Unit 4: Management of the Patient with Peptic Ulcer Disease
Management of the Patient with Peptic Ulcer Disease
Case Scenario:
A 60-year-old white female presents to your office for a follow-up after a recent Urgent Care visit with her daughter. The patient’s daughter reports that the patient has not been eating much over the past few weeks and complains of a gnawing pain in her stomach when she does eat, and that she seems to get “full” very quickly. The patient has complained of mild nausea for the last two weeks. The patient has a history of a recent fall from a ladder about 9 months ago, in which she shattered multiple teeth and developed an infection. She has been under the care of an oral surgeon for this. Her daughter reports that she has been experiencing increased forgetfulness and that the patient’s colleagues have noticed she seems to be “off her game” over the last few weeks. Yesterday, she was evaluated at Urgent Care and found to have a hemoglobin of 8.5 and a hematocrit of 25; she was instructed to follow up in your office today. Upon examination today, her lung sounds are clear and his heart rhythm is regular. She has mild tenderness on palpation over her upper abdomen, but normal bowel sounds. Her skin is pale and dry. No other abnormalities are noticed on exam.
Diagnosis
The patient has symptoms of peptic ulcer disease (PUD), most likely a gastric ulcer that is made worse by iron-deficiency anemia from constant stomach bleeding. Pain in the upper abdomen that worsens after eating, feeling full quickly, feeling sick, and a pale complexion are all signs of a stomach ulcer rather than a duodenal ulcer. Her low hemoglobin (8.5 g/dL) and hematocrit (25%) show that she has lost blood, probably from a slow bleed in her upper GI tract (Zhuo et al., 2024). Recently, the patient took antibiotics for a long time to treat a tooth infection. This makes the healthcare provider worry that the nonsteroidal anti-inflammatory drug (NSAID) use or stress-related ulceration could hurt the lining of their stomach.
Treatment Plan and Rationale
The goals of treating PUD are to (1) get rid of Helicobacter pylori if it is present, (2) lower the production of stomach acid, and (3) help the mucosa heal. As part of the first treatment, a urea breath test or stool antigen test is performed to detect H. pylori, the most common cause of gastric ulcers. A proton pump inhibitor (PPI), bismuth subsalicylate, tetracycline, and metronidazole should be given to the patient for 14 days as part of a bismuth quadruple therapy if H. pylori is proven (Shell, 2021). People who do not have H. pylori are treated by lowering their stomach acid and staying away from things that can cause ulcers, like NSAIDs and alcohol. Because her hemoglobin is low, she might need to take extra iron and be sent for an upper endoscopy to check on the ulcer’s size, bleeding, and risk of cancer.
Prescription Plan
The patient should be prescribed Pantoprazole (Protonix) 40 mg PO twice daily for 8 weeks, to be taken 30 minutes before meals without crushing or chewing the tablets. By inhibiting gastric acid secretion, this proton pump inhibitor promotes ulcer healing and stops bleeding (Laucirica et al., 2023). Bismuth subsalicylate 524 mg PO four times a day, tetracycline 500 mg PO four times a day, and metronidazole 500 mg PO three times a day for 14 days should be part of the therapy if an H. pylori infection is diagnosed. The H. pylori infection is successfully eradicated, and the risk of recurrence is reduced with this combination medication. Two times a day with meals, the patient should take ferrous sulfate 325 mg PO to treat iron-deficiency anemia brought on by persistent gastrointestinal blood loss (Shell, 2021). For pain management, acetaminophen 500 mg PO every 6 hours as needed is recommended, while avoiding NSAIDs that can worsen gastric irritation. If anemia worsens or the patient becomes symptomatic, such as experiencing dizziness or syncope, hospitalization for blood transfusion may be required.
Patient Education
Teaching patients is very important to help them heal and prevent problems from recurring. The person should be told to stay away from NSAIDs, aspirin, alcohol, and cigarettes because they slow down the healing of ulcers and raise the risk of bleeding (Zhuo et al., 2024). She should take all of her medicines as directed and finish the full course of antibiotics if H. pylori is found. It is best to eat small meals more often and avoid spicy or acidic foods that can irritate the stomach lining. The person should also know the signs of stomach bleeding, such as black, tarry stools, vomiting blood, or feeling dizzy, and should get emergency medical help if these occur (Shell, 2021). She should keep taking iron supplements until her hemoglobin levels return to normal. To help the body absorb the iron better, she should take them with vitamin C. Report any prolonged tiredness, worsening abdominal pain, or vomiting right away, as these could be signs of complications or an ulcer perforation. Peptic ulcer disease patients who receive educational reinforcement are much more likely to take their medications as prescribed and achieve better outcomes.
Follow-Up and Referral Plan
The patient should return to the clinic in 4 weeks to have their symptoms, hemoglobin levels, and ability to take medication rechecked. At that point, a second hemoglobin and hematocrit test should be performed to see if things have improved. If treatment for H. pylori was started, a urea breath test should be repeated 4 weeks later to confirm the infection is gone. Upper endoscopy should only be done by a gastroenterologist to check for active bleeding, ulcer size, or cancer, especially in a patient over 60 years old who has anemia and feels full quickly (Chey et al., 2022). If the results show a bleeding ulcer or other problems, endoscopic hemostasis or a meeting with a surgeon may be needed.
References
Laucirica, I., Iglesias, P. G., & Calvet, X. (2023). Peptic ulcer. Medicina Clínica (English Edition), 161(6), 260–266. https://doi.org/10.1016/j.medcle.2023.05.015
Shell, E. J. (2021). Pathophysiology of Peptic Ulcer Disease. Physician Assistant Clinics, 6(4), 603–611. https://doi.org/10.1016/j.cpha.2021.05.005
Zhuo, M., Fang, M., Yin, Y., Wang, J., Wei, Z., Lu, J., & Jia, Y. (2024). Investigating the prevalence burden of peptic ulcer disease in older adults aged 70+ from 1990 to 2019: an analysis of Global Disease Burden Studies. European Journal of Gastroenterology & Hepatology, 37(1), 39–46. https://doi.org/10.1097/meg.0000000000002847
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Scenario
A 60-year-old white female presents to your office for a follow-up after a recent Urgent Care visit with her daughter.
- The patient’s daughter reports that the patient has not been eating much for the past few weeks and complains of a gnawing pain in her stomach when she does eat and reports that she seems to be getting “full” very quickly with eating.
- The patient complains of mild nausea over the last two weeks.
- The patient has a history of a recent fall from a ladder about 9 months ago in which she shattered multiple teeth and develop and infection. She has been under the care of an oral surgeon for this.
- Her daughter reports that she has been having an increase in forgetfulness and that the patient’s colleagues have noticed she seems to be “off her game” for the last few weeks.
- Yesterday she was evaluated at Urgent Care and found to have a hemoglobin of 8.5 and hematocrit of 25, and she was instructed to follow-up in your office today.
- Upon examination today his lung sounds are clear and heart rhythm is regular. She has mild tenderness on palpation over her upper abdomen, but normal bowel sounds. Her skin is pale and dry. No other abnormalities are noticed on exam.
Please develop a discussion post that responds to each of the following prompts. Where appropriate your discussion needs to be supported by scholarly resources. Be sure to include in-text citations in the context of the discussion and provide a full reference citation at the end of the discussion post:
- Provide your diagnosis.
- Discuss how you would treat the patient’s current presentation and provide a rationale supported by scholarly reference for your treatment plan.
- Include your specific prescription(s) for the patient. (This must include the medication name, dose, route, and frequency as well as any special instructions that apply as you would include when writing a prescription).
- Describe the patient education you would provide in relation to your treatment plan.
- Provide your plan for follow-up and/or referral (if indicated)
Please be sure to validate your opinions and ideas with citations and references in APA format.