Peptic Ulcer Disease-Done

PEPTIC ULCER DISEASE
SCENARIO:
The wife of C.W., a 70-year-old man, brought him to the emergency department (ED) at
4:30 this morning. She told the ED triage nurse that he had had dysentery for the past 3 days,
and, last night, he had a lot of “dark red” diarrhea. When he became very dizzy, disoriented,
and weak this morning, she decided to bring him to the hospital. C.W.'s vital signs (VS) were
70/- (systolic blood pressure [BP] 70 mm Hg, diastolic BP inaudible), 110, 20, 99.1° F (37.3°
C). A 16-gauge IV catheter was inserted, and a lactated Ringer's (LR) infusion was started.
The triage nurse obtained the following history from the patient and his wife. C.W. has had
idiopathic dilated cardiomyopathy for several years. The onset was insidious, but the
cardiomyopathy is now severe, as evidenced by an ejection fraction (EF) of 13% found during
a recent cardiac catheterization. He experiences frequent problems with heart failure (HF)
because of the cardiomyopathy. Two years ago, he had a cardiac arrest that was attributed to
hypokalemia. He also has a long history of hypertension (HTN) and arthritis. He has also had
atrial fibrillation in the past but it has been under control recently. Fifteen years ago he had a
peptic ulcer.
An endoscopy showed a 25 × 15 mm duodenal ulcer with adherent clot. The ulcer was
cauterized, and C.W. was admitted to the medical intensive care unit (MICU) for treatment of
his volume deficit. You are his admitting nurse. As you are making him comfortable, Mrs. W.
gives you a paper sack filled with the bottles of medications he has been taking: enalapril
(Vasotec) 5 mg PO bid, warfarin (Coumadin) 5 mg/day PO, digoxin (Lanoxin) 0.125 mg/day,
PO, potassium chloride 20 mEq PO bid, and diclofenac sodium (Voltaren) 50 mg PO tid. As
you connect him to the cardiac monitor, you note that he is in sinus tachycardia. Doing a quick
assessment, you find a pale man who is sleepy but arousable and oriented. He is still dizzy,
hypotensive, and tachycardic. You hear S3 and S4 heart sounds and a grade II/VI systolic
murmur. Peripheral pulses are all 2+, and trace pedal edema is present. Lungs are clear.
Bowel sounds are present, mi epigastric tenderness is noted, and the liver margin is 4 cm
below the costal margin. A Swan-Ganz catheter and an arterial line are inserted.
QUESTIONS:
1. What may have precipitated C.W.'s gastrointestinal (GI) bleeding?
2. From his history and assessment, identify five signs and symptoms (S/S) of GI bleeding
and loss of blood volume.
3. What is the most serious potential complication of C.W.'s bleeding?
4. What is the effect of C.W.'s blood pressure on his kidneys?
ANSWERS:
1. Taking warfarin, digoxin, and NSAID all daily can cause GI bleeding. Diarrhea may
have precipitated ulcers because as well because of irritation from acid.
2. FIVE SIGNS AND SYMPTOMS (S/S) OF GI BLEEDING AND LOSS OF BLOOD
VOLUME.
 Previous peptic ulcer
 Dark Red diarrhea
 Dizzy, disoriented and weak
 Mid epigastric tenderness
 pale man who is sleepy but arousable and slightly disoriented
3. The most serious potential complication of C. W’s bleeding leads to Hypovolemic shock
4. The effect of C.W.'s blood pressure on his kidneys causing itself fail to regulate blood
pressure.
Healthy kidneys produce a hormone called aldosterone to help the body regulate blood
pressure. Kidney damage and uncontrolled high blood pressure each contribute
to a negative spiral.
Case study progress:
C.W. receives a total of 4 units of packed red blood cells (PRBCs), 5 units of fresh
frozen plasma (FFP), and several liters of crystalloids to keep his mean BP above 60 mm
Hg. On the second day in the MICU, his total fluid intake is 8.498 L and output is 3.66 L for
a positive fluid balance of 4.838 L. His hemodynamic parameters after fluid resuscitation
are pulmonary capillary wedge pressure (PCWP) 30 mm Hg and cardiac output (CO) 4.5
L/min.
QUESTIONS:
5. Why will you want to monitor his fluid status very carefully?
6. List at least six things you will monitor to assess C.W.'s fluid balance.
7. Explain the purpose of the FFP for C.W.
ANSWERS:
5. He already has a positive fluid volume, he received 4 units of packed red blood cells as
well as 5 units of fresh frozen plasma. Too much of a good thing can also be bad, he has a
history of hypertension and his pulmonary wedge is above average.
6. 6 THINGS TO MONITOR IN ASSESSING C. W’S FLUID BALANCE
 Urine output
 Weight
 Edema/Capillary refill
 Blood pressure/ heart rate
 Electrolyte levels
 Intake/output
7. Fresh frozen plasma is full of coagulation factors without platelets, RBCs or leukocytes.
These are to increase fluid volume and help with the coagulation factor deficiency.
Case study progress:
As soon as you get a chance, you review C.W.'s admission laboratory results. These
were drawn before he received the PRBCs.
Chart view:
Lab work:
 Sodium – 138 mEq/L
 Potassium – 6.9 mEq/L
 BUN – 90 mg/dL
 Creatinine – 2.1 mg/dL
 WBC – 16,000/mm 3
 Hgb – 8.4 g/dL
 Hct – 25%
 PT – 23.4 seconds
 INR – 4.2
QUESTIONS:
8. After examining the lab results, are there any concerns with C.W.'s electrolyte levels?
Explain your answer.
9. In view of the previous lab results, what diagnostic test will be performed and why?
10. Evaluate this ECG strip, and note the effect of any electrolyte imbalances.
11. Why do you think BUN and creatinine are elevated?
12. What do the low hemoglobin (Hgb) and hematocrit (Hct) levels indicate about the
rapidity of C.W.'s blood loss?
13. What is the explanation for the prolonged prothrombin time/international normalized
ratio (PT/INR)?
14. What will be your response to the prolonged PT/INR? (Select all that apply.)
a. Prepare to administer a STAT dose of protamine sulfate.
b. Hold the warfarin.
c. Monitor C.W. for signs and symptoms of bleeding.
d. Obtain an order for aspirin if needed for pain.
e. Avoid injections as much as possible.
15. What safety precautions should be considered in light of his prolonged PT/INR?
16. How do your account for the elevated white blood cell count?
ANSWERS:
8. High potassium level slows the firing ability of the ventricle and reloading ability which
widens the QRS can also cause tachycardia, very common to cause vtach and vfib.
BUN and Creatinine elevated: because associated with GI bleeding.
9. Endoscopy: to see where Gi bleeding is located and to find the cause, see if there is
an additional bleed from originally cauterized space or if the cauterized space opened.
Blood is clots more slowly with PTT and INR inc, so there is a risk for bleeding and
they have very low hmg and hct which is also indictive of bleeding
10. Elevated T Wave caused by Hyperkalemia
11. Elevated BUN and creatinine are commonly elevated with GI bleeds, Because of
bleeding there is intravascular dehydration which decreases renal perfusion and that
elevates BUN and creatinine.
12. Blood loss is the most important prevalent cause of anemia. The normal Hb level for
males is 14 to 18 g/dl; that for females is 12 to 16 g/dl. When the hemoglobin
level is low, the patient has anemia.
13. Because of his coumadin, he will have a prolonged PT which means his medications
are working at a therapeutic effect. His INR is elevated as well due to the medication,
normal patients not on warfarin therapy should be less than 2.
14. What will be your response to the prolonged PT/INR? (Select all that apply.)
a. Prepare to administer a STAT dose of protamine sulfate.
b. Hold the warfarin.
c. Monitor C.W. for signs and symptoms of bleeding.
d. Obtain an order for aspirin if needed for pain.
e. Avoid injections as much as possible.
15. Use Cautiously in:
 Malignancy;
 Patients with history of ulcer, liver disease, or acute kidney injury;
 History of poor compliance;
 Asian patients or those who carry the CYP2C9*2 allele and/or the CYP2C9*3 allele,
or with the VKORC1 AA genotype (↑ risk of bleeding with standard dosing; lower
initial doses should be considered);
 Geri: Due to greater than expected anticoagulant response, initiate and maintain at
lower doses;
 Rep: Women of reproductive potential;
 Pedi: Has been used safely but may require more frequent PT/INR assessments.
16. Kidney failure, hospitalization, possible infection and hypovolemia.

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PEPTIC ULCER DISEASE

 Patients with history of ulcer, liver disease, or acute kidney injury;

 History of poor compliance;

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