Peptic Ulcer Disease: A Case Study Review Cassandre Miller

[Pages:20]Peptic Ulcer Disease: A Case Study Review

Cassandre Miller

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Introduction: FK is a 64 year old Caucasian male who is 5'8", weighing between 116 lbs and

123 lbs. He was originally referred to Fort Hamilton Hospital from University of Cincinnati Hospital for jaw pain related to a mandibular fracture. During admission, FK was transferred to the ICU with a severe gastric bleed. FK has presented with several co-morbidities and factors contributing to his admittance such as malnutrition, ETOH abuse, COPD, cirrhosis, anemia and cancer of the tongue. This case study began 11/11/2015 and concluded 12/02/2015 with a primary medical and nutritional focus on FK's perforated peptic ulcer and peptic ulcer disease. While the patient has several comorbidities, the gastric bleed and peptic ulcer disease will be the primary focus of the study.

The patient was chosen for this study due to the severity of his condition and underlying malnutrition. The research surrounding environmental and social conditions in the presentation of peptic ulcer disease is overwhelming and has been well researched for a number of years. However, methods of treatment, medicine and nutrition therapies are always changing and the research of this condition continues to grow.

Social History: FK is a single, unemployed man living alone in a two story walk up apartment. He

is receiving medical insurance from Medicare. He also receives moderate assistance from family but takes care of himself 50%-75% of the time. FK cooks for himself on a regular basis, usually using a crockpot or eating canned foods. The patient was a long time smoker, smoking approximately 1.5 packs per day but reported recently quitting 8/22/15. FK has a history of alcohol abuse and admitted consuming 14.4 oz alcohol per week, including 24 cans of beer with occasional bourbon. However, the patient reported upon arrival 11/11/15 that he did not drink any alcohol for about a week, additional medical reports otherwise conflicted with that statement. Following discharge from FK's first visit, he was subsequently admitted to an Extended Care Facility.

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Normal anatomy and physiology of applicable body functions: Explanation of disease process

H.pylori is the most common cause of gastric ulcers, though the transmission is not well understood. The H.pylori bacterium is thought to be transmitted via the fecaloral route and is usually found in people of poor socio-economic backgrounds. The use of NSAIDs can cause an H.pylori infection because of their acidic properties. Frequent NSAID use can damage the mucosal lining by inhibiting prostaglandin synthesis, which maintain homeostatic functions by regulating gastric acid secretions. [1] If prostaglandin is inhibited, the stomach may over-produce gastric acid, causing inflammation in the stomach and additionally creating an environment where H.pylori can flourish.

Excessive gastric acid is only one of the potential "hostile" factors in Peptic Ulcer Disease. Decreased mucosal defense is another potential factor. Some "protective" factors such as prostaglandins, mucus, bicarbonate and blood flow in the mucosa can be disrupted by the "hostile" factors, causing a peptic ulcer.

A peptic ulcer is an open sore that can occur in the lining of the stomach (gastric ulcer) or in the duodenum (duodenal ulcer.) Under normal homeostatic conditions, the stomach and intestinal lining can withstand the corrosiveness of stomach acid. However, once the lining breaks down, the tissue may become inflamed or develop an ulcer. A gastric ulcer usually develops in the first layer of the stomach lining. Once the ulcer develops it can cause a perforation which is extremely dangerous and can cause internal bleeding. As mentioned previously, there are several factors that can increase the risk of an H.pylori induced gastric ulcer or peptic ulcer. Some of the most common factors include smoking, alcohol abuse, radiation treatments, and regular NSAID use. [2] Each factor mentioned has occurred with the patient, FK.

Past Medical History: FK's previous visits to Fort Hamilton Hospital included one in 2012 for cellulitis in

his right ankle, then again in 2014 with pain in his right ankle from a fall. During his 2014 visit he was diagnosed with peripheral vascular disease.

FK did not visit Fort Hamilton again until his recent visit where he was admitted November 11, 2015 with weakness and malaise due to a severe gastric bleed. He was

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then discharged November 20th after two repairs to the gastric ulcer. The patient was then subsequently admitted again November 22nd from the Butler County Care Facility with blood found in his stool. The ulcer was repaired a third time and he was discharged December 2nd with a schedule follow up to perform an exploratory EGD in 6 weeks.

FK had several other co-morbidities which included cancer of the tongue and a reconstructed broken jaw. He was receiving treatment for oral cancer at UC Hospital prior to the time of his visit to Fort Hamilton. The patient was diagnosed in 2006 with cancer on the base of his tongue. FK received 42 radiation treatments and several doses of chemo. During the time of his visit, the patient still had a large mass on the base of his tongue and was encourage to schedule an appointment with his ENT for an oral exam and possible biopsy at UC Hospital. FK's broken jaw also seemed suspicious to some of the medical staff not only at Fort Hamilton but also at UC Hospital and there was some speculation as to whether or not a mass was also growing in the weakened mandibular region.

The patient had an extensive health history with additional co-morbidities which are as follows: Diagnosis:

? Hypertension ? Radiation - 42 treatments ? Hx antineoplastic chemo ? Peripheral vascular disease ? ETOH abuse ? Cirrhosis ? Seizures - with ETOH withdrawal ? COPD (chronic obstructive pulmonary disease) ? Cancer - Base of tongue ? Forgetfulness ? Anemia

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Theoretical discussion of disease condition Gastric ulcers are generally caused by a variety of environmental factors, most of

which are contributed by "hostile" factors such as NSAID use, alcohol abuse, and tobacco use, among many others. Smoking as well as age can increase a person's risk of developing a perforated gastric ulcer. These factors increase the risk because they affect the gastric secretion in the gastric mucosa. Recurrence of a perforation is high in populations over 60 years of age. Additionally, mortality rate due to perforated gastric ulcers is also increased in these populations. [3]

Alcohol abuse is also strongly correlated with recurrent gastric bleeds from a perforated gastric ulcer. According to a study, alcohol abuse was identified in "19.7 % of patients with non-variceal upper gastrointestinal bleeding." Recurrent bleeds were as high as 16.7% in alcohol abusers versus 9.1% in those that did not abuse alcohol. Patients with non-variceal upper gastrointestinal bleeding that also abuse alcohol are at a higher risk of re-bleeding and their risk of mortality is increased. Most patients are followed by a primary care doctor or gastroenterologist and placed on a long-term proton pump inhibitor to prevent further peptic ulcers and gastric bleeds. [4] It is also strongly recommended that patients limit NSAID use, alcohol, and smoking during treatment of Peptic Ulcer Disease.

Usual treatment of Peptic Ulcer Disease and perforated peptic ulcers. If a patient is found to have gastro-intestinal bleeding or discomfort, either a stool

sample is tested or an exploratory endoscopy is performed. The endoscopy is a more invasive method where samples or biopsies of the ulceration may be taken to determine the cause is H.pylori. Once the bacteria is found to be the culprit of the ulcer, antibiotics are administered to eradicate H.pylori from the patient's digestive tract. If the ulcer is bleeding, cauterizing and closing the perforation safely is the most immediate concern.

While there are several causes of peptic ulcer disease, oftentimes a person's risk factors can easily be decreased by making several lifestyle changes early on in life. Quitting smoking or reducing NSAID and alcohol consumption are some of the most profound ways to prevent an H.pylori infection. Smoking in particular has been found to adversely affect the gastric mucosal protective mechanisms, thus predisposing a person

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to peptic ulcer disease. Several clinical studies have observed that smokers are move likely to develop ulcers which subsequently are more difficult to heal if smoking cessation does not occur.

Other than reducing alcohol consumption, NSAID use or smoking cessation, some patients may be placed on a proton pump inhibitor or antibiotics. A proton pump inhibitor may be given to a patient to prevent additional ulcers as well as to prevent an existing ulcer from bleeding again. It works by reducing the amount of stomach acid produced while the ulcer heals. [5]

Diagnosing whether or not a patient has a peptic ulcer can be determined through various different diagnostic tools. Some research suggests that gastric ulcers can be found by using a CT scan. Other diagnoses are found via exploratory endoscopy. The perforation is usually repaired laparoscopically by cauterizing the crater. Duodenorrhaphy or gastrorrhaphy, suturing of either a duodenal ulcer or gastric ulcer, has long since replaced the need for gastric resection which used to be a common treatment in reparation of a perforated peptic ulcer. [6] Due to the seriousness of this illness it is important that the diagnosis is definitively made and repaired in a timely manner.

Patient's symptoms upon admission leading to present diagnosis Some symptoms associated with peptic ulcer disease, or a perforated gastric

ulcer can include, but are not limited to bloody or dark tarry stools, fatigue, vomiting, and weight loss. All of these classic symptoms were presented in the patient at the time of his visit. FK was admitted with severe malaise and fatigue with fainting spells at his home. He was found confused and was previously referred to Fort Hamilton Hospital from the patient's ENT at UC West Chester. The patient was severely underweight and was experiencing some slight abdominal discomfort. Most of his perforated ulcer symptoms were hidden by the fact that he was not eating well due to his mandibular fracture (and possible jaw mass) as well the mass on the base of his tongue. Additionally, the patient's history of alcohol abuse also covered up some of the symptoms he was experiencing such as the weight loss and loss of appetite.

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Following the exploratory endoscopy, FK was found to have a severe gastric bleed. Cultures were taken of the patient's stool as well as inside the stomach lining, showing that he did have an H.pylori infection.

The etiology of peptic ulcer disease shows overwhelming evidence blaming smoking as highly correlating with the disease, as explained throughout this case study. In smokers under the age of 75, H.pylori infection was found to account for about 77% of all gastric perforations. Excessive NSAID use also accounted for nearly one third of gastric perforations from H.pylori infections. [6]

There are some indications that radiation treatment or exposure to radiation treatment can predispose a patient to be more susceptible to gastric ulcers. This is usually due to the disruption of fast growing cells such as the gastric lining and gastric mucosal secretions. FK had approximately 42 radiation treatments in the past due to tongue cancer. The treatment would have been focused on his neck and upper GI area. Unfortunately there are not enough studies to show if radiation has lasting effects to possibly indicate it in being part of the etiology of peptic ulcer disease.

Laboratory findings and interpretation :

Labs WBC

Hemoglobin

Normal values

Patient's levels on 11/12 Interpretation

3.5-10.5 billion cells/L

16.3 billion cells/L

- A high level may indicate smoking, infection, inflammation, or tissue damage

Male: 13.5-17.5 g/dL (135-175 g/L)

8.7 g/dL

- Low levels may indicate bleeding from the digestive tract, poor nutrition, anemia, and low levels of iron, folate, vitamin B12, or vitamin B6

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Labs HCT (Hematocrit)

INR NA K+ CL (Chloride) CO2 (bicarbonate)

BUN

Creatinine Glucose

Normal values

Patient's levels on 11/12 Interpretation

Male: 38.8-50.0 %

26.2%

- Low levels may indicate bleeding, anemia, malnutrition, and nutritional deficiencies of iron, folate, vitamin B12, and vitamin B6 - Each indication has been presented in the patient.

< or = 1.1

1.1

Within normal limits

135 to 145 mEq/L

137 mEq/L

-Within normal limits -Normal electrolyte balance

3.7 to 5.2 mEq/L.

4.3 mEq/L

-Within normal limits -Normal electrolyte balance

98-107 mEq/L

99 mEq/L

-Within normal limits -Normal electrolyte balance.

98-107 mEq/L

29 mEq/L

- Low results can indicated diarrhea. It may also indicate Kidney disease, however FK's renal panels were normal. - FK was experiencing diarrhea

6 to 20 mg/dL

55 mg/dL

- Higher than normal results can indicate: Congestive heart failure, excessive protein levels in the gastrointestinal tract, gastrointestinal bleeding or dehydration. - FK was malnourished which usually also occurs with dehydration - FK also had gastrointestinal bleeding

Male: 0.7 to 1.3 mg/dL

1.0 mg/dL

-Within normal limits - Normal Kidney function

Fasting: 70-100 mg/dL

85 mg/dL

Within normal limits

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