sector of gastroenterological disorder
TRANSCRIPT
Sector of Gastroenterologica
l DisorderMunzur Morshed, Pharm D. candidate
2011Arnold & Marie Schwartz College of Pharmacy and
Health SciencesInternal Medicine-Advanced Pharmacy Practice
Maimonides Medical Center
Objectives Provide brief overview of the patients case Discuss the disease state, presentation
and signs and symptoms Explain pharmacological management
options that are available Display the place in therapy of each
medications Provide a synopsis of a major landmark
trial Discuss the patient’s appropriate
management options
Case PresentationHistory of Present Illness
LZ is a 49 y/o male, PMH significant of mild chronic gastritis, who came in to the ER, complaining of abdominal pain of moderate severity in the epigastric and RUQ that had started while the patient was sleeping last night. He subsequently had two episodes of nausea and vomiting and was brought in to the ER for further evaluation.
Case presentation-History of present illness cont…PMH: GastritisFH: UnknownSH: UnknowmNKDAVS: Temp: 98 ° F, BP: 139/76 mm
Hg, HR: 58 BPM, RR:21 BPM, Pain
scale: 10/10-Terrible pain to the abdomen
Case presentation- PhysicalsPhysical Findings: ABW: 63.2 kg, Height: 5’5, IBW: 57 kg Mental status: alert awake and oriented x 3; PERRL HEENT: Normocephalic, atraumatic, normal
oropharynx Lungs: Normal chest excursion, respiration breath
sounds are clear and equal bilaterally. No wheezes, rhonchi, or rales.
CV: Normal S1, S2, no murmur, rubs or gallops Extremities: Normal range of motion (ROM) in all
four extremeties, non-tender to palpitation, distal pulses are intact.
GI:Tender abdomen, nausea, and vomittingCXR: Not PerformedEKG: Normal sinus rhythym and elevation of the ST-
segment.Abdominal Ultrasound: Distended gall bladder with
thickening of the wall. This could represent cholecystitis. No stones were seen. If clinical suspicion is high, recommend HIDA scan
Case presentation-Lab Findings
Na: 139 mEq/L K: 3.8 mEq/L Cl: 1o3 mEq/L CO2: 28 mEq/L SCr: 0.9 mg/dL BG :188 mg/dL ABG analysis
pCO2: 46 ↑ , pO2: 26↓ ↓, 02Sat:100
WBC: 8.6 Hgb: 14.8 g/dL Hct: 41.8% ↓ Neutrophils: 84.5
↑ ↑ Plt: 132x
10^3/mm^3 Anion Gap: 8.0 ↓
Case presentation- Medications PTA
Omeprazole (Prilosec) 20 mg PO Daily
Diagnosis
Abdominal pain with nausea and vomitting
Abdominal Pain Perceived location of pain
not necessarily to its site of origin,which may be remote from the abdominal cavity
Caused by Inflammation (e.g.-
appendicitis, colitis) Organs being stretched or
distended (e.g.- Hepatitis, gallstones)
Lack of blood supply to the organs (e.g.- Ischemic colitis)
Abnormal contractions of the intestinal muscles (IBS)
Epidemiology Nearly 5 million American patients
presents to the ED with complaints of abdominal pain per year
Accounts for 5-10% of all ED visits 50% were hospitalized ▪ Contributing to overall mortality of 10%
American College of Emergency Physicians. Clinical policy:critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumaticacute abdominal pain. Ann Emerg Med. October 2000;36:406-415 Powers RD, Guertler AT. Abdominal pain in the ED: stability and change over 20 years. AmJ Emerg Med. 1995;13:301-303. McCaig LF, Stussman BJ. National Hospital Ambulatory Medical Care Survey: 1996 EmergencyDepartment Summary. Advanced data from Vital and Health Statistics, No. 293. Hyattsville,MD: National Center for Health Statistics; 1997.
PathophysiologyAmong the multiple mechanisms,
some of the reason of the pain originating in the abdomen is due to:
Inflammation of the parietal peritoneume.g. release of acid into the peritoneum from the
duodenum
Vascular Disturbancese.g. embolism to the superior mesenteric
artery
Obstruction of the hollow viscus
e.g acute billiary obstruction by a
gallstone
Injury to the abdominal walle.g. tear in the abdominal musulature from trauma
EtiologyExtra-abdominal
CausesAbdominal Wall
-Rectus Muscle Hematoma
Infectious
- Herpes Zoster
Metabolic
- AKA, DKA, SCD
Thoracic - MI, Pneumonia, -Pulmonary Embolism
Toxic - Opoid Withdrawal, - Heavy metal poisoning
http://www.merckmanuals.com/professional/sec02/ch011/ch011b.html#sec02-ch011-ch011b-398
Diagnosing abdominal painFactors
History
Findings on physical exam
Laboratory Test
Diagnostic Test
HistoryKey points of information on obtaining
history includes:
Location of the pain Alcohol Intake
Exacerbating and ameliorating factors
Medication history (e.g. NSAID’s)
Associated symptoms(e.g. fever, chills, nausea, vomiting,
diarrhea)Far more valuable than any lab or radiographic examination
Accurate diagnoses can be made on the basis of history alone
Findings on Physical exam
Will provide the valuable clues to the severity of the pain and the urgency of the situation
Facial Expression
Position in bed
Respiratory activityMeasurement of the patients vital signs is extremely crucial
Fever Signs that require urgent attention and intervention
Hypotension
Tachycardia
Tachypnea
Laboratory examinationsMay be value, but rarely establishes a definitive diagnosisComplete Blood Count (CBC)
Leukocytosis• >20,000/uL may be seen in a perforation of viscus, pelvic inflammatory disease, intestinal infarction• Normal WBC count is also very common
Blood Chemstry BUN, Glucose, LFT’s, Serum Electrolytes
Urinalysis Helps reveal the patients state of hydration Assess renal dysfunction, bleeding
Diagnostic TestsTests Detail
Upper and lower endoscopy
Best method to detect lesion within lumen and mucosa of the GI tract• Upper endoscopy detect ulcer
disease, and gastritis• Lower endoscopy detect acute
inflammatory bowel disease and tumor
ERCP (Endoscopic Retrograde Cholangiopanceatography )
Appropriate way to visualize the disease of the common bile duct and pancreas
HIDA Scan(Hepatobiliary Iminodiacetic Acid)
Appropriate to detect biliary disease if acute or chronic gallbladder related illness is suspectedUsually performed if a positive test for acute cholecystitis is present
Approach to treatment Ascertain urgent surgical
intervention is required Provide pain and other
symptomatic relief Initiatate empiric ABX therapy if
intraabdominal infection is suspected
Decrease the risk of developing serious complications such as dehydration, shock, etc
Pharmacologic TherapySymptom Relief- Pain ControlOpoid Analgesics Morphine
HydromorphoneMeperidine
Antacids or H2 Blocker
FamotidineRanitidine
Pharmacologic Therapy
Anti-Emetics Empiric Antibiotic
Prochloperazine (Compro)
Second-generation Cephalosporin
Promethazine (Phenergan)
Metronidazole
Ondasetron (Zofran)
B-Lactams
Opoid Analgesics
Morphine Hydromorphone
MOA Binds to opiate receptors in the CNS inhibiting the pain pathway, altering the perception of pain
Dose 2-5 mg IV initially; Titrate to effect
1-2 mg SC or IM; Titrate to effect
Contraindications
Documented hypersensitivity HypotensionCompromised airway
Opoid Analgesics cont…Morphine Hydromorphi
ne
Interactions
Phenothiazines:Antagonize the analgesic effect
TCAs, MAOIs, and other CNS depressant:
Potentiates adverse effects
Bupronorphine:Antagonize the analgesic effect,
increase CNS effects
TCAs, MAOIs, and other CNS depressant:
Potentiates adverse effects
Side Effects
Bradycardia, Hypotension, Drowsiness, Urinary Retention
Opoid Analgesics cont…Meperidine
MOA Binds to opiate receptors in the CNS inhibiting the pain pathway, altering the perception of pain
Dose 75-100 mg IM /IV Q-3-4 hrs.
Contraindications
Documented hypersensitivity MAOI’s Compromised airway
Opoid Analgesics cont…
Meperidine
Interactions Cimetidine: increased respiratory and CNS depression Hydantoins: decrease effect of meperidine
Side Effects Bradycardia, Hypotension, Drowsiness, Urinary Retention
H-2 blockersFamotidine Ranitidine
MOA Inhibits the release of histamine at the H2 receptor which then inhibits the release of gastric acid
Dose 20mg/50 ml IV
50 mg/50 ml IV
Contraindications
Hypersensitivity to H-2 blockers
Interactions Delaviridine Decrease effect of the delaviridineAzoles Decrease effect of Azoles
Anti-EmeticsProchlorperazine
Promethazine
Ondasetron
Dose 5-10 mg IM 12.5-25 mg IM
8-12 mg IV
C/I Hypersensitivity to the drugCNS depressionComa
Hypersensitivity to the drug
Side Effect
Agitation, Hypotension,Weight gain
Confusion,Delirium,DrowsinessEuphoria
Headache,MalaiseDrowsinessDizziness
Empiric Antimicrobial Initiate empiric antibiotic therapy if intra-
abdominal infection is suspected Second generation cephalosporin PLUS
metronidazole is the corner stone of therapyAntibiotic Dose
Cefotetan 1-3 g IV q12h
Cefoxitin 2 g q4-8h or 3 g q6h
Metronidazole
Loading : 15mg/kg infusion over 1 hourMaintenance: 7.5mg/kg IV infusion over 1 hour, q6h
Zosyn 3.375 g q6h IV
Levofloxacin 750 mg QD IV
Monitoring Parameter Monitor closely every hour for
improvement in pain Toxicity such as decrease blood
pressure, respiratory rate, and symptoms of GI constipation
Follow-up with frequent re-examination as soon as possible
Landmark TrialIntravenous Morphine for Early Pain Relief in Patients with Acute Abdominal PainPurpose To determine whether or not morphine affects the
evaluation or outcome for patients with acute abdominal pain
Study Design
Prospective, randomized, placebo-controlled trial
Methods 75 patients underwent randomization to receive Morphine Sulfate (n=35) and Normal Saline (n= 36) Patients ± 18 years old with abdominal pain for ± 48 hours were included If allergic to MS or who had systolic blood pressures < 90 mm Hg were excluded Study solution was titrated to the patient's response until adequate analgesia (up to a volume equivalent of 20 mg of MS) The pain response were monitored using a visual analog scale (VAS)
Landmark Trial cont…Intravenous Morphine for Early Pain Relief in Patients with Acute Abdominal PainResult The VAS pain level improved more for the MS
groupStudy solution dose was less in the MS group than it was in the NS group, 1.5 ± 0.5 mL vs 1.8 ± 0.4 mL (p <0.01)
Conclusion
Compared to placebo, the administration of MS to patients with acute abdominal pain ,effectively relieved the pain and did not alter the ability of physicians to accurately evaluate and treat patients.
Pace S., Burke ET. Intravenous Morphine for Early Pain Relief in Patients with Acute Abdominal Pain. Academic Emergency Medicine. 1996:3 (12,); 1086–1092.
Conclusion Definitive therapy is dependent on
the etiology of the pain Mainstays of therapy include
providing adequate analgesia and symptomatic relief
Prescribe empiric antibiotic if only suspecting intra-abdominal infection
Monitor patient very closely for symptomatic pain
Patient Case: Findings pertaining to the problem
Patient came in to the ED complaining of mid upper abdominal pain that is at a scale of 10/10
On admission, abdominal ultrasound had shown a distended gall bladder with thickening of the gall bladder wall
Lab work had shown that the patient has an anion gap of 8.0-suggesting a serious intra-abdominal process
Has an elevated neutrophil count, suggesting possible inflammation
Patient Case: Etiology of the problem
It was unknown
Patient Case: Treatment Morphine sulfate 5 mg IV STAT
Morphine is indicated for the treatment of moderate to severe pain No contraindications present
No asthma, low blood pressure, or any reports of hypersensitivity Appropriate to use to control the pain according to the package
insert and clinical trials Other alternative are meperidine (Demerol), fentanyl citrate (Sublimaze).
The dose is also appropriate to use at time Some toxicities that can occur are
Respiratory depression Bradycardia Hypotension.
No drug-interactions present Not on any benzos, cimitedine, chlorpromazine, codeine, etc.
Patient should be monitored for improvement in the pain level for efficacy
Monitor respiratory rate and symptoms of GI▪ Nausea, vomiting, constipation and hypotension
Patient Case: Treatment cont…
Zofran 4 mg IV STAT- To control nausea/vomitting
Patients abdominal pain and vomiting improved and patient was discharged on:▪ Cipro 500 mg PO BID x 7 days▪ Metronidazole 250 mg- 2 TAB PO TID for 7
days Follow up with Dr.Wasserman in
his office on Monday.
References American College of Emergency Physicians. Clinical policy:critical
issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumaticacute abdominal pain. Ann Emerg Med. October 2000;36:406-415
Powers RD, Guertler AT. Abdominal pain in the ED: stability and change
over 20 years. AmJ Emerg Med. 1995;13:301-303. McCaig LF, Stussman BJ. National Hospital Ambulatory Medical Care
Survey: 1996 EmergencyDepartment Summary. Advanced data from Vital and Health Statistics, No. 293. Hyattsville,MD: National Center for Health Statistics; 1997.
http://www.merckmanuals.com/professional/sec02/ch011/ch011b.html#sec02-ch011-ch011b-398. Accessed on 12/18/2010
Bryan DE. Abdominal Pain in Elderly Persons.E-Medicine.Available at http://emedicine.medscape.com/article/776663-print . Accessed on 12/18/2010
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