CASE PRESENTATION

ON (PUD)
PEPTIC ULCER DISEASE

PRESENTED BY
PHARM D INTERN
 PEPTIC ULCER
• Peptic ulcers are open sores that develop on the inside lining of the stomach and the upper portion of the small intestine.

Peptic ulcers include:

• Gastric ulcers that occur on the inside of the

stomach.

• Duodenal ulcers that occur on the inside of the

upper portion of small intestine (duodenum).

 PUD
• Peptic Ulcer occurs when there is an imbalance between aggressive factors (gastric acid and pepsin) and protective factors

(gastric mucus, bicarbonate, prostaglandins).

• Peptic ulcer disease affects 1-2 per 1000 people annually.

• The most common causes of peptic ulcers are infection with the bacterium Helicobacter pylori (H. pylori) and long-term use

of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen sodium.

• Stress and spicy foods do not cause peptic ulcers. However, they can make the symptoms worse.

• The incidence is declining, possibly due to decreasing prevalence of H pylori infection.

 ETIOLOGY
• Helicobacter pylori infection

• Non-steroidal anti-inflammatory drugs

• Hyper-secretion of gastric acid (e.g., Zollinger-Ellison syndrome)

• Viral infections (e.g., cytomegalovirus)

• Radiation therapy

• Chemotherapy

• Crohn's disease

• Idiopathic
 HELICOBACTER PYLORI INFECTION

• HP is transmitted person-to-person by three different pathways; fecal-oral, oral-oral, and iatrogenic

• Transmission of the organism is thought to occur by the fecal-oral route, either directly from an infected person, or

indirectly from fecal-contaminated water or food

• Members of the same household are likely to become infected when someone in the same house is infected

RISK FACTORS:
• Crowded living conditions, unclean water, and consumption of raw vegetables
• Transmission of HP can occur iatrogenically when infected instruments such as endoscopes are used
 NON STEROIDAL ANTI-INFLAMMATORY AGENTS
NONSALICYLATES:
• Nonselective NSAIDs: Indomethacin, ibuprofen, naproxen, ketoprofen, diclofenac
• Partially selective NSAIDs: etodolac, nabumetone, meloxicam

SELECTIVE COX-2 INHIBITORS:

Celecoxib, Valdecoxib

SALICYLATES:
• Acetylated: aspirin
• Nonacetylated: salsalate, trisalicylate
 SIGNS & SYMPTOMS
 Mild epigastric pain.
 Abdominal fullness, or cramping.
 Nausea, vomiting, and weight loss.
 Heartburn, dyspepsia (indigestion), belching, and bloating often accompany the pain.
 Pain from DU often occurs 1 to 3 hours after meals and is usually relieved by food, whereas food may precipitate or
accentuate ulcer pain in GU

 A typical nocturnal pain that awakens the patient from sleep.

 Severity of ulcer pain varies from patient to patient, and may be seasonal, occurring more frequently in the spring or fall.
 Episodes of discomfort usually occur in clusters lasting up to a few weeks followed by a pain-free period or remission lasting
from weeks to years
 Changes in the character of the pain may suggest the presence of complications.
 Complications: ulcer bleeding, perforation, obstruction, or gastric cancer.
 RISK FACTORS
• Taking NSAIDs increases the risk of peptic ulcers.

• Smoke: Smoking may increase the risk of peptic ulcers in people who are infected with H. pylori.

• Drink alcohol: Alcohol can irritate and erode the mucous lining of the stomach, and it increases the amount of stomach acid

that's produced.

• Have untreated stress.

• Eating spicy foods.

• Coffee

• Chocolate

• Acidic foods, such as citrus and tomatoes

• Caffeine
INTERNAL BLEEDING:

• If a peptic ulcer develops near the site of a blood vessel, it can damage the vessel and cause bleeding. Internal
bleeding is one of the most common complications of a peptic ulcer occurring in between 15-20% of cases.
• Risk factors for bleeding include
- continued use of non-steroidal anti-inflammatory drugs (NSAIDs), and
- being 60 years of age, or over.
• Depending on the site and type of the blood vessel, this could cause moderate but long-term bleeding which can lead
to anemia
• Alternatively, the bleeding can be rapid and massive, causing to:
- vomit blood (hematemesis), and/or
- pass stools that are very dark or tar-like (melena).

• If the bleeding is mild/moderate, it can usually be treated by giving injections of proton pump inhibitors (PPIs).
• Massive bleeding can be treated using blood transfusions to replace any blood loss.
PERFORATION:

• Peptic ulcers can lead to a hole through (perforate) the wall of the stomach or small intestine. It occurs in an estimated 2-
10% of all cases.
• Perforation is potentially very serious because bacteria that live in the stomach can move out of the stomach and infect
the lining of the abdomen (peritoneum). This is known as peritonitis.
• Peritonitis is a medical emergency because tissue of the peritoneum is usually sterile (germ-free) so unlike other parts of
the body, such as the skin, it does not have an inbuilt defense mechanism for fighting off infection.
• In peritonitis, an infection can rapidly spread into the blood (sepsis) before spreading to other organs. This carries the risk
of multiple organ failure and, if left untreated, death.
• The most common symptom of peritonitis is the sudden onset of abdominal pain that then gets steadily worse.
• Peritonitis requires admission to hospital where the patient will be treated with injections of antibiotics to get rid of the
infection. Surgery is then used to seal the hole in the stomach wall.
GASTRIC OBSTRUCTION:

• In some cases, a peptic ulcer can produce inflammation (swelling) and /or scar tissue that can obstruct the normal passage of
food through the digestive system. This is known as gastric obstruction. Gastric obstruction occurs in an estimated 5-8% of
cases of peptic ulcers.
• Symptoms of gastric obstruction include:
- repeated episodes of vomiting, with large amounts of vomit that contain undigested food,
- a persistent feeling of bloating, or fullness,
- feeling very full after eating less food than usual, and
- unexplained weight loss.
• If the obstruction is due to inflammation, PPIs or H2-receptor antagonists can be used to reduce the inflammation.
• If the obstruction is due to scar tissue, surgery will be required to treat it. One option is to pass a small balloon through an
endoscope and then inflate it in order to widen the site of the obstruction.
• In more severe cases of scarring, it may be necessary to surgically remove the affected section of stomach, before and
reattaching the remainder of the stomach
 DIAGNOSIS
1. Physical examination

2. Endoscopy

3. Barium Swallow

4. Test for H. Pylori

 TREATMENT
NON-PHARMACOLOGIC TREATMENT

 Patients with PUD should eliminate or reduce psychological stress, cigarette smoking, and the
use of nonselective NSAIDs (including aspirin)

 Alternative agents such as acetaminophen, a nonacetylated salicylate (e.g., salsalate), or a

COX-2 selective inhibitor should be used for pain relief

 Although there is no need for a special diet, patients should avoid foods and beverages that
cause dyspepsia or exacerbate ulcer symptoms (e.g., spicy foods, caffeine, alcohol)
PHARMACOLOGIC TREATMENT

 Antibiotic medications to kill H. pylori: If H. pylori is found in the digestive tract, the doctor may recommend a
combination of antibiotics to kill the bacterium.
 Medications that block acid production and promote healing. Proton pump inhibitors: reduce stomach acid by blocking
the action of the parts of cells that produce acid.
 Medications to reduce acid production. Acid blockers — also called Histamine (H-2) blockers — reduce the amount of
stomach acid released into the digestive tract, which relieves ulcer pain and encourages healing. They block a natural
chemical called histamine, which tells the stomach to make acid.
 Medications that protect the lining of the stomach and small intestine: Cytoprotective agents: they helps to protect the
tissues that line the stomach and small intestine.
Example: sucralfate and misoprostol
 Antacids that neutralize stomach acid: Antacids neutralize existing stomach acid and can provide rapid pain relief.
Antacids can provide symptom relief but generally aren't used to heal the ulcer.
H. PYLORI TREATMENT:

 First-line eradication therapy is a proton pump inhibitor (PPI)–based, three-drug regimen containing two antibiotics,

usually clarithromycin and amoxicillin, reserving metronidazole for back-up therapy (e.g., clarithromycin–metronidazole

in penicillin-allergic patients)

 The PPI should be taken 30 to 60 minutes before a meal along with the two antibiotics

 Although an initial 7-day course provides minimally acceptable eradication rates, longer treatment periods (10 to 14

days) are associated with higher eradication rates and less antimicrobial resistance.

 If there’s a resistance to clarithromycin or metronidazole, or if the first line therapy fails, quadruple therapy treatment

with two antibiotics (like metronidazole and tetracycline) plus bismuth and a proton-pump inhibitor is used (10-14 days).
 For treatment of NSAID-induced ulcers, nonselective NSAIDs should be discontinued if an active ulcer is confirmed

 Uncomplicated NSAID-induced ulcers heal with standard regimens of an H2RA, PPI, or sucralfate if the NSAID is discontinued

 If the NSAID must be continued, consideration should be given to reduce the dose or switch to acetaminophen, a
nonacetylated salicylate, a partially selective COX-2 inhibitor, or a selective COX-2 inhibitor.

 PPIs are the drugs of choice when NSAIDs must be continued because potent acid suppression is required to accelerate ulcer
healing.

 Patients at risk of developing serious ulcer-related complications while on NSAIDs should receive prophylactic co-therapy with
cytoprotective agent or a PPI

• HP-positive patients should receive eradication therapy

• In HP negative patients, higher PPI doses heal the majority of ulcers.

 PATIENT INFORMATION AND COMPLAINTS

 37 year old male patient.

Diet : Mixed
 c/o Abdominal Pain x 5 days Sleep : Disturbed
 c/o Hematemesis 1 episode Appetite : Decreased
 c/o vomiting x 2 days Habits : Nil
 c/o melena 3 episodes No Known Allergies
 c/o constipation

 NO PAST HISTORY / MEDICATIONS

 LABORATORY
CBC
EXAMINATIONS
TEST VALUE NORMAL VALUE
Hb 10.9 13.0 – 17.0 g/dl

PCV 33.9 35 – 45 %

PC 3.5 1.5 – 5 L/cumm

TLC 12,500 4 – 11k cells/cumm

RBC 4.5 4.5 – 5.5 million/cumm

ESR 17 0 – 20 mm/hr

RFT Normal

LFT Normal

S. Lytes Normal
 Upper GI Endoscopy : Ulcer in duodenum
 Urease Breath Test: Positive
 Blood Culture: Positive for H. Pylori

Confirmatory Diagnosis : CHRONIC DUODENAL ULCER (PUD)

 DRUG CHART
BRAND NAME GENERIC NAME DOSE CATEGORY FREQUENCY INDICATION

Inj. Emeset Ondansetron 4 mg Anti emetic S.O.S N, V

H.Pylori Kit Amoxycillin + 1.5 g Penicillin + 1-0-1 PUD

Clarithromycin + Macrolide +
Lansoprazole PPI

Syp. Cremaffin Sodium Picosulphate 2 Tsp Laxative 0-0-1 Constipation

Plus + Liq. Paraffin + Mg.
Hydroxide

1 Unit PCV Transfused on D2

 PHARMACEUTICAL CARE PLAN
SUBJECTIVE EVIDENCES OBJECTIVE EVIDENCES

 c/o Abdominal Pain x 5 days  Hb : 10.9 g/dl

 c/o Hematemesis 1 episode  WBC: 12,500 cells/cumm
 c/o vomiting x 2 days  Upper GI Endoscopy : Ulcer in duodenum
 c/o melena 3 episodes  Urease Breath Test: Positive
 c/o constipation
 Blood Culture: Positive for H. Pylori

ASSESSMENT: Based on the subjective and objective evidence the diagnosis was made as
CHRONIC DUODENAL ULCER
 MONITORING PARAMETERS
& PATIENT COUNSELLING
DRUG ADR M.P PATIENT COUNSELING

ONDANSETRON • Constipation • Reduction – N,V • To be reported back if experiences severe palpitation,

• Headache • ECG syncope, dizziness.
• QT prolongation • Increase the intake of water.

AMOXICILLIN • Rash • Resolution of signs and symptoms • Report back in case od serious ADRs.
• Headache of bacterial infection is indicative of
• Clostridium def. diarrhea efficacy.
• Hypersensitivity reactions • CBC
• SJS
 DRUG ADR M.P PATIENT COUNSELING

CLARITHROMYCIN • Abdominal pain • CBC • Immediately report symptoms of Clostridium

• Diarrhea • RFT defficile- associated diarrhea
• Disorder of taste • LFT • Avoid activities requiring mental alertness
• Indigestion
• N, V, Headache
• Prolonged QT interval

LANSOPRAZOLE • Hypomagnesemia • S. Lytes • Food to be taken after 30 mints of drug adm.

• Bone/Hip Fractures • Vitamin B12 (after 1-2 years) • Patient should be asked to report persistent watery
• Reduced Vit B12 abs. stools continues
• Clost. difficle diarrhea
• Abd pain
 LIFESTYLE
MODIFICATIONS
 Protection from H. Pylori infections: by frequently washing hands with soap and water and by eating foods that have
been cooked completely.
 Use caution while using NSAIDs – if on regular pain relievers – (1) take steps to reduce the risk of stomach problems. For
instance, always take NSAID medication with meals.
(2) Avoid drinking alcohol when taking these medication, since the two can combine to increase the risk of PUD.
(3) If on long use of NSAIDS – always take it with additional medications such as an antacid, a proton pump inhibitor, an
acid blocker or cytoprotective agent.
 Control stress.
 Don't smoke - Smoking may interfere with the protective lining of the stomach, making the stomach more susceptible to
the development of an ulcer. Smoking also increases stomach acid.
 Limit or avoid alcohol - Excessive use of alcohol can irritate and erode the mucous lining in the stomach and intestines,
causing inflammation and bleeding.
 If you’re diagnosed with H. pylori, take all of the antibiotics you’re prescribed. Not taking the entire course can keep the
bacteria in the system.
 Take steps to increase physical activity. Regular exercise can activate the immune system.
 Reduce spicy food. (chilies and hot peppers)
 Avoid junk foods
 Eat more fruits and vegetables – cauliflower, cabbage, radishes, apples, blackberries, strawberries
 Consume more probiotic-rich foods, such as yogurt, buttermilk
 Avoid caffeine, take decaffeinated green tea if needed.
 Avoid caffeinated beverages, carbonated beverages and chocolate
 Avoid acidic foods, such as citrus and tomatoes.
 Broccoli contains sulforaphane, a compound that exhibits anti-H. pylori activity.
 Consume more honey and garlic - shown to inhibit H. pylori growth in lab, animal, and human trials.
THANK YOU!