1. Peptic Ulcer Disease
A Case Study Approach

2. Introduction: FK: Admission: 65 year old male Weight: 116-123 lbs
UBW: 138 lbs per patient.
Hx of Tobacco use, ETOH abuse, COPD, cirrhosis of the liver, anemia and cancer of the tongue
Admission:
Originally referred to Fort Hamilton from University of Cincinnati for a mandibular fracture.
Was admitted to ICU due to a severe gastric bleed from a perforated gastric ulcer.

3. Social History: Single Lives along in a 2 story walk up apartment
Moderate assistance from family
Takes care of himself 50-75% of the time.
Home meals
Uses crockpot or eats mostly canned foods and soups.
Alcohol use
24 cans of beer per week, with occasional bourbon
Tobacco use
1.5 packs per day, reportedly quit 8/22/15

4. Explanation of the Disease Process:

5. Explanation of the Disease Process:
Most common cause of Peptic Ulcer Disease: H.Pylori
Usually transmitted via fecal-oral route
Usually found in people with poor socio-economic background
Factors that influence an H.Pylori infection:
NSAID use can cause an H.pylori infection due to inhibiting Prostaglandin synthesis (maintains homeostatic function in the gut by regulating acid secretion.)
Inflammation and acidic environment allows H.pylori to flourish.
Disruption of “protective factors” such as prostaglandins, mucus, bicarbonate and blood flow in the mucosa
Usually damaged by “hostile factors”
smoking, alcohol abuse, radiation treatments, and regular NSAID use

6. Explanation of the Disease Process:
How a perforation occurs:
Under normal conditions the stomach can withstand the corrosiveness of gastric acid.
A “hostile factor” is introduced.
“Protective factors” are disrupted.
Gastric acid begins to break down the lining of the stomach.
Tissue becomes inflamed and an ulcer occurs (usually in the first layer of the stomach lining.)
Gastric acid continues to erode the lining, causing further damage and potentially a perforation.
A perforation can cause internal bleeding.

7. Past and Current Admissions
Past visits to Fort Hamilton:
Cellulitis in 2012
Pain in right ankle from a fall in 2014
During this visit he was diagnosed with peripheral vascular disease.
Current and recurrent admissions:
11/11/15 Weakness and malaise due to a perforated gastric ulcer
2 repairs during admission
Mass found on tongue, referred patient to his ENT for further testing
Patient had a broken jaw
Was severely malnourished.
11/20/15 readmission, recurrent gastric bleed.
Ulcer was repaired a 3rd time.

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

9. Recurrence and mortality
Recurrence of a gastric bleed from peptic ulcer disease
Populations over 60 years of age
Mortality is also increased in this population.
Alcohol abuse increases recurrence almost 2 fold.
Mortality is also increased in this population regardless of age.
Recurrent bleeds were as high as 16.7% in alcohol abusers versus 9.1% in those that did not abuse alcohol.

10. Usual Treatment of Peptic Disease:
Prior to perforation:
Proton Pump Inhibitors
Antibiotics
Limiting use of NSAIDs, cessation of smoking and alcohol use.
For a perforated peptic ulcer:
Cauterizing the wound and closing the perforation via hemoclips
Closing the wound is the most immediate concern
Gastrorrhaphy: suturing of the gastric ulcer
Replaced the need to resection the stomach entirely
Vagotomy
May be considered for severe, recurrent bleeds
Where sections of the vagus nerve are cut to decrease gastric acid secretions
Usually performed in conjunction with an antrectomy
A vagotomy and antrectomy were considered, but due to the patient’s surgical risk being increased due to his cirrhosis and high blood pressure these procedures were declined.
antrectomy= removal of the distal third of the stomach.

11. Patient’s Symptoms: Bloody or dark tarry stools Fatigue Vomiting
Weight loss
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.

12. Pertinent Laboratory Findings:
WBC:
Normal: billion cells/L
Patient’s values:16.3 billion cells/L
Indicates infection, inflammation or tissue damage
Hgb:
Normal: Male: g/dL
Patient’s values: 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
Hematocrit:
Normal: Male: %
Patient’s values: 26.2%
- Low levels may indicate bleeding, anemia, malnutrition, and nutritional deficiencies of iron, folate, vitamin B12, and vitamin B6

13. Pertinent Medication:
Pantoprazole
May be used to treat GERD
Also a proton pump inhibitor, can help treat peptic ulcer disease
amoxicillin-clavulanate (AUGMENTIN)
May be used to treat infections
thiamine, B-1 and folic acid
Supplemented for those at risk for deficiencies, often in the elderly or ETOH abuse patients.

14. Treatment: First visit: Second visit:
An exploratory colonoscopy found pus and blood in his colon from the infection.
An EGD found the perforation in his stomach.
Laproscopically: A gold probe was used to cauterize the perforation
Hemoclips were placed on both sides to keep the wound closed.
This was performed twice
Patient was placed on proton pump inhibitors
Second visit:
The wound was closed using hemoclips/endoclips only

15. Hemoclip/Endoclip treatment:

16. MNT: Risk factors for malnutrition: Found to be Severely malnourished
15.5% weight loss within one month
Consuming less than 50% for one month
Found to be Severely malnourished
Needs based on patient’s admission weight of 52.9 kg (116 lbs 7 oz):
Tube feed was suggested but declined by the Patient‘s Gastroenterologist.
Patient was given Boost Plus TID to increase calories and protein.
Patient‘s diet varied from Regular to Heart Healthy to Soft Dysphagia.
Patient refused swallow test from SLP.
Calories per kg 30-35
Protein grams per kg
Fluid needs if on tube feed
calories
68-79 grams
Not applicable

17. Diet analysis:

18. Prognosis:
FK’s prognosis was good upon his second discharge. He was admitted to an extended care facility where he would be monitored for improvement.
Patient will not have access to alcohol
Unfortunately FK is in a population at risk for recurrent bleeds, but will be monitored closely for blood in stool.

19. Summary & Conclusion What I learned:
The first line of defense against Peptic Ulcer Disease is a proton pump inhibitor like Protonix.
Surgical interventions like a vagotomy can be performed in severe cases.
Incidence of H.pylori is directly correlated with age and chemical abuse
What I would have done differently:
Once a tube feed was declined, TPN recommendations during admission could have been made.