t+e be e.it# o. !i ,i % %e eti& te#ti % to ea'!y dia% o#i# +a0e ot bee dete'mi ed" Ot+e' #t'u&tu'a! ab o'ma!itie# &ou!d be &au#ed by i 6u'y, #u'%e'y, o' 'adiatio t+e'a/y" Com/'e##io o. o e o' bot+ u'ete'# &a a!#o be &au#ed by ot+e' de0e!o/me ta! de.e&t# ot &om/!ete!y o&&u''i % du'i % t+e .eta! #ta%e #u&+ a# a ab o'ma!!y /!a&ed 0ei , a'te'y, o' tumo'" Bi!ate'a! &om/'e##io o. t+e u'ete'# &a o&&u' du'i % /'e% a &y due to e !a'%eme t o. t+e ute'u#" C+a %e# i +o'mo e !e0e!# du'i % t+i# time may a!#o a..e&t t+e mu#&!e &o t'a&tio # o. t+e b!adde', .u't+e' &om/!i&ati % t+i# &o ditio " Sou'&e# o. ob#t'u&tio t+at &a a'i#e .'om ot+e' 0a'iou# &au#e# i &!ude ,id ey #to e#, b!ood &!ot#, o' 'et'o/e'ito ea! .ib'o#i#"

T+e ob#t'u&tio may be eit+e' /a'tia! o' &om/!ete a d &a o&&u' a y*+e'e .'om t+e u'et+'a! meatu# to t+e &a!y&e# o. t+e 'e a! /e!0i#" 1yd'o e/+'o#i# &a a!#o 'e#u!t .'om t+e 'e0e'#e .!o* o. u'i e .'om t+e b!adde' ba&, i to t+e ,id ey#" T+i# 'e.!u4 &a be &au#ed by #ome o. t+e .a&to'# !i#ted abo0e a# *e!! a# &om/'e##io o. t+e b!adde' out!et i to t+e u'et+'a by /'o#tati& e !a'%eme t o' im/a&tio o. .e&e# i t+e &o!o , a# *e!! a# ab o'ma! &o t'a&tio # o. b!adde' mu#&!e# 'e#u!ti % .'om eu'o!o%i&a! dy#.u &tio o' ot+e' mu#&u!a' di#o'de'#"

III. PAT OP YSIO!OGY

Ob#t'u&tio t+at o&&u'# a y*+e'e a!o % t+e u//e' u'i a'y t'a&t *i!! !ead to i &'ea#ed /'e##u'e *it+i t+e #t'u&tu'e# o. t+e ,id ey due to t+e i abi!ity to /a## u'i e .'om t+e ,id ey to t+e b!adde'" Commo &au#e# o. u//e' t'a&t ob#t'u&tio i &!ude ob#t'u&ti % #to e# a d u'ete'o/e!0i& 6u &tio 2UPJ3 ob#t'u&tio &au#ed by i t'i #i& a''o*i % o. t+e u'ete'# o' a o0e'!yi % 0e##e!" Ob#t'u&tio o&&u''i % i t+e !o*e' u'i a'y t'a&t &a a!#o &au#e t+i# i &'ea#ed /'e##u'e t+'ou%+ t+e 'e.!u4 o. u'i e i to t+e ,id ey"

Commo &au#e# i &!ude b!adde' dy#.u &tio 2#u&+ a# eu'o%e i& b!adde'3 a d u'et+'a! ob#t'u&tio 2#u&+ a# /o#te'io' u'et+'a! 0a!0e# i ma!e i .a t#3 o' &om/'e##io 2#u&+ a# .'om /'o#tati& +y/e't'o/+y i o!de' ma!e adu!t#3" A yt+i % t+at &au#e# ob#t'u&tio !ead# to i &'ea#ed /'e##u'e bei % t'a #mitted to t+e de!i&ate ti##ue# t+at ma,e u/ t+e .i!t'atio #y#tem *it+i t+e ,id ey#, *+i&+ &ou!d e0e tua!!y 'e#u!t i i .e&tio , #to e .o'matio , o' !o## o. .u &tio " Additio a! &om/!i&atio # a'i#i % .'om ob#t'u&tio o. t+e !o*e' u'i a'y t'a&t i &!ude t+e #ta% atio o. u'i e .!o* *+i&+ &a a!#o !ead to i .e&tio i t+e b!adde'" Ob#t'u&tio may be a 'e#u!t o. a tumou' i t+e /e!0i# &om/'e##i % t+e u'ete'# o' u'et+'a, .o' e4am/!e i /atie t# *it+ ad0a &ed &e'0i&a! &a &e' 2#ta%e IIIA to IVB3"

I". M#DICA!$SURGICA! INT#R"#NTIONS T+e %oa! o. t'eatme t .o' +yd'o e/+'o#i# i# to 'e#ta't t+e .'ee .!o* o. u'i e .'om t+e ,id ey a d de&'ea#e t+e #*e!!i % a d /'e##u'e t+at bui!d# u/ a d de&'ea#e# ,id ey .u &tio " T+e i itia! &a'e .o' t+e /atie t i# aimed at mi imi7i % /ai a d /'e0e ti % u'i a'y t'a&t i .e&tio #" Ot+e'*i#e, #u'%i&a! i te'0e tio may be 'e8ui'ed" T+e timi % o. t+e /'o&edu'e de/e d# u/o t+e u de'!yi % &au#e o. +yd'o e/+'o#i# a d +yd'ou'ete' a d t+e a##o&iated medi&a! &o ditio # t+at may be /'e#e t" Fo' e4am/!e, /atie t# *it+ a ,id ey #to e may be a!!o*ed 9$: *ee,# to /a## t+e #to e *it+ o !y #u//o'ti0e /ai &o t'o! i. u'i e .!o* i# ot &om/!ete!y b!o&,ed by t+e #to e" I., +o*e0e', t+e /atie t de0e!o/# a i .e&tio o' i. t+ey o !y +a0e o e ,id ey, #u'%i&a! i te'0e tio may be do e eme'%e t!y to 'emo0e t+e #to e" Fo' /atie t# *it+ u'i a'y 'ete tio a d a e !a'%ed b!adde' a# a &au#e o. +yd'o e/+'o#i#, b!adde' &at+ete'i7atio may be a!! t+at i# eeded .o' i itia! t'eatme t" Fo' /atie t# *it+ u'ete'a! #t'i&tu'e# o' #to e# t+at a'e di..i&u!t to 'emo0a!, a u'o!o%i#t may /!a&e a #te t i to t+e u'ete' t+at by/a##e# t+e ob#t'u&tio a d a!!o*# u'i e to .!o* .'om t+e ,id ey" U#i % a .ibe'o/ti& #&o/e i #e'ted t+'ou%+ t+e u'et+'a i to t+e b!adde', t+e u'o!o%i#t &a 0i#ua!i7e

*+e'e t+e u'ete' e te'# a d &a t+'ead t+e #te t t+'ou%+ t+e u'ete' i to t+e ,id ey /e!0i# by/a##i % a y ob#t'u&tio " ;+e a #te t &a ot be /!a&ed, a a!te' ati0e i# i #e'ti % a /e'&uta eou# e/+'o#tomy tube" A u'o!o%i#t o' i te'0e tio a! 'adio!o%i#t u#e# .!uo'o#&o/y to i #e't a tube t+'ou%+ t+e .!a , di'e&t!y i to t+e ,id ey to a!!o* u'i e to d'ai " Some &o ditio #, .o' e4am/!e 'et'o/e'ito ea! .ib'o#i# o' tumo'#, may 'e8ui'e #te'oid t+e'a/y, a .o'ma! o/e'atio o' !a/a'o#&o/y to 'e!ie0e t+e +yd'o e/+'o#i# o' +yd'ou'ete' *+i!e o'a! a!,a!i i7atio t+e'a/y may be u#ed to di##o!0e u'i& a&id ,id ey #to e#" T'eatme t +a# t*o %oa!#-to 8ui&,!y 'edu&e t+e amou t o. e4t'a u'i e i t+e ,id ey &au#ed by t+e ba&,u/ a d to &o''e&t<t'eat t+e u de'!yi % &au#e" Medi&a! a d<o' #u'%i&a! t'eatme t may be e&e##a'y" A tibioti&# a'e %i0e to t'eat t+e i .e&tio " T+e &au#e o. t+e u'i a'y b!o&,a%e mu#t be #u'%i&a!!y &o''e&ted" Cy#to#&o/y may be /e'.o'med to 'emo0e ,id ey #to e# .'om t+e u'ete'" Sto e# t+at a'e too !a'%e .o' 'emo0a! by &y#to#&o/y may be t'eated *it+ e4t'a&o'/o'ea! #+o&, *a0e !it+ot'i/#y 2ES;(3" I ES;(, ,id ey #to e# a'e b'o,e a/a't u#i % #+o&, *a0e# t+at a'e t'a #mitted t+'ou%+ t+e #,i " T+e .'a%me t# may t+e /a## du'i % u'i atio , o' may be 'emo0ed u#i % &y#to#&o/y /'o&edu'e#" A #ma!! tube 2#te t3 may be /!a&ed du'i % &y#to#&o/y i t+e u'ete' to e ab!e /a##a%e o. ,id ey #to e#" Su'%i&a! t'eatme t o. t+e /'o#tate may be e&e##a'y to 'edu&e ob#t'u&tio o. t+e u'et+'a" I. +yd'o e/+'o#i# i# due to be i% /'o#tati& +y/e't'o/+y 2BP13, t'eatme t o/tio # i &!ude t'a #u'et+'a! 'e#e&tio o. /'o#tate 2TURP3, t'a #u'et+'a! i &i#io o. /'o#tate 2TUIP3, a d t'a #u'et+'a! !a#e'$i du&ed /'o#tate&tomy 2TU(IP3" Tumo'# a..e&ti % out.!o* o. u'i e .'om t+e ,id ey# o' t+at b!o&, t+e u'ete'#, b!adde', o' u'et+'a a'e 'emo0ed #u'%i&a!!y" I #ome &a#e#, a tube may be i #e'ted di'e&t!y i to t+e ,id ey to d'ai t+e ,id ey 2/e'&uta eou# e/+'o#tomy3 to /'e0e t .u't+e' dama%e to t+e 'e a! ti##ue" 5e.i iti0e t'eatme t o. a u//e' t'a&t ob#t'u&tio &a be a&&om/!i#+ed by u#e o. a e/+'o#&o/e i #e'ted t+'ou%+ t+e e/+'o#tomy"

". NURSING R#SPONSI%I!ITI#S St'ai i % U'i e .o' Ca!&u!i" I. ,id ey o' ot+e' u'i a'y t'a&t #to e# a'e #u#/e&ted, t+e /+y#i&ia *i!! o'de' a!! u'i e to be #t'ai ed" You &a do t+i# by /ou'i % t+e u'i e t+'ou%+

%au7e, &+ee#e&!ot+, o' a #t'ai e'" Sa0e a y &a!&u!i" Ca!&u!i t+at a'e /a##ed #/o ta eou#!y may be a# #ma!! a# %'ai # o. #a d o' a# !a'%e a# /ebb!e#" Mea#u'e a d di#&a'd t+e u'i e, a d #a0e a y mate'ia! #t'ai ed out o. it .o' e4ami atio by t+e /+y#i&ia o' !abo'ato'y /e'#o e!" See I P'a&ti&e: Nu'#i % Ca'e P!a =>$9 .o' &a'e o. t+e &!ie t *it+ 'e a! &a!&u!i" Ca'i % .o' t+e C!ie t U de'%oi % Sto e Remo0a!" P'e$a d /o#to/e'ati0e &a'e .o' #u'%i&a! 'emo0a! o. #to e# i# ba#i&a!!y t+e #ame a# .o' ot+e' abdomi a! /'o&edu'e#, *it+ &a'e.u! ob#e'0atio a d #t'ai i % o. t+e u'i e? a a!y#i# o. a #to e &a di#&o0e' t+e &au#ati0e a%e t" ;+e t+e ty/e o. #to e i# , o* , a//'o/'iate /'e0e tati0e mea#u'e# &a be ta,e " Ste'i!e te&+ i8ue i# e&e##a'y *+e &a'i % .o' d'ai a%e tube# /o#to/e'ati0e!y" Fo' t+e &!ie t u de'%oi % ES;(, e4/!ai t+e /'o&edu'e" 5e/e di % o t+e met+od o. ES;( u#ed, t+e &!ie t *i!! eit+e' be /!a&ed o a t'eatme t tab!e t+at +a# a bui!t$i *ate' &u#+io o' t+e &!ie t *i!! be imme'#ed i a tub o. *ate'" I. u#i % t+e #ubme'#io ta ,, /!a&e #ma!! *ate' *i %# o t+e &!ie t@# a'm# to ,ee/ t+e a'm# a.!oat a d out o. t+e *ay" A mi!d #edati0e i# u#ua!!y o'de'ed be.o'e t+e /'o&edu'e, a d %e e'a! a e#t+e#ia may be admi i#te'ed" T+e /'o&edu'e i# ot tota!!y *it+out di#&om.o't" 5o&ume t a!! tea&+i %" Nu'#i % &a'e a.te' ES;( i &!ude# ob#e'0atio o. u'i e, *+i&+ *i!! be #!i%+t!y b!oody .o' :A to A= +ou'#" T+e &o!o' i# mo#t o.te de#&'ibed a# B'o#e"C T+e b!eedi % 'e#u!t# .'om u'ete'a! t'auma &au#ed by t+e %'a0e!$!i,e #to e .'a%me t# /a##i % t+'ou%+ i t+e u'i e" St'ai t+e u'i e a d e &ou'a%e .!uid#" T+e &!ie t may be b'ui#ed i t+e a'ea o. t+e !ate'a! /e!0i& bo e#" "I. R#&#R#NC#S +tt/:<<*+at$*+e $+o*"&om< u'#i %<u'i a'y$di#o'de'#$adu!t$&a'e$ u'#i %$/a't$A< +tt/:<<***"medi&i e et"&om<+yd'o e/+'o#i#</a%eA"+tm +tt/:<<***"md%uide!i e#"&om<+yd'o e/+'o#i# +tt/:<<***"*i,i/edia"&om

I.INTRODUCTION A /e/ti& u!&e', a!#o , o* a# /e/ti& u!&e' di#ea#e 2PU53, i# t+e mo#t &ommo u!&e' o. a a'ea o. t+e %a#t'oi te#ti a! t'a&t t+at i# u#ua!!y a&idi& a d t+u# e4t'eme!y /ai .u!" It i# de.i ed a# mu&o#a! e'o#io # e8ua! to o' %'eate' t+a D"E &m" A# ma y a# FDG>DH o. #u&+ u!&e'# a'e a##o&iated *it+ 1e!i&oba&te' /y!o'i, a 'od$#+a/ed ba&te'ium t+at !i0e# i t+e a&idi& e 0i'o me t o. t+e #toma&+? +o*e0e', o !y ADH o. t+o#e &a#e# %o to a do&to'" U!&e'# &a a!#o be &au#ed o' *o'#e ed by d'u%# #u&+ a# a#/i'i , ibu/'o.e , a d ot+e' NSAI5#" Fou' time# a# ma y /e/ti& u!&e'# a'i#e i t+e duode um-t+e .i'#t /a't o. t+e #ma!! i te#ti e, 6u#t a.te' t+e #toma&+-a# i t+e #toma&+ it#e!." About AH o. %a#t'i& u!&e'# a'e &au#ed by a ma!i% a t tumo', #o mu!ti/!e bio/#ie# a'e eeded to e4&!ude &a &e'" 5uode a! u!&e'# a'e %e e'a!!y be i% "

II. SIGNS AND SYMPTOMS Sym/tom# o. a /e/ti& u!&e' &a be a'do(ina) pain, &!a##i&a!!y e/i%a#t'i& #t'o %!y &o''e!ated to mea!time#" I &a#e o. duode a! u!&e'# t+e /ai a//ea'# about t+'ee +ou'# a.te' ta,i % a mea!? b!oati % a d abdomi a! .u!! e##? *ater'ras+ 2'u#+ o. #a!i0a a.te' a e/i#ode o. 'e%u'%itatio to di!ute t+e a&id i e#o/+a%u# $ a!t+ou%+ t+i# i# mo'e a##o&iated *it+ %a#t'oe#o/+a%ea! 'e.!u4 di#ea#e3? au#ea, a d &o/iou# 0omiti %? !o## o. a//etite a d *ei%+t !o##? +e(ate(esis 20omiti % o. b!ood3? t+i# &a o&&u' due to b!eedi % di'e&t!y .'om a %a#t'i& u!&e', o' .'om dama%e to t+e e#o/+a%u# .'om #e0e'e<&o ti ui % 0omiti %" (e)ena 2ta''y, .ou!$#me!!i % .e&e# due to o4idi7ed i'o .'om +emo%!obi 3? 'a'e!y, a u!&e' &a !ead to a %a#t'i& o' duode a! /e'.o'atio , *+i&+ !ead# to a&ute /e'ito iti#" T+i# i# e4t'eme!y /ai .u! a d 'e8ui'e# immediate #u'%e'y" A +i#to'y o. +ea'tbu' , %a#t'oe#o/+a%ea! 'e.!u4 di#ea#e 2GER53 a d u#e o. &e'tai .o'm# o. medi&atio &a 'ai#e t+e #u#/i&io .o' /e/ti& u!&e'" Medi&i e# a##o&iated *it+ /e/ti& u!&e' i &!ude NSAI5 2 o $#te'oid a ti$i .!ammato'y d'u%#3 t+at i +ibit &y&!oo4y%e a#e, a d mo#t %!u&o&o'ti&oid# 2e"%" de4amet+a#o e a d /'ed i#o!o e3" I /atie t# o0e' AE *it+ mo'e t+a t*o *ee,# o. t+e abo0e #ym/tom#, t+e odd# .o' /e/ti& u!&e'atio a'e +i%+ e ou%+ to *a''a t 'a/id i 0e#ti%atio by e#o/+a%o%a#t'oduode o#&o/y" T+e timi % o. t+e #ym/tom# i 'e!atio to t+e mea! may di..e'e tiate bet*ee %a#t'i& a d duode a! u!&e'#: A %a#t'i& u!&e' *ou!d %i0e e/i%a#t'i& /ai du'i % t+e mea!, a# %a#t'i& a&id /'odu&tio i# i &'ea#ed a# .ood e te'# t+e #toma&+" Sym/tom# o. duode a! u!&e'# *ou!d i itia!!y be 'e!ie0ed by a mea!, a# t+e /y!o'i& #/+i &te' &!o#e# to &o &e t'ate t+e #toma&+ &o te t#, t+e'e.o'e a&id i# ot 'ea&+i % t+e duode um" 5uode a! u!&e' /ai *ou!d ma i.e#t mo#t!y :GI +ou'# a.te' t+e mea!, *+e t+e #toma&+ be%i # to 'e!ea#e di%e#ted .ood a d a&id i to t+e duode um" A!#o, t+e #ym/tom# o. /e/ti& u!&e'# may 0a'y *it+ t+e !o&atio o. t+e u!&e' a d t+e /atie tJ# a%e" Fu't+e'mo'e, ty/i&a! u!&e'# te d to +ea! a d 'e&u' a d a# a 'e#u!t t+e /ai may o&&u' .o' .e* day# a d *ee,# a d t+e *a e o' di#a//ea'" U#ua!!y, &+i!d'e a d t+e e!de'!y do ot de0e!o/ a y #ym/tom# u !e## &om/!i&atio # +a0e a'i#e " Bu' i % o' % a*i % .ee!i % i t+e #toma&+ a'ea !a#ti % bet*ee ID mi ute# a d I +ou'# &ommo !y a&&om/a ie# u!&e'#" T+i# /ai &a be mi#i te'/'eted a# +u %e', i di%e#tio o' +ea'tbu' " Pai i# u#ua!!y &au#ed by t+e u!&e' but it may be a%%'a0ated by t+e #toma&+ a&id *+e it &ome# i to &o ta&t *it+ t+e u!&e'ated a'ea" T+e /ai &au#ed by /e/ti& u!&e'# &a be .e!t a y*+e'e .'om t+e a0e! u/ to t+e #te' um, it may !a#t .'om .e* mi ute# to #e0e'a! +ou'# a d it may be *o'#e *+e t+e #toma&+ i# em/ty" A!#o, #ometime# t+e /ai may .!a'e at i%+t a d it &a &ommo !y be tem/o'a'i!y 'e!ie0ed by eati % .ood# t+at bu..e' #toma&+ a&id o' by ta,i % a ti$ a&id medi&atio " 1o*e0e', /e/ti& u!&e' di#ea#e #ym/tom# may be di..e'e t .o' e0e'y #u..e'e'" III. P ATOP YSIO!OGY 1i#to'i&a!!y, ou' u de'#ta di % o. t+e /at+o/+y#io!o%y o. /e/ti& u!&e' di#ea#e .o&u#ed o ab o'ma!itie# i t+e #e&'etio o. %a#t'i& a&id a d /e/#i , a d o t+e #u//'e##io o. a&id a# a t'eatme t #t'ate%y" Today, %a#t'i& +y/e'#e&'etio -a##o&iated *it+ %a#t'i oma i Ko!!i %e'$E!!i#o #y d'ome, a t'a! G$&e!! +y/e'/!a#ia, a i &'ea#e i /a'ieta!$&e!! ma##, a d a /+y#io!o%i&a! imba!a &e bet*ee t+e a ta%o i#ti& %a#t'i& +o'mo e# %a#t'i a d #omato#tati -i# #ti!! a im/o'ta t i##ue i /e/ti& u!&e' di#ea#e" Mo'eo0e', it i# , o* t+at &+o!i e'%i& +y/e'#e #iti0ity a d /a'a#ym/at+eti& domi a &e a'e 'e!ated to t+e #timu!atio ot o !y o. +yd'o&+!o'i& a&id but a!#o /e/#i , *+i&+ i# o.te e%!e&ted a# a &o.a&to' i t+e de0e!o/me t o. e'o#i0e i 6u'y to t+e %a#t'i& mu&o#a" P#y&+o!o%i& #t'e##, &i%a'ette #mo,i %, a!&o+o! &o #um/tio , u#e o. o #te'oida! a ti$i .!ammato'y d'u%# 2NSAI5#3 i &!udi % a#/i'i , o'a! bi#/+o#/+o ate#, /ota##ium &+!o'ide, immu o#u//'e##i0e medi&atio #, a d a a%e$'e!ated de&!i e i /'o#ta%!a di !e0e!# +a0e a!! bee #+o* to &o t'ibute to /e/ti& u!&e' di#ea#e" It *a#, +o*e0e', t+e i#o!atio o. 1" /y!o'i a d it# ide ti.i&atio a# t+e mo#t im/o'ta t &au#e o. /e/ti& u!&e' di#ea#e t+at !ed to

e4/!o'atio o. t+e 'o!e o. i .!ammatio a d it# a##o&iated &yto,i e &a#&ade i %a#t'i& a&id #e&'etio " 1" /y!o'i e0ade# atta&, by t+e +o#t immu e #y#tem a d &au#e# &+'o i&, i do!e t i .!ammatio by #e0e'a! me&+a i#m#" 1" /y!o'i &a dama%e t+e mu&o#a! de.e #e #y#tem by 'edu&i % t+e t+i&, e## o. t+e mu&u# %e! !aye', dimi i#+i % mu&o#a! b!ood .!o*, a d i te'a&ti % *it+ t+e %a#t'i& e/it+e!ium t+'ou%+out a!! #ta%e# o. t+e i .e&tio " 1" /y!o'i i .e&tio &a a!#o i &'ea#e %a#t'i& a&id #e&'etio ? by /'odu&i % 0a'iou# a ti%e #, 0i'u!e &e .a&to'#, a d #o!ub!e mediato'#, 1" /y!o'i i du&e# i .!ammatio , *+i&+ i &'ea#e# /a'ieta!$&e!! ma## a d, t+e'e.o'e, t+e &a/a&ity to #e&'ete a&id" T+e 1" /y!o'i &ytoto4i $a##o&iated %e e Ca%A a!#o +a# a im/o'ta t 'o!e: it i te'.e'e# *it+ %a#t'i& e/it+e!ia! &e!!$#i% a!i % /at+*ay#, t+e'eby 'e%u!ati % &e!!u!a' 'e#/o #e# a d /o##ib!y &o t'ibuti % to a/i&a! 6u &tio ba''ie' di#'u/tio , i te'!eu,i $= #e&'etio a d /+e oty/i& &+a %e# to %a#t'i& e/it+e!ia! &e!!#" U de'#ta di % t+e /at+o/+y#io!o%y o. /e/ti& u!&e' di#ea#e i# at #omet+i % o. a &'o##'oad#: me&+a i#m# o. i 6u'y di..e' di#ti &t!y bet*ee duode a! a d %a#t'i& u!&e'#" 5uode a! u!&e' i# e##e tia!!y a 1" /y!o'i$'e!ated di#ea#e a d i# &au#ed mai !y by a i &'ea#e i a&id a d /e/#i !oad, a d %a#t'i& meta/!a#ia i t+e duode a! &a/" Ga#t'i& u!&e', at !ea#t i ;e#te' &ou t'ie#, i# mo#t &ommo !y a##o&iated *it+ NSAI5 i %e#tio , a!t+ou%+ 1" /y!o'i i .e&tio mi%+t a!#o be /'e#e t" C+'o i&, #u/e'.i&ia! a d at'o/+i& %a#t'iti# /'edomi ate i /atie t# *it+ %a#t'i& u!&e'#, *+e e0e o'ma! a&id !e0e!# &a be a##o&iated *it+ mu&o#a! u!&e'atio " I bot+ &o ditio #, u!&e' i# a##o&iated *it+ a imba!a &e bet*ee /'ote&ti0e a d a%%'e##i0e .a&to'#, *it+ i .!ammatio bei % a !eadi % &au#e o. t+i# imba!a &e" T+e i#o!atio o. 1" /y!o'i i t+e ea'!y 9>=D# *a# o e o. t+e mo#t e4&iti % ad0a &e# i t+e +i#to'y o. /e/ti& u!&e' di#ea#e, a d it +a# d'amati&a!!y &+a %ed t+e ma a%eme t o. /e/ti& u!&e'" E'adi&atio o. 1" /y!o'i i .e&tio i# o* t+e mai #tay o. t'eatme t .o' /e/ti& u!&e' di#ea#e, a d +a# 'e#u!ted i 0e'y +i%+ u!&e' +ea!i % 'ate# a d 'e&u''e &e 'ate# t+at +a0e d'o//ed d'amati&a!!y, e#/e&ia!!y .o' i di0idua!# *it+ a duode a! u!&e'" T+e %'eate' 'e&o% itio o. t+e 'o!e o. NSAI5# a d a#/i'i i %a#t'oi te#ti a!$t'a&t i 6u'y +a# !ed to t+e de0e!o/me t o. t+e'a/euti& a d /'e0e ti0e #t'ate%ie# t+at 'e!y o t+e u#e o. a ti#e&'eto'y d'u%#, t+e /'o#ta%!a di a a!o% mi#o/'o#to!, o' #e!e&ti0e &y&!o$o4y%e a#e 2COL3$: i +ibito'# 2&o4ib#3" 5u'i % t+e 9>=D#, 1" /y!o'i i .e&tio *a# .ou d i mo'e t+a >DH o. /atie t# *it+ duode a! u!&e'#, a d #ome FDH o. /atie t# *it+ %a#t'i& u!&e'#" T+e de&!i i % i &ide &e a d /'e0a!e &e o. /e/ti& u!&e' i de0e!o/ed &ou t'ie# +a# /a'a!!e!ed t+e .a!!i % /'e0a!e &e o. 1" /y!o'i i .e&tio ,M9AN e#/e&ia!!y i /o/u!atio # *it+ +i%+ i .e&tio 'ate#" O !y 1" /y!o'i e'adi&atio i# a e..e&ti0e t'eatme t .o' bot+ duode a! a d %a#t'i& u!&e'#" A ti#e&'eto'y d'u%# *o', *e!! .o' &o t'o!!i % #ym/tom# a d a!!o*i % u!&e'# to +ea!, a d t+e ab#o!ute be e.it o. e'adi&ati % 1" /y!o'i i .e&tio i# #ma!! *it+ 'e#/e&t to +ea!i % a!o e" I a Co&+'a e meta$ a a!y#i# t+e e'adi&atio o. 1" /y!o'i i .e&tio &ombi ed *it+ t+e u#e o. a u!&e'$+ea!i % d'u% #i% i.i&a t!y i &'ea#ed duode a! +ea!i % to =IH 2i te t$to$t'eat a a!y#i#3, *it+ t+e 'e!ati0e 'i#, o. t+e u!&e' /e'#i#ti % bei % D"OO 2>EH CI D"E=$D"FO3 &om/a'ed *it+ t+e u!&e'$+ea!i % d'u%# a!o e? but e'adi&atio *a# ot #i% i.i&a t!y #u/e'io' to u!&e'$+ea!i % d'u%# .o' %a#t'i&$u!&e' +ea!i % 2'e!ati0e 'i#, 9"I:? >EH CI D">:$9">D3" 5e#/ite t+ei' *e!!$a&&e/ted a ti$i .!ammato'y a d a a!%e#i& be e.it#, NSAI5 u#e i# /'obab!y t+e mo#t &ommo &au#e o. %a#t'oi te#ti a! mu&o#a! i 6u'y i ;e#te' &ou t'ie#" NSAI5#, i &!udi % a#/i'i , #i% i.i&a t!y i &'ea#e t+e 'i#, o. ad0e'#e %a#t'oi te#ti a! e0e t#, /a'ti&u!a'!y t+o#e 'e!ated to %a#t'i& a d<o' duode a! mu&o#a! i 6u'y: e'o#io #, u!&e'# a d u!&e' &om/!i&atio #, e#/e&ia!!y b!eedi %" About 9E$IDH o. 'e%u!a' NSAI5 u#e'# +a0e o e o' mo'e u!&e'# *+e e4ami ed e do#&o/i&a!!y, a d I$A"EH o. NSAI5 u#e'# +a0e &!i i&a!!y #i% i.i&a t u//e' %a#t'oi te#ti a! e0e t#, i &!udi % u!&e'# a d u!&e' &om/!i&atio #" Patie t# ta,i % !o*$do#e a#/i'i .o' t+e /'e0e tio o. a &a'dio0a#&u!a' e0e t, #u&+ a# myo&a'dia! i .a'&tio o' t+'omboti& #t'o,e, a'e a!#o at i &'ea#ed 'i#, o. %a#t'oi te#ti a! i 6u'y a d &om/!i&atio #" I a#ym/tomati& /atie t# ta,i % !o*$do#e a#/i'i 2FE$I:E m%<day3 .o' PI mo t+#, e do#&o/i&a!!y ob#e'0ed u!&e'# o' e'o#io # a'e 'e/o'ted i AF"=IH o. &a#e#" T+e 'i#, o. u//e' %a#t'oi te#ti a! b!eedi % e0e t# i# do#e$de/e de t, *it+ a odd# 'atio 2OR3 o. I"I .o' IDD m% o. a#/i'i 2>EH CI 9":$>"D3 a d a OR o. O"A .o' 9": % o. a#/i'i 2>EH CI :"E$9O"E3"M:DN I mu!ti0a'iate mode!# ad6u#ted .o' a%e, #e4, a d &!i i&a! 'i#,, !o*$do#e a#/i'i a!o e *a# i de/e de t!y a##o&iated *it+ a i &'ea#ed 'i#, o. u!&e' b!eedi %, *it+ a OR o. :"A 2>EH CI 9"=$I"I3"

T+e i 6u'iou# %a#t'oi te#ti a! e..e&t# o. NSAI5# a'e !a'%e!y &au#ed by t+e i +ibitio o. COL9 a d it# 'o!e i o'ma! mu&o#a! de.e #e me&+a i#m# 2di#&u##ed abo0e3, a d a!#o t+'ou%+ t+e i +ibitio o. t+'ombo4a e A:, *+i&+ &om/'omi#e# /!ate!et .u &tio a d 'e#u!t# i %a#t'oi te#ti a! b!eedi %" C!i i&a! t'ia!# +a0e 'e/eated!y demo #t'ated t+at &o4ib# a'e a##o&iated *it+ .e*e' u!&e'#, !e## %a#t'oi te#ti a! b!eedi % a d .e*e' u!&e' &om/!i&atio # t+a o #e!e&ti0e NSAI5#, but &o &u''e t u#e o. !o*$do#e a#/i'i b!u t# t+i# be e.it" It i# e4/e&ted t+at t+e *it+d'a*a! o. #e0e'a! &o4ib# *i!! !ead to ma y /atie t# #*it&+i % ba&, to o #e!e&ti0e NSAI5#, *it+ a a ti&i/ated i &'ea#e i &a#e# o. %a#t'oi te#ti a! b!eedi %, e#/e&ia!!y i e!de'!y /atie t#" 1" /y!o'i i .e&tio a d NSAI5# a'e i de/e de t 'i#, .a&to'# .o' /e/ti& u!&e' di#ea#e t+at +a0e additi0e o' #y e'%i#ti& e..e&t# o ad0e'#e %a#t'oi te#ti a! out&ome#" I a meta$ a a!y#i#, t+e OR .o' t+e i &ide &e o. /e/ti& u!&e' *a# O9"9 i /atie t# i .e&ted *it+ 1" /y!o'i a d a!#o ta,i % NSAI5#, &om/a'ed *it+ u i .e&ted &o t'o!# ot ta,i % NSAI5#" T+e OR a''o*ed to 9="9 *+e &om/a'i % 1" /y!o'i$i .e&ted /atie t# *it+ 1" /y!o'i$u i .e&ted /atie t# *+o *e'e ot ta,i % NSAI5#" 1" /y!o'i i .e&tio a!#o /ote tiate# t+e u!&e' b!eedi % i du&ed by !o*$do#e a#/i'i " To%et+e', 1" /y!o'i i .e&tio a d NSAI5 u#e a&&ou t .o' a//'o4imate!y >DH o. /e/ti& u!&e' di#ea#e" I". M#DICA!$SURGICA! INT#R"#NTIONS You %e' /atie t# *it+ u!&e'$!i,e #ym/tom# a'e o.te t'eated *it+ a ta&id# o' 1: a ta%o i#t# be.o'e EG5 i# u de'ta,e " Bi#mut+ &om/ou d# may a&tua!!y 'edu&e o' e0e &!ea' o'%a i#m#M&itatio eededN, t+ou%+ t+e *a' i % !abe!# o. #ome bi#mut+ #ub#a!i&y!ate /'odu&t# i di&ate t+at t+e /'odu&t #+ou!d ot be u#ed by #omeo e *it+ a u!&e'" Patie t# *+o a'e ta,i % o #te'oida! a ti$i .!ammato'ie# 2NSAI5#3 may a!#o be /'e#&'ibed a /'o#ta%!a di a a!o%ue 2Mi#o/'o#to!3 i o'de' to +e!/ /'e0e t /e/ti& u!&e'#, *+i&+ a'e a #ide$e..e&t o. t+e NSAI5#" ;+e 1" /y!o'i i .e&tio i# /'e#e t, t+e mo#t e..e&ti0e t'eatme t# a'e &ombi atio # o. : a tibioti&# 2e"%" C!a'it+'omy&i , Amo4i&i!!i , Tet'a&y&!i e, Met'o ida7o!e3 a d 9 /'oto /um/ i +ibito' 2PPI3, #ometime# to%et+e' *it+ a bi#mut+ &om/ou d" I &om/!i&ated, t'eatme t$ 'e#i#ta t &a#e#, I a tibioti&# 2e"%" amo4i&i!!i Q &!a'it+'omy&i Q met'o ida7o!e3 may be u#ed to%et+e' *it+ a PPI a d #ometime# *it+ bi#mut+ &om/ou d" A e..e&ti0e .i'#t$!i e t+e'a/y .o' u &om/!i&ated &a#e# *ou!d be Amo4i&i!!i Q Met'o ida7o!e Q Pa to/'a7o!e 2a PPI3" I t+e ab#e &e o. 1" /y!o'i, !o %$te'm +i%+e' do#e PPI# a'e o.te u#ed" T'eatme t o. 1" /y!o'i u#ua!!y !ead# to &!ea'i % o. i .e&tio , 'e!ie. o. #ym/tom# a d e0e tua! +ea!i % o. u!&e'#" Re&u''e &e o. i .e&tio &a o&&u' a d 'et'eatme t may be 'e8ui'ed, i. e&e##a'y *it+ ot+e' a tibioti&#" Si &e t+e *ide#/'ead u#e o. PPIJ# i t+e 9>>D#, #u'%i&a! /'o&edu'e# 2!i,e )+i%+!y #e!e&ti0e 0a%otomy)3 .o' u &om/!i&ated /e/ti& u!&e'# be&ame ob#o!ete" Pe'.o'ated /e/ti& u!&e' i# a #u'%i&a! eme'%e &y a d 'e8ui'e# #u'%i&a! 'e/ai' o. t+e /e'.o'atio " Mo#t b!eedi % u!&e'# 'e8ui'e e do#&o/y u'%e t!y to #to/ b!eedi % *it+ &aute'y, i 6e&tio , o' &!i//i %" Ra itidi e a d .amotidi e, *+i&+ a'e bot+ 1: a ta%o i#t#, /'o0ide 'e!ie. o. /e/ti& u!&e'#, +ea'tbu' , i di%e#tio a d e4&e## #toma&+ a&id a d /'e0e tio o. t+e#e #ym/tom# a##o&iated *it+ e4&e##i0e &o #um/tio o. .ood a d d'i ," Ra itidi e a d .amotidi e a'e a0ai!ab!e o0e' t+e &ou te' at /+a'ma&ie#, bot+ a# b'a d$ ame d'u%# a d a# %e e'i&#, a d *o', by de&'ea#i % t+e amou t o. a&id t+e #toma&+ /'odu&e# a!!o*i % +ea!i % o. u!&e'#" Su&'a!.ate, 2Ca'a.ate3 +a# a!#o bee a #u&&e##.u! t'eatme t o. /e/ti& u!&e'#" ". NURSING R#SPONSI%I!ITI#S Mo ito' t+e /atie t .o' #i% # o. b!eedi % t+'ou%+ .e&a! o&&u!t b!ood, 0omiti %, /e'#i#te t dia''+ea, a d &+a %e i 0ita! #i% #" Mo ito' i ta,e a d out/ut" Mo ito' t+e /atie t@# +emo%!obi , +emato&'it, a d e!e&t'o!yte !e0e!#" Admi i#te'ed /'e#&'ibed I"V" .!uid# a d b!ood 'e/!a&eme t# i. a&ute b!eedi % i# /'e#e t" Mai tai a#o%a#t'i& tube .o' a&ute b!eedi %, /e'.o'atio , a d /o#to/e'ati0e!y, mo ito' tube d'ai a%e .o' amou t a d &o!o'" Pe'.o'm #a!i e !a0a%e i. o'de'ed .o' a&ute b!eedi %"

E &ou'a%e bed 'e#t to 'edu&e #timu!atio t+at may e +a &e %a#t'i& #e&'etio " P'o0ide #ma!!, .'e8ue t mea!# to /'e0e t %a#t'i& di#te tio i. ot a&ti0e!y b!eedi %" ;at&+ .o' dia''+ea &au#ed by a ta&id# a d ot+e' medi&atio #" Re#t'i&t .ood# a d .!uid# t+at /'omote dia''+ea a d e &ou'a%e %ood /e'i ea! &a'e" Ad0i#e /atie t to a0oid e4t'eme!y +ot o' &o!d .ood a d .!uid#, to &+e* t+o'ou%+!y, a d to eat i a !ei#u'e!y .a#+io to 'edu&e /ai " Admi i#te' medi&atio # /'o/e'!y a d tea&+ /atie t do#e a d du'atio o. ea&+ medi&atio " Ad0i#e /atie t to modi.y !i.e#ty!e to i &!ude +ea!t+ /'a&ti&e# t+at *i!! /'e0e t 'e&u''e &e# o. u!&e' /ai a d b!eedi %"

"I. R#&#R#NC#S +tt/:<< u'#i %&'ib"&om< u'#i %$ ote#$'e0ie*e'</e/ti&$u!&e'< +tt/:<<e "*i,i/edia"o'%<*i,i<Pe/ti&Ru!&e' +tt/:<<***"med#&a/e"&om<0ie*a'ti&!e<E::>DDR: