Case Study Peptic Ulcer Disease-1.docx 2q6q6p

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 1week 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 ission were:      

Hemoglobin 8.3 g/dL (reference range 11-13) Packed cell volume (PCV) 0.275 (0.3600.470) Mean cell volume (MCV) 75 fL (80-100) Mean cell hemoglobin (MCH) 25 pg (2732) Platelets 264 x 109/L (150-400) Hematocrit 0.31 (0.36-0.46)

     

C-reactive protein 45 mg/L (0-4) 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 itted to the ward. Q1 Q2 Q3 Q4 Q5 Q6 Q7

How serious is the bleed? What immediate treatment options should be considered? How would you treat this patient’s (a) shock and (b) symptoms? How would you suggest Mrs GE’s current drug therapy be managed acutely? What is the mechanism for non-steroidal anti-inflammatory (NSAID)-induced ulcers? How effective is misoprostol at preventing NSAID-induced peptic ulcers? 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 Q9 Q10

Is endoscopic treatment of the bleed more effective than drug treatment? What is the likelihood of the patient suffering a re-bleed? 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 itted to the medical high-dependency unit. The consultant wanted an acidsuppressing drug to be prescribed. Q11

Which acid-suppressing drug, and what dose regimen and route would you suggest? What evidence is there to 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 Q13

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

Mrs GE’s 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 patient’s symptoms had resolved and her blood results were normalising. She was discharged back to her care home to complete the treatment. Q15 Q16 Q17 Q18

Outline a pharmaceutical care plan for Mrs GE’s further treatment. In the patient’s discharge letter, what would you recommend the general practitioner (GP) prescribe to eradicate the H. pylori? Should Mrs GE be prescribed iron therapy, and if so, for how long? 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 Q20

Should the GP check to see whether the H. pylori eradication was successful? If so, how? 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 Q22

How would you recommend her GP manage her osteoarthritis? How would you recommend her GP manage her gout?