DUODENAL ULCER CASE STUDIES

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Mr B is a 57-year-old man who was admitted yesterday after starting to pass black stools.He has a two-day history of severe stomach pains and has suffered on and off with indigestion for some months.He is a life-long smoker, with mild chronic cardiac failure (CCF) for which he has been taking enalapril 5 mg twice daily for 2 years.He also recently started taking naproxen 500 mg twicedaily for arthritis.Yesterday his haemoglobin was reported as 10.3 g/dL (range12–18 g/dL), platelets 162 × 109/L (range 150–450 × 109/L), INR 1.1 (range0.8–1.2) (ranges from Good Hope Hospital Biochemistry Department, available at www.goodhope.org.uk/departments/pathweb/refranges.htm)withU+Es and LFTs normal.He was mildly tachycardic (87 bpm) and had a slightlylow blood pressure of 115/77 mmHg and was given 1.5 L of saline.He has just returned from endoscopy this morning and has been newly diagnosed as having a bleeding duodenal ulcer.He has been written up for hisusual medication for tomorrow if he is eating and drinking again.

1a What risk factors does Mr B have for a bleeding peptic ulcer?

1b Has his treatment so far been appropriate?

2 Should Mr B be given a proton pump inhibitor (PPI)? State your reasons.If yes,what would you recommend?

3 What is likely to be the next stage of treatment for Mr B?

4 What drugs should Mr B be discharged on?5What counselling would you give him?

6 What follow-up should Mr B have?

ANSWERS
1a What risk factors does Mr B have for a bleeding peptic ulcer?

The prevalence of peptic ulcers increases with age, as Helicobacter pylori infection rates increase with increasing age – Mr B is 57 years of age.Peptic ulcers are more common in smokers.Mr B is also taking an NSAID (non-steroidal anti-inflam-matory drug), which is associated with ulceration.

1b Has his treatment so far been appropriate?

The management of a bleeding ulcer is dictated by the severity of the bleed.MrB is not particularly old, he is not shocked (pulse rate less than 100 bpm, sys-tolic blood pressure over 100 mmHg), and active bleeding has not been reported.He had the appropriate fluid replacement (saline, a crystalloid).Blood was not needed as he did not have particular signs of hypovolaemic shock and his haemoglobin is above 10 g/dL.He had no risk factors to suggest that anti-bacterial prophylaxis was necessary before endoscopy.His enalapril and furosemide were temporarily stopped, and if his blood pressure, hydration state and renal function are normal it is reasonable to restart them tomorrow as planned.If not, his CCF should be reviewed.However, the naproxen should not be restarted.

2 Should Mr B be given a proton pump inhibitor (PPI)? State your reasons.If yes,what would you recommend?

The use of a PPI in this situation is not fully established.A Cochrane Review hassuggested that the use of a PPI does not affect mortality in patients with a bleed-ing peptic ulcer.Mr B has clearly had a recent bleed, and in this situation the British Society of Gastroenterology guidelines suggest that he should be given an infusion of omeprazole, which may help prevent re-bleeding by stabilising the clotting process.However, this may also be achieved by giving oral omepra-zole.Therefore it would have been advisable to start omeprazole 40 mg twice daily, by the oral route.High-dose omeprazole is usually given for 72 hours.

3 What is likely to be the next stage of treatment for Mr B?

Mr B needs a full-dose PPI (see below) for 4–8 weeks to heal his ulcer.Followingthis he should be tested for H.pylori, and if this test is positive he should have eradication treatment.Note that in patients already taking a PPI a two-week washout period is needed before a breath test or a stool antigen test is used.

4 What drugs should Mr B be discharged on?

He should be discharged with:
enalapril 5 mg twice daily
furosemide 40 mg daily
omeprazole 20 mg twice daily (or other full-dose PPI).
If possible, his NSAID should be permanently stopped and therefore considera-tion will need to be given to managing his pain relief.A first option would be to try paracetamol with an opioid such as codeine.However, as he has rheuma-toid arthritis it is unlikely that this will be adequate to control his symptoms.A selective COX-2 inhibitor (e.g.celecoxib) is unlikely to be suitable for Mr B as he has CCF.Therefore, after trying paracetamol/opioids it is likely that Mr B will need an NSAID.NSAIDs can be given during ulcer-healing, but they are best avoided if possible.If an NSAID proves to be necessary, the lowest dose of the safest NSAID (i.e.ibuprofen) should be given.When his treatment for ulcer healing is completed he should take a PPI (e.g.omeprazole 20 mg daily) for gastroprotection.

5 What counselling would you give him?

Simple lifestyle advice – avoiding fatty foods, reducing weight where possible and giving up smoking.
Discuss the use of NSAIDs.Ibuprofen is available without a prescription, and you should discuss the risks of using an NSAID without gastroprotection and the possibility of the inadvertent use of two NSAIDs if he is prescribed another NSAID in the future.
Discuss his analgesia (as above).

6 What follow-up should Mr B have?
If Mr B is symptomatic following H.pylori eradication he should be re-tested for H.pylori, and if this test is positive he should be given a further course of eradication treatment, using a different antibacterial combination to the one given previously (regimens detailed in the BNF).

He should also be reviewed annually and given advice on lifestyle and the management of any dyspeptic symptoms.

From the book,

Pharmacy Case Studies edited by Soraya Dhillon and Rebekah Raymond

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