Gastrointestinal Disorders 2018

Gastrointestinal Disorders 2018

1. III Upper GI Bleed p22

   • clinical symptoms
     • Predictors of death
       • Predictors of recurrence
         • Management of Upper GI Bleed:
           • Volume
             • crystalloid( NS )  and colloid (blood) to keep Hgb at 8-10 (if Hgb<7)
             • Risk scores
               • p 23 Blatcford and Rockall scales Risk score Blatchford , and Rockall scores a) risk of rebleeds b) need for urgent care or non urgent?
               • Endoscopy
                 • Enodscopic trt: a) perform within 12-24 h of presentation b)Endoscopic strategies: Combine epinephrine (may add ethonalamine) with another endoscopic therapy c)Others: cyanocrylate,Thrombin, Sodium tetradecyl sulfate, Polidocanol) d)Thermal coaptive therapy suing probe thermocoagulation, electocoagulation, laser - cheaper! and argon plasma coagulation d)place hemostatic clips
                 • Pharmacotherapy
                   • Pharmacological therapy: a) DC offending drug eg NSAID b)Erythromycin 250mg iv before endoscopy (optional) c)PPI eg Protonix or Esomeprazole(Europe) 80mg bolus + 8mg/h drip - can reduce lesion size given before endoscope. PPI given if endoscopy will be delayed or cannot be done too. Also give 80mg bolus + infusion 8mg/h over 72 h if pt has active bleed or can see an intact vessel(non bleeding) but it has a clot stuck to it. i)PPI associated with decr rebleeds, mortality , additional surgery- if pt had active bleeds and received endoscopic interventions ii) po daily dose can be used if it's a clean base in ulcer and not raised iii) Test for H.pylori and retest if -ve result. If it's H.pylori can use 2 ABX and PPI regime (quad,triple) and when H.pylori is eradicated there is no need for PPI after H.pylori is cleaned out. iv) assess need for continuing daily PPI- if needed do single daily dose PPI. v)assess need for NSAID/aspirin. Opt for COX2 + PPI if need NSAIDS. but if there is risk of CV DX -no COX2. vi) if need 81mg aspirin: use PPI. Reinitiate aspirin within 1-3- 7days and use PPI too. (Plavix more bleed risk cf aspirin) d) if ulcer was not due to H.pylori (-ve test) and not due to NSAIDS : then this is when you would use PPI long term  
                   • Prophylaxis of SRMD
                     • SRMD: Stress related Mucosal Damage Talks of risk for SRMD and contributing factors Risk factors in Box 4 for ICU..would need to treat if ICU pt has these risks
                     • p 24 Prevention: a)Antacids po or enteral tube. S/E: Diarrhea, constipation, electrolyte abnormalities b)Sucralfate : may lead to accumulation of Al and constipation. Can bind to other drugs in GI tract. Does not affect PLT. c)H2 blocker can be first line (po, IV intermittent, infusion) Cimetidine is the only FDA approved SRMD prevention. Can be asscoiated with CNS SE and thrombocytopenia Renal dosing needed d) PPI Health systems pharmacists have minimal recommendation for PPI in SRMD prevention due to lact of data, Yet is is commonly used. PPIs similar to H2 blocker wrt efficacy PO PPI as efficacious to iv to keep equivalent pH. Problem associated with C.dif in hospitalized pt.     
                     • Upper GI bleed + Cirrhosis
                       • administer Ceftriaxone see Q7 p 44 GIT disorders