Clinical Reasoning Cycle in a Patient with Duodenal Ulcer

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Patient Situation

Mohamed Salah, a 48-year-old man who is a recent immigrant from the Middle East, is taken to the hospital with a history of epigastric discomfort, vomiting, as well as occasional black bowel movement for further evaluation. He is set to undergo an upper endoscopy this morning. He has a 20-year smoking history that includes one packet of cigarettes every day for the last two decades.

Collected Cues

Mr Salah seems pale upon arrival and describes increased substernal pain, particularly 2–3 hours after a meal. He is now refraining from drinking and uses over the counter (OTC) antacids. He complains of increased exhaustion as a result of physical activity. His weight on measurement was 63.5kg, and his height of 165cm tall. His vital signs were recorded and documented on the patient cardex. A pulse rate of 102 beats per minute, a blood pressure of 135/90 mmHg, a breathing rate of 18 breaths per minute, an oxygen saturation level of 99 per cent on room air, and a temperature of 37°C. He estimates his pain as a 6/10 on the pain scale. The endoscopy indicated a duodenal ulcer, while laboratory tests revealed a haemoglobin level of 10.2 g/dL and a haematocrit level of 30%.

Helicobacter pylori infection is revealed by histopathology of biopsied tissue.

Role of Helicobacter Pylori in Pathophysiology of Duodenal Ulcer Disease

Helicobacter pylori (H. pylori) colonises the whole stomach in individuals with duodenal ulcers. The infection-induced inflammation of the surrounding mucosa is more pronounced in the posterior antral region, with the acid-secreting body portion of the stomach remaining relatively unaffected (Lehours and Ferrero 2019). Duodenal ulcers are associated with little if any, mucosal atrophy. This trend of gastritis leads to an upsurge in gastrin release, followed by a rise in acid production. An increase in gastrin secretion from the antral mucosa is observed while resting and becomes more obvious after intake of a protein-containing meal or activation with an intravenous gastrin-releasing peptide.

The underlying process by which H. pylori illness leads to increased gastrin secretion by the antral mucosa has generated great attention. Low intraluminal pH generally inhibits gastrin secretion, mediated by the production of somatostatin from D cells next to G cells (Lehours and Ferrero 2019). The increased gastrin response seen in people with Helicobacter pylori-infected duodenal ulcers is primarily due to a dysfunction of the somatostatin-mediated acid inhibitory regulation of gastrin release. Within the antral mucosa of H. pylori-infected patients, somatostatin and messenger RNA levels for somatostatin are decreased. It is widely established that lowering gastric acid by proton-pump inhibitors treatment or pernicious anaemia depletes antral somatostatin levels. Proton-pump inhibitors also duplicate the excessive reaction to gastrin-releasing peptides observed in patients infected with Helicobacter pylori.

Proton pump inhibitors are among the drugs used to manage duodenal ulcers (PPIs). PPIs neutralise gastric acid and preserve the stomach and duodenal linings. While PPIs do not eliminate H. pylori, they aid in the battle against the infection. PPIs include esomeprazole, lansoprazole, and omeprazole (Eslick et al., 2020). Histamine receptor antagonists are also indicated to manage duodenal ulcers because they act by inhibiting histamine, a substance produced by your body that stimulates your stomach to create acid. Ranitidine and cimetidine are examples of histamine receptor blockers. Antibiotics may also be used to eradicate Helicobacter pylori. Antibiotics such as clarithromycin and amoxicillin may heal most peptic ulcers caused by Helicobacter pylori or peptic ulcers caused by Helicobacter pylori.

Cultural Consideration

Given that Mr Salah is a Middle Eastern immigrant, it is critical to consider his cultural background while planning his care. Cultural differences between rural and urban areas may be connected with dyspepsia among persons from the Middle East. Dietary habits in many Asian metropolitan communities have changed dramatically due to growing urbanisation. A recent analysis on nutritional transition in East Asian nations that are quickly expanding emphasised the rising pattern in animal food items, especially fat consumption, resulting from economic affluence (Chuah and Mahadeva 2018). Urban respondents with dyspepsia self-medicate more than their rural colleagues with over-the-counter medications or herbal/traditional therapies.

Additionally, it has been claimed that religious considerations may impact dyspepsia patients’ healthcare-seeking behaviour. In a community-based study conducted in a primarily Muslim environment in East Malaysia, it was shown that married Muslim females reported greater psychosocial symptoms and indigestion than their male colleagues but had lower consultation rates (Chuah and Mahadeva 2018). Ideally, cultural norms would significantly impact how diseases are presented in the Middle East.

Process Information

Mr Salah’s health could have been worsened by the lifestyle he was living previously. He reports a smoking history of one packet of cigarettes each day for two decades. Heavy smoking is the most potent risk factor for the existence of symptoms in people with duodenal ulcers (Ket et al., 2021). Excessive alcohol intake by people with peptic ulcer disease may be associated with gastroduodenal symptoms. The background of smoking predisposed Mr Salah to the symptoms he was experiencing due to increased stomach acids. Furthermore, smoking increases bile salt reflux and gastric bile salt content, raising duodenogastric reflux and elevating the risk of stomach ulcers in smokers (Ket et al., 2021). Additionally, the presence of H. pylori infection was a significant risk factor for duodenal ulcers

Most of the vital signs of Mr Salah are abnormal compared to the normal ranges. His heart rate beats at 102 beats per minute, indicating tachycardia, an increased temperature at 37°C and blood pressure of 135/90 mmHg. Mr Salah reported increasing substernal pain following his hospital admission and rated his pain on a scale of 6/10. Acute pain is physiologically related to a stress reaction characterised by increased blood pressure, pulse rate, and temperature, which accounts for his vital signs increasing.

Endoscopy is performed to evaluate the upper gastrointestinal system for signs of ulceration, and in Salah’s case, duodenal ulcers are seen. Histology is performed on the endoscopically obtained tissue to establish the presence of Helicobacter pylori. The patient’s haemoglobin level of 10.2 g/dL and haematocrit of 30% is below the normal limit. Haemoglobin and haematocrit levels in males are estimated between 13.2 and 16.6 g/dL and 40 to 54 per cent, respectively (Cheung et al., 2021). In certain research, anaemia was substantially more prevalent in H. pylori-positive individuals than in H. pylori-negative patients (Cheung et al., 2021). This research explains why haematocrit and haemoglobin levels were lower than usual in the patient’s case

Prioritised Care Plan

Priority number	Problems	Goals	Actions	Rationale	Outcomes	Evaluation
1	Acute pain associated with abdominal muscle spasms as evidenced by the patient report of substernal pain and a score of 6/10	Relief of pain from a pain scale of 6/10 to 2/10.	Administer prescribed drugs.	Antibiotics like amoxicillin act by killing H. pylori.	The patient will demonstrate pain relief on a scale of 6/10 to 2/10 and stable vital signs.	The patient reported a decrease in pain sensation from a scale of 6/10 to 2/10.
2	Imbalance nutrition: Less than body requirements related to epigastric pain as evidenced by vomiting and inadequate dietary intake.	Demonstrate to the client a healthy diet with sufficient calorie intake.	Obtain the client’s nutritional history.	The client may not be consuming sufficient calories to help reduce the pain.	The patient will be able to demonstrate healthy eating patterns after an hour of nursing intervention.	After an hour of intervention, the patient demonstrated an understanding of a healthy eating pattern with foods rich in calories.
3	Deficient knowledge related to recurrent duodenal ulceration as evidenced by inadequate lifestyle modification.	Understand the importance of adhering to the prescribed drug regimen.	Discuss the various treatment choices and the rationales for their use.	When used appropriately, antibiotics and acid regulation drugs may aid in the quick healing of an ulcer.	After ten minutes of intervention, the client will demonstrate verbal comprehension of the critical significance of adhering to the prescribed medical regimen.	After ten minutes of intervention, the patient was able to verbalise and understand the importance of adhering to prescribed medications.
4	Anxiety-related to the nature of disease as evidenced by fatigue and substernal pain.	Demonstrate techniques for reducing anxiety.	Assess the patient’s anxiety level.	Clients with duodenal ulcers experience anxiety, although it is not obvious.	The client will show techniques for reducing anxiety after half an hour of intervention.	The client was able to show techniques necessary to reduce anxiety levels after half an hour of intervention.
5	Risk for deficient fluid volume related to vomiting.	The patient is to show signs of normovolemic.	Monitor hematocrit and haemoglobin levels.	Gastric mucosa erosion caused by an ulcer leads to gastrointestinal haemorrhage.	The patient will be normovolemic, as indicated by a systolic blood pressure higher than or equal to 90mmHg and a heart rate of 90 beats per minute.	The patient was able to show signs of normovolemic with a systolic blood pressure of 90mmHg and a heart rateof 90.

References

Cheung, A. S., Lim, H. Y., Cook, T., Zwickl, S., Ginger, A., Chiang, C., & Zajac, J. D. (2021). Approach to interpreting common laboratory pathology tests in transgender individuals. The Journal of Clinical Endocrinology & Metabolism, 106(3), 893-901. Web.

Chuah, K. H., & Mahadeva, S. (2018). Cultural factors influencing functional gastrointestinal disorders in the east. Journal of Neurogastroenterology and Motility, 24(4), 536. Web.

Eslick, G. D., Tilden, D., Arora, N., Torres, M., & Clancy, R. L. (2020). Clinical and economic impact of “triple therapy” for Helicobacter pylori eradication on peptic ulcer disease in Australia. Helicobacter, 25(6), e12751. Web.

Ket, S. N., Sparrow, R. L., McQuilten, Z. K., Gibson, P. R., Brown, G. J., & Wood, E. M. (2021). Critical peptic ulcer bleeding requiring massive blood transfusion: Outcomes of 270 cases. Internal Medicine Journal, 51(12), 2042-2050. Web.

Lehours, P., & Ferrero, R. L. (2019). Helicobacter: Inflammation, immunology, and vaccines. Helicobacter, 24, e12644. Web.