Lecture 11 - GI inpatient Flashcards
Upper GI Bleeding Major causes
inflammation, ulcers, cancer within Esophagus, gastric or Duodenal speces
Mallory-weiss tear
Misoprostol MOA
synthetic analog of prostaglandin E to replace those lost when other agents that inhibit the roduction
Sucralfate MOA
provides protective covering, not widely used.
Achgalasia
Disorder involving lower esophageal sphincter
Zollinger-Ellison’s Syndrome
Hypersecretion of gastrin due to tumor
Modifiable risk factors PUD
Multiple NSAID use Concomitant anticoagulants Corticosteroids SSRIs Tobacco use
Non-modifiable risk factors PUD
Age > 25
History of PUD
H.Pylori infectin
Acid suppression therapy recommended in patients who….
are receiving prolonged ( > 6 months) high-dose steroids or when used concomitantly with NSAIDs
PUD and SSRI therapy
- using PPIs appear to mitigate the risk
2. no really clinically relevant, would prob keep person on SSRI in practice
PUD and smoking
> 10 cig per day can increase gastric acid secretion
Stress-related mucosal damage (SMRD)
most likely to occur in critical care patients
Estimated in 75% of pts will develop within 72hrs
SMRD in critically ill patients
Coagulopathy
long time on vent
head injury
History of GI bleed
2 + of following
Sepsis, > 7 days ICU, High dose Corticosteroids > 250mg hydrocort, overt bleeding > 6 day
SMRD in non-critically ill patients
> 2 of the following
GERD Duodenal or Gastric ulcer H.pylori infection active Presumed/known upper GI bleed pts receiving antiplatelet/ aspirin therapy Receiving H2 blocker or PPI at home
Prophylaxis against PUD
Most compelling to consider in….
Chronic NSAIDs + multiple NSAIDs
Previous PUD
Concomitant use w/ corticosteroids
Less compelling to consider in…
65+
combo SSRI + NSAIDs
Prophylaxis for SRMD
hospitalized pts meeting criteria previously outlined, only while criteria is met**
Agents for Prophylaxis NSAIDs
Oral H2RAs (able dose) = famotidine 20mg BID or 40mg QD
PPI - omen 20mg daily
Misoprostol 800mcg/.day
Agents for Prophylaxis SRMD
H2RA are preferred, PPI for those who cant tolerate or take
same doses as other….famotidine 20mg BID, 40mg QD, or omeprazole 20mg QD
sucralfate maybe considered if either or both CI
When are H2RAs and PPI CI
Hypersensitivity is only firm CI
Cautiously use H2RAs when…
CNS toxicity in pts > 50 w/ renal or hepatic dysfunction
Famotidne = specific QTc prolong in pts w/ renal dysfunction
Cautiously use PPI when….
combo w/ clopidogrel (esp omep/esomep)
Long-term use associated w/ inc MI, C.Dif, Bone fracture
what makes pt high risk for GI bleed?
previous GI bleed
Rockall score
Good score = < 3
Bad score = > 8
Risks for mortality from GI bleed
> 60yrs old Addition comorbidities, renal failure or metastatic cancer > 8 unit of blood w/in 1st 12hrs INR > 1.5 while not on anything Elevated BUN
Acute management of GI bleed
- Fluid resuscitation - IV fluids
- Endoscopic procedure +
can do pantoprazole 40mg IV q12hrs, or 80mg bolus X 1, then 8mg/hr drip for 42-72hrs…then move to 40mg PO BID
Continuous PPI > Intermittent
IV > PO
Re-bleeding risks
> 65yrs old
Chronic CVD comorbidities….HTN/CAD
Shock or coagulopathy at presentation
Long term management PUD
PPI > H2RAs
PPI - 1 QD dosing, can use 2 BID for severe case, 4-8weeks for those without severe complicating factors
refractory = ulcers after 12weeks of therapy
H2RA specific info
renal adjust
comparable results between agents
concern for thrombocytopenia
cimetidine numerous DDI
PPI specific infco
no renal adjust
no efficacy diff between agents
30-60min b4 meal = max pump inhib
DDI
Atazanavir = dec bioavailability
Levo = reduced absorption
Digoxin/nifedipine = inc absorption
Omeprazole info
Prilosec
40 QD, 20-40mg/day range
Lansoprazole info
Prevacid
30 QD, 15-30mg/day range
Pantoprazole info
Pantoprazole
40 QD, 40-80mg/day
Dexlansoprazole info
Dexilant
30-60mg QD dose + range
Famotidine info
20mg BID or 40mg HS
20-40mg day range
Cimetidine info
switch, dont use this shit
anticoagulant & anti platelet use after UGIB
Aspirin: reinitaiton w/ 7 days, ideally 1-3 days and with use of PPI
Thienopyridines: can use after resolution of bleeding/endoscopy
Warfarin: 1-7 days, but inc risk for recurrent UGIB
Novel anticoagulants: no sooner than 7 days after UGIB
PUD prophylaxis summary indications
Inpatient: highest risk include critically ill
Outpatient: highest risk include chronic NSAID/anticoag use
