Learning Objectives

LEARNING OBJECTIVES
After completing this case study, the reader should be able to: • List the options for the evaluation and
treatment of a patient with symptoms suggestive of peptic ulcer disease (PUD). • Identify the desired
therapeutic outcomes for patients with PUD. • Identify the factors that guide selection of a Helicobacter
pylori eradication regimen and improve adherence with the regimen. • Compare the efficacy of three-
and four-drug H. pylori treatment regimens and regimens lasting 7, 10 and 14 days or provided in
sequential order. • Create a treatment and monitoring plan for a patient diagnosed with PUD, given
patient-specific information. PATIENT PRESENTATION Chief Complaint “My stomach has been hurting
really badly for the past month or so. It seems to get worse at night.” HPI Justine Ward is a 67-year-old
woman who presents to her primary care physician with complaints of episodic epigastric pain for the
past 6 weeks. Her pain is nonradiating. It is sometimes worse with meals, but sometimes eating helps
nonradiating. It is sometimes worse with meals, but sometimes eating helps improve the pain. She has
been experiencing occasional nausea, bloating, and heartburn. She denies any change in color or
frequency of bowel movements. She does not have a history of PUD or GI bleeding. She mentions that
she has been having frequent headaches for the past month and has been taking naproxen sodium one
to two times daily. PMH CAD with drug-eluting stent placement × 3 months Hypothyroidism × 22 years
Hyperlipidemia × 10 years Lactose intolerance × 47 years Postmenopausal; LMP ~13 years ago FH Her
mother died at the age of 75 from lymphoma. Her father is alive and has a history of glaucoma, prostate
cancer, and AMI at age 70. She has five siblings who are alive. All siblings have a history of hypertension
and hyperlipidemia. SH She is married and has raised three children; she is not employed outside the
home. She has never smoked and drinks one to two glasses of wine most days of the week. Meds Plavix
75 mg PO daily Lisinopril 5 mg PO daily Metoprolol tartrate 25 mg PO twice daily Aspirin 325 mg PO daily
Synthroid 125 mcg PO daily Atorvastatin 80 mg PO daily MVI tablet PO daily Tums 500 mg PO PRN
stomach pain Naproxen sodium 220 mg PO PRN headache (one to two times daily for the past month)
Lactaid one tablet PO PRN dairy product consumption All NKDA NKDA ROS Unremarkable except for
complaints noted above Physical Examination Gen Slightly overweight woman in moderate distress VS
BP 110/72 left arm (seated), P 99, RR 16 reg, T 37.2°C; Wt 68 kg, Ht 5′3″ Skin Warm and dry HEENT
Normocephalic; PERRLA; EOMI Chest CTA CV RRR; S1 and S2 normal; no MRG Abd Soft; mild epigastric
tenderness; (+) BS; no splenomegaly or masses; liver size normal Rect Nontender; stool heme (+) Ext
Normal ROM; no cyanosis, clubbing, or edema Neuro CN II–XII intact; A & O × 3 Labs Assessment
Suspected PUD QUESTIONS Problem Identification 1.a. Identify this patient’s drug therapy problems.
1.b. What information (signs, symptoms, diagnostic tests, and laboratory values) indicates the presence
of PUD? CLINICAL COURSE (PART 1) Justine’s PCP referred her for a nonemergent EGD, which revealed a
5.5-mm superficial ulcer in the superior duodenum. The ulcer base was clear and without evidence of
active bleeding (see Fig. 35-1). In addition, inflammation of the duodenum was detected and biopsied.
FIGURE 35-1: Endoscopy depicting duodenal ulcer with pigmented spots as noted by arrows. (Reprinted
with permission from Kasper DL, Fauci AS, Hauser SL, et al, eds. Harrison’s Principles of Internal
Medicine, 19th ed. New York, McGraw-Hill Education, 2015.) Desired Outcome 2. What are your
treatment goals for treating this patient’s PUD? Therapeutic Alternatives 3.a. Considering the patient’s
presentation, what nonpharmacologic alternatives are available to treat her PUD? 3.b. In the absence of
information about the presence of H. pylori, what pharmacologic alternatives are available to treat
duodenal ulcers? Optimal Plan 4. Based on the patient’s presentation and the current medical
assessment, design a pharmacotherapeutic regimen to treat her duodenal ulcer, anemia, and frequent
headaches. Outcome Evaluation 5. What clinical and laboratory parameters are necessary to evaluate
therapy for 5. What clinical and laboratory parameters are necessary to evaluate therapy for
achievement of the desired therapeutic outcomes and to detect or prevent adverse effects? Patient
Education 6. What information should be provided to the patient to ensure successful therapy, enhance
compliance, and minimize adverse effects? CLINICAL COURSE (PART 2) At the time of the EGD, a biopsy
of the duodenal mucosa was taken and indicated the presence of inflammation and abundant H. pylori–
like organisms. FOLLOW-UP QUESTIONS 1. What is the significance of finding H. pylori in the duodenal
biopsy? 2. Based on this new information, how would you modify your goals 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 ulcer that will accomplish the new treatment goals. 5.
How should the PUD therapy you recommended be monitored for efficacy and adverse effects? 6. What
information should be provided to the patient about her therapy? 7. How should her frequent
headaches now be treated? SELF-STUDY ASSIGNMENTS 1. Describe the advantages and limitations of
both endoscopic and nonendoscopic diagnostic tests to detect H. pylori. 2. After performing a literature
search on H. pylori eradication therapy, compare the efficacy of three-and four-drug regimens. 2. Based
on the literature search on H. pylori eradication therapy, determine whether therapy should be
continued for 7–14 days or provided in a sequential order. 3. Describe the role of pharmacists and nurse
practitioners in treating patients with PUD. CLINICAL PEARL Rapid urease breath tests for diagnosis of H.
pylori should not be used for patients who have received bismuth-containing medications, proton pump
inhibitors, or antimicrobials within the previous 4 weeks due to the increased risk of a false-negative
result.

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