A 62–year–old man complains of epigastric pain that is worse with fasting and better after food. He has found that the pain is relieved by antacids. A tentative diagnosis of duodenal ulcer is confirmed by endoscopy. A 13C-urea breath test (Chapter 12) indicates Helicobacter pylori infection.
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(a) Should the patient be given treatment to eradicate H. pylori?
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Correct answer:
Yes, successful eradication of H. pylori infection usually results in long-term remission of the ulcer.
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(b) If so, what drugs would you prescribe?
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Correct answer:
Inhibition of acid secretion with a proton-pump inhibitor (e.g. omeprazole) in combination with two antibacterials (e.g. clarithromycin and metronidazole or amoxicillin) can eradicate H. pylori in over 90% of patients in 7 days. Reinfection is rare. (See Chapter 12 for connection between H. pylori infection and acid secretion.)Pregnancy should be excluded and an ultrasound scan arranged to determine the location of the device. If the device is not seen on ultrasound scan a plain abdominal X-ray should be requested to exclude an extra-uterine location.
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(c) What treatment might you give to heal the ulcer?
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Correct answer:
Ulcer-healing drugs either reduce acid secretion (proton-pump inhibitors, histamine H2–receptor antagonists) or protect the gastric mucosa (sucralfate, bismuth, misoprostol). Following the successful eradication of H. pylori, it is not usually necessary to use these drugs unless the ulcer is large or complicated by haemorrhage.
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(d) A year later, the patient develops arthritis and requires NSAIDs to control the pain. How could you minimize the risk of the NSAID treatment inducing further ulcers?
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Correct answer:
Gastric or duodenal ulcers occur in 1–5% of patients taking NSAIDs, the incidence increasing greatly in those over 60 years of age. The patient here is 60 years old and has a significant risk of ulceration. This can be minimized by giving an NSAID that is a non-selective COX-inhibitor (e.g. ibuprofen) in combination with either misoprostol or a proton–pump inhibitor. An alternative would be to give a selective COX–2 inhibitor (e.g. celecoxib), but these drugs are associated with an increased incidence of myocardial infarction and stroke (Chapter 32).
