: Current Knowledge in PT : Gastrointestinal Disease // : 22/10/57 : :

10

Gastrointestinal Disease

Pre-test 1. The preferred management of a 70-year-old woman with rheumatoid arthritis who is at risk of developing

an NSAID-induced ulcer or ulcer-related complication is

A. Misoprostol 100 g twice daily

B. Famotidine 40 mg twice daily

C. Pantoprazole 40 mg daily

D. Omeprazole 40 mg twice daily

PPI 2 Omeprazole pantoprazole pantoprazole 40 mg

daily Omeprazole 40 mg twice daily

2.Which of the following statement best characterizes the current status of drug therapy in the prevention of

stress-related mucosal bleeding?

A. Large randomized, controlled trials confirm that an intravenous proton pump inhibitor is superior to an

intravenous H2-receptor antagonist

B. Antacids are the drugs of choice because they are effective and least costly

C. Continuous infusion of an H2-receptor antagonist provides similar efficacy as intermittent intravenous

administration

D. Sucralfate is not effective

A PPI H2RA evidence

H2RA continuous drip IV push q 8 h

3. Which of the following best describes the patient group for whom screening esophagogastroduodenoscopy

(EGD) is recommended to evaluate for the presence of gastroesophagealvarices?

()

A. All patients with chronic hepatitis C infection

B. All patients with chronic hepatitis C infection who have a history of alcohol abuse

C. All patients with cirrhosis

D. Patients with cirrhosis if they have documented decompensated cirrhosis

gastroesophagealvarices screen

4. Which one of the following oral regimens is recommended as a preferred pharmacologic medication for

primary prophylaxis against variceal hemorrhage?

A. Nadolol 20 mg daily

B. Atenolol 50 mg daily

C. Lisinopril 10 mg daily

D. Spironolactone 100 mg daily

Beta-blocker non-selective

beta2-blocker portal vein

portal hypertension

5. Which one of the following treatments for H.pylori is best for the patient who has a history of penicillin

allergy (anaphylaxis)?

A. Amoxicillin 1 g twice daily plus clarithromycin 500 mg twice daily plus esomeprazole 40 mg once daily for 7

days

B. Amoxicillin 1 g twice daily plus clarithromycin 500 mg twice daily plus esomeprazole 40 mg once daily for

14 days

C. Bismuth subsalicylate 525 mg 4 times/day plus metronidazole 250 mg 4times/day plus tetracycline 500 mg

4 times/day plus esomeprazole 40 mg once daily 7 days

D. Bismuth subsalicylate 525 mg 4 times/day plus metronidazole 250 mg 4 times/day plus tetracycline 500

mg 4 times/day plus esomeprazole 40 mg once daily 14 days

2 penicillin

6. What 2 factors are strong independent risk factors for clinical important bleeding in IPD patients?

A. Mechanical ventilation and renal failure

B. Respiratory failure and liver failure

C. Mechanical ventilation and coagulopathy

D. Multiple trauma and coagulopathy

stress ulcer Mechanical ventilation and coagulopathy INR prolong

PPI H2RA Bleeding

7. Which test is best to perform in the patient who receiving long term esomeprazole therapy?

A. Peripheral bone mineral density (BMD) screening

B. Serum magnesium

C. Serum potassium

D. Chest radiograph

PPI BMD PPI

screen BMD Mg

PPI Mg

8. A woman who is 20 weeks pregnant is seen at the clinic for heartburn. She has tried antacids with very

little relief. All tests and evaluations are normal. Which one of the following is best to recommend for this

patient?

A. Omeprazole 20 mg once daily

B. Magnesium and aluminum hydroxide, 15 ml orally four times/day

C. Ranitidine 150 mg orally twice daily

D. Calcium carbonates 500 mg orally four times/day as needed

9. Which one of the following is not a recommended lifestyle modification aimed to decrease the incidence of

acid reflux and enhance esophageal clearance?

A. Refraining from food consumption 3-4 hours before going to bed

B. Gum chewing

C. Wearing tight-fitting Clothes

D. Smoking cessation

GERD

10. Which one of the following patients would most need referral to a gastroenterologist?

A. A 71-year-old patient with heartburn for past month

B. A 38-year-old patient with no relief of GERD symptoms after esomeprazole 20 mg/day PPI for 4 weeks

C. A 42-year-old patient with GERD symptoms and persistent difficulty swallowing

D. A 55-year-old patient with GERD for 5 years

GERD

Upper Gastrointestinal Bleeding case: CC: BZ 70 ER (vomiting coffee-ground material; black)

(tarry stool) confusion, dizziness

PMH: MI, HTN, Type2 DM, Hypercholesterolemia and low back pain

CM:

ASA 81 mg OD

Enalapril 5 mg BID

Amlodipine 10 mg OD

Carvediol 6.25 mg BID

Simvastatin 10 mg OD

Glipizide 5 mg OD

Piroxicam 10 OD as needed for low back pain

SH: Smoking 10 pack year

Alcohol: Occasional drink

Three can of cola per day

FH: Father died by MI at 65 y/o

Mother died by stroke at 68 y/o

All: NKDA

PE:

GEN: Thai male, look fatique and confuse

VS: BP 98/52 mmHg, HR 101 bpm, RR 30 rpm, T 37.7 C

HEENT: PERRLA, moderate pale, no jaundice

Lung: Clear

Heart: Tachycardia, Normal S1 S2 no murmur

ABD: Soft, Moderate tenderness at epigastrium, Hyperactive bowel sound

EXT: Edema 1+, Cold extremities

NEURO: A&Ox2

PR: Melena ( )

Lab test:

Na 135 mEq/L Glucose 140 mg/dL

K 4.1 mEq/L WBC 11000/mm3

Cl 103 mEq/L Platelet 102000/mm3

Bicarb 25 mEq/L Hgb 7.9 g/dL (12-14)

BUN 19 mg/dL Hct 23.2% (Hgb x 3)

Scr 1.2 mg/dL PT 16 sec (10-13)

INR 1.3 (0.9-1.1)

Nasogastric aspiration reveals blood in stomach

Diagnosis: Upper gastrointestinal bleeding

( Peptic ulcer Develop GI bleeding .)

Nsaids H.pyroli

Question 1. What is the risk factors of gastrointestinal bleeding in this patient ?

2

1. > 65

2. Nsaid ASA (Piroxicam 10 mg OD High dose)

Ref. Guidelines for Prevention of NSAID-Related Ulcer Complications

2. How can we manage this patients gastrointestinal bleeding?

Endoscope, PPI

- bleeding ( BP drop shock )

BP stable Endoscope PPI Endoscope PPI

- Endoscope warfarin

trauma bleeding check INR

-PPI high dose

3. What is the role of proton pump inhibitors to treat the patients gastrointestinal bleeding?

- PPI

- PPI Endoscope (

) PPI rebleeding

rebleeding

PPI

4. Which drugs and regimen of proton pump inhibitors should give to this patient?

Omeprazole 80 mg bolus Omeprazole 8 mg/h continuous infusion 48-72

Ref. Statement C3 International Consensus on Nonvariceal Upper Gastrointestinal Bleeding

( pH 3-4 maintain pH

6 PPIs high dose)

5. A week later, the patient become stable and prepare to discharge. The cardiologist decide to initiate the

antiplatelet agents for his cardiovascular disease. Which one is better in this patient between aspirin or

clopidogrel?

ASA GI bleed ASA MI

GI bleed low dose ASA

ASA bleed 48 ASA

Clopidogrel bleed ASA

Ref. Statement E3 Statement E4 International Consensus on Nonvariceal Upper Gastrointestinal

Bleeding

6. Which pain killers is appropriate for this patient to prevent gastrointestinal rebleeding?

NSAIDs GI 2

- GI bleeding 2 ( 1) moderate GI risk MI

high CV risk Coxib MI NSAIDs

Naproxen Sodium PPI

- GI bleed complication high GI risk NSAIDs

opioid ( alternative )

Ref. Table 5 The First International Working Party Report on Management of Patients on NSAIDs

7. Dose the H.pylori test should perform in this patient?

American College of Gastroenterology Guideline on the Management of Helicobacter

pylori Infection

Table 1. Indications for Diagnosis and Treatment of H. pylori

Established

Active peptic ulcer disease (gastric or duodenal ulcer)

Confirmed history of peptic ulcer disease (not previously treated for H. pylori)

Gastric MALT lymphoma (low grade)

After endoscopic resection of early gastric cancer

Uninvestigated dyspepsia (depending upon H. pylori prevalence)

Controversial

Nonulcer dyspepsia

Gastroesophageal reflux disease

Persons using nonsteroidal antiinflammatory drugs

Unexplained iron deficiency anemia

Populations at higher risk for gastric cancer

8. If the H.pylori test is positive, which medications should be initiated?

Table 4. First-Line Regimens for Helicobacter pylori Eradication Regimen Duration Eradication

Rates Comments

Standard dose PPI b.i.d. (esomeprazole is q.d.), clarithromycin 500 mg b.i.d., amoxicillin 1,000 mg b.i.d.

1014 7085% Consider in nonpenicillin allergic patients who have not previously received a macrolide

Standard dose PPI b.i.d., clarithromycin 500 mg b.i.d. metronidazole 500 mg b.i.d.

1014 7085% Consider in penicillin allergic patients who have not previously received a macrolide or are unable to tolerate bismuth quadruple therapy

Bismuth subsalicylate 525 mg p.o. q.i.d. metronidazole 250 mg p.o. q.i.d., tetracycline 500 mg p.o. q.i.d., ranitidine 150 mg p.o. b.i.d. or standard dose PPI q.d. to b.i.d.

1014 7590% Consider in penicillin allergic patients

PPI + amoxicillin 1 g b.i.d. followed by:

5 >90% Requires validation in North America

PPI, clarithromycin 500 mg, tinidazole 500 mg b.i.d.

5

PPI = proton pump inhibitor; pcn = penicillin; p.o. = orally; q.d. = daily; b.i.d. = twice daily; t.i.d. = three times daily; q.i.d. = four times daily. *Standard dosages for PPIs are as follows: lansoprazole 30 mg p.o., omeprazole 20 mg p.o., pantoprazole 40 mg p.o., rabeprazole 20 mg p.o., esomeprazole 40 mg p.o. Note: the above recommended treatments are not all FDA approved. The FDA approved regimens are as follows: 1. Bismuth 525 mg q.i.d. + metronidazole 250 mg q.i.d. + tetracycline 500 mg q.i.d. 2 wk + H2RA as directed 4 wk. 2. Lansoprazole 30 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. 10 days. 3. Omeprazole 20 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. 10 days. 4. esomeprazole 40 mg q.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. 10 days. 5. Rabeprazole 20 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. 7 days.

9. The gastrointestinal specialist discuss with you about the sequential treatment of H.pylori in this patient.

What is the rational and evidence to use regimen?

Sequential treatment

Fail

clarithromycin

10. Despite the standard regimen for H.pylori treatment, this patient still have the positive test of H.pylori,

which next agent could be start in this patient?

Post-test

1. The preferred noninvasive test to confirm H.pylori eradication is

A. Stool antigen test

B. Whole-blood antibody-detection test

C. Serologic antibody detection test

D. Urea breath test

2. The following statements best characterize the current status of H.pylori testing and treating except

A. Asymptomatic patients with a documented history of PUD should be tested for H.pylori, and if

possible, should receive eradication therapy

B. Symptomatic patients with uninvestigated dyspepsia should be tested for H.pylori, and if

positive, should receive eradication therapy

C. Symptomatic patients with an active peptic ulcer should be tested for H.pylori, and if positive,

should receive eradication therapy

D. Asymptomatic patients who do not have an active ulcer or a documented history of an ulcer but

who were tested for H.pyori and found to be positive should be offered eradication therapy

3. Antimicrobial resistance to H.pylori is most likely to occur with which of the following agents?

A. Metronidazole and clarithromycin

B. Clarithromycin and tetracycline

C. Metronidazole and amoxicillin

D. Amoxicillin and tetracycline

4. A 73 year old man presents with several episodes of hematemesis. Examination shows signs of

orthostatic hypotension and melena. What is the first priority in caring for this patient?

A. Nasogastric tube placement and gastric lavage

B. Resuscitation with adequate IV access and appropriate fluid and blood product fusion

C. Intravenous infusion of H2-receptor antagonists to stop the bleeding

D. Urgent upper panendoscopy

5. After initial stabilization and resuscitation of the patient, each of the following options should be

considered in the management of UGI bleeding except

A. Stop acute bleeding

B. Treat the underlying abnormality

C. Prevent rebleeding

D. Emergency surgery

6. F.G., a 74-year-old man, is brought to the emergency department by his wife, who says he passed

out in the bathroom, where she found him lying on the floor. On examination, F.G. admits to

experiencing 1 month of increasing weakness and intermittent black, tarry stools. His drugs includes

atrial fibrillation, hypercholesterolemia, osteoarthritis, constipation, and hypertension. His drugs

include lisinopril 10 mg once daily, amlodipine 10 mg/day, omeprazole 20 mg/day, simvastatin 20

mg/day at bedtime, amiodarone 200 mg twice daily, ferrous sulfate 325 mg twice daily, metoprolol

50 mg twice daily, naproxen 500 mg twice daily, warfarin 2.5 mg/day, and psyllium1 package daily.

F.G. has tried up to 3 g of acetaminophen daily without adequate relief of arthritic pain. F.G. is

slowly transfused with 4 units of packed red blood cells on admission. An upper endoscopy is

performed, and a hemostatic procedure is completed. Which one of the following is the best to

recommend for F.G.s outpatient drug regimen after discontinuing naproxen?

A. Increase omeprazole to 20 mg twice daily

B. Initiate celecoxib 200 mg once daily

C. Initiate celecoxib 200 mg once daily with twice daily omeprazole 20 mg

D. Initiate morphine sulfate controlled-release 15 mg twice daily

7. Which one of the following is the preferred gastro-protective therapy for a 67-year-old woman with

rheumatoid arthritis receiving naproxen 500 mg by mouth daily, metoprolol 25 mg by mouth twice

daily, aspirin 81 mg by mouth once daily, and alen-dronate 70 mcg by mouth weekly?

A. Lansoprozole 30 mg daily

B. No concomitant therapy necessary

C. Misoprostol 200 mcg twice daily

D. Esomeprazole 40 mg twice daily

8. A 60-year-old woman is currently taking quadruple therapy consisting of rabeprazole, bismuth

subsalicylate, metronidazole, and tetracycline for treatment of an H.pylori infection after a diagnosis

of GI bleeding secondary to a duodenal ulcer. It is essential that be informed of which one of the

following adverse effects of her drug regimen?

A. Myalgias will increase in frequency

B. Blood glucose control will worsen

C. Bodily fluids, such as urine, tears, and sweat, will turn orange

D. Stool will become blackish

9. A 47-year-old woman with a 2/day history of smoking and a duodenal ulcer has tested positive for

H.pylori by FAT and is initiating treatment with clarithromycin, amoxicillin, and lansoprazole for 10

days. Which one of the following strategies is most important to initiate to maximize her chance of

successful eradication?

A. Pretest the patient for polymorphisms of the cytochrome P450(CYP) 2C19 enzyme

B. Obtain H.pylori susceptibilities to ensure the appropriate antibiotic drugs are used

C. Educate the patient on proper use of the therapy and potential adverse effects

D. Initiate concomitant tobacco cessation therapy

10. A 72-year-old woman with a medical history of hypothyroidism and osteoporosis presents to the

pharmacy with a bottle of naproxen to purchase for self-treatment of chronic musculoskeletal pain.

She currently takes calcium carbonate, ibandronate, and levothyroxine. Which one of the following is

the best assessment of her potential risk of gastrointestinal (GI) toxicity from chronic nonsteroidal

anti-inflammatory drug (NSAID) use?

A. She has no risk factor for GI toxicity

B. She has one risk factor for GI toxicity

C. She has two risk factors for GI toxicity

D. She has three risk factors for GI toxicity