Peptic Ulcer Disease

Peptic Ulcer Disease
PHAR 501
Section:
Instructor:	Dr. Peter Loewen
Email:	peter.loewen@ubc.ca
Office:	PHRM 6624
Office Hours:
Class Schedule:
Classroom:
Important Course Pages
	Syllabus
	Lecture Notes
	Assignments
	Course Discussion

Pre-session Objectives

Before arriving at the session, students should be able to:

describe the pathophysiology of gastric and duodenal ulcers and their typical presenting signs and symptoms.
describe the pharmacology of the drugs used for gastroprotection in PUD.

Session Objectives

Following the session & upon reflection and study, students should be able to:

assess risk level for PUD events in patients on NSAID/ASA therapy.
choose a rational diagnostic approach for detecting H.pylori infection
design a rational primary or secondary prevention plan for PUD risk minimization in patients at high risk for such events.
design a pharmacotherapeutic plan for treatment of acute PUD-associated bleeding and other symptomatic PUD states.

Prereadings

PL's PEPTIC ULCER DISEASE PREVENTION & THERAPY PLOP.
ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. American Journal of Gastroenterology 2017; 112: 212–39.
Najm WI. Peptic ulcer disease. Prim. Care 2011;38:383–94–vii.
Li B-Z, Threapleton DE, Wang J-Y, Xu J-M, Yuan J-Q, Zhang C, et al. Comparative effectiveness and tolerance of treatments for Helicobacter pylori: systematic review and network meta-analysis. BMJ 2015 Aug 19;351:h4052.
Review the cases below

Other Key Resources

Brooks J, Warburton R, Beales ILP. Prevention of upper gastrointestinal haemorrhage: current controversies and clinical guidance. Ther Adv Chronic Dis. 2013 Sep;4(5):206–22.
Sachar, H., et al. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. JAMA Internal Medicine, 2014;174:1755–1762.
Malfertheiner P, Megraud F, O'Morain CA, Atherton J, Axon ATR, Bazzoli F, et al. Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report. Gut 2012;61:646–64.
McColl KEL. Helicobacter pylori Infection. New England Journal of Medicine 2010;362:1597–604.
Katz MH. Failing the acid test: benefits of proton pump inhibitors may not justify the risks for many users. Arch. Intern. Med. 2010;170:747–8.
Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann. Intern. Med. 2010;152:101–13.
Lanza FL, Chan FKL, Quigley EMM. Guidelines for Prevention of NSAID-Related Ulcer Complications. Am J Gastroenterology 2009;104:728–38.
Bhatt DL, Scheiman J, Abraham NS, Antman EM, Chan FKL, Furberg CD, et al. ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use. Journal of the American College of Cardiology 2008;52:1502–17.
Gralnek IM, Barkun AN, Bardou M. Management of acute bleeding from a peptic ulcer. New England Journal of Medicine 2008;359:928–37.
Chey WD, Wong BCY, Practice Parameters Committee of the American College of Gastroenterology. American College of Gastroenterology Guideline on the Management of Helicobacter pylori Infection. Am J Gastroenterology 2007;102:1808–25.
Richard Hunt MD, Carlo Fallone MD, Sander Veldhuyzan van Zanten MD, Phil Sherman MD. Canadian Helicobacter Study Group Consensus Conference: Update on the management of Helicobacter pylori–an evidence-based evaluation of six topics relevant to clinical outcomes in patients evaluated for H pylori infection. Can. J. Gastroenterol. 2004;18:547.

Session plan

Student-led discussion of the approach and plan for each of the following cases:

Case 1

ID/CC/HPI: FF is a 78 y/o female who presents to your clinic today with complaints of abdominal pain. Pain worse upon awakening, radiating to back. Relieved by meals, but recurs within 2-4 hours. Partially relieved by ranitidine PRN and Tums®.

PMH: ACS 7 years ago, HTN, CHF (EF <35%), insomnia.

MEDS: OTC ranitidine 75 mg po bid PRN x 3 months. Tums ii qid PRN. rampril 5, bisoprolol 10, hctz 25, amlodipine 5, zopiclone 3.75 hs PRN. No aspirin (“upsets her stomach”).

OE/INVESTIGATIONS: Vitals all normal. Abdominal exam unremarkable.

What would be your approach to managing FF’s abdominal pain?

Case 2

ID/CC/HPI: PK is a 68 y/o female who presents via ambulance to your emergency department today with complaints of severe abdominal pain and dizziness. She vomited brown stuff just prior to calling 911 and had black tarry stools earlier the same day.

PMH: OA L hip & knees, COPD, current smoker.

MEDS: diclofenac 75 mg PO bid x 3 years, rainitidine 150 bid, intermittent prednisone 50mg/d x 2 week courses (2-3/year) for AECOPD (last 1 month ago), Advair® ii bid, tiotroprium QD.

OE/INVESTIGATIONS: BP 125/80 supine, 100/80 sitting up. HR 95 supine, 130 sitting up. Other vitals normal. Oriented x3. JVP not visible. Postural dizziness. Melena stool, no FRBPR, FOB+, no further emesis witnessed. HgB 85, MCV elevated, plt 50.

Presumptive diagnosis: Acute upper GI bleed.

What would be your assessment of and pharmacotherapeutic approach to managing PK’s condition?

Case 3

ID/CC/HPI: RG is a 45 y/o male who presents to your clinic today with complaints of abdominal discomfort. The pain waxes and wanes throughout the day. Partially relieved by meals, but recurs soon thereafter. Temporarily relieved by Zantac® . Doesn’t feel any “burning”.

PMH: none.

MEDS: prn OTC Zantac®

OE/INVESTIGATIONS: Vitals all normal. Abdominal exam unremarkable.

What would be your approach to managing RG’s abdominal pain, presuming you suspect that this isn’t GERD?

Case 4

ID/CC/HPI: JC is a 60 y/o female diagnosed several months ago with osteoarthritis, mainly affecting her hands and knees. She started with glucosamine/chondroitin, progressed to acetaminophen 4g/d, and today presents with “unbearable” stiffness and pain impeding her ability to work. She has tried a few doses of OTC naproxen and found that it provided impressive relief, but was reluctant to take it regularly without talking to you first.

PMH: OA, hysterectomy 20 years ago.

MEDS: glucosamine/chondroitin bid, acetaminophen 1000 mg qid.

OE/INVESTIGATIONS: Nothing remarkable.

What would be your approach to managing JC’s OA?

What if JC’s PMH included ischemic stroke 2 years ago and ASA 325 mg/d x 2 years?

Case 5

ID/CC/HPI: PR is an 81 y/o male who presents to your clinic today for a followup visit 1 week after he was diagnosed with a bleeding peptic ulcer (coffee ground emesis, moderate dyspepsia, no significant drop in HgB) in the context of aspirin therapy. At that time he was started on PPI (planned 4 week course) and the clinic team (you were on vacation) switched his aspirin to clopidogrel. No other investigations were done at that time.

PMH: MI 2 years ago, PCI no stent. Ischemic stroke 6 years ago. HTN. DM2.

MEDS: clopidogrel 75, rabeprazole 20, metoprolol 100 bid, metformin 1000 bid, HCTZ 25.

OE/INVESTIGATIONS: No further coffee ground emesis, vitals normal, no further dyspeptic complaints.

What would be your approach to minimizing PR’s risk of future PUD events?