1. using PPIs appear to mitigate the risk 2. no really clinically relevant, would prob keep person on SSRI in practice

Lecture 11 - GI inpatient Flashcards by Patryk Lasiuk

Upper GI Bleeding Major causes

inflammation, ulcers, cancer within Esophagus, gastric or Duodenal speces

Mallory-weiss tear

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Misoprostol MOA

synthetic analog of prostaglandin E to replace those lost when other agents that inhibit the roduction

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Sucralfate MOA

provides protective covering, not widely used.

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Achgalasia

Disorder involving lower esophageal sphincter

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Zollinger-Ellison’s Syndrome

Hypersecretion of gastrin due to tumor

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Modifiable risk factors PUD

Multiple NSAID use
Concomitant anticoagulants
Corticosteroids
SSRIs
Tobacco use

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Non-modifiable risk factors PUD

Age > 25
History of PUD
H.Pylori infectin

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Acid suppression therapy recommended in patients who….

are receiving prolonged ( > 6 months) high-dose steroids or when used concomitantly with NSAIDs

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PUD and SSRI therapy

using PPIs appear to mitigate the risk

2. no really clinically relevant, would prob keep person on SSRI in practice

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PUD and smoking

> 10 cig per day can increase gastric acid secretion

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Stress-related mucosal damage (SMRD)

most likely to occur in critical care patients

Estimated in 75% of pts will develop within 72hrs

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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

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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

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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

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Prophylaxis for SRMD

hospitalized pts meeting criteria previously outlined, only while criteria is met**

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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