Professional Documents
Culture Documents
Pre-Res Case Presentation: Jo Anne N. Ramos, MD
Pre-Res Case Presentation: Jo Anne N. Ramos, MD
Pre-Res Case Presentation: Jo Anne N. Ramos, MD
Jo Anne N. Ramos, MD
GOOD AFTERNOON!
Objectives
To present a case of a male patient who came in
Objectives
To review the journals regarding the
General Data
E.M.
56 year-old
Male
Mulawin Lane, Old Cabalan, Olongapo City
First admission
Chief Complaint
LIGHTHEADEDNESS/PALLOR
1 day PTA
consult with private MD, given Multivitamins and PPI (Omeprazole 40mg/tab OD) and CBC requested. No follow-up was done.
(+) lightheadedness, (+) pallor, (+) black tarry stool, (-) hematochezia
sought consult and subsequently admitted
pains
(-) DM (-) Allergies/Asthma/PTB (-) Previous blood transfusion, surgery, or hospitalizations
Family History
(+) Hypertension- maternal side
Personal/Social History
Unemployed at the moment
Review Of Systems
No weight loss, (+) easy fatiguability, no loss of appetite No jaundice, no abnormal pigmentation of the skin No headache, no colds, no throat pain No palpitation, no chest pain, no paroxysmal nocturnal dyspnea, no
orthopnea
No cough, no difficulty of breathing No changes in bowel habits, (+) melena, (-) diarrhea, (-) hematochezia,(-
Review of Systems
No polyuria, polydipsia, polyphagia
exercise capacity
Physical Examination
Patient is conscious, coherent, pale, lying comfortably on bed
Vital Signs: BP 100/70 CAR 109 RR 24 T 36.8 Pale palpebral conjunctiva, (-) nasoaural discharge, (-)
Cont.
filled rectal vault, (-) tenderness, (+) black stool on examining finger
Extremities are grossly normal, no edema, no clubbing, no
Salient Features
56 year-old
Male Hypertensive
Dizziness
Diclofenac
Epigastric pain
Melena Pallor
Differential Diagnosis
Characteristic of GI bleeding
Hematemesis Coffee-ground emesis Hematochezia
Melena
causes melena
Diverticula
True and false (pseudodiverticula)bleeding,
Esophageal Varices
Increased resistance to portal flow leads to a dilated veins.
NONVARICEAL BLEEDING Clinical Indicators Absence of liver dse History of peptic ulcers History of H. pylori History of retching/vomiting NSAID/Aspirin use Chronic renal dse Valvular Heart dse History of hereditary hemorrhagic telangiectasia
VARICEAL BLEEDING Cinical Indicators History of varices/variceal bleeding Spider angiomata Caput medusa Ascites Splenomegaly Hepatic encephalopathy Pancytopenia, low albumin
Esophagitis
Chronic intake of NSAID
S/S:
Odynophagia/dysphaghia Pyrosis
Stomatitis
Feeling of something stuck on the throat Nausea/Vomiting
Admitting Diagnosis
Upper GI Bleeding prob. Secondary to BPUD vs. NSAID-induced gastropathy Anemia Secondary
Diet: NPO, insert NGT Diagnostics: CBC, ABO typing, Na, K, BUN, SGPT/SGOT, Bleeding profile, Urinalysis, Blood Uric A, Chest Xray, 12-lead ECG IVF: PNSS 1L x 80 cc/hr
Admitting Orders
Therapeutics: Sucralfate 1 gm/tab, 1 tab now then QID Omeprazole 40mg/IV now then 40mg/IV OD Tranexamic Acid 1 g,/IV now
Diagnostics
Exam Blood type/Rh Hemoglobin Hematocrit Result B+ 44 0.14 0.85 0.14 0.01 Ref. Value -------140-180 0.40-0.50 0.30-0.70 0.20-0.40 0.01-0.05 Exam APTT PROTIME % Activity Result 27.3 sec 10.1 sec 145.6% Ref. Value 28-42 10-13.6 70-130
WBC Count
Neutrophils Lymphocytes Eosinophils
INR
MCHC RDW BUA
0.85
31 0.195 0.640 0.200-0.400
Platelet
MCH MCV
274 x 10 9
23.8 76.8
150-350
28-32 82-96
Cholesterol
Triglycerides HDL LDL
4.26
1.53 1.35 2.21
3.1-5.6
0.34-2.28 1.42-6.42 3.9-4.9
Diagnostics
Diagnostics
Light yellow Clear 1.010
Acidic
Negative for Glucose, Protein
Microscopic Analysis
EC 02 / uL Bacteria none
Chest Xray
Clear lung fields Normal Heart Size Atherosclerotic Aorta Diaphragms and bony thoracic cage are intact
Order:
Secure and transfuse 4U PRBC properly typed and crossmatched, each
oral mucosa and palms, no coffee ground appearance per NGT, chest/lungs findings are normal, abdominal findings are normal
hypotension Cont. Sucralfate 1gm/tab QID, Omeprazole 40mg/IV OD, Tranexamic Acid 500 mg/IV q6
medications given. He shows improvement from anemia with no other signs and symptoms of continuous GI bleeding. He is hemodynamically stable.
CBC
initial Hgb Hct WBC neutrophils lymphocytes eosinophis platelet 44 0.14 20.22 0.86 0.14 0.01 274 repeat 100 0.30 7.17 0.87 0.12 0.12 256 Ref value 140-180 0.40-0.50 5.0-10.0 0.30-0.70 0.12 0.01-0.06 256
EGD result
ESOPHAGUS GE Junctions CARDIA FUNDUS BODY ANTRUM PYLORUS
NORMAL
Stomach distensible No mass (+) 0.5cm ulcer whitebased at antrum
DUODENAL BULB (+) 1.0 cm ulcer white-based with surrounding inflammation at anterior aspect of duodenal bulb IMPRESSION: Gastric Ulcer; Duodenal Ulcer
O>
A> UGIB secondary to Gastric Ulcer and Duodenal Ulcer secondary
P> Diet as tolerated D/C IV Omeprazole and shift to Omeprazole tab Start following medications
Amoxicillin 500mg/tab, 2 tab BID Clarithromycin 500mg/tab, 1 tab BID For 7 days Omeprazole 20 mg/tab 1 tab OD for 2 weeks
Cont.
knee pain
For possible discharge
S> (-) dizziness, (-) epigatsric pain, (+) BM, yellowish to brown
O> Less pallor A> Patient improved
P> MGH w/ following medications: Amoxicillin 500mg/tab, 2 tabs BID for 6 more days Clarithromycin 500mg/tab, 1 tab BID for 6 more days Omeprazole 20mg/tab, 1 tab OD for 2 weeks Follow-up at OPD after 1 week.
Discussion
UGIB secondary to Chronic NSAID use
Bleeding from the upper GI tract is approximately 4 times as common as bleeding from the lower GI tract and is a major cause of morbidity and mortality.
1. 2. 3. 4.
1. Diuelafoys lesion 2. Vascular ectasia 3. Portal hypertensive gastropathy 4. Gastric varices 5. Neoplasia 6. Esphagitis 7. Gastric erosions
1. 2. 3. 4. 5.
Boonpongmanee S, Fleischer DE, Pezzullo JC, Collier K, Mayoral W, Al-Kawas F, et al. The frequency of peptic ulcer as a cause of upper-GI bleeding is exaggerated. Gastrointest Endosc. Jun 2004;59(7):788-94.
telangiectasia)
Portal hypertensive gastropathy Neoplasms, benign or malignant Hemobilia Hemosuccus Aortoenteric fistula
patients with UGIB, PUD was responsible for 2740% of all bleeding episodes.
Stabile BE, Stamos MJ. Surgical management of gastrointestinal bleeding. Gastroenterol Clin North Am. Mar 2000;29(1):189-222
include those with a history of alcohol abuse, chronic renal failure, and/or nonsteroidal antiinflammatory drug (NSAID) use.
Cheung FK, Lau JY. Management of massive peptic ulcer bleeding. Gastroenterol Clin North Am. Jun 2009;38(2):231-43
barrier and has a direct inflammatory effect on gastric and duodenal mucosa.
There is an interplay between H. pylori and
Gastric mucosal barrier: 1.Mucous-bicarbonate layer 2.Surface epithelial layer 3.Microvascular system
Noxious agents: 1.Hydrochloric Acid 2.Pepsin 3.Histamine 4.Bile 5.Pancreatic enzymes 6.Drugs 7.Bacteria
Membrane phospholipids
Phospholipase A2 Stomach Kidney Platelets Endothelium Arachidonic Acid Macrophages Leukocytes Fibroblasts Endothelium
COX-1 housekeeping
COX-2 inflammation
TXA2, PGI2, PGE2, Gastrointestinal mucosal integrity Platelet aggregation Renal function
Membrane phospholipids
Stomach Endothelium
Arachidonic Acid
COX-1 housekeeping
COX-2 inflammation
Prostaglandin depletion: 1.Inc HCl secretion 2.Dec mucin secretion 3.Dec HCO3 secretion 4.Dec surface active phospholipid 5.Dec epithelial cell proliferation
Prostaglandin depletion: 1.Inc HCl secretion 2.Dec mucin secretion 3.Dec HCO3 secretion 4.Dec surface active phospholipid 5.Dec epithelial cell proliferation
involve active arterial bleeding or those with a visible, protuberant, nonbleeding vessel in the base of the ulcer.
Despite the dangers associated with a bleeding peptic
Management
Rescusitation Discontinue factors that may propagate further
bleeding
Assess the level of bleeding Etiology of bleeding
Resuscitation
Discontinue anticoagulants (warfarin, heparin), thrombolytic agents Discontinue antiplatelet agents if possible (aspirin,clopidogrel)
Hematemesis,coffee ground emesis indicate upper GI bleeding Melena usually indicates upper GI bleeding, but can originate more distally
Maroon stool, red blood in the stool typically indicate lower GI bleeding
Any bleeding in the presence of hemodynamic compromise can be upper GI in origin
Pharmacologic Treatment:
TRIPLE THERAPY 1. Bismuth subsalicylate 2tabs QID+ Metronidazole 250mg QID+ Tetracycline 500mg QID 2. Ranitidine bismuth citrate 400mg BID + Tetracycline 500mg QID+Clarithromycin/Metronidaz ole 500mg BID 3. Omeprazole 20mg BID + Clarithromycin 500mg BID + Metronidazole 500mg BID or Amoxicillin 1g BID QUADRUPLE THERAPY Omeprazole 20mg (Lansoprazole 30mg) OD Bismuth subsalicylate 2 tab QID Metronnidazole 250mg QID Tetracycline 500mg QID
Center for Disease Control and Prevention, The Key to Cure H. pylori infection and Ulcer, the 2010 update
Thank You!