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Peptic ulcer disease presents as an upper abdominal pain. It tends to follow the consumption of a meal and the patient will experience dyspepsia. The patient may also be able to point to an exact location of their pain. Epigastric tenderness, nausea and vomiting, feeling full quickly, weight loss, diarrhea, anemia symptoms, and gastrointestinal bleeding. When collecting the history, if the patient  explains that they have had a past Helicobacter pylori infection, use NSAIDs regularly, smoke, or have a personal or family history of the disease (Lynch, 2019).

Tests to be ordered consist of Helicobacter pylori urea breath test or stool antigen test. A positive result would indicate the presence of that bacteria. Antibiotics, bismuth products and PPIs can interfere with the test results. An upper endoscopy can be used to diagnose the presence of a peptic ulcer. If an ulcer is found, it should be tested for Helicobacter pylori . The endoscopy should be performed again to rule out a gastric ulcer or malignancy.  A CBC should be ordered if the patient is experiencing anemia symptoms (microcytic anemia). The blood test does not diagnose the ulcer, but provides the level of urgency in which the patient should be treated. Lastly, a fasting serum gastrin level can be ordered for patients who have an ulcer and diarrhea, or multiple duodenal ulcers (Lynch, 2019).

For a bleeding ulcer, an endoscopy and blood transfusion should be ordered immediately, including a PPI prescription as well. Embolization of the ulcer via interventional radiology to stop the bleeding if it cannot be stopped via endoscopy. If there is no bleeding and the patient is Helicobacter pylori  negative they can begin a PPI, such as omeprazole, lansoprazole, or esomeprazole. H2 antagonists such as ranitidine, famotidine, or nizatidine are not as effective as PPIs but still provide healing in the majority of patients when using this type of medication. If the patient is not bleeding, but received a positive Helicobacter pylori result then they should discontinue NSAIDs or aspirin if they are currently taking it. PPI and two antibiotics, such as clarithromycin and amoxicillin (triple therapy). For a patient with macrolide exposure, a PPI, bismuth, tetracycline, and nitroimidazole is recommended (quadruple therapy). The use of antibiotics may cause diarrhea, increase risk of other infections and interferes with some birth control options. It is important to reassess for Helicobacter pylori after treatment has concluded (Lynch, 2019).

The patient should be educated on the risk of NSAIDs and aspirin regular use, especially if the patient is taking corticosteroids and is older than sixty years of age.  Avoid excessive alcohol intake should also be avoided. Patients should also understand the risks of perforation of the stomach, gastric antrum or duodenum from the ulcer. This could result in peritonitis or shock (Lynch, 2019).

If I suspected a patient had peptic ulcer disease based on their history, symptoms, physical exam and test results, I would then refer them to a gastrointestinal specialist to manage the ulcer more effectively, especially if the patient is positive for Helicobacter pylori. The antibiotic therapy and combinations of medications should be monitored by someone who prescribes for this disease regularly and could pick up on the nuances of patient symptoms as they progress.

Lynch, K. L. (2019, May 16). Peptic Ulcer Disease. Retrieved from https://online.epocrates.com/diseases/80/Peptic-ulcer-disease.