case study of patient with peptic ulcer disease with explanation about PUD and its medical nutrition therapy based on Krause Book

1. Peptic Ulcer Disease: Case
Study and Medical Nutrition
Therapy
Batoul Ghosn, LD, MSc.
Tehran University of Medical Sciences
Email: Batoul.Ghosn@lau.edu

2. Patient’s profile
Age: 21 yrs old
Gender: Female
Work: Student
Date of admission: 12/2/2014
Physical activity: active lifestyle
Socioeconomic status: Good
Lives with her family
No Family History

3. Chief Complaint
Severe upper GI pain
Headache due to abdominal pain
Anorexia: lack or loss of appetite for food.
Nausea
8 kg weight loss in 6 month> 16 %= severe weight
loss

4. Anthropometric
measurements
 Ht= 156 cm
 UBW=51 kg
 Actual BW = 45 kg
 BMI= 18.5 kg/m2 _ Normal

5. Medical Diagnosis
Gastric ulcer due to H pylori infection
B12 deficiency
Hyperacidity : endoscopy results revealed
esophagitis grade 1

6. What is Peptic Ulcer
•A peptic ulcer is a distinct breach in the mucosal
lining of the stomach (gastric ulcer) or the first part of
the small intestine (duodenal ulcer) as a result of
caustic effects of acid and pepsin in the lumen.
•H pylori is one of the most common causes of peptic
ulcer.
•Ulcers can also be caused or worsened by drugs
such as aspirin, iboprufen, and other NSAIDS
•Four times as many peptic ulcers arise in
the duodenum as in the stomach itself.
•Duodenal ulcers are generally benign.

7. What is Gastric ulcer
 A stomach or gastric ulcer is a break in the tissue lining
the stomach. The term 'peptic ulcer' refers to those that
occur in either the stomach or the first part of the small
intestine that leads out of the stomach, called the
duodenum.
 It was thought that stress, smoking and diet were the
principal causes of stomach ulcers. However,
the Helicobacter pylori (H. pylori) bacterium is now
known to be responsible for most duodenal ulcers and
60 per cent of stomach ulcers. The H. pylori bacterium
also prompts many symptoms of dyspepsia, or
indigestion.
 Treatment for stomach ulcers includes the use of
antibiotics to kill the infection, and acid-suppressing
drugs.

8. What is H pylori infection
•Helicobacter pylori (H. pylori) is a type of
bacteria that causes infection in the stomach.
•It is found in about two-thirds of the world's
population.
•It may be spread by unclean food and water
• It causes peptic ulcers and can also
cause stomach cancer.
•The best treatment is a combination of
antibiotics and acid-reducing medicines.

9. B12 defficiency
Gastrointestinal Manifestations
 Vitamin B12 deficiency might also
manifest with gastrointestinal complaints.
Some frequently mentioned symptoms
include anorexia, flatulence, diarrhea,
and constipation.
 These symptoms can develop among
patients with a vitamin B12 deficiency
without accompanying anemia,
macrocytosis, or overt neurologic
deficits.

10. Causes
•The most common cause of ulcers is infection of the
stomach by bacteria called Helicobacter pylori (H.pylori).
•Most people with peptic ulcers have these bacteria living
in their digestive tract. Yet, many people who have these
bacteria in their stomach do not develop an ulcer.
•The following factors raise your risk for peptic ulcers:
• Drinking too much alcohol
• Regular use of aspirin, ibuprofen, naproxen, or other
nonsteroidal anti-inflammatory drugs (NSAIDs).
Taking aspirin or NSAIDs once in a while is safe for
most people.
• Smoking cigarettes or chewing tobacco
• Being very ill, such as being on a breathing machine
• Having radiation treatments

11. Causes
•The exact way H. pylori infects someone is still
unknown.
•H. pylori bacteria may be passed from person to
person through direct contact with saliva, vomit or
fecal matter.
•H. pylori may also be spread through contaminated
food or water

12. Causes of hyperacidity
 Diet, increased consumption of spicy foods and oily foods increases
the extent of acid production.
 • If you consume foods that are very rich in fiber content, it takes a
long time for the food to pass through the stomach. As a result, the
acid production continues until the stomach is emptied, resulting in
increased amount of acid in the stomach.
 • Stomach ulcer or cancers that increase the production of gastrin
automatically increase the acid production.
 • Stress is the major cause for a great number of ailments in the
body. It is found that individuals who are severely stressed produce
increased amounts of acid in the stomach.
 • Bacterial infection by the bacterium H. pylori is also found to
increase the acid production.
 • Irregular meals like not having meals regularly at a particular time.
Existence of a long gap between meals results in accumulation of
the secreted acid in the stomach.
 • In some people, lack of sufficient sleep also increases the acid
production.

13. Signs and Symptoms (Gastric
ulcer)
Some stomach ulcers don’t produce any symptoms.
If present, they can include:
Abdominal pain just below the ribcage
Indigestion
Nausea
Loss of appetite
Vomiting
Weight loss
Bright or altered blood present in vomit or bowel
motions
Symptoms of anaemia, such as light-headedness
Shock due to blood loss – a medical emergency.

14. Signs & symptoms (H pylori
infection)
 An ache or burning pain in your
abdomen
 Abdominal pain that's worse when
your stomach is empty
 Nausea
 Loss of appetite
 Frequent burping
 Bloating
 Unintentional weight loss

15. Possible complications
 Complications associated with H. pylori
infection include:
 Ulcers. H. pylori can damage the protective
lining of your stomach and small intestine.
This can allow stomach acid to create an
open sore (ulcer). About 10 percent of people
with H. pylori will develop an ulcer.
 Inflammation of the stomach lining. H.
pylori infection can irritate your stomach,
causing inflammation (gastritis).
 Stomach cancer. H. pylori infection is a
strong risk factor for certain types of stomach
cancer.

16. Possible Complications
Left untreated, peptic ulcers can result in:
• Internal bleeding. Bleeding can occur as slow
blood loss that leads to anemia or as severe
blood loss that may require hospitalization or a
blood transfusion. Severe blood loss may cause
black or bloody vomit or black or bloody stools.
• Infection. Peptic ulcers can eat a hole through
the wall of your stomach or small intestine,
putting you at risk of serious infection of your
abdominal cavity (peritonitis).
• Scar tissue. Peptic ulcers can also produce scar
tissue that can block passage of food through the
digestive tract, causing you to become full easily,
to vomit and to lose weight.

17. Medical Treatment
Treatment for peptic ulcers depends on the cause.
Treatments can include:
Antibiotic medications to kill H. pylori. If H. pylori is
found in the digestive tract, the doctor may recommend a
combination of antibiotics to kill the bacterium. The patient
will need to take antibiotics for two weeks, as well as
additional medications to reduce stomach acid.
Medications that block acid production and promote
healing. Proton pump inhibitors reduce stomach acid by
blocking the action of the parts of cells that produce acid.
These drugs include the prescription and over-the-counter
medications omeprazole (Prilosec), lansoprazole
(Prevacid), rabeprazole (Aciphex), esomeprazole
(Nexium) and pantoprazole (Protonix).
Long-term use of proton pump inhibitors, particularly at
high doses, may increase the risk of hip, wrist and spine

18. Medical Treatment
 Medications to reduce acid production. Acid blockers — also
called histamine (H-2) blockers — reduce the amount of
stomach acid released into the digestive tract, which relieves
ulcer pain and encourages healing.
 Available by prescription or over-the-counter, acid blockers
include the medications ranitidine (Zantac), famotidine (Pepcid),
cimetidine (Tagamet) and nizatidine (Axid).
 Antacids that neutralize stomach acid. The doctor may
include an antacid in your drug regimen. Antacids neutralize
existing stomach acid and can provide rapid pain relief. Side
effects can include constipation or diarrhea, depending on the
main ingredients.
 Antacids can provide symptom relief, but generally aren't used
to heal the ulcer.
 Medications that protect the lining of your stomach and
small intestine. In some cases, the doctor may prescribe
medications called cytoprotective agents that help protect the
tissues that line the stomach and small intestine.
 Options include the prescription medications sucralfate
(Carafate) and misoprostol (Cytotec). Another nonprescription
cytoprotective agent is bismuth subsalicylate (Pepto-Bismol).

19. Medications
Takeprom : A proton pump
inhibitor used to inhibit gastric acid secretion for
the treatment of duodenal or gastric
ulcer, GERD and hyperchlorhydria
Leflumax: Antibiotic
Amoxil: Antibiotic
Cobalt: B12 supplement

20. Past Medical History
B12 deficiency

21. Past Surgical History
Endoscopy:
Results : Mild chronic inflammation and congestion in
lamina propria (mucosa or mucous membrane
always refers to the combination of the epithelium
plus the lamina propria)
Esophagitis grade 1 ( inflammation of the
esophagus graded according to its severity)

22. Lab values
Lab tests Result Normal range
B12 Pg/ml 187-883
Vitamin d 25ng/ml 30-100
Calcium 9.2 mg/dl 8.5-9.5
Folate 9.2 ng/ml 3.1-20.5
Total protein 76 g/l 64-83
Albumin 45 g/l 38-51
Ferritin 24 ng/ml 6.9-280
Creatinine 0.8 mg/dl 0.4-1.1
BUN 9 mg/dl 7-18
SGOT
SGPT
T. Bilirubin 0.7 mg/dl 0.1-1.2
Sodium 138 mmol/l 135-145
Potassium 4.1 3.5-5.1
Chloride 104 98-110

23. Cholesterol 166 mg/dl 140-200
TG 46 mg/dl 50-150
HDL 69.2 mg/dl 40-70
LDL 88 mg/dl 60-130
Hemoglobin 13.43 g/dl 12-16
Hematocrit 39.69 % 37-46
Glucose 85 mg/dl 76-115
Hba1c 5 % 4.6-6.2

24. Lab testing
H pylori breath test: The urea breath test is a
rapid diagnostic procedure used to identify infections by H
pylori, a spiral bavterium implicated in gastritis, gastric ulcer and
duodenal ulcer disease. It is based upon the ability of H.
pylori to convert urea to ammonia and carbon dioxide. Urea
breath tests are recommended in leading society guidelines as
a preferred non-invasive choice for detecting H. pylori before
and after treatment.
H pylori breath test revealed positive
H pylori blood test: Blood tests are used to measure
antibodies to H pylori.
H pylori ab IgG 38 U/ml 0-20
H pylori ab IgM 68 U/ml 0-40
Stool analysis: A stool test can detect traces of H pylori in
the feces
Stool analysis for ova and parasites > NONE SEEN

25. Follow up & Monitoring
14/3/2014
Severe upper GI pain
Medications: Gastrisec 20 mg 2/d
Gastrisec:
PPI that works against the bacteria h pylori
which is a cause of stomach ulcers

26.  31/3/2014
 Pain relieved upon medication but
returns when medication not taken
 Lab tests ordered: H pylori blood test
revealed positive
Medications ordered : Gastrisec 20 mg
4/d

27.  23/4/2014
 Pain relieved upon medication but
returns when medication not taken
 Lab tests ordered : H pylori breath test
 Result : positive > H pylori resistant
type
 Medications ordered :
 Pylera
 Gastrisec 20 mg
 Fludinium

28.  Pylera
 PYLERA® capsules in combination with omeprazole,
are used to treat patients with an infection caused by
bacteria called Helicobacter pylori and duodenal ulcer
disease (active or history of within the past 5 years) to
kill the H. pylori bacteria.
 Helicobacter pylori (H. pylori) is a type of bacteria that
lives in the lining of the stomach or duodenum. In some
infected patients, H. pylori can cause stomach problems
including ulcers. Peptic ulcer disease is a term used to
describe these types of ulcers that may occur in the
stomach (gastric ulcer) or duodenum (duodenal ulcer).
 Fludinium:
 used for the symptomatic treatment for peptic ulcer and
other GI problems.

29.  15/7/2014
 Pain relieved upon medication but
returns when PPI not taken
 Lab tests ordered :
 H pylori breath test
 H pylori blood test

30.  1/9/2014
 Pain relieved upon medication but
returns when PPI not taken
 H pylori blood test: positive
 H pylori breath test : negative

31.  H pylori blood test positive:
 Blood tests for H pylori can only tell if
your body has H pylori antibodies.
 The test can be positive for years
even if the infection is cured.

32.  Medical treatment:
 Gastrisec to promote the healing of
gastric ulcer.
 Eliminating H. pylori infections with
antibiotics means that the ulcer can be
cured.
 Fludinium to alleviate symptoms of
peptic ulcer.
 Cobal to correct vitamin b12
deficiency.

33. 24 hr Recall
Breakfast
¼ white bread with
thyme and 2 tsp olive
oil
2 tbsp labneh with 3
tsp olive oil
1 cup of tea with 3 tsp
table sugar
Lunch
• 2 oz baked fish
• 3 tbsp. white rice
• Salad with 3 tsp olive oil
• 1 apple
• 1 orange
Dinner
• ¼ white bread with
thyme and 2 tsp olive
oil
• 2 tbsp labneh with 3
tsp olive oil
• 1 cup of tea with 3 tsp
table sugar
Energy=1414 kcal
CHO=34 %
Protein=12 %
Fat=55 %
Her diet is :
Low in calories=weight loss
High in Fat
Low in protein
Low in carbohydrate
Caffeine intake
REE=1524 kcal
CHO=50 %
Protein= 20 %
Fat= 30 %

34.  Prostaglandins appear to have a similar effect
as the drug omeprazole prescribed for
excess stomach acid
 There is some evidence that an excess of
oleic acid (found chiefly in olive oil and nuts)
may inhibit prostaglandin production.
 The reason for avoiding fatty foods, is that
they are harder to digest, so the body then
produces more stomach acid and aggravates
the condition. Foods that are low in fat can
speed up the recovery.
 A high protein intake is recommended to
provide essential amino acids for tissue
breakdown.

35. Nutrition Diagnosis PES
Problem Etiology Symptoms
Severe abdominal
pain
H pylori infection H pylori breath test
Unintentional weight
loss
Gastric ulcer 8 kg weight loss in 6
months

36. MNT Goals
The main goals for treating a peptic ulcer include
• Getting rid of the underlying cause (particularly H.
pylori infection or use of NSAIDs)
• Preventing further damage and complications
• reducing the risk of recurrence (omeprazole)
• Medication is almost always needed to alleviate
symptoms and must be used to eradicate H.
pylori.
• Surgery is required for certain serious or life-
threatening complications of peptic ulcers and
may be considered if medications are not
working.
• Lifestyle factors, including making changes in
your diet, are important.

37. Diet
There is little evidence that specific dietary factors cause or exacerbate
gastritis or peptic ulcer disease.
• Protein foods temporarily buffer gastric secretions, but they also
stimulate
secretion of gastrin, acid, and pepsin.
• Milk or cream, which in the early days of peptic ulcer management
was considered important in coating the stomach, is no longer
considered
medicinal.
• The pH of a food has little therapeutic importance, except for patients
with existing lesions of the mouth or the esophagus.
• On the basis of their intrinsic acidity and amount consumed, fruit
juices and soft drinks are not likely to cause peptic ulcers or
appreciably interfere with healing. Some patients express discomfort
with ingestion of acidic foods, but the response is not consistent
among patients, and in some, symptoms may be related to heartburn

38. Diet
 Consumption of large amounts of alcohol may worsen the symptoms
 Both coffee and caffeine stimulate acid secretion and may also
decrease LES pressure; however, neither has been strongly implicated
as a cause of peptic ulcers outside of the
increased acid secretion and discomfort associated with their
consumption.
 When very large doses of certain spices are fed orally or placed
intragastrically without other foods, they increase acid secretion and
cause small, transient superficial erosions, inflammation of the mucosal
lining, and altered GI permeability or motility. Most often incriminated are
chili, cayenne and black peppers .
 Small amounts of chili pepper or its pungent ingredient, capsicum, may
serve to increase mucosal protection by increasing production of mucus.
Interestingly, another spice, curcumin, through its anti-inflammatory
activity that inhibits NF-KB pathway activation may be a
chemopreventive candidate against H. pylori-related cancer

39. Diet
 Studies suggest that green tea, broccoli sprouts, black
currant oil, and kimchi (fermented cabbage) help with H.
pylori eradication. Probiotics containing lactobacillus and
bifidobacterium have also been studied
for prevention, management, and eradication of H. pylori.
 Omega-3 and omega-6 fatty acids are involved in
inflammatory, immune, and cytoprotective physiologic
conditions of the GI mucosa.
 Overall, a high-quality diet without nutrient deficiencies
may offer some protection and may promote healing.
Persons being treated for gastritis and peptic ulcer disease
should be advised to avoid foods that exacerbate their
symptoms, and to consume a nutritionally complete diet
with adequate dietary fiber from fruits and vegetables.

40. Diet
 Eat white meats such as chicken or turkey and fish.
Remember to remove the fatty skin from chicken.
 Oily fish, like salmon, mackerel, sardines and herring
contain omega-3 fatty acids. They help to reduce the
risk of ulcers by producing compounds called
prostaglandins, that help to protect the lining of the
stomach and intestines.
 Eat more vegetables and fruit in order to help protect
the lining of the stomach and intestine and they contain
high levels of antioxidants which lower the risk of ulcers
and ease symptoms when an ulcer has already
developed.
 Vitamin E from foods like wheatgerm, hazelnuts, cold-
pressed sunflower seed oil, soybean oil, will help along
with zinc, found in seafood and whole grains.
 Amino acids also have a healing action. Good food
sources include: seaweed, wheatgerm, cheddar
cheese, almonds, sunflower seeds and sesame seeds.
Alternatively, L-Glutamine can be taken to help an ulcer

41. Diet
CAFFEINATED FOODS
 Foods and drinks that contain, like chocolate, coffee
and soft drinks, can make your ulcer worse. Avoid them.
DAIRY PRODUCTS
 Many dairy products are high in fat. Avoid them or use
low-fat alternatives.
Spicy foods and seasonings
 Avoid chili peppers, black pepper, mustard, curry and
other strong spices.
SALT AND SALTY FOODS
 There is evidence that people with a Helicobacter
pylori infection who have a high salt intake are at
greater risk of developing stomach cancer.

42. Thank you