I need some advice on behalf of my mother, who is 68 years old. For 16 days, my mother feels like something stuck in the throat area, projectile vomiting when eating or drinking anything, weakness, body aches, nausea. She vomits about twice a day and cannot keep food or even soup down. She is currently on iv drip in the hospital as she became very dehydrated. Doctor has kept her nil by mouth and did an endoscopy today finally.
She saw an ENT and Internal medicine doctor while in the hospital. ENT dismissed her after nothing found in the throat using a camera but the internal medicine doctor did some investigations. Results showed UTI (epithelial cells 20-25/HPF and pus cells 30-35), TSH (13.5) raise, slight Candida albicans growth from the throat swab, and some white blood cell counts irregularities. An endoscopy was done, which found H.pylori from RUT biopsy and erosion lesions. All reports are attached.
Unfortunately, the GI doctor has now gone for holidays, leaving her in the hospital with no explanations of the endoscopy and biopsy findings or information about if the symptoms correlate with the results.
My questions are: Can H.pylori and the erosions lesions found in the endoscopy be the cause of her vomiting, nausea, weakness, and other test results? Or does the doctor need to investigate further, looking at the pancreas, thyroid, brain, nerves, etc., in more detail to explain these issues? Her gallbladder was removed many years ago. Any other angles of investigation would you recommend?
If H.pylori is the cause, what is the best treatment? She is already on some antibiotics (current medications attached) and probably has a resistance developed as she has taken several throughout her life.
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I completely understand that you must be very concerned and upset about your mother's health. I am sorry to hear that she has been admitted to the hospital because of dehydration. First of all, thankfully, her endoscopy (attachment removed to protect patient identity) did not show any nasty or ominous findings. It showed normal esophagus and a few erosion in the stomach and duodenum, which are likely due to H.pylori infection as confirmed by positive RUT (Rapid Urease Test).
Yes, these erosions in the stomach and duodenum can define her current symptoms. In medical terms, we call this a peptic ulcer disease (PUD). PUD can cause abdominal pain, stomach burning, vomiting, decreased appetite, and some serious case bleeding. Since these erosions are occurring secondary to H pylori infection, treatment of H pylori will cause the resolution of her erosions and symptoms.
Your query of other investigation to look for other causes. Well, since her TSH (thyroid-stimulating hormone) is high, which shows the thyroid gland is hypo functioning (low functioning) medically termed as hypothyroidism. Her weakness, loss of energy (apathy) could be related to hypothyroidism. This will also go away once treatment starts to achieve the target TSH level in the coming few weeks. The target TSH level is less than 10 for her age.
The pancreatic disorder usually comes with severe abdominal pain, which I did not find in her history. I do not think that she has any brain or nerve problem. Otherwise, she would have complained of headache, blurring of vision, loss of consciousness, or altered behavior. None of these symptoms present, as you mentioned.
For H.pylori treatment, she is supposed to take a 14 dose of antibiotics, which frequently causes gastric upset such as vomiting, nausea, and diarrhea. Almost similar symptoms for which she has been brought in the hospital. I want that once she is stable enough to take oral medicines, we should defer the treatment. However, a proton pump inhibitor (PPI) such as Esomeprazole 40 mg twice daily half an hour before meals can be given to suppress her stomach acid production and heal the erosions fully. I hope her symptoms will vanish in the next 48 hours of the start of PPI.
Plus, I suggest her to take tablet Ondansetron 8 mg thrice daily half an hour before meals. This medication would treat her nausea, vomiting and improve her indigestion and appetite.
I suggest to start her tablet Thyroxine 50 mcg before breakfast daily and would increase the dose based on her symptoms improvement and TSH monitoring. If an internal medicine physician has already given you a prescription for her hypothyroidism, I urge you to follow that. Otherwise, you can follow my recommendation for her hypothyroidism. Please find the treatment plan below.
I hope this helps.
Peptic ulcer disease H pylori-induced.Investigations to be done:
Urea breath test (UBT) after two weeks of completion of PPI therapy, and four weeks after completion of antibiotic use.
Can check serum amylase and lipase if there is suspicion of pancreatitis. Plus ultrasound abdomen and pelvis.
Drug-induced peptic ulcer disease.Probable diagnosis:
Peptic ulcer disease H pylori-induced.Treatment plan:
Capsule Esomeprazole 40 mg twice daily half an hour before meals, tablet Ondansetron 8 mg thrice daily half an hour before meals. If she is unable to tolerate anything by mouth, I suggest you to ask the treating physician to give by intravenous route. IV Omeprazole 40 mg twice daily instead of capsule Esomeprazole and injection Ondansetron instead of oral Ondansetron. For H pylori, the first line treatment should be given, if the patient is non-responsive to first line therapy, then second line therapy can be given. The failure of treatment to first line therapy can be confirmed after two weeks of completion of therapy by Urea breath test (UBT) for H pylori. It is not necessary that she has developed resistance to antibiotics only because she has been previously exposed to antibiotics. Let us try with the first line therapy. I hope this will work. Capsule Amoxil 1 gm twice daily for 10 days, tablet Clarithromycin 500 mg twice daily for 10 days, and continue capsule Esomeprazole 40 mg twice daily for now, while taking the above antibiotics and thereafter for total of six weeks.
If for example she did not tolerate the medication, please let me know I would recommend add on therapies or second line therapies.
Follow up to discuss long term management plan for her.
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