SCENARIO 3

Mrs Ms come to the UGD with nausea, dizziness, hematemetics and bloody bowel
movements. Provisional diagnosis was peptic ulcer Dyspepsia. Early action in the
UGD Mrs Ms was given intravenous Ringer's lactate and transferred to ward
medicine. Moreover given paracetamol 4x1, omeprazole 2x1, domperidone 3x1,
intravenous ceftriaxone 1gr/1g. After the endoscopy, in getting test results positive for
peptic ulcer were then given traxenamat acid 3x1 (250 mg / 8 hours intravenously).

STEP 1 CLARIFICATION OF TERMS

1. Peptic ulcer
- The upper gastrointestinal tract diseases
- The loss of superficial epithelial / deeper layers with more than 5 mm in
diameter, can be observed by endoscopy
- Open wounds are oval to the intestinal lining
- Diseases of the gastrointestinal tract due to mucosal damage
- Duodenum damage
2. Dyspepsia
- Indigestion
- Clinical symptoms that cause pain in the abdomen
3. Endoscopy
Methods to look inside the body using a flexible tube that has a tiny camera in
the end.

STEP 2 DETERMINE PROBLEM

1. What is causes a peptic ulcer?
2. Are there any interactions between these drugs? How are they interact?
3. Do the an endoscopy can cause peptic ulcer will getting worse?
4. Whether the drug is given to patients in accordance with the scenario, is it
right?

STEP 3 BRAINSTORMING
1. Peptic ulcer is caused by :
- Helicobacter pylori infection
- The effects of NSAID drugs and NSAIDs
- Stress
- Sensitivity GI mucosa against gastric acid and gastrin

- Smoking
2. No drug interaction in the scenario
3. Endoscopy is not going to cause peptic ulcer will be getting worse because
endoscopy performed only once
4. True or not the medication that given to the patient in according to the
scenario will be discussed in 4th step

STEP 4 ANALYSIS OF PROBLEMS

1. Pathophysiology of peptic ulcer are:
- Ulcer due to increased secretion of gastric acid, pepsin, and gastrin, GI
-

mucosal
Ulcer due to Helicobacter pylori
This happens due to Helicobacter pylori secrete toxins and enzymes that
can disrupt mucosal integrity through changes in the immune response,
inflammation, and increased secretion of gastrin, which stimulates gastric

acid secretion
Ulcer due to the use of NSAIDs
NSAIDs can cause erosion of the mucosa through two mechanisms, those
are topical that causes damage to the epithelial cells and inhibit the

synthesis of prostaglandins
Ulcer due to oral corticosteroids
Combination with NSAID use is shown to increase the risk of ulcers
Ulcer due to smoking
Smoking can impair ulcer healing and spurring repeated attacks

2. Etiology of ulcer are:

- Helicobacter pylori infection
- The effects of NSAID drugs and NSAIDs
- Stress
- Sensitivity GI mucosa against gastric acid and gastrin
- Smoking
3. Signs and symptoms of ulcer are:
- Stomach pain
In general, occur at night and cause awakened at 24.00-03.00
- Pain duodenal often occurs on an empty stomach
- Symptoms of dyspepsia as burning on epigastrum, belching, and flatulence

Ulcer due to a combination of Helicobacter pylori infection and NSAIDs

can cause bleeding, perforation, and penetrate surrounding organs such as

the pancreas, gallbladder, and liver

4. How to diagnose ulcers than with endoscopy
- Test radiology to detect ulcers or irritation
- Non-invasive:
a. Serological tests using the ELISA method to detect
antibodies against H.pylori
b. Urease positive test indicates presence of H. pylori bacteria activity
the use of urease to convert urea to ammoniac
so that the environment becomes acidic bacteria
5. Drugs for peptic ulcer

No

Drug classes

H2 receptor

drugs
Cimetidine,

Inhibit acid secretion by

Diarrhea,

antagonists

famotidine,

inhibiting the binding

constipation,

nizatidin, and

between histamine with

headache

PPIs (proton

ranitidine
Omeprazole,

its receptors
Bind K + / H +-ATPase

Diarrhea,

pump

Pantoprazole,

in irevesibel thus

stomach,

inhibitors)

lansoprazole,

inhibiting the proton

nausea,

esomeprazol, and

pump and inhibit the

headache

rabeprazol
antacids

secretion of HCl
Al (OH), and Mg (OH)

Antacids

Examples of

Mechanism of action

binds to gastric acid and

Side effects

Mg : Diarrhea
Al:constipation

increased mucosal
4

Sucralfate

resistance to acid
Binds to ulcers tissue, it

Constipation,

can form a coating that

dry mouth,

protects the ulcer from

nausea

stomach acid, thereby

allowing ulcers to heal
5

Misoprostol

(regenerate)
Prostaglandin E1
analogue that is
antisecretory and

Diarrhea

cytoprotective that can

prevent ulcers due to
6

Antibiotics

Amoxicillin,

NSAID use
Stop the growth of

Nausea,

clarithromycin,

Helicobacter pylori

vomiting,

metronidazole,

diarrhea

tetracycline
6. Non-pharmacological therapy of peptic ulcer,
- Reduce stress, smoking, and use of NSAIDs
- Avoid foods and beverages that cause dyspepsia and aggravate ulcer
symptoms, such as acidic foods, spicy, caffeine

7. Algorithm peptic ulcer

8. Analysis of drugs given in the scenario

No
1

Drugs
Ringer's lactate
infusion

Indication
Nausea, vomiting

Paracetamol

Dizziness

Omeprazole

First line peptic ulcer

Domperidone

Vomiting

Ceftriaxone

Antibiotics

Traxenamat acid

Shorten bleeding

9. Treatment in the UGD is right because the treatment depend on each

symptoms
10. Treatment of side effects on peptic ulcer,
- Lowering the dose of drug
- Replace drug

STEP 5 LEARNING OUTCOME

1. How the right conditions for the use of antacids in peptic ulcer?
2. How monitoring and evaluation of peptic ulcer therapy?
3. How does the mechanism of drug action in the scenario?

STEP 6 SELF-STUDY

STEP 7 REPORTS THE LEARNING OUTCOME

1. The right conditions for the use of antacids in peptic ulcer, namely in antacids
that can be absorbed and not be absorbed. Antacids that can be absorbed is an
antacid that can be absorbed by the bloodstream so that if in continuous use
can cause changes in blood acid-base and cause alkalosis. Examples of sodium
bicarbonate and calcium carbonate. While antacids are not absorbed are drugs
that bind to gastric acid forming material which is survive in the stomach
reduces digestive fluids and reduce ulcer symptoms without causing alkalosis.
An example is the Al (OH), and Mg (OH)
2. Monitoring and evaluation of peptic ulcer therapy, namely:
- Allergy testing (if due to Helicobacter)
- Urease test
- Note if there are drug interactions
- Paracetamol: use if necessary
- Omeprazole: cultivated drink before bed
- Domperidone: should not be used continuously

- Therapy is successful between 3-4 days

- PPI should not be stopped arbitrarily
- Keeping a diet and mealtimes
3. Mechanism of action of drugs in the scenario
No
1
2

Drugs

Mechanism of action

Ringer's lactate

Rehydration or help for

infusion

Iv injection

Paracetamol

Work on COX3 receptor

Bind K + / H +-ATPase
in irrevesible thus

Omeprazole

inhibiting the proton

pump and inhibit the
secretion of HCl

Domperidone

Work on Dopamine
receptor 2
Inhibit the synthesis of
microbial cell wall

Ceftriaxone

(peptidoglycan synthesis
of bacteria needed for
toughness walls)
Substant which inhibits

Traxenamat acid

activation of
plasminogen

CONCLUSION

Peptic ulcer is the loss of superficial epithelial / deeper layers with more than 5 mm in
diameter, can be observed by endoscopy. In the scenario, it caused by Helicobacter
pylori, the drug is omeprazole for peptic ulcer. It is better to avoid the food or
beverage that caused peptic ulcer.