Scenario 1 Harry

Question 1

What is hematemesis?

Answer 1

The Vomiting of blood

Question 2

How does ibuprofen help Harry’s back pain?

Answer 2

When cells are damaged they release arachidonic acid. The two enzymes that break it down are cox-1 and cox-2 and convert it into prostaglandin H2 which then convert it into many other chemicals which increase temperature, lower pain threshold, and inflammation. The ibuprofen comes in and is absorbed through the stomach wall to our blood stream. It attaches to cox-1 and cox-2 and prevents the enzymes from breaking arachidonic acid down which prevents pain. Then eventually Cox-1 and Cox-2 reject the ibuprofen then you need to see if you want more.

Question 3

What is dyspepsia?

Answer 3

Pain in the upper gut: stomach oesophagus and duodenum

Question 4

How does Gaviscon work?

Answer 4

When Gaviscon hits the stomach acid it goes into a foam barrier and surrounds the stomach contents and keeps them in the stomach rather than in the oesophagus where is hurts.

Question 5

What is a side effect of Gaviscon?

Answer 5

Constipation or diarrhoea

Question 6

What is an endoscopy?

Answer 6

An upper gastrointestinal (UGI) endoscopy is a procedure that allows your doctor to look at the interior lining of your esophagus , your stomach, and the first part of your small intestine (duodenum ) through a thin, flexible viewing instrument called an endoscope. It relays it onto a TV

Question 7

What is a biopsy?

Answer 7

Taking a small tissue sample and examining it under a microscope

Question 8

What is the pathophysiology of H.pylori?

Answer 8

H.pylori could be in your stomach as 50 per cent of people have it in them or you may have got through and infection which could be through contaminated foods. The H.pylori changes the chemical urea to carbon dioxide and ammonia because it has the enzyme urease. Ammonia is an alkaline so it neutralizes the acidity and makes it thin and watery therefore the h.pylori moves down using its flagella. Once it has moved to the stomach cells it can adhere to the stomach cells using liposachride. Once it has stuck to the stomach cells it can secrete dangerous exotoxins like Cag A and Vac A. Cag A disrupts cell integrity and breaks down tight juntions between stomach cells . Also stimulates the production of cytokins such as interlukin A which promotes imflation. Vac A causes death to stomach cells. This combined causes the breakage of the stomach cells which causes the hydrochloric acid comes in which damages the surrounding area causing the stomach ulcer.

Question 9

When the H.plylori causes inflammation what does that do? And what can it cause?

Answer 9

The H.pylori infection will promote inflammation will result in a lot more hydrochloric acid being produced by the parietal cells. This is because inflammation promotes hydrochloric acid in the stomach due to histamine. With so much hydrochloric acid being produced it could leak into the duodenum causing a duodenal Ulcer.

Question 10

What is the pharmacodynamics of amoxicillin?

Answer 10

antibiotic stops the H pylori from making its cell wall. The cell wall is protective - it prevents the bacterial cell contents from spilling out and prevents stuff in the bactrium’s environment that might be harmful to the bacterium from getting into the bacterium. - in this case - the clarithromycin

Question 11

What does Clarithromycin do?

Answer 11

works inside the bacterium - inhibits ribosomes’ ability to make proteins - so the bacterium can’t carry out its norma; cell functions and dies

Question 12

Define gastric ulcer

Answer 12

A break in the protective mucosal line of the stomach wall and underlying muscularis mucosa layer

Question 13

Discuss the pathophysiology of gastric ulceration

Answer 13

Hcl and pepsin penetrate the mucosal barrier which will be right up to the muscularis mucosa. This strong acid inflamed and destroys the cells and pepsin digests the proteins in the cells plasma membranes and inside the cells so kills the cells etc.

Blood vessels in the stomach wall are eroded which means bleeding.
Ulceration thru thickness of stomach wall means perforation

Question 14

Pharmacokenetics of amoxicillin

Answer 14

Absorbed rapidly
Bioavailability 80 percent

Distribution: most bodily fluids/ csf less than 1 percent / protein bound 20 percent

Metabolism: heptic

Excreted 60 percent in 8 hours
Half life: 61.3 mins

Question 15

What shouldn’t you take gaviscon with?

Answer 15

Antacids may impair absorption of many drugs eg

ACE inhibitors, antibacterials, digoxin

Question 16

Why is a mixture of 2 antibiotics used off triple therapy

Answer 16

One is ineffective- H.pylori is tough

Resistance - easily develops to just one antibiotic so needs two

Question 17

What happens if the infection persists?

Answer 17

Retreat with quadruple therapy including antibiotics not used before and taken for 14 days

Question 18

Why is a proton pump inhibitor used? And what does it do?

Answer 18

Esomeprazole block the H+/ k+ part of the pump so therefore HCL cannot be formed this means:

Less acid formed so less corrosion/inflammation
Less acid so less peosinogen activated to pepsin so
Less breakdown of structural proteins in gut wall cells
Less cell necrosis
Ulcer able to heal

Question 19

Why should Harry cut down smoking

Answer 19

Increases the risk of getting h.pylori
Slows the process of the ulcer healing
Increases the likelihood that stomach ulcers will reoccur
Increases the production of substances that may harm the mucosal layer such as pepsin
Decreases factors that protect and heal the lining, including blood flow and secretion of mucus

Question 20

Why should Harry stop taking ibuprofen?

Answer 20

It blocks cox-1 and cox-2 and cox-1 carries out the “housekeeping functions” which are:
Increase blood flow to stomach wall so stimulate mucus producing cells
enables platelets to stick together when blood clot production required
enables production of macrophages

If these are blocked it means:
Bleeding
Less mucus barrier
Chronic inflammation due to reduced immune cell function in the stomach wall

Question 21

Pharmacokinetics of amoxicillin

Answer 21

Absorbed rapidly

Distribution: most bodily fluids/ csf less than 1 percent / protein bound 20 percent

Metabolism: heptic metabolism accounts for 30 percent of most penicillins

Excreted 60 percent in 8 hours
Half life: 61.3 mins

Question 22

Pharmacokinetics of clarithromycin

Answer 22

Absorbed: clarithromycin is well absorbed acid stable and may be taken with food
Protein binding 70 percent
Metabolised: heptic - metabolised using cytochromes to 14-hydroxyclarithromycin and N-desmethylclarothromycon
Excretion: 30 percent after 12 hours
Half life: 3-4 hours

Question 23

Pharmacokinetics of I ibuprofen

Answer 23

Absorbed: 80 percent GI tract 
Protein binding: 90 percent
Metabolised: by oxidation to 2 inactive metabolised 
Elimated: urine
Half life: 3 hours

Question 24

Pharmacokinetics of esomeprazole?

Answer 24

Absorption: 90 percent
Protein binding: 97 percent
Mainly heptic. Completely metabolised by the cytochrome p450 system.
Elimation: 80 percent excreted as metabolites in the urine and 20 percent in feces
Half life: 1houurs
Bioavailability 65 percent

Question 25

Side effects of triple therapy?

Answer 25

Diarrhoea, nausea, inflammation in the bowel. Could mean clostridium difficile

Question 26

Side effects of amoxicillin

Answer 26

Breathing problems, dark urine and allergic reactions e.g. Redness of the skin

Question 27

Side effects of ibuprofen

Answer 27

Nausea, vomiting, diarrhoea

Question 28

Side effects of esomeprazole

Answer 28

Dizziness, diarrhoea, tachycardia

Question 29

Progression after gastric ulceration

Answer 29

Bleeding/ small scale/chronic- malena - haemorrhage -shock - death

Perforation - heck and pepsin enter the peritoneal cavity and digest any tissue there - peritonitis - shock - death

Question 30

What tests could you see if Harry still had h.pylori

Answer 30

Urea breath test and stool antigen test