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Peptic Ulcer Disease

Peptic Ulcer Disease

Introduction

Epigastric pains have been always linked to gastric troubles; for centuries, physicians had considered that the imbalance between protective and acidic gastric factors had a major contribution to these complaints and caused an ulcer. However, at the end of the 20th century, the medical society discovered the key role of Helicobacter pylori infection and developed evidence-based management strategies. Although a substantial improvement in the peptic ulcer treatment has been achieved in the recent decades, this condition still poses a serious medical and social danger. This paper studies peptic ulcer in a typical and most common way by analyzing a relevant case study, providing basic information on the disease, and developing a coherent care plan.

In the US, over 15 million of individuals suffer from the peptic ulcer disease today (Torpy, 2012). Up to 16% of all elderly patients with abdominal pains have a peptic ulcer (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013). The case study discusses the clinical situation and suggests an explanation of the condition in brief. In the next paragraphs, data on pathophysiology, signs, diagnostics, and treatment options are presented. Finally, a discussion on the negative effects of the disease on the patients and their family is made. Medical care suggestions and socio-economic aspects of this disorder are discussed at the end of the paper.

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Case Study Analysis

A 60-year-old Italian male suffers from abdominal pain that he has already had before. Although the case scenario does not verify the terms, one may assume that his abdominal problem is of chronic nature or has an acute-on-chronic course. It is also noteworthy that in the past, the man had heartburns that were managed by antacids; this fact strongly suggests that gastric acids refluxed into the esophagus and thus were indicating a gastro-esophageal reflux. Logically, hyper acidic exacerbations and upper abdominal pains can help diagnose some stomach conditions.

Abdominal pains become especially bad at night as it is the circadian time for the vagal overactivity and naturally occurring hyperacidity. The patient’s gnawing pains did not move and localized around the umbilical area. In few hours, the pain became less intensive; it might be an indication of visceral but not the peritoneal origin of the complaint.

The man’s past medical history is prominent for a long intake of NSAIDs in high doses with the aim to alleviate gout symptoms. As it is discussed later in the paper, NSAIDs are the strong damaging agents against gastric mucosa; thus, they help natural acids damage the underlying wall of the stomach/duodenum. He also had some stomach history many years ago; it is another contributing factor. The queasy stomach issue is associated with the unbalanced gastric juices in gastric diseases. For ulcer, the inner lining of the stomach/duodenum, wine consumption may be another damaging factor to be considered.

Physical examination perfectly correlates with the patient’s complaints and history. His anterior abdominal wall is tender and susceptible in the epigastrium. Negative peritoneal signs further prove the peritoneal origin of the pain. Elevated BP can indicate possible arterial hypertension, but long-standing hypertension would result in left ventricular over-activity on EKG, so the arterial hypertension is either not very severe or well managed. The man’s arterial tension of 175/70 mmHg can be associated with a stressful situation. His bradycardia of 64 BPM may indicate that the dose of propranolol (beta-blocker) is adequate for controlling tachycardia. Beta-blockers also alleviate hypertension; on examination, his blood pressure is elevated; thus, the pressure profile will need a further follow-up. His normal EKG (while pains continue) rejects heart attack. Out of all his lab investigations, Helicobacter pylori positive test is of most importance for the gastrointestinal diagnosis.

In conclusion, according to the patient’s complaints, history, and examination data, he suffers from a peptic ulcer, induced by NSAIDs and Helicobacter Pylori. Until fibroscopy is performed, it is not definitely known whether it is a peptic ulcer of gastric or duodenal.

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Peptic Ulcer: General Information

Normal anatomy and pathology. Ventriculus is located in the epigastric and umbilical regions of the abdomen and followed by the duodenum that encircles the head of the pancreas to the right of the vertebral column (Standring, 2008). The fundus and body of the ventriculus are situated to the left of the midline while the pylorus (containing the acid-producing parietal cells) is located to the right. The inner lining of the gastric wall is the mucous membrane covered with a single layer of column epithelium of submucous coat. As a rule, this coat, as well as muscular and serous coats, is common for the duodenum. In the case of peptic ulcer, the inner lining is damaged, and the developing small sores penetrate into the lowermost limit of the mucosa (muscularis mucosae) (Anand, 2015; Torpy, 2012). A defect in peptic ulcer may spread further and affect submucosa or muscularis propria (Banerjee et al., 2010). Johnson classification of peptic ulcers divides lesions into four types: I – ulcers are located near the lesser curvature, acid secretion is normal, II – a combination of stomach and duodenal ulcers with increased secretion, III – prepyloric ulcers with increased secretion, IV – gastric ulcers with normal secretion (Anand, 2015).

Pathophysiology. Normally, the epithelial cells produce mucus, bicarbonate, and prostaglandins in order to protect the cavities of the body from the natural acids and acidic enzymes (Anand, 2015). Thus, on the inner surface of the stomach, there is a balance between the protective and aggressive factors. Peptic ulcer develops when the balance is shifted towards the damaging agents. Gram-negative spirochete, Helicobacter Pylori, produces urease around itself and alkalines the microenvironment causing mucosal inflammation. NSAIDs block the prostaglandin production and, thus, disrupt the mucosa. Consequently, up to 30% of those who take these drugs develop adverse effects (Anand, 2015). Moreover, the combination of Helicobacter pylori and NSAIDs has an additive effect (Sostres et al., 2015). NSAIDS more commonly cause gastric ulcers than duodenal ulcers (Abramovicz, Zucotti, & Pflomm, 2010). Other contributing factors include previous history of peptic ulcer, smoking, alcohol abuse, stress (especially severe issues: burns, trauma, or surgery, for example), depression, social deprivation, intake of oral steroids, and genetics (Anand, 2015; Sondashi, Odimba, & Kelly, 2011; Torpy, 2012).

Signs/symptoms. Typical signs of a peptic ulcer include abdominal pains, dyspepsia, and heartburn (Anand, 2015; Buttaro et al., 2013; Torpy, 2012). Abdominal pains usually develop at night or are associated with meals. Dyspepsia is a common issue even in healthy individuals, but the recent guidelines suggest that new onset of dyspepsia in adults older than 50 years is an indication of esophagogastroduodenoscopy (Banerjee et al., 2010). Heartburn, especially in relation to dyspepsia, is infrequently related to gastroesophageal reflux, which often accompanies peptic ulcer and Helicobacter pylori infection (NICE, 2014).

Progression trajectory. A peptic ulcer is dangerous for its major complications: perforation, obstruction, and bleeding (Banerjee et al., 2010; Buttaro et al., 2013). Bleeding occurs in the case of vessel erosion; it is the most common complication of peptic ulcer. Perforation is a surgical emergency because the gastric contents escape into the peritoneal cavity (especially, if the anterior wall is damaged) or surrounding structures (especially, if posterior wall is damaged) (Buttaro et al., 2013). The outlet obstruction syndrome develops in the case severe scars of pylorus or duodenum cause lumen narrowing or obliteration; consequently, these patients suffer from severe vomiting, bloating, and weight loss (Banerjee et al., 2010).

Diagnostic testing. Upper endoscopy is a golden standard for peptic ulcer diagnostics. During esophagogastroduodenoscopy, the mucosa of the esophagus, stomach, and duodenum is visualized; consequently, biopsy may be taken and samples checked for Helicobacter pylori (Buttaro et al., 2013; Torpy, 2012). Peptic ulcers appear as mucosal lesions with smooth base, which are often filled with fibrinoid exudate that usually are 0.5-2.5 cm in diameter (Anand, 2015). Helicobacter pylori testing is recommended for all individuals who undergo fibroscopy (Buttaro et al., 2013). Urease activity, histopathology, and serum antibodies can be checked in order to obtain reliable information on the infection presence (Anand, 2015).

Treatment options. In the recent decades, the introduction of antibiotics into the peptic ulcer treatment strategy, as supported by Helicobacter pylori positive tests, has considerably reduced the incidence, morbidity, and mortality rates from peptic ulcer (Bashinskaya, Nahed, Redjal, Kahle, & Walcott., 2011). The current treatment schemes include non-pharmacologic and pharmacologic interventions. The former include avoiding alcohol and smoking, allaying stress, and NSAIDs cessation. The latter comprises antisecretory therapy and empiric triple therapy for Helicobacter pylori eradication. For example, esomeprazole + amoxicillin + clarithromycin + metronidazole is a recognized combination (Ghana Ministry of Health, 2010). Endoscopy must be repeated after a course of treatment in order to prove the eradication efficacy (Anand, 2015; Torpy, 2012). It is also recommended for individuals without Helicobacter pylori who take NSAIDs in order to introduce antisecretory agents for eight weeks if a peptic ulcer is diagnosed (NICE, 2014). Taking proton pump inhibitors with NSAIDs prevents the peptic ulcer formation (Abramovicz et al., 2010).

Care Plan Development

Educational patterns. The patient mentioned at the beginning of this paper has a classical course of peptic ulcer: two potent mutually reinforcing risk factors for the peptic ulcer development, typical pains without evidence of any major complications (no occult blood in the rectum and normal hemoglobin in CBC, negative peritoneal symptoms, no data for obstructive bowel syndrome). Thus, this man needs assurance and support against his fears of the heart attack. Moreover, his EKG is normal; this instrumental result must be clearly explained and normal finding emphasized to him. As soon as both risk factors are modifiable, the patient has optimistic prognosis concerning his pains, general medical perspective, and social activity. It is strongly advised to stop wine abuse as this damaging factor may interfere with the mucosa healing of his stomach. His NSAIDs intake must be also stopped; non-NSAIDs painkillers and other groups of drugs for controlling gout should be considered, at least for the period of ulcer treatment. On the other hand, his eradication therapy must be taken at hours as prescribed in order to achieve the best pharmacological effect.

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Interdisciplinary team. The uncomplicated peptic ulcer can be successfully treated on the outpatient basis if strict adherence to the current recommendations is followed. Control fibroscopy is planned on an elective basis after the completion of the cycle. The patient’s arterial hypertension needs additional evaluation. On examination, his blood pressure is elevated, but no tachycardia is present. Should blood pressure with low pulse persist, an additional angiotensin-converting enzyme inhibitor or angiotensin II blocker could be considered. It is not known what his lipid profile is; therefore, this patient should make a lipidogram in order to evaluate the efficacy of Zocor. A low-density lipoprotein level is of utmost importance since it is the key risk factor for atherosclerosis and subsequent coronary or carotid lesions. The patient’s gout is to be re-evaluated aiming at reducing the symptoms without further administration of Indocin. Probably, his diet should contain less meat; moreover, colchicine is a non-NSAID drug that could be applied, and angiotensin II blockers are new agents that show effectiveness in the gout treatment (Rothschild, 2015). Thus, interdisciplinary cooperation on gastroenterology/fibroscopy, cardiology, and gout is essential for the effective management of this case.

Physical and psychological demands. From the case scenario, the body-mass index of a patient cannot be calculated, but the case description mentions that he moves not enough. Thus, one may assume his physical activity is insufficient; this fact that worsens the blood pressure profile, alters body mass index, and worsens the lipid profile. Until now, the low physical activity might have been attributed to gout symptoms, although with the new interdisciplinary approach this condition is to be improved. Thus, the patient needs to be taught about the importance of sufficient physical actions to supporting his cardiovascular system and ways of avoiding heart attack by altering the lifestyle. In this case, the patient has a very positive feature: he is not willing to ignore social activities, and he does teaching on the side. This pattern should be encouraged in order to manage the man’s depression: as soon as pains resolve, his further activities will be safe to continue and with time he can ensure the effectiveness of the medical aid. However, he is not very compliant with the current drug regimen, so the health care provider must convince him that a strict drug regimen cannot be violated. His son and daughter can be engaged in the rehabilitation program; they can explain to the man that the current deterioration is potentially curable, and their communication will not be burdened.

Facilitators and barriers to optimal management. As soon as the peptic ulcer is an outpatient disease treated with tablets, the key obstacle is the patient himself. Therefore, strong compliance needs to be achieved as soon as possible; otherwise, the evidence-based treatment protocol may fail. In order to reduce wine consumption, the patient should put the bar at eliminating alcohol from his diet at least for the treatment period. His wife who suffers from joint troubles is another barrier to be effectively managed. She needs further medical assessment; maybe her example can improve her husband’s interest in terms of the depression management.

Care Plan Synthesis

Disorder management. Treatment of peptic ulcer invariably includes endoscopy and careful history analysis (Anand, 2015). All patients with new-onset dyspepsia after the age of 50 should undergo fibroscopy, as well as all individuals with Helicobacter pylori postive tests, or high-resk patients taking NSAIDs (Anand, 2015; Banerjee et al., 2010).

Endoscopy aims at visualization of the ulcer, identification of its location and complications statement. If peptic ulcer is complicated by bleeding, perforation or obstruction, an abdominal surgeon is usually engaged and intensive care treatment is planned. Bleeding is usually accompanied by hypotension and anemia, thus intensive volume resuscitation is required to replace the lost blood. Packed red blood cells are needed if hemoglobin and hematocrit level falls below safe levels. Bleeding ulcers can be coagulated during endoscopy by using special coagulation electrodes. Perforation usually requires laparotomy to evacuate the gastric contents from the abdominal cavity and to place securing sutures on the perforated locus. Obstruction is also a surgical complication requiring creation of bypass shunts for the nutritive mass to proceed downwards without resistance.

Medical approach to uncomplicated peptic ulcers depends on etiology. Positive Helicobacter pylori test is a clear indication for antisecretory agents and antibiotics, as will be detailed later (Bashinskaya, Nahed, Redjal, Kahle, & Walcott., 2011). Acid suppressive agents can be given both orally and intarvenously. Oral administartion is simple and effective and thus can be recommended for uncomplicated cases that receive treatmnet on an out-patient basis. Intravenous route of admnistration is best for critical patients, for example psenting with bleeding in an emergency department. NSAIDs anamnesis determines the need for cessation of these drugs and proton pump inibitors prolongation even if concomittant Helicobacter pylori eradication is successful (Sondashi, K.J., Odimba, B.F.K., & Kelly, P., 2011).

Dietary limitations, although helpful, are not specially indictaed after the end of medication scheme (Anand, 2015). It is a common sense to avoid beverages, alcohol and foods that provoke pains or dyspepsia in clients. If Helicobacter pylori eradication is not achieved (for example, form resistance to antibiotics), in complicated ulcers, or in rccurent ulcers, a proton pump inhibitor is indicated to continue for more one year. Moreover, continuation of NSAIDs even after successful Helicobacter pylori eradication places the patient at risk for reccurent peptic hemorrhage, so a one year prolongation of proton pump inhibitor is indicated (Anand, 2015).

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Socio-cultural background impact. Middle-income earners and regular alcohol drinkers suffer from the peptic ulcer oftener, especially if the previous history of the disease is present. These assumptions were proved in the recent research (Sondashi et al., 2011). As for this patient, the man is a retired schoolteacher willing to continue social activities; he has a wife working at the local grocery store. After the peptic ulcer treatment course, the health care provider is advised to concentrate on the patient’s gout symptoms. The man has access to a primary care provider so his economical status must allow him to continue the treatment.

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Evidence-based approach. Evidence-based approach to peptic ulcer treatment started in the 1980th when proton pump inhibitors alone were shown to eradicate Helicobacter pylori in approxiamtely 10% of patients. Later, addition of bismuth derivatives and/or an antibiotic improved the percentage of effective elimination up to 60%. Combination of a couple of antibiotics with proton pump inhibitors is able to achieve positive result in almost 95% of infected individuals. Evidence-based results of triple therapy as suggested in the previous chapter of this paper is a proven strategy that has strongly demonstarted its effectiveness (Bashinskaya, Nahed, Redjal, Kahle, & Walcott., 2011). However, if this patient would show allergy or ineffectiveness of one scheme, the World Health Organozation has approved at least three recipes for peptic ulcer management: esomeprasole or omeprasole or rabeprasole in combination with various doses of amoxicillin and clarithromicin and metronidasole, but one of these antibiotics may be omitted if doses of the other two is doubled (Ghana Ministry of Health, 2010). Thus, health care providers have strong evidence-based instruments to cure this patient.

Conclusion

Peptic ulcer is a nice example of how modern medicine achieves high effectiveness due to scientific advances. It was discovered that Helicobacter pylori plays the central role in shifting the tiny balance between acidity and natural cytoprotection mechanisms in the stomach. By administrating antibiotics, the causative agent is eliminated and patients who were condemned to suffer from visceral abdominal pains, dyspesia and life-threatening complications, today achieve optimistic prognosis. Evidence-based recommendations are today applied worldwide and thus safe many millions of lives in both adults and children. Nevertheless, a broad understading of peptic ulcer from positions of medical history, social and economical aspects, physical and psycological demands, the need for education in a given individual can not be rejected. The World Health Organization defines health as the state of both physical, social and mental well-being (WHO, 2015), so a comprehesive approach to treatmnet is able to deliver best health care to all patients with peptic ulcer.

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