- What would you prescribe initially?
From the symptoms presented, I would suspect that Mike has peptic ulcer disease due to H. pylori. This bacterium sticks to the layer of mucus within the stomach, causing the protective layer to break down, causing the acid to eat the stomach. The initial medications I would order for the patient would be a combination of two antibiotics to prevent the H. pylori from becoming resistant to the medications. The combination of antibiotics I would recommend would be Amoxicillin 1000 mg PO BID and Flagyl 500 mg PO BID. I would also add Protonix 40 mg PO Daily to help heal acid damage to the stomach.
- How long would you prescribe these medications?
Amoxicillin and Flagyl would be taken for 10-14 days. Protonix would be taken for around 8 weeks, this helps heal damage from ulcers while preventing new ones.
- What other possible meds could you prescribe to assist with the side effects from the medications prescribed?
Along with the Protonix and the antibiotic combination, I would order this patient Carafate 1000 mg Q6H for 4 weeks. Carafate forms a coating over ulcers protecting them from further injury. I would educate this patient to take this medication on an empty stomach, an hour before meals. I would also order Bismuth subsalicylates (Pepto-Bismol) 300 mg PO QID PRN X10 days for stomach pain. Bismuth subsalicylate is a mild antiacid that reduces excess stomach acid, easing discomfort. It protects the stomach and lower part of the esophagus from stomach acid (NHS, 2019). Mike should be educated to take Pepto-Bismol 30 minutes before or after taking the Carafate, never at the same time.
- How would the treatment vary if the patient has GERD instead?
Treatment would be similar, but the antibiotics and Carafate would not be ordered. Protonix would be continued along with the Pepto-Bismol. I would order a H-2-receptor blocker, such as, Pepcid to decrease the acid within the stomach, in turn reducing heart burn. I would educate the patient to avoid caffeine, carbonated beverages, citrus fruits, garlic, spicy, fried, and fatty foods to prevent relaxation of the lower esophageal sphincter (LES) (Henricks, 2018).
Discussion Question 2
List differential diagnosis that would help confirm GERD while ruling out other diagnosis. Which medication is the best medication for treatment of GERD and why? What labs or other diagnostic tests that are used to confirm GERD? Your response should be at least 350 words.
Gastroesophageal reflux disease (GERD) is when stomach acid flows back into the esophagus and irritates the lining. This often causes heartburn, belching, bitter taste, and discomfort in the upper abdomen. To diagnose GERD, usually an esophageal pH test is ordered. The esophageal pH test is an outpatient procedure that measures the amount of acid that flows back into the stomach during a 24-hour period. An upper endoscopy can be used to view the structure of the esophagus and stomach, helping the provider to see inflammation or complications, such as, Barretts esophagus. Medications that should be ordered are histamine blockers, such as, Pepcid to help lower acid secretions. Proton Pump Inhibitors, such as, Protonix are good to order to suppress acid production and help heal the erosion within the esophagus. Protonix is considered the best and most effective treatment with GERD patients. Another drug that could be ordered alone with Protonix is Prokinetic agents, such as, Reglan to enhance the smooth muscles of the GI tract (John Hopkins, 2021). Reglan 10 mg PO QID for 8 weeks is normally used. This medication should be taken 30 minutes before meals and at bedtime.
A differential diagnosis for this would be acute gastritis, which is inflammation, irritation, or erosion of the stomach lining. It is often caused by excessive alcohol use, chronic vomiting, stress, or medications like inflammatory drugs. Symptoms include abdominal pain and bloating, indigestion, nausea, and burning feeling in the stomach between meals. This is often diagnosed the same as GERD, with an upper endoscopy. Depending on the cause, treatment will vary. If it is caused by H. pylori, there will be a combination of antibiotics and acid blocking drug. If caused by pernicious anemia, B12 vitamin shots are usually given. The basic treatment for this is taking antiacids, proton pump inhibitors, and H-2 blockers.
Another diagnosis would be esophagitis. This is inflammation that can damage tissue of the esophagus. It can be caused by stomach acid backing up into the esophagus, infection, or oral medications. Symptoms often include heartburn, difficulty swallowing, chest pain, and food getting stuck in the esophagus. Treatment of this is based off the cause and severity of tissue damage. This can lead to many issues if left untreated, such as, scarring, narrowing, and difficulty swallowing.
RxList. (2020, September 10). Carafate tablets (sucralfate): Uses, dosage, side effects, interactions, warning. RxList. Retrieved February 13, 2022, from https://www.rxlist.com/carafate-drug.htm#indications
NHS. (2022, August 13). Pepto-Bismol . NHS choices. Retrieved February 13, 2022, from https://www.nhs.uk/medicines/pepto-bismol/
Henricks, M., Henricks, M., Schipani, D., Welch, A., Contributor, E. H. G., Delshad, S., Rodriguez, D., Ryan, A., & By. (n.d.). Gerd diet: Foods to avoid and foods to consider. EverydayHealth.com. Retrieved February 13, 2022, from https://www.everydayhealth.com/gerd/guide/diet/
Gastroesophageal reflux disease (GERD) treatment. Johns Hopkins Medicine. (2021, March 3). Retrieved February 13, 2022, from https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/gastroesophageal-reflux-disease-gerd-treatment
Mayo Foundation for Medical Education and Research. (2021, February 23). Esophagitis. Mayo Clinic. Retrieved February 13, 2022, from https://www.mayoclinic.org/diseases-conditions/esophagitis/symptoms-causes/syc-20361224