PEPTIC ULCER DISEASEThe Pain of It All . . . . . . . . . . . . . . . . . . . . . . . . Level IIJohn W. Devlin, PharmD, BCPS, FCCP, FCCM

LEARNING OBJECTIVESAfter completing this case study, students should be able to:• Devise an algorithm for evaluation and treatment of a patient withsigns and symptoms suggestive of peptic ulcer disease (PUD).• Identify desired therapeutic outcomes for patients with PUD.• Identify factors that guide selection of a Helicobacter pylori eradicationregimen and improve adherence with these regimens.• Given patient-specific information and the prescribed drugtreatment regimen, formulate a monitoring plan for a patientwho is receiving drug therapy for PUD.

PATIENT PRESENTATION_ Chief Complaint“My stomach has been hurting for the past few weeks. Over theweekend, I noticed my bowel movements were black and tarry.”_ HPIWilliam Smith is a 62-year-old man who presents to the emergencydepartment on Sunday evening complaining of intermittent burningepigastric pain for more than 2 months. His pain is non-radiating andoccurs to the right of his epigastrium. This pain changes in intensityand is worse with meals. He also has noticed intermittent belching,being bloated, being weak when walking, and complains of nauseaafter eating. Since last Friday, he has been having black, tarry bowelmovements. He does not have any history of PUD or GI bleeding andhas not experienced anorexia or vomiting._ PMHCOPD 10 yearsType 2 DM 10 yearsOsteoarthritis 15 years in the right shoulder_ FHHis father died at age 55 of an acute MI and his mother died at age66 from lung CA. He has three siblings who are alive and well._ SHPresently employed as an accountant. He is married and has threedaughters. He still smokes a cigar occasionally despite his COPD,and he drinks a case of beer per week._ MedsMetformin 500 mg po twice dailyEC aspirin 325 mg po once dailyIpratropium MDI 2 puffs 4 times dailyAlbuterol MDI 2 puffs PRNIbuprofen 200 mg 2 tablets PRN shoulder painMaalox 1 tablespoonful PRN stomach pain_ AllPenicillin—hives_ ROSUnremarkable except for complaints noted above_ Physical ExaminationGenOverweight man in moderate distressVSBP 120/62 right arm (seated), P 109, RR 18 reg, T 37.9°C; Wt 102kg, Ht 5'9''SkinWarm and dryHEENTPERRLA; EOMI; discs flat; no AV nicking, hemorrhages, or exudates

ChestBilateral rhonchi, faint wheezesCVS1 and S2 normal; no MRGAbdNormal bowel sounds and mild epigastric tenderness; liver sizenormal; no splenomegaly or masses observedRectNontender; melenic stool found in rectal vault; stool heme (+)ExtNormal ROM except for restricted right shoulder movementNeuroCN II–XII intact, DTRs 2 + throughout_ LabsNa 144 mEq/L Hgb 9.2 g/dL Ca 9.2 mg/dLK 3.9 mEq/L Hct 26.2% Mg 2.0 mEq/LCl 98 mEq/L Plt 230 103/mm3 Phos 4.0 mg/dLCO2 30 mEq/L WBC 8.4 103/mm3 Albumin 3.9 g/dLBUN 10 mg/dL MCV 74 m3

SCr 1.1 mg/dL Retic 0.3%FBG 154 mg/dL Fe 49 mcg/dL

Problem Identification1.a. Identify this patient’s drug therapy problems.1.b. What information (signs, symptoms, diagnostic tests, and laboratoryvalues) indicates the presence of peptic ulcer disease?

■ CLINICAL COURSE (PART 1)An EGD revealed a 6-mm ulcer in the gastric antrum (Fig. 29-1). Theulcer base is clear and without evidence of active bleeding. In addition,inflammation of the antrum was detected and biopsied. Refer toTable 29-1 for the characteristics of common causes of PUD.

Desired Outcome2. What are your treatment goals for treating this patient’s PUD?

Therapeutic Alternatives3.a. Considering the patient’s presentation, what nonpharmacologicalternatives are available to treat his PUD?3.b. In the absence of information about the presence of H. pylori,what pharmacologic alternatives are available to treat gastriculcers?

Optimal Plan4. Based on the patient’s presentation and the current medicalassessment, design a pharmacotherapeutic regimen to treat hisgastric ulcer, anemia, and osteoarthritis.

Outcome Evaluation5. What clinical and laboratory parameters are necessary to evaluatetherapy for achievement of the desired therapeutic outcomes andto detect or prevent adverse effects?

Patient Education6. What information should be provided to the patient to ensuresuccessful therapy, enhance compliance, and minimize adverseeffects?

■ CLINICAL COURSE (PART 2)At the time of endoscopy, a biopsy of the gastric mucosa was takenand indicated the presence of inflammation and abundant H.pylori–like organisms (Fig. 29-2).

■ FOLLOW-UP QUESTIONS1. What is the significance of finding H. pylori in the gastric biopsy?2. Based on this new information, how would you modify yourgoals for treating this patient’s PUD?3. What pharmacotherapeutic alternatives are available to achieve

the new goals?4. Design a pharmacotherapeutic regimen for this patient’s ulcerthat will accomplish the new treatment goals.5. How should the PUD therapy you recommended be monitoredfor efficacy and adverse effects?6. What information should be provided to the patient about histherapy?7. How should his osteoarthritis-related shoulder pain now betreated?

■ SELF-STUDY ASSIGNMENTS1. Describe the advantages and limitations of both endoscopic andnonendoscopic diagnostic tests to detect H. pylori.2. After performing a literature search on H. pylori eradicationtherapy, compare the efficacy of two-drug, three-drug and four-