JSS Academy of Higher Education & Research, Mysuru

(Deemed to be University – Accredited ‘A+’ Grade by NAAC)

JSS College of Pharmacy, Ooty

(An ISO 9001:2015 Certified Institution)

CASE TITLE – HELICOBACTER PYLORI INDUCED ULCER

1. INTRODUCTION
 Peptic ulcers are open sores that develop on the inside lining of your stomach and the
upper portion of the small intestine. The most common symptom of a peptic ulcer is
stomach pain.
Peptic ulcers include:
 Gastric ulcers that occur on the inside of the stomach.
 Duodenal ulcers that occur on the inside of the upper portion of your small intestine
(duodenum).

2. EPIDEMIOLOGY
 Peptic ulcer disease (PUD) is a global problem with a lifetime risk of development
ranging from 5% to 10%.
  Overall, there is a decrease in the incidence of PUD worldwide due to improved
hygienic and sanitary conditions combined with effective treatment and judicious use
of NSAIDs.
  Duodenal ulcers are four times more common than gastric ulcers. Also, duodenal
ulcers are more common in men than in the woman.
 H pylori infection accounts for 80%-90% of duodenal ulcers and 10%-20% of gastric
ulcers.

 A study revealed that the point prevalence of active peptic ulcer was 3.4% and the
lifetime prevalence was 8.8%. Helicobacter pylori was present in 84.6% subjects with
peptic ulcer.

3. ETIOLOGY
 The most common causes of peptic ulcers are infection with the bacterium
Helicobacter pylori (H. pylori) and long-term use of nonsteroidal anti-inflammatory
drugs (NSAIDs) such as ibuprofen, naproxen sodium.
 Stress.

4. PATHOPHYSIOLOGY
 The peptic ulcer disease (PUD) mechanism results from an imbalance between gastric
mucosal protective and destructive factors.
 With peptic ulcers, there is usually a defect in the mucosa that extends to the
muscularis mucosa. Once the protective superficial mucosal layer is damaged, the
inner layers are susceptible to acidity. Further, the ability of the mucosal cells to
secrete bicarbonate is compromised.
 H. pylori is known to colonize the gastric mucosa and causes inflammation. The H.
pylori also impairs the secretion of bicarbonate, promoting the development of
acidity.
5. RISK FACTORS
 In addition, having high risks related to taking NSAIDs. 
 Smoking may increase the risk of peptic ulcers in people who are infected with H.
pylori.
 Drink alcohol. 
 Have untreated stress.
 Eat spicy foods.

6. CLINICAL PRESENTATION
 Epigastric pain.
 Dyspepsia (e.g., distension, bloating)
 Heartburn.
 Hematemesis.
 Melaena.
 Chest discomfort.
 Epigastric tenderness.
 Symptoms of anemia.

7. DIAGNOSIS
 Urea breath test
 Serological tests
 Stool test
 Esophagogastroduodenoscopy: permits direct visualization of superficial erosions
and sites of active bleeding.

8. COMPLICATIONS
 Internal bleeding. 
 A hole (perforation) in the stomach wall. 
 Obstruction. 
 Gastric cancer. 

9. MANAGEMENT
NON-PHARMACOLOGICAL:
 Control stress-Stress may worsen the signs and symptoms of a peptic ulcer. Some
stress is unavoidable, but they can learn to cope with stress with exercise, spending
time with friends or writing in a journal.
 Don't smoke-Smoking may interfere with the protective lining of the stomach, making
the stomach more susceptible to the development of an ulcer. Smoking also increases
stomach acid.
 Limit or avoid alcohol-Excessive use of alcohol can irritate and erode the mucous
lining in your stomach and intestines, causing inflammation and bleeding.
 It is important to avoid foods and flavourings that induce the stomach to produce
acids, such as chili powder, garlic, black pepper, and caffeine. 
 Drinking plenty of water.

PHARMACOLOGICAL:
 CASE DISCUSSION – HELICOBACTER PYLORI INDUCED ULCER
1. SUBJECTIVE
 Patient Name: Mr. XYZ
 Age: 27 Year
 Gender: Male
 Chief Complaints: C/O complains with epigastric pain for 2 days, black tarry stool.
He was in usual state of health 5 days back when he started having epigastric pain.
 Past Medical History: reveals the absence of any disease in the patient.
 Past Medication History: NIL
 Social History: NIL
 Allergies: NIL

2. OBJECTIVE
 CT scan performed and it showed antral thickening. GP was consulted who did EGD
which showed oozing of blood with some ulcerated antral mass.
 Biopsy of the antral mass was done and the patient was discharged on pain
medications. But the patient came back again the next day with worsening abdominal
pain. He was also complaining of black stool during this presentation.
 Haemoglobin was stable around 16 mg/dl.
 Biopsy of the antral mass showed a typical presentation of mucosal ulceration with
associated acute inflammatory exudate.
 Helicobacter immunoperoxidase stain is positive for organisms.

3. ASSESSMENT
 HELICOBACTER PYLORI INDUCED ULCER

4. TREATMENT GIVEN
 Patient was discharged on quadruple therapy including Pepto-Bismol, metronidazole,
clarithromycin and pantoprazole for 1 weeks with outpatient follow up.

5. PHARMACISTS INTERVENTION
 As first line therapy to eradicate the Helicobacter pylori is the standard triple
therapy if the therapy fails then we can choose the quadrupole therapy.

6. PHARMACEUTICAL CARE PLAN

DRUG DOSE FREQUENCY

CAP.AMOXICILLIN 1 GM BID
TAB.CLARITHROMYCIN 500 MG BID
CAP.OMEPRAZOLE 40 MG BID
TAB.PARACETAMOL 500 MG TID
 Standard triple drug regimen should be continued for 14 day and should follow-up
once after 14 days.

7. PATIENT COUNSELLING
 REGARDING DISEASE:
 The patient was counselled about the diseases condition, etiology and complication of
the diseases.
 The patient was counselled regarding the sign and symptoms of the condition.
 Peptic ulcer is manageable disease, if not treated may lead towards complications.
 REGARDING DRUG:
 CAP.OMEPRAZOLE should be taken 30min prior to the meal.
 Antibiotic course should be completed.
 Do not stop using the medicine without consulting doctor.
 The missed dose should be taken as soon as remembered. Skip the next dose if it is
near the next scheduled dose.
 REGARDING LIFE-STYLE:
 Control stress-Stress may worsen the signs and symptoms of a peptic ulcer.
 Smoking cessation.
 Limit or avoid alcohol.
 Avoid foods and flavourings that induce the stomach to produce acids, such as chili
powder, garlic, black pepper, and caffeine. 
 The diet should contain plenty of foods that provide plenty of vitamin A and fiber that
dissolves easily. 
 Drinking plenty of water.
 Should stay hygiene.
 Avoid late night meal and sleeping immediately after meal.

8. MONITORING PARAMETERS
 Amoxicillin – LFT, RFT.
 Clarithromycin - BUN, creatinine.
 Omeprazole - C. difficile associated diarrhoea and hypo magnesia when patients are
on omeprazole long term.

9. REFERENCES
1. Fashner J, Gitu A. Diagnosis and Treatment of Peptic Ulcer Disease and <i>H.
pylori</i> Infection [Internet]. Aafp.org. 2021 [cited 1 September 2021]. Available
from: https://www.aafp.org/afp/2015/0215/p236.html
2. Peptic Ulcer Disease - American College of Gastroenterology [Internet]. American
College of Gastroenterology. 2021 [cited 1 September 2021]. Available from:
https://gi.org/topics/peptic-ulcer-disease/
3. Malik T, Gnanapandithan K, Singh K. Peptic Ulcer Disease [Internet].
Ncbi.nlm.nih.gov. 2021 [cited 1 September 2021]. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK534792/
4. Peptic Ulcer Disease | Calgary Guide [Internet]. The Calgary Guide to
Understanding Disease. 2021 [cited 1 September 2021]. Available from:
https://calgaryguide.ucalgary.ca/peptic-ulcer-disease/
5. Peptic ulcer - Symptoms and causes [Internet]. Mayo Clinic. 2021 [cited 1
September 2021]. Available from: https://www.mayoclinic.org/diseases-
conditions/peptic-ulcer/symptoms-causes/syc-20354223
6. Peptic Ulcer Disease: Background, Anatomy, Pathophysiology [Internet].
Emedicine.medscape.com. 2021 [cited 1 September 2021]. Available from:
https://emedicine.medscape.com/article/181753-overview
7. SINGH V, TRIKHA B, NAIN C, SINGH K, VAIPHEI K. Epidemiology of
Helicobacter pylori and peptic ulcer in India. Journal of Gastroenterology and
Hepatology. 2002;17(6):659-665.