Peptic Ulcer Disease

Day 1 Mrs GE, an 86-year-old Caucasian woman, was taken to A&E from her care home. She had a 1-
week history of tiredness, weakness, and some epigastric discomfort and nausea. She had one episode
of melena the previous day and coffee ground vomit earlier today. Her past medical history included
osteoarthritis, gout, hypertension, and resting tremor secondary to anxiety. She had no known drug
allergies and was taking the following prescription drugs:
Propranolol 40 mg up to three times Indometacin 25 mg three times daily
daily when required Allopurinol 100 mg daily
Arthrotec (diclofenac 50 mg + Ramipril 10 mg daily
misoprostol 200 micrograms) tablets Simvastatin 40 mg at night
twice daily

Her hematology and biochemistry results on admission were:

Hemoglobin 8.3 g/dL (reference range C-reactive protein 45 mg/L (0-4)

11-13)
Packed cell volume (PCV) 0.275 (0.360-
0.470)
Mean cell volume (MCV) 75 fL (80-100)
Mean cell hemoglobin (MCH) 25 pg (27-
32)
Platelets 264 x 109/L (150-400)
Hematocrit 0.31 (0.36-0.46)
International normalised ratio (INR)
1.01
Sodium 141 mmol/L (135-145)
Potassium 4.0 mmol/L (3.5-5)
Creatinine 105 micromol/L (45-84)
Urea 20.3 mmol/L (1.7-8.3)

Her blood pressure was recorded as 115/59 mmHg, her respiratory rate was 24 and her pulse rate 155
beats per minute (bpm). A provisional diagnosis of upper gastrointestinal (GI) bleeding was made and
she was admitted to the ward.

Q1 How serious is the bleed?

Q2 What immediate treatment options should be considered?
Q3 How would you treat this patients (a) shock and (b) symptoms?
Q4 How would you suggest Mrs GEs current drug therapy be managed acutely?
Q5 What is the mechanism for non-steroidal anti-inflammatory (NSAID)-induced ulcers?
Q6 How effective is misoprostol at preventing NSAID-induced peptic ulcers?
Q7 How can the cause of the bleed be confirmed, the bleeding stopped, and re-bleeding
prevented?

An urgent endoscopy was arranged for Mrs GE.

Q8 Is endoscopic treatment of the bleed more effective than drug treatment?

Q9 What is the likelihood of the patient suffering a re-bleed?
Q10 What test should be performed on Mrs GE during the endoscopy?
An endoscopy was performed and active duodenal bleeding was noted and treated. Following the
procedure Mrs GE was admitted to the medical high-dependency unit. The consultant wanted an acid-
suppressing drug to be prescribed.

Q11 Which acid-suppressing drug, and what dose regimen and route would you suggest? What
evidence is there to support your recommendation? What alternatives could be used?

Mrs GE was prescribed omeprazole 80 mg intravenously (IV) to be given immediately, followed by an 8

mg/h omeprazole infusion for 72 hours, then omeprazole 40 mg orally twice daily for 5 days. Her
Helicobacter pylori test was reported as positive.

Q12 Does infection with H. pylori predispose to NSAID-induced damage to the GI mucosa?
Q13 What other factors could have contributed to Mrs GEs duodenal ulcer, and might potentially
increase the chances of relapse?

Mrs GEs consultant wanted to eradicate the bacteria.

Q14 When should H. pylori eradication begin?

The consultant prescribed omeprazole 20 mg daily to continue for 2 months. After a week of
observation in hospital the patients symptoms had resolved and her blood results were normalising.
She was discharged back to her care home to complete the treatment.

Q15 Outline a pharmaceutical care plan for Mrs GEs further treatment.
Q16 In the patients discharge letter, what would you recommend the general practitioner (GP)
prescribe to eradicate the H. pylori?
Q17 Should Mrs GE be prescribed iron therapy, and if so, for how long?
Q18 What counselling should Mrs GE be given in preparation for discharge to optimise successful
treatment and adherence to treatment?

Mrs GE completed the H. pylori eradication therapy and remained well and symptom free. Her care
home arranged for her to be reviewed by her GP.

Q19 Should the GP check to see whether the H. pylori eradication was successful? If so, how?
Q20 How long does Mrs GE need to be prescribed a proton pump inhibitor (PPI)?

Mrs GE told the nursing staff in her home that her knees were painful, and that she was worried that the
gout in her toe would return.

Q21 How would you recommend her GP manage her osteoarthritis?

Q22 How would you recommend her GP manage her gout?