An example scenario

Trigger text

A persistent pain

Image: 79-year-old woman in her home by the phone - looking uncomfortable.

You are an SHO in A&E at the DRI. Nancy Allen, aged 79, has been referred by her GP for tests.

Over the last 2 days she has just not been feeling right and has had a persistent burning pain in her stomach. She has had the pain several times before but this time her antacid tablets haven't helped at all. She has also noticed soft black stools. The pain had continued this morning and Nancy felt sick enough to vomit. Worried, she rang her friend and cancelled her lift to the Senior Citizens Club, and then went to see her GP.

Patient data

Presenting Problem

Mrs Nancy Allen is a 79-year-old pensioner who has been sent to the Emergency Dept that morning by her general practitioner because of upper abdominal pain and black stools over the last 2 days.

History of Present Illness

An epigastric burning sensation present for the last 2 days
Her pain is moderately severe but non radiating - relieved a little by eating and by an antacid (Gaviscon)
No history of weight loss but some vomiting occurs with the pain, this has occurred occassionally in the past
Bowel motions were soft and black over last 2 days
Has felt lethargic and weak
Long history of dyspepsia with periodic epigastric pain over last 2 years (three episodes of pain over last 12 months, each lasting about 2 or 3 weeks)
Takes over the counter ranitidine tablets for a week when pain occurs
Developed low back pain 3 weeks ago with X-rayof lumbar spine showing moderate degenerative changes
Began taking diclofenac, prescribed for her husband and left in the bathroom cupboard since his death

Past Medical History

Barium meal many years ago showed a scarred stomach
Has osteoarthritis, particularly affecting the hips
Moderate hypertension for many years controlled with felodipine (slow release tablets)
Moderate chronic airflow limitation related to lifelong cigarette smoking
Cholecystectomy 10 years ago for gallstones following episodes of biliary colic
Caesarean section for birth of second child 50 years ago
Chest X-ray three years ago showed no abnormality

Family History

Father had stomach ulcers and died of ischaemic heart disease aged 72

Personal and Social History

Widowed 2 years ago and lives alone in own home with some support from neighbours
Both children married and living in Plymouth
Main social contact with senior citizens club and local church
Largely independent in daily living but is considering meals on wheels to avoid strain of shopping
Drinks 4 or 5 units of alcohol per day as sherry before the evening meal
No history of known drug allergies
Has stopped smoking for 5 years but still gets breathless climbing stairs.
Current medications
o Felodipine slow release (10 mg daily)
o Diclofenac 50 mg twice daily for 3/52
o Ranitidine 150 mg periodically
Histopathology (see full report) - chronic active gastritis with numerous H. pylori organisms. Diagnostic Decision/Mechanism
H. pylori - associated peptic ulcer + improperly treated + exposure to risk factors (intake of NSAIDs) >>> inhibition of the protective mechanisms in the mucosa >>> bleeding from the ulcer as a complication

Progress management

Transfused 2 units of packed cells
Diclofenac ceased and omeprazole 20 mg daily begun
No signs of rebleeding
Repeat haemoglobin 2 days later was 11.8 g/dL (NR 12.0-16.0)
Prescription for one week triple therapy (omeprazole, amoxycillin, clarithromycin) with emphasis on the importance of compliance and possible side effects.
Continuation of omeprazole for 7 weeks after triple therapy completed

Outcome

Discharged after 4 days and asked to ring if side effects or further bleeding occurred
At an outpatient visit one week later reported no further epigastric pain

Investigations and management after eight weeks

Endoscopy showed reduced (0.4 cm) gastric ulcer and no signs of recent haemorrhage

Biopsies from ulcer edge were negative for malignancy

Multiple gastric antrum and corpus biopsies negative for H. pylori

Omeprazole continued for a further 4 weeks

Investigations and management after 12 weeks

Endoscopy showed ulcer completely healed and biopsies from scar negative for malignancy

Omeprazole was ceased

Advised to avoid non-steroidal anti inflammatory drugs and to present promptly if dyspeptic symptoms recurred

GP helped her to go through medications and discard any that were her husband's or are not appropriate

She was referred to a physiotherapist and prescribed paracetamol, but this failed to relieve her back pain

Switched to ibuprofen (200 mg qid) plus misoprostol (200 p g qid)

Misoprostol induced diarrhoea and had to be ceased

Switched to a Cox-2 specific non-steroidal anti-inflammatory drug which was well tolerated until the pain settled, and then it was ceased.