Peptic Ulcer Disease: A Case Study

Review

Cassandre Miller

1
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.

2
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

3
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

5
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.

6
 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 8.7 g/dL - Low levels may

(135-175 g/L) indicate bleeding from
the digestive tract, poor
nutrition, anemia, and
low levels of iron, folate,
vitamin B12, or vitamin
B6

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

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

8
Labs Normal values Patient’s levels on 11/12 Interpretation

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

9
Medications at home medications and hospital medications:
Medications Indications Food/Drug Possible common Observable effects
Interations side effects on patient if
applicable.

atorvastatin Used in antifungal Diarrhea, You are not

conjunction with medications, heartburn, gas, supposed to take
diet, weight loss boceprevir, joint pain, this medication if
and exercise to cimetidine, forgetfulness/ you consume 2 or
decrease the risk clarithromycin, memory loss, more alcoholic
of heart disease cobicistat- confusion beverages daily or
and stroke containing if you are 65 years
medications, of age or older.
colchicine, digoxin, Both of these
efavirenz, oral contraindications
contraceptives, apply to FK. The
cholesterol- medication can
lowering affect the liver and
medications, the patient does
niacin, medications have a past
that suppress the medical history of
immune system, cirrhosis. The
rifampin, patient also has a
spironolactone, past medical
teleprevir history that
includes
forgetfulness and
memory loss.

furosemide Hypertension, aminoglycoside Frequent urination, The patient’s

(LASIX) Edema antibiotics, blurred vision, edema was slowly
angiotensin- headache, improving during
converting enzyme constipation, each admission
(ACE) inhibitors, diarrhea and his high blood
angiotensin II pressure was
receptor under control.
antagonists (ARB),
corticosteroids,
cisplatin,
cyclosporine,
digoxin, laxatives,
medications for
diabetes, high
blood pressure
and pain

10
Medications Indications Food/Drug Possible common Observable effects
Interations side effects on patient if
applicable.

metoprolol tartrate High blood alcohol, bupropion, dizziness or N/A

(LOPRESSOR) pressure, Angina; cimetidine, lightheadedness,
It is in a class of clonidine, tiredness,
drugs called beta diphenhydramine, depression,
blockers and fluoxetine, nausea, dry
works in hydroxychloroquin mouth, stomach
conjunction with e, paroxetine, pain, vomiting, gas
other high blood propafenone, or bloating,
pressure quinidine, heartburn,
medications. ranitidine, constipation, rash
reserpine, ritonavir, or itching, cold
terbinafine, hands and feet,
thioridazine runny nose

miconazole An anti-fungal None noted increased burning, N/A

agent used for itching or irritation
athlete’s foot, jock of the skin;
itch and yeast stomach pain;
infections. fever
FK presented with
a yeast infection
around the area of
the testes which
was treated with
the powder form of
this medication.

pantoprazole Used to treat antibiotics, Headache, This medication

GERD anticoagulants nausea, vomiting, can cause an
(blood thinners), gas, joint pain, H.pylori infection
atazanavir, constipation by disrupting the
diuretics, iron acid balance in the
supplements, gastric lining.
ketoconazole, However, it is also
methotrexate, a proton-pump
nelfinavir inhibitor and can
be used to treat
the effects of
peptic ulcer
disease.

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Medications Indications Food/Drug Possible common Observable effects
Interations side effects on patient if
applicable.

amoxicillin- used to treat allopurinol and diarrhea, upset The patient was
clavulanate certain infections probenecid stomach, vomiting, experiencing
(AUGMENTIN) caused by mild skin rash diarrhea and an
bacteria. 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 This drug is a medications for drowsiness, dry The patient was
(FLEXERIL) muscle relaxant depression, mouth, dizziness, experiencing an
used to relieve seizures, allergies, upset stomach upset stomach
pain caused by coughs, or colds, during admission.
strains, sprains MAO inhibitors, However, the
and other muscle sedatives, sleeping patient was also
injuries pills, tranquilizers experiencing an
and vitamins infection from
H.pylori which can
also cause GI
upset.

Hydrocodone- Pain killer and anti- antidepressants; nausea, vomiting, During admission,
acetaminophen inflammatory antihistamines; constipation, FK was lethargic at
(NORCO) antipsychotics, drowsiness, times and would
medications for dizziness, often sleep most of
irritable bowel lightheadedness, the day.
disease, motion fuzzy thinking,
sickness, anxiety,
Parkinson's abnormally happy,
disease, seizures, dry throat, difficulty
ulcers, or urinary urinating, rash,
problems; itchiness,
monoamine narrowing of the
oxidase (MAO) pupils
inhibitors,
ipratropium,
sedatives, sleeping
pills and
tranquilizers

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Medications Indications Food/Drug Possible common Observable effects
Interations side effects on patient if
applicable.

lisinopril Used in aspirin and other cough, dizziness, As mentioned

(PRINIVIL, conjunction with nonsteroidal anti- headache, previously, the
ZESTRIL) other medications inflammatory excessive patient was
to treat high blood drugs, diuretics, tiredness, nausea, experiencing
pressure potassium diarrhea, diarrhea and
supplements, weakness, tiredness though
sneezing, runny several other
nose, decrease in medications and
sexual ability, rash physical conditions
could contribute to
this.

oxyCODONE moderate to antidepressants; nausea, vomiting, N/A

(OXY IR) severe pain antihistamines, loss of appetite,
requiring relief diuretics, dry mouth,
around the clock, buprenorphine, dizziness, stomach
usually pain from medications for pain, drowsiness,
surgery. glaucoma, irritable flushing, sweating,
bowel disease, weakness,
and urinary headache, mood
problems, changes.
nalbuphine;
naloxone,
pentazocine

potassium chloride Supplemented in None noted N/A N/A

(KLOR-CON) those with low
potassium levels
or people with high
blood pressure by
working to
counteract the
affects of sodium
in the blood.

thiamine, B-1 thiamine Coffee, tea, Areca, N/A N/A

deficiency, beri- Horsetail, raw fish
beri, pellagra, and shellfish
preventing
memory loss,
Alzheimers
disease, alcohol
withdrawal
(especially from
Wernicke's
encephalopathy
syndrome)

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Medications Indications Food/Drug Possible common Observable effects
Interations side effects on patient if
applicable.

folic acid folate deficiency, 5-fluorouracil, N/A N/A

megaloblastic capecitabine
anemia, long term (xeloda),
alcoholism (causes fosphenytoin,
deficiency), poor methotrexate,
diet, memory loss,, phenobarbital,
age-related phenytoin,
macular primidone,
degeneration pyrimethamine,
green tea, and
possibly Zinc
[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

14
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

15
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):

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

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

Carbohydrates Protein Fat Calories

First meal
11:00 am
Half of a bologna 16 grams 9 grams 26 grams 325 calories
sandwich on white
bread with
american cheese
and regular
mayonnaise

1 cup of canned 7 grams 3 grams 2 grams 63 calories

soup, chicken
noodle

Second Meal
6:00-6:30 pm
Beef Stew, 1 1/2 31 grams 20 grams 15 grams 340 calories
cups (1 medium
bowl)

2 beers 26 grams 3 grams 0 grams 310 calories

1.5 oz bourbon or 0 grams 0 grams 0 grams 97 calories

rum

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

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

17
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

18
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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