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Discontinue acetaminophen
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Discontinue oxycodone
Perform endoscopic cautery
Start clarithromycin, amoxicillin, and pantoprazole
Start pantoprazole alone
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This patient who presents with abdominal pain that is worse after eating as well as bloating and belching most likely has recurrent peptic ulcer disease with a new gastric ulcer. In a patient who does not have other risk factors for recurrent peptic ulcers, the patient should get tested for H. pylori, for which the best treatment is clarithromycin, amoxicillin, and pantoprazole. Peptic ulcer disease can be caused by conditions that increase the production of gastric acid and conditions that weaken the gastric mucosal barrier’s ability to resist gastric acid. The classic example of increased gastric acid production is Zollinger-Ellison syndrome where a gastrin secreting tumor leads to diffuse ulcer formation. Decreased barrier function can be due to lifestyle factors such as smoking, medications such as non-steroidal anti-inflammatory drugs, and Helicobacter pylori infection. In a patient who does not have other risk factors for peptic ulcer development, the most effective treatment for recurrent ulcer disease due to H. pylori infection is triple therapy with clarithromycin, amoxicillin, and pantoprazole. Gisbert et al. studied the effect of H. pylori therapy as opposed to anti-secretory therapy in the treatment of recurrent peptic ulcer disease. They find that the eradication of H. pylori is more effective at preventing recurrent disease. Incorrect Answers: Answer 1: Discontinuing acetaminophen is incorrect because acetaminophen is not associated with the development of peptic ulcer disease. Gastrointestinal complications of an acetaminophen overdose include hepatotoxicity and fulminant liver failure but these would present with acute onset of right upper quadrant abdominal pain that is associated with jaundice and death if not promptly treated. Answer 2: Discontinuing oxycodone is incorrect because opioids are not associated with the development of peptic ulcer disease. Gastrointestinal complications of chronic opioid use include constipation and ileus, but these would present with episodic squeezing abdominal pain. Answer 3: Performing endoscopic cautery is incorrect because there is no evidence that this patient has a bleeding ulcer at this time. Signs of ulcer bleeding include hematemesis and melena as well as potentially peritoneal inflammation if a full-thickness erosion has developed. Answer 5: Starting pantoprazole alone is incorrect because a patient with recurrent peptic ulcer disease is likely to have an underlying cause such as H. pylori infection so they should be treated with triple therapy. Bullet Summary: The most effective treatment for recurrent peptic ulcer disease caused by H. pylori is clarithromycin, amoxicillin, and pantoprazole.
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