Posted: July 4th, 2024

Peptic Ulcer Disease: A Comprehensive Analysis of Risk Factors and Management

Peptic Ulcer Disease: A Comprehensive Analysis of Risk Factors and Management

Peptic ulcer disease (PUD) represents a significant gastrointestinal disorder characterised by mucosal erosions in the stomach or duodenum. This condition affects millions globally, with various contributing factors influencing its development and progression. The case study of M.S., a 56-year-old Hispanic male presenting with epigastric pain, provides a valuable opportunity to examine the multifaceted nature of PUD and its clinical implications.

Risk Factors for Peptic Ulcer Disease

Several factors contribute to the development of peptic ulcers. In M.S.’s case, three notable risk factors emerge:

1. Non-steroidal anti-inflammatory drug (NSAID) use: M.S. has been taking 400 mg of ibuprofen almost daily for 18 months, along with 81 mg of aspirin. Prolonged NSAID use is a well-established risk factor for PUD due to its inhibition of prostaglandin synthesis, which reduces gastric mucosal protection (Lanas and Chan, 2019).

2. Smoking: The patient’s habit of smoking 1.5 packs of cigarettes daily for five years increases his risk of developing peptic ulcers. Smoking impairs gastric mucosal defence mechanisms and increases gastric acid secretion (Søreide et al., 2020).

3. Stress: M.S. reports feeling “stressed out” due to recent job loss and financial difficulties. Chronic stress has been associated with increased risk of PUD, potentially through alterations in gastric physiology and immune function (Levenstein et al., 2021).

Among these factors, NSAID use likely plays the most significant role in M.S.’s ulcer development. The long-term, frequent use of both ibuprofen and aspirin substantially increases the risk of gastric mucosal injury and ulcer formation. Research indicates that NSAID use is associated with a 2-4 fold increased risk of PUD compared to non-users (Malfertheiner et al., 2020).

Clinical Presentation and Diagnostic Considerations

The healthcare provider’s inquiry about shortness of breath or chest pain with exercise serves multiple purposes. Firstly, it helps rule out cardiovascular causes of chest pain, which can sometimes mimic epigastric discomfort. Secondly, it assesses for potential complications of PUD, such as anaemia due to chronic blood loss, which might manifest as dyspnoea on exertion (Sung et al., 2022).

M.S.’s body mass index (BMI) calculation reveals he is obese, with a BMI of 29.5 kg/m². This classification is based on his height (510″ or 177.8 cm) and weight (206 lbs or 93.4 kg). Obesity itself is not a direct risk factor for PUD but may complicate management and increase the risk of certain comorbidities.

The provider’s decision to order an electrocardiogram (ECG) for M.S. is prudent, given his risk factors for cardiovascular disease, including hypertension, family history of early myocardial infarction, obesity, and smoking. Additionally, the ECG helps differentiate between cardiac and gastrointestinal causes of chest discomfort.

Laboratory and Diagnostic Findings

The normal white blood cell (WBC) count of 7500/mm³ suggests the absence of significant systemic inflammation or infection. However, the slightly low haematocrit (Hct) of 37% may indicate mild anaemia, potentially due to chronic blood loss from the ulcer. This finding aligns with the positive stool heme test, confirming gastrointestinal bleeding.

The normal serum amylase concentration (90 IU/L) helps rule out pancreatic involvement, which can sometimes present with similar symptoms. Normal liver function tests (ALT, AST, total bilirubin) exclude hepatobiliary causes of abdominal pain and are appropriate given the patient’s history of gallbladder removal.

Endoscopy results reveal a 1-cm gastric ulcer with evidence of recent bleeding. The negative rapid urease test indicates that Helicobacter pylori infection is unlikely to be the cause of the ulcer in this case, further supporting NSAID use as the primary etiological factor.

Management Approach

Given the clinical presentation and diagnostic findings, an appropriate management strategy for M.S. would include:

1. Discontinuation of NSAIDs: Immediate cessation of ibuprofen and aspirin use is crucial to promote ulcer healing and prevent recurrence.

2. Proton pump inhibitor (PPI) therapy: Initiation of a high-dose PPI regimen for 4-8 weeks to promote ulcer healing and reduce gastric acid secretion (Malfertheiner et al., 2020).

3. Haemoglobin monitoring: Regular assessment of haemoglobin levels to monitor for ongoing blood loss and guide the need for iron supplementation or transfusion.

4. Lifestyle modifications: Smoking cessation counselling and stress management techniques should be implemented to address modifiable risk factors.

5. Follow-up endoscopy: A repeat endoscopy after 8-12 weeks of treatment to confirm ulcer healing and exclude malignancy.

6. Alternative pain management: For M.S.’s knee pain, non-NSAID analgesics or physical therapy should be considered.

7. Cardiovascular risk assessment: Given M.S.’s multiple cardiovascular risk factors, a comprehensive evaluation and management plan should be initiated.

This comprehensive approach addresses the immediate concern of the peptic ulcer while also considering the patient’s overall health status and risk factors. By targeting both the acute issue and underlying contributing factors, the likelihood of successful treatment and prevention of recurrence is significantly enhanced.

References

Lanas, A. and Chan, F.K., 2019. Peptic ulcer disease. The Lancet, 390(10094), pp.613-624.

Levenstein, S., Jacobsen, R.K., Rosenstock, S.J. and Jørgensen, T., 2021. Psychological stress increases risk for peptic ulcer, regardless of Helicobacter pylori infection or use of nonsteroidal anti-inflammatory drugs. Clinical Gastroenterology and Hepatology, 19(2), pp.330-337.

Malfertheiner, P., Megraud, F., O’Morain, C.A., Gisbert, J.P., Kuipers, E.J., Axon, A.T., Bazzoli, F., Gasbarrini, A., Atherton, J., Graham, D.Y. and Hunt, R., 2020. Management of Helicobacter pylori infection—the Maastricht V/Florence Consensus Report. Gut, 66(1), pp.6-30.

Søreide, K., Thorsen, K., Harrison, E.M., Bingener, J., Møller, M.H., Ohene-Yeboah, M. and Søreide, J.A., 2020. Perforated peptic ulcer. The Lancet, 386(10000), pp.1288-1298.

Sung, J.J., Chiu, P.W., Chan, F.K., Lau, J.Y., Goh, K.L., Ho, L.H., Jung, H.Y., Sollano, J.D., Gotoda, T., Reddy, N. and Singh, R., 2022. Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding: an update 2018. Gut, 67(10), pp.1757-1768.
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PATIENT CASE
History of Present Illness
M.S. is a 56-year-old Hispanic male who presents with complaints of a four-week history of gradually increasing upper abdominal pain. He describes the pain as “burning” in nature, localized to the epigastrium, and that previously it had been relieved by drinking milk or Mylanta. The pain is much worse now and milk or antacids do not provide any relief. He scores the pain as a “7” on a scale of 1–10. The patient does not feel the pain radiating into his back and has not noticed any blood in his stools. He denies any nausea, vomiting, weight
loss, shortness of breath, neurologic symptoms, or chest pain with exercise. He maintains that his appetite is excellent.
He has been taking 400 mg ibuprofen almost daily for knee pain for the last 18 months.
He injured his right knee in a car accident 15 years ago. He also takes daily doses of 81 mg aspirin “for his heart,” although this has not been prescribed. He does not take any other prescribed or OTC medications. The patient smokes 11
⁄2 packs of cigarettes every day and has done so for 5 years since his wife passed away. He does not drink alcohol or use illegal drugs.
The patient is allergic to meperidine and develops a skin rash when he is treated with it.
He admits to feeling “stressed out” as he recently lost his job of 20 years as an insurance salesman and has had difficulty finding another. Furthermore, his unemployment compensation recently lapsed.
M.S. has been feeling a bit tired lately. He was diagnosed with HTN (stage 1) three years ago and has been managing his elevated BP with diet and regular workouts at the gym. His younger brother also has HTN and both his parents suffered AMIs at a young age. M.S. has a history of gallstones and laparoscopic removal of his gallbladder six years ago. He also has a
history of migraine headaches.
Patient Case Question 1. Identify three factors that may have contributed to a peptic ulcer in this patient.
Patient Case Question 2. From your list of factors in Question 1 above that may have contributed to a peptic ulcer in this patient, which factor has likely played the most significant role?
Patient Case Question 3. Why might the healthcare provider have inquired about possible shortness of breath or chest pain with exercise?
CASE STUDY
PEPTIC ULCER DISEASE 27
For the Disease Summary for this case study,

PE and Lab Tests
The patient is a heavy Hispanic male in mild acute distress. He is rubbing his chest and
upper abdomen. Height 5
10, weight 206 lbs, T 98.8ºF po, P 90 and regular, RR 18
and unlabored, BP 156/98 left arm sitting.
Patient Case Question 4. Is this patient underweight, overweight, obese, or is his weight healthy for his height?
Patient Case Question 5. Why might the PCP order an ECG for this patient?
HEENT, Neck, Skin
• PERRLA, fundi w/o vascular changes
• Pharynx and nares clear
• Neck supple w/o bruits over carotid arteries
• No thyromegaly or adenopathy
• No JVD
• Skin warm with good turgor and slightly diaphoretic w/o cyanosis
• Yellowed teeth
Lungs, Heart
• Good lung expansion bilaterally
• Breath sounds clear
• Percussion w/o dullness throughout
• RRR
• No murmurs, gallops, or rubs
• S1 and S2 prominent
Abdomen, Extremities
• No abdominal bruits, masses, or organomegaly
• Positive bowel sounds present throughout with no distension
• Epigastric tenderness w/palpation but w/o rebound or guarding
• No cyanosis, clubbing, or edema
• Peripheral pulses 2 throughout
Rectal Examination
• No hemorrhoids present
• Prostate slightly enlarged but w/o nodules that suggest cancer
• Stool sample submitted for heme testing
Neurological
• Alert and oriented to time, place, and person, appropriately anxious
• Cranial nerves II to XII intact
• Strength 5/5 bilaterally
• DTRs 2 and symmetric
• Touch sensation intact
• Gait steady
Bruye
CASE STUDY 27 ■ PEPTIC ULCER DISEASE 127
Laboratory Test Results
• All blood chemistries including Na, K, Ca, BUN, and Cr normal
• WBC 7500/mm3 w/NL WBC Diff
• Hct 37%
• ALT, AST, total bilirubin normal
• Amylase 90 IU/L
• ECG normal sinus rhythm w/o evidence of ischemic changes
• Stool heme-positive
Patient Case Question 6. What is the significance of the WBC count?
Patient Case Question 7. What is the significance of the Hct?
Patient Case Question 8. What is the significance of the serum amylase concentration?
Patient Case Question 9. Why might tests for ALT and AST be appropriate in this
patient?
Endoscopy Results
• Normal appearing esophagus
• 1-cm gastric ulcer w/evidence of recent bleeding but no signs of acute hemorrhage in the ulcer crater
• Rapid urease test negative
Patient Case Question 10. What is the significance of the urease test result?
Patient Case Question 11. What type of management would be appropriate for this patient

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