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

Thank You!