irritable bowl syndrome and peptic ulcer final (1).pptx

Irritable Bowel Syndrome
Fatma Saeed Fahmy
Ahmed Gamal Fahmy
Prof.Dr. Amira Ahmed
Prepared by:
Under Supervision of

Outlines
 Introduction about IBS
 Definition of IBS
 Pathophysiology of IBS
 Clinical Manifestation of IBS
 Diagnostic findings of IBS
 Medical Management of IBS
 Nursing Management of IBS

General objectives:
At the end of this lecture the participants should be able
to
Define IBS
 Review Pathophysiology of IBS
 Explain Clinical Manifestation of IBS
 Know Diagnostic findings of IBS
 Describe Medical Management of IBS
 Discuss Nursing Management of IBS

Introduction
IBS is one of the most common GI problems. It occurs
more commonly in women than in men, and the cause is
still unknown. Various factors are associated with the
syndrome: heredity, psychological stress or conditions such
as depression and anxiety, a diet high in fat and stimulating
or irritating foods, infection, alcohol consumption, and
smoking.

Definition of IBS
• IBS is considered a function GI disorder not
structure characterized by abdominal pain and
altered bowel habits over a period of at least 3
months.

Incidence of IBS
• IBS affects approximately (10-25) percent of the
global population .
• Nevertheless, in the United States alone, 2.4-3.5
million persons visit doctors yearly because of
IBS.
• The prevalence of IBS reaches 35-43% in some
developing countries

• Irritable bowel syndrome in Egyptian medical
students, prevalence and associated factors: a cross-
sectional study
• Prevalence of irritable bowel syndrome: according to
Rome III criteria, irritable bowel syndrome (IBS) was
diagnosed in 50 of the study sample. As regards the IBS
group, 8 (16%) students had constipation dominant IBS,
10 (20%) had diarrhea dominant IBS, and 32 (64%) had
mixed IBS.

Pathophysiology
• Alteration of GIT motility : Increase or decrease in frequency
• A condition of visceral hypersensitivity: (leading to abdominal
discomfort or pain) and gastrointestinal motor disturbances (leading to
diarrhea or constipation)
• Brain-gut axis: The change in motility may be related to the CNS
neurologic regulatory system and the peristaltic waves are affected at
specific segments of the intestine and in the intensity with which they
propel the fecal matter forward.
• Post-infection: About 10% of IBS cases caused by acute
gastroenteritis infection.
• Genetics

Clinical Manifestations
Symptoms range in intensity and duration from mild and to severe and
continuous.
• The primary symptom is an alteration in bowel patterns—constipation,
diarrhea, or a combination of both.
• Pain, bloating, spasm and urgency often accompany this change in
bowel pattern.
• The abdominal pain is sometimes precipitated by eating and is frequently
relieved by defecation.
• unexplained weight loss, iron deficiency anemia.

New Diagnostic Findings
Kruis criteria Manning criteria Rome criteria

Assessment and Diagnostic Findings
• The Rome IV criteria
• Are used to diagnose IBD, which requires at least 3 days a
month in the last 3 months associated with 2 or more of the
following:
- improvement in abdominal pain or discomfort with defecation,
- onset associated with a change in frequency of stool
- onset accompanied by a change in form or appearance of stool.
- Visible abdominal distention.

• Manning criteria
• At least 2 of the following:
- onset of pain linked to more frequent bowel movement.
- Looser stools associated with pain.
- Pain relieved by passage of stool.
- Noticeable abdominal bloating.
- Sensation of incomplete evacuation more than 25% of
the time.

Cont.
• The Kruis score system
Symptoms must be present for 2 years
• Abdominal pain, bloating, bowel irregularity
• Description of Abdominal pain
Signs that exclude IBS:
Abnormal physical finding or history for any diagnosis
other than IBS:
- Erythrocyte sedimentation rate more than 20 mm/2h
- Leukocytosis more than 10.000/cc
- Anemia Hgb less than 12 for female and 14 for male.
- Rectal bleeding.

Cont.
• The ACG guidelines also recommend:
• Screening for celiac disease in patients with IBS-D
or Mixed.
• No endoscopy if younger than 50 years and no
alarm symptoms such as weight loss, bleeding or
anemia.

Medical Management
The goals of treatment are aimed at relieving abdominal pain, controlling the diarrhea or
constipation through mix of drug, diet and reducing stress:
1- Diet
• Restriction and then gradual reintroduction of foods that are possibly irritating may
help determine what types of food are acting as irritants (eg, lentils, beans, caffeinated
products, fried foods, alcohol, spicy foods).
• A healthy, high-fiber diet is prescribed to help control the diarrhea and constipation.
• Exercise can assist in reducing anxiety and increasing intestinal motility.
2- Reduction of stress
• Patients often find it helpful to participate in a stress reduction or behavior-
modification program.

Cont.
3- Drug therapy
• Hydrophilic colloids (i.e., bulk) and antidiarrheal agents (eg,
loperamide) may be given to control the diarrhea and fecal
urgency.
• Antidepressants can assist in treating underlying anxiety and
depression.
• Anticholinergic and calcium channel blockers decrease
smooth muscle spasm, decreasing cramping and constipation.

NURSING PROCESS
Assessment
• The nurse takes a health history to identify the onset, duration, and characteristics of
abdominal pain; diarrhea, straining at stool (tenesmus), nausea, anorexia, or weight loss;
and family history of IBD.
• It is important to discuss dietary patterns, including the amounts of alcohol, caffeine,
and nicotine containing products used daily and weekly.
• The nurse asks about patterns of bowel elimination, including character, frequency, and
presence of blood, pus, fat, or mucus.
• It is important to note allergies and food intolerance, especially milk (lactose)
intolerance.
• Assessment includes auscultating the abdomen for bowel sounds and their
characteristics; palpating the abdomen for distention, tenderness, or pain.

NURSING DIAGNOSES
• Diarrhea related to the inflammatory process
• Acute pain related to increased peristalsis and GI inflammation
• Deficient fluid volume deficit related to anorexia, nausea, and diarrhea
• Imbalanced nutrition, less than body requirements, related to dietary
restrictions, nausea, and malabsorption
• Activity intolerance related to fatigue
• Anxiety related to impending surgery
• Ineffective coping related to repeated episodes of diarrhea
• Risk for impaired skin integrity related to malnutrition and diarrhea
• Risk for ineffective therapeutic regimen management related to insufficient
knowledge concerning the process and management of the disease

MAINTAINING NORMAL ELIMINATION
PATTERNS
• The nurse determines if there is a relationship between diarrhea and
certain foods, activity, or emotional stress.
• Identifying precipitating factors, the frequency of bowel movements,
and the character, consistency, and amount of stool passed is important.
• The nurse provides ready access to a bathroom, commode, or bedpan
and keeps the environment clean and odor free.
• It is important to administer antidiarrheal medications as prescribed, to
record the frequency and consistency of stools after therapy is initiated,
and to encourage bed rest to decrease peristalsis.

RELIEVING PAIN
• The character of the pain is described as dull, burning, or crampy.
• Asking about its onset is relevant. Does it occur before or after
meals, during the night, or before elimination? Is the pattern
constant or intermittent? Is it relieved with medications?
• The nurse administers anticholinergic medications as prescribed 30
minutes before a meal to decrease intestinal motility and
administers analgesics as prescribed for pain.
• Position changes, local application of heat (as prescribed).

MAINTAINING FLUID INTAKE
• To detect fluid volume deficit, the nurse keeps an accurate record of
oral and intravenous fluids and maintains a record of output (ie,
urine, liquid stool, vomitus).
• The nurse monitors daily weights for fluid gains or losses and
assesses the patient for signs of fluid volume deficit (ie, dry skin and
mucous membranes, decreased skin turgor, oliguria, exhaustion,
decreased temperature, increased hematocrit, elevated urine
specific gravity, and hypotension).
• It is important to encourage oral intake of fluids and to monitor the
intravenous flow rate.

MAINTAINING OPTIMAL NUTRITION
• Parenteral nutrition (PN) is used when the symptoms of IBD are severe.
• The nurse maintains an accurate record of fluid intake and output as well as
the patient’s daily weight.
• The patient should gain 0.5 kg daily during PN therapy. Because PN is very
high in glucose and can cause hyperglycemia, blood glucose levels are
monitored every 6 hours.
• Elemental feedings high in protein and low in fat and residue are instituted
after PN therapy because they are digested primarily in the jejunum, do not
stimulate intestinal secretions, and allow the bowel to rest.

Cont.
• The patient is encouraged to eat at regular times and to chew food
slowly and thoroughly.
• The patient should understand that, although adequate fluid intake
is necessary, fluid should not be taken with meals because this
results in abdominal distention.
• If oral foods are tolerated, small, frequent, low-residue feedings are
given to avoid over distending the stomach and stimulating
peristalsis.
• Alcohol use and cigarette smoking are discouraged.
• Encourage suitable diet for IBS.

PROMOTING REST
• The nurse recommends intermittent rest periods during the
day and schedules or restricts activities to conserve energy and
reduce the metabolic rate.
• The nurse suggests bed rest for a patient who is febrile, has
frequent diarrheal stools, or is bleeding.
• The patient on bed rest should perform active exercises to
maintain muscle tone and prevent thromboembolic
complications.
• If the patient is unable to perform these active exercises, the
nurse performs passive exercises and joint range of motion.

Objectives
• At the end of this presentation the participanta
will be able to define:
• Define peptic ulcer.
• Identify causes & factors for the development of
peptic ulcer.
• Enlist signs/symptoms and complication of peptic
ulcer.
• Discuss diagnosis and treatment of peptic ulcer.
• Apply nursing intervention for peptic ulcer.

Peptic Ulcer
• An Ulcer is …
 Erosion in the lining of the stomach or the first part of
the small intestine, an area called the duodenum.
Ulcers damage the mucosa of the alimentary tract,
which extends through the muscularis mucosa into the
sub mucosa or deeper.

Ulcers that form in the stomach are called gastric ulcers; in
the duodenum, they are called duodenal ulcers. Both types
are referred to as peptic ulcers.

PATHOPHYSIOLOGY
• Erosion. The erosion is caused by the increased concentration
or activity of acid-pepsin or by decreased resistance of the
mucosa.
• Damage. A damaged mucosa cannot secrete enough mucus to
act as a barrier against HCl.
• Acid secretion. Patients with duodenal ulcers secrete more
acid than normal, while patients with gastric ulcers tend to
secrete normal or decreased levels of acid.
• Decreased resistance. Damage to the gastroduodenal mucosa
results in decreased resistance to bacteria and
thus infection from the H. pylori bacteria may occur.

Statistics and Epidemiology
• Peptic ulcer disease may occur in both genders and in
all ages.
• Peptic ulcer disease occurs with the greatest
frequency in people between 40 and 60 years of age.
• It is relatively uncommon in women of childbearing
age, but it has been observed in children and even in
infants.
• After menopause, the incidence of peptic ulcers in
women is almost equal to that in men.

ETIOLOGY/ RISK FACTORS
• Lifestyle
– Smoking
– Acidic drinks
– Medications
• H. Pylori infection
– 90% have this bacterium
– Passed from person to person
– (fecal-oral route or oral-oral route)
• Age
– Duodenal 30-40
– Gastric over 50
• Gender
– Duodenal: are increasing in
older women
• Genetic factors
– More likely if family
member has Hx
• Other factors: stress can
worsen but not the cause

Peptic ulcer is classified into gastric, duodenal or
esophageal ulcer.
 Gastric ulcer. Gastric ulcer tend to occur in the lesser
curvature of the stomach, near the pylorus.
 Duodenal ulcer. Peptic ulcers are more likely to occur in
the duodenum than in the stomach.
 Esophageal ulcer. Esophageal ulcer occur as a result of
the backward flow of HCl from the stomach into the
esophagus.
TYPES

Gastric ulcer
Duodenal Ulcer
Middle age 50-60
Any age specially 30-40
More in female
More in male
Same
Stress job eg. Manager
tion
Epi. Can radiate to back
Epigastric , discomfort
n
Immediately after eating
2-3 hours after eating & midnight
t
Eating
Hunger
by

Gastric ulcer
Duodenal Ulcer
Lying down or vomiting
Eating
Relived by
Few weeks
1-2 months
Duration
Common(to relieve the
pain)
Uncommon
Vomiting
Pt. afraid to eat
Good
Appetite
Avoid fried food
Good , eat to relieve the pain
Diet
wt. Loss
No wt. loss
Weight
60%
40%
Hematemesis
40%
60%
Melena

Clinical Manifestations
• Pain. As a rule, the patient with an ulcer complains of dull,
gnawing pain or a burning sensation in the midepigastrium or
the back that is relieved by eating.
• Pyrosis. Pyrosis (heartburn) is a burning sensation in the
stomach and esophagus that moves up to the mouth.
• Vomiting. Vomiting results from obstruction of the pyloric
orifice, caused by either muscular spasm of the pylorus or
mechanical obstruction from scarring.
• Constipation and diarrhea. Constipation or diarrhea may
occur, probably as a result of diet and medications.
• Bleeding. 15% of patients may present with GI bleeding as
evidenced by the passage of melena (tarry stools).

Investigations
• Stool examination for fecal occult blood.
• Complete blood count (CBC) for decrease in blood cells.

To establish the diagnosis of peptic ulcer, the following assessment and
laboratory studies should be
• Esophagogastroduodenoscopy. Confirms the presence of an ulcer and allows
cytologic studies and biopsy to rule out H. pylori or cancer.
• Physical examination. A physical examination may reveal pain, epigastric
tenderness, or abdominal distention.
• Barium study. A barium study of the upper GI tract may show an ulcer.
• Endoscopy. Endoscopy is the preferred diagnostic procedure because it allows
direct visualization of inflammatory changes, ulcers, and lesions.
• Occult blood. Stools may be tested periodically until they are negative for occult
blood.
• Carbon 13 (13C) urea breath test. Reflects activity of H. pylori.
• performed:

Complications
• Hemorrhage
– Blood vessels damaged as ulcer erodes into the muscles of
stomach or duodenal wall
– Coffee ground vomitus or occult blood in tarry stools
• Perforation
– An ulcer can erode through the entire wall
– Bacteria and partially digested food spill into
peritoneum=peritonitis
• Narrowing and obstruction (pyloric)
– Swelling and scarring can cause obstruction of food leaving
stomach=repeated vomiting

Medical Management
 Antacids
 Antibiotics such as amoxicillin, clarithromycin, metronidazole,
 Tetracycline
 Histamine receptor antagonists
 Proton pump inhibitor
 Sucralfate
.

• The introduction of antibiotics to eradicate H. pylori
and of H2 receptor antagonists as a treatment for
ulcers has greatly reduced the need
for surgical interventions.
• Pyloroplasty. Pyloroplasty involves
transecting nerves that stimulate the acid secretion and
opening the pylorus.
• Antrectomy. Antrectomy is the removal of the pyloric
portion of the stomach with anastomosis to either the
duodenum or jejunum.
Surgical Management

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 Goals
• Goals and expected outcomes may include:
The client will report satisfactory pain control at a level of less
than 2 to 4 on a scale of 0 to 10.
• The client uses pharmacological and nonpharmacological pain
relief measures.
• The client will exhibit increased comfort such as baseline
levels for HR, BP, and respirations, and relaxed muscle tone
for body posture.
• The client will be normovolemic as evidenced by systolic BP
greater than or equal to 90 mm Hg (or client’s baseline),
absence of orthostasis, HR 60 to 100 beats/minute, urine
output greater than 30 ml/hr, and normal skin turgor.
•

Nursing Interventions
1. Providing Pain Relief and Comfort
 Assess the client’s pain, including the location, characteristics,
precipitating factors, onset, duration, frequency, quality,
intensity, and severity.
Clients with gastric ulcers typically demonstrate pain 1 to 2
hours after eating. The client with duodenal ulcers
demonstrates pain 2 to 4 hours after eating or in the middle of
the night. With both gastric and duodenal ulcers, the pain is
located in the upper abdomen and is intermittent. The client
may report relief after eating or taking an antacid.

 Encourage the use of nonpharmacological pain relief measures such
as acupressure, biofeedback, distraction, guided imagery, massage,
and music therapy
 Nonpharmacological relaxation techniques will decrease the
production of gastric acid, which in turn will reduce pain.
 Instruct the client to avoid NSAIDs such as aspirin.
These medications may cause irritation of the gastric mucosa.
 Instruct the client that meals should be eaten at regularly paced
intervals in a relaxed setting.
An irregular schedule of meals may interfere with the regular
administration of medications.

 Encourage the importance of smoking cessation.
Smoking decreases the secretion of bicarbonate from the
pancreas into the duodenum, resulting in increased acidity of
the duodenum.

2. Improving Nutritional and Fluid Balance
 Obtain a nutritional history.
Clients may often overestimate the amount of food eaten. The client
may not eat sufficient calories or essential nutrients as a way to
reduce pain episodes with peptic ulcer disease. Because of this,
clients are at high risk for malnutrition.
 Assess for body weight changes.
Weight loss is an indication of inadequate nutritional intake. Gastric
ulcers are more likely to be associated with vomiting, loss of
appetite, and weight loss than duodenal ulcers.

 Monitor laboratory values for serum albumin.
This test indicates the degree of protein depletion (2.5 g/dL indicates
severe depletion; 3.8 to 4.5 g/dL is normal).
 Assist the client with identifying foods that cause gastric
irritation.
Clients need to learn what foods they can tolerate without gastric pain.
Soft, bland, non-acidic foods cause less gastric irritation. The client is
more likely to increase food intake if the foods are not associated with
pain. Foods that may contribute to mucosal irritation include spicy
foods, pepper, aNd raw fruits and vegetables.

Nutrition
Food groups Allowed Prohibited
Fruits
Apple, papaya, melon,
banana
Lemon
Vegetables
Leafy dark green
vegetables, carrot, beet,
green bean, spinach,
radish, zucchini, leek
Spicy peppers (black
pepper, chilies)
Legumes
Bean soup, lentils,
chickpeas, soybean
-
Meats
Lean meat (beef, pork,
chicken, fish)

 Instruct on the importance of abstaining from excessive alcohol.
Alcohol causes gastric irritation and increases gastric pain.
 Encourage the client to limit the intake of caffeinated beverages
such as tea and coffee.
Caffeine stimulates the secretion of gastric acid. Coffee, even if
decaffeinated, contains a peptide that stimulates the release of gastrin
and increases acid production.

 Teach about the importance of eating a balanced diet with
meals at regular intervals
Specific dietary restrictions are no longer part of the treatment for
PUD. During the symptomatic phase of an ulcer, the client may find
benefit from eating small meals at more frequent intervals.
 Assess for the signs of hematemesis or melena.
The client with a bleeding ulcer may vomit bright red blood or coffee
grounds emesis. Melena occurs when there is bleeding in the upper GI
tract.

 Monitor the client’s fluid intake and urine output.
The kidney will reabsorb water into circulation to support a
decrease in blood volume. This compensatory mechanism results
in decreased urine output. A decrease in circulatory blood volume
leads to decreased renal perfusion and decreased urine output
 Monitor the client’s vital signs, and observes BP and HR
for signs of orthostatic changes.
The erosion of an ulcer through the gastric or duodenal mucosal
layer may cause GI bleeding. The client may develop anemia. If
bleeding is brisk, changes in vital signs and physical symptoms
of hypovolemia may develop rapidly. A decrease in BP and an
increase in HR with changes in position is an early indicators of
decreased circulatory volume.

 Instruct the client to immediately report symptoms of
nausea, vomiting, dizziness, shortness of breath, or dark
tarry stools
These assessment findings are signs of GI bleeding and should be
reported immediately.
 Administer IV fluids, volume expanders, and blood
products as ordered.
Isotonic fluids, volume expanders, and blood products can restore
or expand intravascular volume.

3. Reducing Anxiety
 Assess the client’s level of anxiety.
Clients with peptic ulcers are anxious, but their anxiety level is not
visible.
 Acknowledge awareness of the client’s anxiety.
Acknowledgment of the client’s feelings validates the feelings and
communicates the acceptance of those feelings.
 Encourage to express fears openly
Open communication enables the client to develop a trusting
relationship that aids in reducing anxiety and stress.

• Use simple language and brief statements when giving
instructions to the client.
When experiencing moderate to severe anxiety, clients may be
unable to comprehend anything more than simple, clear, and
brief instructions.
• Decrease sensory stimuli by maintaining a quiet
environment.
Anxiety may escalate to a panic state with the excessive
conversation, noise, and equipment around the client.
• Provide emotional support to the client.
Providing emotional support will give a client calming and
relaxing mood that will lower anxiety and stress related to the
condition.

4. Initiating Patient Education and Health
Teachings
• Assess the client’s knowledge and misconceptions
regarding peptic ulcer disease, lifestyle behaviors, and the
treatment regimen.
Clients may have inaccurate information about how lifestyle
behaviors contribute to peptic ulcer disease. The client needs
accurate knowledge to make informed decisions about taking
prescribed medications and modifying behaviors that
contribute to peptic ulcer disease or GI bleeding.

• Explain the pathophysiology of the disease and how it
relates to the functioning of the body.
An understanding of the disease process helps to foster the
willingness to follow the recommended treatment plan and
modify behaviors to prevent recurrent episodes or related
complications.
• Instruct the client on what signs and symptoms to report to
the health care provider.
Recognizing the signs and symptoms can help ensure the early
initiation of treatment.
• Discuss the therapy options and the rationales for using
these options.

• Discuss the lifestyle changes required to prevent further
complications or episodes of peptic ulcer disease.
The modifications of lifestyle behaviors such as alcohol use,
coffee, and other caffeinated beverages, and the overuse
of aspirin or other nonsteroidal anti-inflammatory drugs is
necessary to prevent recurrent ulcer development and prevent
complications during the healing phase.

Refernces
• Palsson OS, Peery A, Seitzberg D, Amundsen ID, McConnell B, Simrén M (December 7,
2020). "Human Milk Oligosaccharides Support Normal Bowel Function and Improve
Symptoms of Irritable Bowel Syndrome: A Multicenter, Open-Label Trial". Clinical and
Translational Gastroenterology. 11 (12): e00276.
• "Irritable bowel syndrome - Symptoms and causes". Mayo Clinic. Retrieved December
5, 2023.
• doi:10.1038/nrgastro.2010.4. PMID 20101257. S2CID 20898797.
• ^ Rothenberg ME (June 2021). "An Allergic Basis for Abdominal Pain". The New England
Journal of Medicine. 384 (22): 2156–
2158. doi:10.1056/NEJMcibr2104146. PMID 34077648. S2CID 235322218.
• ^ Kim JH, Yi DY, Lee YM, Choi YJ, Kim JY, Hong YH, et al. (August 2022). "Association between
body mass index and fecal calprotectin levels in children and adolescents with irritable bowel
syndrome". Medicine. 101 (32):
e29968. doi:10.1097/MD.0000000000029968. PMC 9371505. PMID 35960084.
• ^ Jump up to:a b
• Chang WY, Yang YT, She MP, Tu CH, Lee TC, Wu MS, et al. (2022). "5-HT 7 receptor-dependent
intestinal neurite outgrowth contributes to visceral hypersensitivity in irritable bowel
syndrome". Laboratory Investigation. 102 (9): 1023–1037. doi:10.1038/s41374-022-00800-z.
PMC 9420680. PMID 35585132. S2CID 248867188.

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