CASE PRESENTATION ON

H. PYLORI INDUCED
ULCER

NAME – JILL CHAUHAN

ROLL NO. – 29
PD4Y
PHARMACOTHERAPEUTICS - 111
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FARM NOTE ON
HELICOBACTER PYLORI
INDUCED ULCER
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FINDING
 Patient Demographic details

Name : Rajesh Kumar Ward : 602 / MMW

Age : 44 years DOA: 01-07-2025
Sex : Male DOD : 05-07-2025
Address : Vavol , Gandhinagar
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 Subjective Data
C/O A: Burning epigastric pain since 20 days especially after night meals
Nausea
Medical history : Nil
Social History : 10 cigarettes/day since 15 years
Alcohol consumption occasionally
Medication history : Occasionally Pantoprazole (40 mg)
No known allergy
No family history
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 Objective Data
VITALS:
T-normal RS-BLAE+
CVS-S1S2+ Bp-124/80mmHg
PR- 78/min GIT-Soft and tender
RR-18/min EXT – Bowel sounds normal
CNS-Conscious and oriented
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 Lab TEST RANGE
Urea 28 mg/dl
Investigation
S. Cr 0.9 mg/dl
Na 138 mEq/l
K 4.1 mEq/l
RBS 98 mg/dl
T Bili 0.9 mg/dl
D Bili 0.1 mg/dl
T Protein 7.3 g/dl
Albumin 4.8 g/dl
AST 28 IU/L
ALT 20 IU/L
ALP 111 IU/L
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TEST RANGE
RBC 5.4 ×10⁶/cmm
WBC 12000/cmm [H]
Neutrophils 80% [H]
Lymphocytes 55% [H]
Monocytes 9%
Eosinophils 2%
Hb 12.5 g/dl [L]
MCV 90 fl
MCHC 32 g/dl
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 Others Examinations
Platelets : 2,60,000/cmm
Stool Occult Blood : Positive for H. pylori
USG Abdomen : Normal
 ASSESSMENT
 Diagnosis
On the basis of patient’s complain of burning epigastric pain since 20
days especially after night meals and sometimes feeling of nausea and also
increament in WBC indicates infection or inflammation.
Also , Stool occult blood test reveals the presence of H. pylori. From all of
the above information , final diagnosis is made.

FINAL DIAGNOSIS – HELICOBACTER PYLORI

INDUCED ULCER
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 Etiology
Uncommon causes:
Common causes : • Hypersecretion of gastric acid (e.g., Zollinger
Ellison syndrome)
• Viral infections(e.g. , cytomegalovirus)

• Vascular insufficiency(crack cocaine–

• Helicobacter pylori infection associated)
• Non-steroidal anti-inflammatory • Radiation
drugs
• Chemotherapy(e.g.,hepatic artery infusions)
• Critical illness(stress-related
mucosal damage) • Rare genetic subtypes

• Idiopathic
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Therapy needed or not ?
Yes , the therapy is needed as the patient is experiencing
the symptoms since 20 days and also the investigation
reveals the presence of H. Pylori in Stool antigen test.
Therapy helps in complete eradication of the H. pylori ,
prevent recurrences and complications .
Standard Treatment for
H. pylori eradication
 Two Drug Regimen
• Clarithromycin 500mg tid x14days+PPI x14-28 days.
• Amoxicillin 1g bid x14days +PPI X 14-28days.

• The use of a single antibiotic , bismuth salt , or antiulcer drug does

not achieve this goal.
• Clarithromycin is the single most effective antibiotic.
• Two-drug regimens that combine a PPI and either amoxicillin or
clarithromycin have yielded marginal and variable eradication rates.
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Current Therapy
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DRUG FREQUEN CLASS OF MOA INDICATION SIDE EFFECT RATIONA
CY / DRUG LITY
ROUTE
Ondansetr BD Antiemetic Blocking action of Control nausea Headache, Rational
on IV serotonin in brain. vomiting constipation,
(4cc) fatigue

Pantoprazo OD PPI irreversibly inhibits the Used as part of triple Headache Rational
le IV H⁺/K⁺-ATPase enzyme therapy or quadruple Diarrhea or
(40 mg) (proton pump) in gastric therapy for H. pylori constipation
parietal cells, thereby eradication Nausea
blocking the final step Abdominal pain
of gastric acid secretion

Amoxicilli BID Beta-lactam inhibits bacterial cell Used in triple Nausea, Rational
n ORAL antibiotic wall synthesis by therapy (with a PPI diarrhea, Rash,
(1 g) (Aminopenicil binding to PBPs and clarithromycin) itching
lin group) for eradication of H.
pylori
DRUG FREQUE
NCY /
CLASS OF
DRUG
MOA INDICATION SIDE EFFECT 19
RATIONA
LITY
ROUTE

Clarithro BD Macrolide Inhibiting protein Used in triple Nausea, diarrhoea, Rational

mycin ORAL antibiotic synthesis by blocking therapy Taste disturbances
(500 mg) translocation promotes ulcer (metallic or bitter
healing taste)

NS/RL IV Isotonic Replaces extracellular Supportive care Injection site Rational

1 PINT crystalloid fluid volume and during reactions ,
solution Restores fluid and hospitalization Hypersensitivity
electrolyte balance

Sucralfat TDS Gastrointesti In acidic pH, it Used as adjunct Constipation , Dry Rational
e ORAL nal protectant polymerizes and binds therapy in H. mouth
(10 ml) to ulcerated tissue, pylori-associated Nausea, bloating,
forming a protective ulcers. or indigestion
barrier over the ulcer
site.
 RESOLUTION & RECOMMENDATIONS
Day 1: Burning Epigastric pain after night meals and nausea
Biochemical investigation – Normal ,Hematology Report
Resolve : Pantoprazole , Ondansetron , NS/RL
Day 2: Burning epigastric pain
Stool antigen test – positive for H. pylori
USG Abdomen - Normal
Resolve : No nausea
started with soft diet
same drugs + started triple drug regimen and added sucralfate
Day 3: Epigastric pain
Resolve : Continued Same drugs
Day 4 and 5 : NFC and symptoms relieved gradually
Resolve : Tolerated normal diet
Plan for discharge
  Recommendations to the Physician
• Drug – Drug Interaction
Clarithromycin and ondansetron-The metabolism of Ondansetron can be
decreased when combined with Clarithromycin.
• Information regarding ulcer – location of ulcer , extend of infection has not
been investigated.
• Endoscopy has been not done which will provide information regarding ulcer.
• Urea breath test is also not done.
• Further any hematology report has been not done to evaluate the decrement in
WBC , neutrophils and Lymphocytes.
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 Recommendations to Patient
•Complete the full course of triple therapy (PPI + two antibiotics) as
prescribed.
•Do adhere to the therapy to ensure H. pylori eradication.
•Avoid NSAIDs (like ibuprofen or diclofenac), as they worsen ulcers.
•Take medications on time, especially PPIs before meals and sucralfate on an
empty stomach.
•Avoid spicy, acidic, or oily foods that can irritate the stomach lining.
•Quit smoking as it delays ulcer healing and increases recurrence.
•Avoid alcohol, as it irritates the stomach and reduces treatment effectiveness.
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• Eat small, frequent meals instead of large heavy meals.
• Avoid stress, as it can worsen ulcer symptoms.
• Follow up with your doctor after treatment to confirm H. pylori
eradication.
• Report any signs of complications.
• Stay well-hydrated and maintain a healthy, balanced diet to support
healing.
• Food – Drug Interactions
Concurrent use of PROTON PUMP INHIBITORS and CRANBERRY may
result in reduced effectiveness of proton pump inhibitors.
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• Patient are advised to reduce alcohol and smoking by adapting 5 A’s approach –
1. Ask:
At every visit, inquire about tobacco and alcohol use status. For example, "Do you
currently smoke?" or "How often do you drink alcohol?".
2. Advise:
Provide clear, strong, and personalized advice to quit or reduce alcohol and tobacco
use. For example, "I strongly advise you to quit smoking for your health." or "Reducing
your alcohol intake will significantly benefit your health.".
3. Assess:
Evaluate the individual's willingness to quit or reduce their use. This helps tailor the
intervention approach. For example, "Are you ready to quit smoking in the next 30
days?" or "Are you interested in reducing your alcohol consumption?".
4. Assist:
Provide support and resources to help the individual quit or reduce their use. This may
include Setting goals, developing startegies , medication , support system .
5. Arrange:
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• Provide information regarding discharge medications to the patient or any

relative -
1. Pantoprazole (40 mg) OD – 14 days
o Take it on an empty stomach, preferably 30–60 minutes before breakfast.
o S/E – Headache ,Nausea,Diarrhea or constipation, Abdominal discomfort
2. Amoxicillin (1 g) BID – 14 days
o Do not take with acidic juices (like orange juice) — may reduce
effectiveness.
o S/E – Nausea , diarrhea , skin rash.
3. Clarithromycin (500 mg) BID – 14 days
o Can be taken with meals to reduce GI side effects.
o S/E – Metallic taste in mouth , nausea , diarrhea
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4. Syrup Sucralfate (10 ml) TDS – 3 Weeks
o Do not mix with food or drinks.

o S/E – Constipation , Bloating , dry mouth.

5. Multivitamin Tablet OD – 1 month

o Avoid tea or coffee immediately after — they may interfere with vitamin
absorption.
 MONITORING PARAMETER
DRUG INDICATION THERAPEUTIC TOXICITY TOXICITY
MONITORING MONITORING

Pantoprazole peptic ulcer, H. Symptom relief Vitamin B12 Monitor

pylori eradication (e.g., ulcer pain), deficiency, magnesium, B12
improvement in hypomagnesemi levels (if long-
endoscopy a, fractures term); monitor for
GI symptoms
Ondansetron To treat Nausea Relief of Relief of ECG in patients at
and vomiting nausea/vomiting nausea/vomiting risk, electrolyte
levels (K⁺, Mg²⁺)
Amoxicillin Bacterial Symptom Diarrhea, Monitor for rash,
infections, H. resolution allergic rash, C. bowel changes,
pylori eradication difficile CBC in
infection, long-term/high dose
hypersensitivity use
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DRUG INDICATION THERAPEUTIC TOXICITY TOXICITY
MONITORING MONITORING
Clarithromyc Bacterial Symptom GI upset, QT Monitor ECG in
in infections, H. resolution prolongation, cardiac patients,
pylori triple liver enzyme LFTs in prolonged
therapy elevation, taste use
disturbance
Sucralfate Duodenal/gastric Symptom relief, Constipation, Monitor bowel
ulcers, mucosal ulcer healing on aluminum habits, avoid in
protection follow-up toxicity (esp. in renal failure; serum
endoscopy renal patients), aluminium
dry mouth
 REFRENCE
• DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Peptic Ulcer Disease. In:
Pharmacotherapy: A Pathophysiologic Approach. 10th ,2017. pg- 1041–1056.
• Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter
pylori Infection. Available from
https://acgcdn.gi.org/wp-content/uploads/2018/04/ACG-H.-pylori-Guideline-Summary.pdf
• Lexicomp Online Database [Internet]. Hudson (OH): Wolters Kluwer Clinical Drug Information .
Available from: https://www.uptodate.com
• NICE. Helicobacter pylori eradication treatment. National Institute for Health and Care Excellence.
2024. Available from: https://www.nice.org.uk/guidance/cg184/resources
• IBM Micromedex® [Internet]. Peptic Ulcer Disease: Drug Therapy and Disease Overview. Available
from: https://www.micromedexsolutions.com