Post on 08-Feb-2022
Dr. Melanie Pinchbeck
GI Update 2013
May 11, 2013.
Faculty/Presenter Disclosure
• Faculty: Dr. Melanie Pinchbeck
• Relationships with commercial interests:
–Not Applicable
Disclosure of Commercial Support This program has received financial support from Abbvie,
Aptalis, Ferring, Janssen, Olympus, Pendopharm and Takeda in the form of unrestricted educational grants
• Potential for conflict(s) of interest:
– Takeda markets a product that will be discussed in this program: pantoprazole, dexlansoprazole
– Aptalis markets a product that will be discussed in this program: sucralfate
Mitigating Potential Bias
In addition to drugs produced by the sponsors of this program, drugs of the same class produced by other manufacturers will also be discussed in the same context
Objectives At the conclusion of this presentation, the learner will:
Understand how physiologic changes of pregnancy affect the normal function of the gastrointestinal (GI) tract
Be able to interpret liver biochemistry in pregnant patients and recognize which patterns of biochemistry require further investigation and referral
Have an approach to treatment of gastroesophageal reflux disease, constipation, nausea and vomiting, and hyperemesis gravidarum in pregnancy
Know which common GI medications can be safely prescribed in pregnancy and breastfeeding
Physiologic Changes in Pregnancy
Plasma volume ↑ ~50%
Physical exam
spider angiomas
palmar erythema
liver not palpable
Fasting GB volume & residual volume ↑
GI adaptation to pregnancy
Gastrointestinal motility significantly altered
→ nausea, vomiting, constipation
Enlarging uterus displaces bowel
→ displacement of appendix
Decreased gallbladder motility & increased bile lithogenicity
→ increased risk of gallstones
Clin Colon Rectal Surg. 2010. 23(2): 80-9.
Liver biochemistry in pregnancy
KEY POINT: ↑ ALT, AST, bilirubin and/or fasting total bile acids should be considered pathologic
Liver tests affected by pregnancy
Liver tests NOT affected by pregnancy
↓ serum albumin Aminotransferases (ALT, AST)
↑ Alkaline phosphatase (ALP)
Prothrombin time (INR)
↓ serum bilirubin Total bile acids
Hyperemesis gravidarum (HG) Severe nausea & vomiting of pregnancy which can result
in complications & hospitalization
Caused by steroid hormones & hCG
Differential diagnosis Urinary tract infections, peptic ulcer disease, pancreatitis
Decreased risk Smoking
Maternal age > 30
J Obs Gyn. 2011. 31: 708-12.
HG – Risk Factors Hx of hyperemesis gravidarum (15%)
Helicobacter pylori
Psychiatric disorders
Previous molar pregnancy
Pre-existing diabetes
Asthma
Female fetus
Multiple gestation
J Obs Gyn. 2011. 31: 708-12.
HG - Diagnosis Profuse vomiting & dehydration
Ketonuria
Abnormal electrolytes
Elevated liver enzymes
Loss of > 5% of pre-pregnancy weight
Elevated amylase (salivary)
J Obs Gyn. 2011. 31: 708-12.
Treatment of HG Intravenous fluids
Saline & dextrose solutions
Monitor electrolytes and urinary ketones
Antiemetics
Post-pyloric feeding tubes & total parenteral nutrition only used in severe refractory cases
Thiamine supplementation
J Obs Gyn. 2011. 31: 708-12.
Medications in pregnancy
Gastroenterology. 2006. 131(3): 283-311.
Safety of Antiemetics Drug Risk Factor Type of Study
Diphenhydramine C
Domperidone C Safety unknown
Metoclopramide B No teratogenicity; population-based study
Ondansetron B Controlled trial
Prochlorperazine C No teratogenicity; large database study
Promethazine C No teratogenicity; large database study
Gastroenterology. 2006. 131(3): 283-311.
GERD in pregnancy
30 – 50% of pregnant women
Lifestyle modification
Adequate for mild symptoms
Antacids
H2 – blockers
Proton pump inhibitors
Aliment Pharmacol Ther. 2005. 22(9): 749-57.
Antacids Drug Risk
Factor Use in pregnancy Safety in lactation
Aluminum-containing
none Most low risk Low risk
Calcium-containing
none Most low risk
Low risk
Magnesium- containing
none Most low risk
Low risk
Sodium bicarbonate
none NOT SAFE (alkalosis)
Low risk
Sucralfate B Low risk No human data
Gastroenterology. 2006. 131(3): 283-311.
Antacids Drug Risk
Factor Use in pregnancy Safety in lactation
Aluminum-containing
none Most low risk Low risk
Calcium-containing
none Most low risk
Low risk
Magnesium- containing
none Most low risk
Low risk
Sodium bicarbonate
none NOT SAFE (alkalosis)
Low risk
Sucralfate B Low risk No human data
Gastroenterology. 2006. 131(3): 283-311.
H2-blockers
Drug Pregnancy Risk Factor
Lactation
Famotidine B Enters breast milk; not recommended
Ranitidine B Enters breast milk; use caution
Cimetidine B Enters breast milk; not recommended
Gastroenterology. 2006. 131(3): 283-311.
Proton pump inhibitors
Drug Pregnancy Risk Factor
Lactation
Esomeprazole B Excretion in breast milk unknown; not recommended
Dexlansoprazole B Excretion in breast milk unknown; not recommended
Lansoprazole B Excretion in breast milk unknown; not recommended
Omeprazole C Enters breast milk; not recommended
Pantoprazole B Enters breast milk; not recommended
Rabeprazole B Excretion in breast milk unknown; not recommended
Gastroenterology. 2006. 131(3): 283-311.
Proton pump inhibitors
Drug Pregnancy Risk Factor
Lactation
Esomeprazole B Excretion in breast milk unknown; not recommended
Dexlansoprazole B Excretion in breast milk unknown; not recommended
Lansoprazole B Excretion in breast milk unknown; not recommended
Omeprazole C Enters breast milk; not recommended
Pantoprazole B Enters breast milk; not recommended
Rabeprazole B Excretion in breast milk unknown; not recommended
Aliment Pharmacol Ther. 2005. 22(9): 749-57.
Bloating and constipation
Slowing of intestinal motility, mechanical obstruction, iron supplementation
First line therapy
Gradual fiber supplementation
↑ water intake
Second line therapy
Docusate
Osmotic laxatives
Gastroenterology. 2006. 131(3): 283-311.
Laxatives Laxative Pregnancy
Risk Factor Use in pregnancy & lactation
Mineral oil None Not recommended; ↓ fat-soluble vitamin absorption
Castor oil X Uterine contraction
Lactulose B No human studies in pregnancy
PEG C Effective; negligible absorption
Senna C Low risk for short-term use; secreted in breast milk
Bisacodyl C Low risk for short-term use
Docusate C Low risk
Gastroenterology. 2006. 131(3): 283-311.
Laxatives Laxative Pregnancy
Risk Factor Use in pregnancy & lactation
Mineral oil None Not recommended; ↓ fat-soluble vitamin absorption
Castor oil X Uterine contraction
Lactulose B No human studies in pregnancy
PEG C Effective; negligible absorption
Senna C Low risk for short-term use; secreted in breast milk
Bisacodyl C Low risk for short-term use
Docusate C Low risk
Gastroenterology. 2006. 131(3): 283-311.
Summary & Take Home Points
The appendix can be displaced by an enlarging uterus; appendicitis may present with an atypical location of pain
Elevated serum aminotransferases, bilirubin & serum bile acids are NOT normal in pregnancy & require further investigation
Hyperemesis gravidarum is an extreme form of nausea & vomiting in pregnancy characterized by maternal electrolyte abnormalities, dehydration, elevated liver enzymes, & need for hospitalization
Summary & Take Home Points
Sodium bicarbonate-containing antacids are NOT safe in pregnancy
The use of H2-blockers and proton pump inhibitors in pregnancy is safe Only omeprazole is pregnancy risk factor category C
Fiber supplementation is the 1st line treatment for constipation in pregnancy; osmotic laxatives are the preferred 2nd line therapy
Castor oil is contraindicated in pregnancy
Questions?