College of Pharmacy
CC: 81-year-old man with abdominal pain
HPI:
Pt. acutely developed epigastric pain and abdominal distention. He could not describe the quality of pain. The pain was 10/10 in intensity and there were no exacerbating or relieving factors. It had improved slightly by the time that he had arrived at the ER several hours later. He denied any nausea, vomiting, melena, weight loss or changes in his bowel habits. He reported having intermittent vague, mild upper abdominal discomfort for the past 3 weeks.
PMH:
Hypertension, hypercholesterolemia, osteoarthritis, mild dementia
Medications: Metoprolol 25 mg bid
Ranitidine 150 mg hs
EC Aspirin 81 mg qd
Atorvastatin 20 mg hs
Ibuprofen 200 mg qid
Social history:
Occasional alcohol use, smoking 1ppd, no substance abuse, no travel, and active lifestyle at home
PE: unremarkable except for exquisite pain and tenderness on attempting to palpate/percuss the abdomen
Labs:
Hgb 6.4, HCT 21.6%, SCr 1.6, stool guaiac positive,
others within normal limits
Imaging studies:
Endoscopy revealed an ulcer in the pyloric channel. Diffuse erythema and erosions were noted. Multiple biopsies taken to r/o gastric cancer
Other information:
Gastric biopsies showed active chronic gastritis
H. pylori organisms were seen on Genta stain
Biopsies of the ulcer showed inflammation and necrotic debris w/o evidence of malignancy
Diagnosis: Peptic Ulcer
Questions:
- What is the etiology of this patient’s ulcer?
- What is the possible mechanism by which NSAIDs cause PUD?
- What are the goals of tx for PUD?
- What is a reasonable treatment plan for this patient?
- Provide an example of a treatment regimen used to eradicate H. pylori
- If the presence of H. pylori is found in an asymptomatic patient with GERD but w/o PUD, should the patient be treated?
- Which antisecretory agent is best to use in this patient?
- If the patient must continue his NSAIDs what strategies can we use to prevent his ulcer recurrence?