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:

Indometacin 25 mg three times

daily
Allopurinol 100 mg daily
Ramipril 10 mg daily
Simvastatin 40 mg at night

Propranolol 40 mg up to three
times daily when required
Arthrotec (diclofenac 50 mg +
misoprostol 200 micrograms)
tablets twice daily

Her hematology and biochemistry results on admission were:

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 (4584)
Urea 20.3 mmol/L (1.7-8.3)

Hemoglobin 8.3 g/dL (reference

range 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)

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 rebleeding 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 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
Q17
Q18

In the patients 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 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
Q22

How would you recommend her GP manage her osteoarthritis?

How would you recommend her GP manage her gout?