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Peptic Ulcer Disease: A Case Study Review

Cassandre Miller

Introduction:

FK is a 64 year old Caucasian male who is  5'8", weighing between 116 lbs and 123 lbs. He was originally referred to Fort Hamilton Hospital from University of Cincinnati Hospital for jaw pain related to a mandibular fracture.  During admission, FK was transferred to the ICU with a severe gastric bleed. FK has presented with several co-morbidities and factors contributing to his admittance such as malnutrition, ETOH abuse, COPD, cirrhosis, anemia and cancer of the tongue.  This case study began 11/11/2015 and concluded 12/02/2015 with a primary medical and nutritional focus on FK's perforated peptic ulcer and peptic ulcer disease. While the patient has several co-morbidities, the gastric bleed and peptic ulcer disease will be the primary focus of the study.

The patient was chosen for this study due to the severity of his condition and underlying malnutrition. The research surrounding environmental and social conditions in the presentation of peptic ulcer disease is overwhelming and has been well researched for a number of years. However, methods of treatment, medicine and nutrition therapies are always changing and the research of this condition continues to grow.

Social History: FK is a single, unemployed man living alone in a two story walk up apartment. He

is receiving medical insurance from Medicare. He also receives moderate assistance from family but takes care of himself 50%-75% of the time. FK cooks for himself on a regular basis, usually using a crockpot or eating canned foods. The patient was a long time smoker, smoking approximately 1.5 packs per day but reported recently quitting 8/22/15. FK has a history of alcohol abuse and admitted consuming 14.4 oz alcohol per week, including 24 cans of beer with occasional bourbon. However, the patient reported upon arrival 11/11/15 that he did not drink any alcohol for about a week, additional medical reports otherwise conflicted with that statement. Following discharge from FK’s first visit, he was subsequently admitted to an Extended Care Facility.

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Normal anatomy and physiology of applicable body functions: Explanation of disease

process

H.pylori is the most common cause of gastric ulcers, though the transmission is not well understood. The H.pylori bacterium is thought to be transmitted via the fecal-oral route and is usually found in people of poor socio-economic backgrounds. The use of NSAIDs can cause an H.pylori infection because of their acidic properties. Frequent NSAID use can damage the mucosal lining by inhibiting prostaglandin synthesis, which maintain homeostatic functions by regulating gastric acid secretions. [1] If prostaglandin is inhibited, the stomach may over-produce gastric acid, causing inflammation in the stomach and additionally creating an environment where H.pylori can flourish.

Excessive gastric acid is only one of the potential “hostile” factors in Peptic Ulcer Disease. Decreased mucosal defense is another potential factor. Some “protective” factors such as prostaglandins, mucus, bicarbonate and blood flow in the mucosa can be disrupted by the “hostile” factors, causing a peptic ulcer.

A peptic ulcer is an open sore that can occur in the lining of the stomach (gastric ulcer) or in the duodenum (duodenal ulcer.) Under normal homeostatic conditions, the stomach and intestinal lining can withstand the corrosiveness of stomach acid. However, once the lining breaks down, the tissue may become inflamed or develop an ulcer. A gastric ulcer usually develops in the first layer of the stomach lining. Once the ulcer develops it can cause a perforation which is extremely dangerous and can cause internal bleeding. As mentioned previously, there are several factors that can increase the risk of an H.pylori induced gastric ulcer or peptic ulcer. Some of the most common factors include smoking, alcohol abuse, radiation treatments, and regular NSAID use. [2] Each factor mentioned has occurred with the patient, FK.

Past Medical History:FK’s previous visits to Fort Hamilton Hospital included one in 2012 for cellulitis in

his right ankle, then again in 2014 with pain in his right ankle from a fall. During his 2014 visit he was diagnosed with peripheral vascular disease.

FK did not visit Fort Hamilton again until his recent visit where he was admitted November 11, 2015 with weakness and malaise due to a severe gastric bleed. He was

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then discharged November 20th after two repairs to the gastric ulcer. The patient was then subsequently admitted again November 22nd from the Butler County Care Facility with blood found in his stool. The ulcer was repaired a third time and he was discharged December 2nd with a schedule follow up to perform an exploratory EGD in 6 weeks.

FK had several other co-morbidities which included cancer of the tongue and a reconstructed broken jaw. He was receiving treatment for oral cancer at UC Hospital prior to the time of his visit to Fort Hamilton. The patient was diagnosed in 2006 with cancer on the base of his tongue. FK received 42 radiation treatments and several doses of chemo. During the time of his visit, the patient still had a large mass on the base of his tongue and was encourage to schedule an appointment with his ENT for an oral exam and possible biopsy at UC Hospital. FK’s broken jaw also seemed suspicious to some of the medical staff not only at Fort Hamilton but also at UC Hospital and there was some speculation as to whether or not a mass was also growing in the weakened mandibular region.

The patient had an extensive health history with additional co-morbidities which are as follows:Diagnosis:

• Hypertension

• Radiation - 42 treatments

• Hx antineoplastic chemo

• Peripheral vascular disease

• ETOH abuse

• Cirrhosis

• Seizures - with ETOH withdrawal

• COPD (chronic obstructive pulmonary disease)

• Cancer - Base of tongue 

• Forgetfulness

• Anemia

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Theoretical discussion of disease condition Gastric ulcers are generally caused by a variety of environmental factors, most of

which are contributed by “hostile” factors such as NSAID use, alcohol abuse, and tobacco use, among many others. Smoking as well as age can increase a person’s risk of developing a perforated gastric ulcer. These factors increase the risk because they affect the gastric secretion in the gastric mucosa. Recurrence of a perforation is high in populations over 60 years of age. Additionally, mortality rate due to perforated gastric ulcers is also increased in these populations. [3]

Alcohol abuse is also strongly correlated with recurrent gastric bleeds from a perforated gastric ulcer. According to a study, alcohol abuse was identified in “19.7 % of patients with non-variceal upper gastrointestinal bleeding.” Recurrent bleeds were as high as 16.7% in alcohol abusers versus 9.1% in those that did not abuse alcohol. Patients with non-variceal upper gastrointestinal bleeding that also abuse alcohol are at a higher risk of re-bleeding and their risk of mortality is increased. Most patients are followed by a primary care doctor or gastroenterologist and placed on a long-term proton pump inhibitor to prevent further peptic ulcers and gastric bleeds. [4] It is also strongly recommended that patients limit NSAID use, alcohol, and smoking during treatment of Peptic Ulcer Disease.

Usual treatment of Peptic Ulcer Disease and perforated peptic ulcers.If a patient is found to have gastro-intestinal bleeding or discomfort, either a stool

sample is tested or an exploratory endoscopy is performed. The endoscopy is a more invasive method where samples or biopsies of the ulceration may be taken to determine the cause is H.pylori. Once the bacteria is found to be the culprit of the ulcer, antibiotics are administered to eradicate H.pylori from the patient’s digestive tract. If the ulcer is bleeding, cauterizing and closing the perforation safely is the most immediate concern.

While there are several causes of peptic ulcer disease, oftentimes a person’s risk factors can easily be decreased by making several lifestyle changes early on in life. Quitting smoking or reducing NSAID and alcohol consumption are some of the most profound ways to prevent an H.pylori infection. Smoking in particular has been found to adversely affect the gastric mucosal protective mechanisms, thus predisposing a person

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to peptic ulcer disease. Several clinical studies have observed that smokers are move likely to develop ulcers which subsequently are more difficult to heal if smoking cessation does not occur.

Other than reducing alcohol consumption, NSAID use or smoking cessation, some patients may be placed on a proton pump inhibitor or antibiotics. A proton pump inhibitor may be given to a patient to prevent additional ulcers as well as to prevent an existing ulcer from bleeding again. It works by reducing the amount of stomach acid produced while the ulcer heals. [5]

Diagnosing whether or not a patient has a peptic ulcer can be determined through various different diagnostic tools. Some research suggests that gastric ulcers can be found by using a CT scan. Other diagnoses are found via exploratory endoscopy. The perforation is usually repaired laparoscopically by cauterizing the crater. Duodenorrhaphy or gastrorrhaphy, suturing of either a duodenal ulcer or gastric ulcer, has long since replaced the need for gastric resection which used to be a common treatment in reparation of a perforated peptic ulcer. [6] Due to the seriousness of this illness it is important that the diagnosis is definitively made and repaired in a timely manner.

Patient’s symptoms upon admission leading to present diagnosis Some symptoms associated with peptic ulcer disease, or a perforated gastric

ulcer can include, but are not limited to bloody or dark tarry stools, fatigue, vomiting, and weight loss. All of these classic symptoms were presented in the patient at the time of his visit. FK was admitted with severe malaise and fatigue with fainting spells at his home. He was found confused and was previously referred to Fort Hamilton Hospital from the patient’s ENT at UC West Chester. The patient was severely underweight and was experiencing some slight abdominal discomfort. Most of his perforated ulcer symptoms were hidden by the fact that he was not eating well due to his mandibular fracture (and possible jaw mass) as well the mass on the base of his tongue. Additionally, the patient’s history of alcohol abuse also covered up some of the symptoms he was experiencing such as the weight loss and loss of appetite.

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Following the exploratory endoscopy, FK was found to have a severe gastric bleed. Cultures were taken of the patient’s stool as well as inside the stomach lining, showing that he did have an H.pylori infection.

The etiology of peptic ulcer disease shows overwhelming evidence blaming smoking as highly correlating with the disease, as explained throughout this case study. In smokers under the age of 75, H.pylori infection was found to account for about 77% of all gastric perforations. Excessive NSAID use also accounted for nearly one third of gastric perforations from H.pylori infections. [6]

There are some indications that radiation treatment or exposure to radiation treatment can predispose a patient to be more susceptible to gastric ulcers. This is usually due to the disruption of fast growing cells such as the gastric lining and gastric mucosal secretions. FK had approximately 42 radiation treatments in the past due to tongue cancer. The treatment would have been focused on his neck and upper GI area. Unfortunately there are not enough studies to show if radiation has lasting effects to possibly indicate it in being part of the etiology of peptic ulcer disease.

Laboratory findings and interpretation :

Labs Normal values Patient’s levels on 11/12 Interpretation

WBC 3.5-10.5 billion cells/L 16.3 billion cells/L - A high level may indicate smoking, infection, inflammation, or tissue damage

Hemoglobin Male: 13.5-17.5 g/dL(135-175 g/L)

8.7 g/dL - Low levels may indicate bleeding from the digestive tract, poor nutrition, anemia, and low levels of iron, folate, vitamin B12, or vitamin B6

Labs

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HCT (Hematocrit) Male: 38.8-50.0 % 26.2% - Low levels may indicate bleeding, anemia, malnutrition, and nutritional deficiencies of iron, folate, vitamin B12, and vitamin B6- Each indication has been presented in the patient.

INR < or = 1.1 1.1 Within normal limits

NA 135 to 145 mEq/L 137 mEq/L -Within normal limits-Normal electrolyte balance

K+ 3.7 to 5.2 mEq/L. 4.3 mEq/L -Within normal limits-Normal electrolyte balance

CL (Chloride) 98-107 mEq/L 99 mEq/L -Within normal limits-Normal electrolyte balance.

CO2 (bicarbonate) 98-107 mEq/L 29 mEq/L - Low results can indicated diarrhea. It may also indicate Kidney disease, however FK’s renal panels were normal.- FK was experiencing diarrhea

BUN 6 to 20 mg/dL 55 mg/dL - Higher than normal results can indicate:Congestive heart failure, excessive protein levels in the gastrointestinal tract, gastrointestinal bleeding or dehydration.- FK was malnourished which usually also occurs with dehydration- FK also had gastrointestinal bleeding

Creatinine Male: 0.7 to 1.3 mg/dL 1.0 mg/dL -Within normal limits- Normal Kidney function

Glucose Fasting: 70-100 mg/dL 85 mg/dL Within normal limits

Normal values Patient’s levels on 11/12 InterpretationLabs

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Calcium 8.5 to 10.2 mg/dL. 7.5 mg/dL - Most likely indicates a disorder that affect absorption of nutrients from the intestines.- FK had a history of alcohol abuse which affects absorption of nutrients

AST 10 to 34 U/L 62 U/L - This test is used to monitor liver disease.- FK has cirrhosis of the liver, and this test made denote the severity of it.- However, these enzymes may also increase after surgery

ALT Male: 10 to 40 U/L 37 - Within upper normal limits- This test may also be used to monitor liver disease

Normal values Patient’s levels on 11/12 InterpretationLabs

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Medications at home medications and hospital medications:Medications Indications Food/Drug

InterationsPossible common side effects

Observable effects on patient if applicable.

atorvastatin Used in conjunction with diet, weight loss and exercise to decrease the risk of heart disease and stroke

antifungal medications, boceprevir, cimetidine, clarithromycin, cobicistat-containing medications, colchicine, digoxin, efavirenz, oral contraceptives, cholesterol-lowering medications, niacin, medications that suppress the immune system, rifampin, spironolactone, teleprevir

Diarrhea, heartburn, gas, joint pain, forgetfulness/ memory loss, confusion

You are not supposed to take this medication if you consume 2 or more alcoholic beverages daily or if you are 65 years of age or older. Both of these contraindications apply to FK. The medication can affect the liver and the patient does have a past medical history of cirrhosis. The patient also has a past medical history that includes forgetfulness and memory loss.

furosemide (LASIX)

Hypertension, Edema

aminoglycoside antibiotics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists (ARB), corticosteroids, cisplatin, cyclosporine, digoxin, laxatives, medications for diabetes, high blood pressure and pain

Frequent urination, blurred vision, headache, constipation, diarrhea

The patient’s edema was slowly improving during each admission and his high blood pressure was under control.

Medications

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metoprolol tartrate (LOPRESSOR)

High blood pressure, Angina; It is in a class of drugs called beta blockers and works in conjunction with other high blood pressure medications.

alcohol, bupropion, cimetidine, clonidine, diphenhydramine, fluoxetine, hydroxychloroquine, paroxetine, propafenone, quinidine, ranitidine, reserpine, ritonavir, terbinafine, thioridazine

dizziness or lightheadedness, tiredness, depression, nausea, dry mouth, stomach pain, vomiting, gas or bloating, heartburn, constipation, rash or itching, cold hands and feet, runny nose

N/A

miconazole An anti-fungal agent used for athlete’s foot, jock itch and yeast infections. FK presented with a yeast infection around the area of the testes which was treated with the powder form of this medication.

None noted increased burning, itching or irritation of the skin; stomach pain; fever

N/A

pantoprazole Used to treat GERD

antibiotics, anticoagulants (blood thinners), atazanavir, diuretics, iron supplements, ketoconazole, methotrexate, nelfinavir

Headache, nausea, vomiting, gas, joint pain, constipation

This medication can cause an H.pylori infection by disrupting the acid balance in the gastric lining. However, it is also a proton-pump inhibitor and can be used to treat the effects of peptic ulcer disease.

Indications Food/Drug Interations

Possible common side effects

Observable effects on patient if applicable.

Medications

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amoxicillin-clavulanate (AUGMENTIN)

used to treat certain infections caused by bacteria.

allopurinol and probenecid

diarrhea, upset stomach, vomiting, mild skin rash

The patient was experiencing diarrhea and an upset stomach during admission after this drug was prescribed. However, the diarrhea could have been due to many additional issues the patient was experiencing.

cyclobenzaprine (FLEXERIL)

This drug is a muscle relaxant used to relieve pain caused by strains, sprains and other muscle injuries

medications for depression, seizures, allergies, coughs, or colds, MAO inhibitors, sedatives, sleeping pills, tranquilizers and vitamins

drowsiness, dry mouth, dizziness, upset stomach

The patient was experiencing an upset stomach during admission. However, the patient was also experiencing an infection from H.pylori which can also cause GI upset.

Hydrocodone-acetaminophen (NORCO)

Pain killer and anti-inflammatory

antidepressants; antihistamines; antipsychotics, medications for irritable bowel disease, motion sickness, Parkinson's disease, seizures, ulcers, or urinary problems; monoamine oxidase (MAO) inhibitors, ipratropium, sedatives, sleeping pills and tranquilizers

nausea, vomiting, constipation, drowsiness, dizziness, lightheadedness, fuzzy thinking, anxiety, abnormally happy, dry throat, difficulty urinating, rash, itchiness, narrowing of the pupils

During admission, FK was lethargic at times and would often sleep most of the day.

Indications Food/Drug Interations

Possible common side effects

Observable effects on patient if applicable.

Medications

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lisinopril (PRINIVIL, ZESTRIL)

Used in conjunction with other medications to treat high blood pressure

aspirin and other nonsteroidal anti-inflammatory drugs, diuretics, potassium supplements,

cough, dizziness, headache, excessive tiredness, nausea, diarrhea, weakness, sneezing, runny nose, decrease in sexual ability, rash

As mentioned previously, the patient was experiencing diarrhea and tiredness though several other medications and physical conditions could contribute to this.

oxyCODONE (OXY IR)

moderate to severe pain requiring relief around the clock, usually pain from surgery.

antidepressants; antihistamines, diuretics, buprenorphine, medications for glaucoma, irritable bowel disease, and urinary problems, nalbuphine; naloxone, pentazocine

nausea, vomiting, loss of appetite, dry mouth, dizziness, stomach pain, drowsiness, flushing, sweating, weakness, headache, mood changes.

N/A

potassium chloride (KLOR-CON)

Supplemented in those with low potassium levels or people with high blood pressure by working to counteract the affects of sodium in the blood.

None noted N/A N/A

thiamine, B-1 thiamine deficiency, beri-beri, pellagra, preventing memory loss, Alzheimers disease, alcohol withdrawal (especially from Wernicke's encephalopathy syndrome)

Coffee, tea, Areca, Horsetail, raw fish and shellfish

N/A N/A

Indications Food/Drug Interations

Possible common side effects

Observable effects on patient if applicable.

Medications

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[7]

Treatment: Medical (mention any diagnosis tests and state the results obtained.)Surgical procedures and findings and results

During FK’s first admission, an exploratory colonoscopy as well as an exploratory endoscopy were performed. During the colonoscopy, the physician found that the patient’s colon was filled with pus from an infection. Blood was also found in the patient’s stool, indicating that there was an upper GI bleed. Once the endoscopy was performed, No esophageal varices were found which often occur in those with liver disease and those with a history of alcohol abuse. Prior to the endoscopy, esophageal varices were thought to be a possible cause of the bleed. However, the physician did find a bleeding perforation in the patient’s stomach which was immediately repaired through cauterization. To prevent recurrent bleeding, FK was placed on a proton pump inhibitor. Proton pump inhibitors work by reducing the acid in the stomach, therefore allowing a clot to form and stabilize where the perforation was. Proton pump inhibitors are often used to prevent recurrent bleeds when used in corroboration with antibiotics. Though, this treatment is most effective if a patient is not taking NSAIDs. In fact, it is strongly recommended that patients completely discontinue the use of NSAIDs during Peptic Ulcer treatment. However, the only true way to prevent a recurrent bleed is to completely eradicate H.pylori. [8]

FK was observed after his initial gastric repair and unfortunately, his stool continued to look black and tarry, indicating that his bleed was still ongoing. An additional repair was made via cauterization and his proton pump inhibitor dose was

folic acid folate deficiency, megaloblastic anemia, long term alcoholism (causes deficiency), poor diet, memory loss,, age-related macular degeneration

5-fluorouracil, capecitabine (xeloda), fosphenytoin, methotrexate, phenobarbital, phenytoin, primidone, pyrimethamine, green tea, and possibly Zinc

N/A N/A

Indications Food/Drug Interations

Possible common side effects

Observable effects on patient if applicable.

Medications

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increased. Unfortunately, there is not enough research that shows whether a high dose orally or intravenously is more effective than a lower dose orally or intravenously. [9] Shortly after FK’s second repair he was admitted to an extended care facility where they could watch his improvement closely.

Two days after FK was admitted to the extended care facility, he was admitted again with a bleeding ulcer. The physician indicated that the patient had failed proton pump inhibitors and required additional surgery. A vagotomy and antrectomy were considered, but due to the patient’s surgical risk being increased due to his cirrhosis and high blood pressure these procedures were declined. A vagotomy is a surgical operation where one or more portions of the vans nerve are cut, decreasing a patient’s gastric secretions. This can be performed in conjunction with an antrectomy, or removal of the distal third of the stomach. These procedures, particularly a vagotomy can be used in the management of severe peptic ulcer disease, however with they predate pharmacological use of proton pump inhibitors. A vagotomy sometimes is indicated if a patient is resistant to proton pump inhibitors such as in FK’s case.[10]

The surgical team decided that his ulcer was to be repaired once again by placing hemoclips on both sides of his ulcer to stop the bleeding. Though during surgery, the ulcer was found to be reduced in size and was apparently healing, a vessel was still exposed and required attention. FK was observed for improvement over another week-long admission after his third surgery. A follow up endoscopy was scheduled as an outpatient procedure after his discharge to ensure that his gastric perforation was healing properly. The results of the patient’s follow up endoscopy have yet to be recorded in his chart.

Medical Nutrition Therapy: FK lives alone and normally purchases and prepares for himself with some

assistance from family members. He often uses a crockpot for cooking soft foods and though he has been told by several physicians to follow a low sodium diet, he does not follow one at home. FK eats all of his meals at home and only eats about 2 meals a day. FK has trouble chewing and swallowing due to his broken jaw and mass on his tongue, so the texture of his food is important. He denied choking on any particular texture of

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food but claimed that it was easier to chew and swallow when food was soft and had extra gravy or sauce.

FK’s diet in the hospital ranged from Soft Dysphagia to Heart Healthy. Tube feed was discussed with the Gastroenterologist and Nurse Practitioner but was not recommended due to the patient’s recurrent gastric bleeding. It was also recommended that a Speech Therapist do a swallowing evaluation with the patient, however the patient was uncooperative during each attempt made. Speech Therapy was unable to perform any substantial swallow evaluation so he was placed on a Soft Dysphagia diet per his reported home diet. Sodium restriction was not an important concern during his visit due to a noted loss of muscle mass and subcutaneous fat.

During the patient’s visit Boost Plus was also sent as supplements during each meal to increase his calorie intake. FK did not drink any boost at home but drank several Boosts during his admission at the hospital. In fact, according to nursing staff at Fort Hamilton, the Boost Plus drinks were almost the only item on his tray that he consistently consumed. Though FK did not consume much, other than the Boost Plus, he did end up gaining some weight by the end of his second visit.

According to ASPEN guidelines a nutrition screen is to be performed within 24 hours of a patient’s admission to an acute care setting. FK was referred to nutrition care for assessment with unplanned weight loss, poor oral intake, and difficulty chewing and swallowing. During the patient’s assessment, it was noted that he lost approximately 15.5% of his body weight in about one month’s time. His intake was also severely decreased to less than 50% of his usual intake for about a month or more since he started having pain in his jaw. This two issues immediately indicated that a physical malnutrition screening was necessary. [11]

Upon, his physical assessment, FK was found to have severe malnutrition with significant loss of muscle mass and subcutaneous fat. Due to his protein-calorie malnutrition, his needs were significantly higher than the average person. As mentioned previously, tube feed was discussed with patient’s gastroenterologist but was declined due to FK’s recurring gastric bleeds. Therefore, Boost Plus supplements were given three times a day to increase protein and calories.

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Recommendations for patient’s calories and protein from physical review, based on patient’s initial admission weight of 52.9 kg (116 lbs 7 oz):

A sample of FK’s average 24 hour intake at home with an analysis:

According to his 24 hour recall at home, FK is severely lacking in calories and protein as well as several vitamins and mineral. The patient also drinks more than the recommended amount of alcohol per day which may also contribute to malabsorption of key vitamins and minerals. According to several studies, a primary issue with patients that abuse alcohol is megaloblastic anemia. This particular type of anemia is associated with a deficiency in folate. [12] FK is currently on a vitamin regimen that includes folate. However, according to the patient’s labs he is still found to be anemic. This could be due

Calories per kg 30-35 Protein grams per kg 1.3-1.5 Fluid needs if on tube feed

1588-1853 calories 68-79 grams Not applicable

Carbohydrates Protein Fat Calories

First meal 11:00 amHalf of a bologna sandwich on white bread with american cheese and regular mayonnaise

16 grams 9 grams 26 grams 325 calories

1 cup of canned soup, chicken noodle

7 grams 3 grams 2 grams 63 calories

Second Meal6:00-6:30 pmBeef Stew, 1 1/2 cups (1 medium bowl)

31 grams 20 grams 15 grams 340 calories

2 beers 26 grams 3 grams 0 grams 310 calories

1.5 oz bourbon or rum

0 grams 0 grams 0 grams 97 calories

Totals: 80 grams 35 grams 43 grams 1,135 calories

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to his GI blood loss as well as his possible alcohol induced folate deficiency. FK would benefit from supplementation of both folate and iron.

Some nutrition interventions for FK included promoting protein intake, promoting oral intake, and nutrition supplementation with Boost Plus. The patient seemed receptive to increasing his protein and oral intake and was willing to drink Boost Plus. However, during each subsequent visit he became increasingly irritable and unwilling to cooperate. During his second visit, FK refused a physical malnutrition screen and his body language suggested that he was disinterested in any information or assistance given.

FK was discharged to an extended care facility who would subsequently take care of all of his nutritional needs. Physical Therapy and Speech Therapy found that the patient was unable to take care of himself and required assistance. The patient’s daughter assisted him when she was able to at home, however during his admission she did agree that it was best for FK to be admitted to a facility that would give him “around the clock” care. The patient would be followed by physicians and dietitians at the facility for improvement. He also had a scheduled follow-up endoscopy planned for a week or so after his discharge.

Prognosis and patient motivation/ attitude: FK’s prognosis was good upon his second discharge. He was admitted to an

extended care facility where he would be monitored for improvement. He also would not have access to alcohol while in the facility which would decrease his chanced of a recurring gastric bleed. Unfortunately, peptic ulcer disease is common in the elderly specifically those that have abused alcohol in the past and it is likely that FK will continue to have peptic ulcers. Because the patient is being monitored 24 hours a day for health issues such as blood in his stool, any perforated ulcers would be caught before any major complications arose.

Summary & Conclusion:I learned several things from studying gastric ulcers and peptic ulcer disease. I

learned that the first line of defense against peptic ulcer disease if a perforation is found

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is use of a proton-pump inhibitor. I also learned that if a proton-pump inhibitor does not work, surgery to resect a person’s vagus nerve can be performed to decrease the acidity of mucosal secretions. I was amazed that there was a surgical intervention that could be performed as a permanent solution to decrease the acidity of a person’s gastric secretions.

I also learned that the causes of peptic ulcer disease vary but are primarily found in those of a poorer socio-economic background. H.pylori can be found in many adult’s gastro-intestinal flora, however the amount of H.pylori as well as the incidence of infection are directly correlated with age and chemical abuse. The chemical abuse can vary, but the primary culprits are usually harsh and frequent NSAID use, carcinogens from smoking, and alcohol abuse. It is unfortunate that many people from a poor socio-economic background experience chemical abuse and are therefore subjected to a higher incidence of Peptic Ulcer Disease.

FK in particular was a difficult patient to assist nutritionally due to his recurrent gastric bleed and various other nutritional barriers such as his tongue mass and broken jaw. I immediately wanted to provide his nutrition via a tube feed but was unable to because of his healing ulcer. He also refused to eat most of the food given to him and often complained about not receiving certain foods that he liked. The texture of his food was altered because of his difficulty chewing and swallowing which is what he normally ate at home, however he still had difficulty chewing the food. He refused a proper chewing and swallowing evaluation from Speech Therapy thus making it even more difficult to resolve his nutritional issues. If the patient had been more compliant with procedures it is possible that he may have gained more weight during his admissions.

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