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PATIENT PRESENTATION

Chief Complaint

“My indigestion is so much worse, but I’m glad we have an answer now.”

History of Present Illness

38-year-old woman with a several year history of dyspepsia that worsened over the past few months. Because she also developed iron deficiency anemia, she underwent upper endoscopy which revealed a small peripyloric non-bleeding ulcer. A rapid urease test was positive for H. pylori. Current medications include prn ibuprofen for headache, a hormonal contraceptive and OTC antacids. She smokes ½ PPD cigarettes and drinks “on weekends”.

Student Work-Up

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Missing Information?

Evaluate:

Patient Database

Drug Therapy Problems

Care Plan (by Problem)

TARGETED QUESTIONS

  1. What signs and symptoms of PUD does this patient have?

    Hint: See Clinical Presentation and Diagnosis in PPP

  2. What treatment regimen would you select for this patient’s H. pylori infection? Why did you choose that regimen over other alternatives?

    Hint: See Treatment in PPP and reference 1 below

  3. What is the relationship between use of NSAID medications and the development of PUD?

    Hint: See Treatment in PPP and reference 2 below

  4. What risks and adverse effect of therapy would you discuss with the patient?

    Hint: See Treatment in PPP

  5. What is the best approach to treat her iron deficiency anemia?

    Hint: See chapter 69 in PPP

FOLLOW-UP

The patient returns 6 weeks later. She completed her course of therapy, and her H. pylori stool antigen test is negative indicating successful eradication. She is wondering if she should continue to take the PPI daily so “this doesn’t happen again”. What would you advise?

Hint: See Treatment in PPP

CASE SUMMARY

Global Perspective

Peptic ulcer disease is often associated with Helicobacter pylori infection, and successful long-term treatment entails administration of antimicrobial and acid-suppressing drugs to eradicate the infection. Successful eradication is more likely to occur when the organism is susceptible to the administered antimicrobials, with eradication rates of 80-90% in clinical trials. There are wide variances in H. pylori antimicrobial susceptibility in different parts of the world, so the therapeutic approach may differ from region to region. Resistance rates to clarithromycin and metronidazole have been assessed in most studies. In North America, resistance to clarithromycin is 17-32%, with high rates of metronidazole resistance, 44%. In Southeast Asia, clarithromycin resistance varies, 2-43% but metronidazole resistance is high, 30-100%. In Western Europe, a multinational registry from over 30,000 patients showed resistance rates of 23% for clarithromycin, 32% for metronidazole and dual resistance in 13%. Clinicians should be aware of national and regional H. pylori resistance rates and prescribe eradication regimens with the highest likelihood of ...

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