1. What is the etiology of this patient’s ulcer?

Most peptic ulcers are due to H. pylori infection or NSAID use.  Patient has both of these risk factors.  Other causes include Zollinger-Ellison syndrome (characterized by massive hypersecretion of acid associated with gastrin secreting tumor), viral infection, use of high-dose systemic corticosteroids, radiation, vascular insufficiency

2. What is the possible mechanism by which NSAIDs cause PUD?

Topical irritation of gastric epithelium and interference with PG synthesis via COX-1 inhibition, thus impairing defense mechanisms of upper GI tract

3. What are the goals of tx for PUD?

Relieve pain; prevent complications (e.g. bleeding, obstruction, penetration and perforation); minimize risk of recurrence and reduce the financial costs (i.e. prevent hospitalization)

4. What is a reasonable treatment plan for this patient?

·        Eradicate H. pylori

·        Therapy with antisecretory drug, such as PPI, H2-receptor antagonist or sucralfate to facilitate relief of ulcer symptoms and promote healing.  No need for long-term or maintenance therapy if can d/c both NSAIDs

·        D/C and change Ibuprofen -®Tylenol or possibly COX-2 selective agent like celecoxib.  He'll need long-term gastroprotection as long as he takes even 1 NSAID (prior history of PUD is biggest risk factor for NSAID PUD).  Switching to Tylenol will ¯ risk.  If he takes COX-2 alone (no ASA), may not need gastroprotection.  If on ASA + COX-2, needs gastroprotection for sure.

·        Consider need for low-dose ASA (primary vs. secondary CV prophylaxis) - if deem to need, need to add gastroprotection

·        Life-style changes: quit smoking, avoid food and beverages that cause dyspepsia or worsen ulcer symptoms (spicy foods, alcohol, caffeine)

5. Provide an example of treatment regimen used to eradicate H. pylori

See class notes for the "top 4"

6. If the presence of H. pylori is found in an asymptomatic patient with GERD but w/o PUD, should the patient be treated?

No (relationship of GERD to H. pylori not established)

7. What antisecretory agent is best to use in this patient?

Patient has been on Ranitidine (dose is adjusted appropriately for his renal fxn)  with active ulcer w/o relief of symptoms.  Higher doses of H2RA may worsen patient’s mental status compromised by the underlying dementia and still not high cure rates of NSAID PUD.  For him, a PPI is a better alternative (standard dose).  Will need to continue antisecretory therapy beyond the end of the H. P. eradication therapy until ulcer is healed and continue indefinitely if on even 1 NSAID long-term (see 4. above).

8. If the patient must continue his NSAIDs what strategies can we use to prevent his ulcer recurrence?

Use misoprostol (a prostaglandin analog - at least 400 mcg/d) or regular dose PPI or double-dose H2-antagonist (? adjust to renal function).  Easiest of the 3 to use - PPI (any one in dose equivalent to omeprazole 20 mg/d).