Upper Gastrointestinal Bleeding in Critically Ill Patient: Literature Review

Critically ill patients are at risk for stress ulcers in the upper digestive tract. Various risk factors have been associated with this condition. Patients who are critically ill are at risk of bleeding due to stress related mucosal disease (SRMD). Upper gastrointestinal tract problems usually occur as a result of severe physiological stress. Patients may develop gastric erosion and develop stress ulcers with severe gastrointestinal bleeding which can be fatal. Routine pharmacological use of stress ulcer prophylaxis (SUP) does not reduce overall mortality in intensive care patients. This increases the risk of infectious complications, particularly nosocomial pneumonia and Clostridium difficile-associated diarrhea. Early enteral nutrition has been shown to be effective in preventing stress ulceration of the upper gastrointestinal tract in critically ill patients. Routine use of stress ulcer prophylaxis in all critically ill patients may be dangerous and does not appear to be cost-effective. SUP administration must follow an algorithm that clearly balances risks and benefits.

Serum Hs-CRP level and clinical significance of patients with stress ulcer caused by massive blood loss after trauma

Stress ulcer refers to a specific type of irritation of the inner wall of the gastrointestinal tract that occurs rapidly due to acute physiological stress such as severe disease, infection, or trauma. This study investigated the serum Hs-CRP level and clinical significance of patients with stress ulcers caused by massive blood loss after trauma. For this purpose, we studied 113 patients with enormous blood loss after trauma. During the study, 26 patients developed stress ulcers. Therefore, patients with massive blood loss after trauma were divided into two groups with and without stress ulcers. In addition to clinical and demographical evaluations, serum Hs-CRP levels were measured by ELISA test method in all patients at baseline, 6, and 12 days after starting the study. Results showed that 24 patients were excluded from the study due to termination of cooperation or death. Finally, 89 patients participated in the final analysis. Of these 89 patients, 26 developed stress ulcers. There was a significant difference between the two groups with stress and non-stress ulcers in terms of mean age (P=0.001) and gender (P=0.041). Also, there was a significant difference between the two groups regarding re-bleeding (P=0.012), the number of hospitalization days (P=0.001), and a decrease in hemoglobin (P=0.035). But there was no difference between the two groups regarding the need for re-surgery (P=0.276). The results of this study showed that increased serum hs-CRP levels are directly related to stress ulcers. Patients with higher serum Hs-CRP levels were more likely to develop stress ulcers than patients without stress ulcers during six days (P=0.04) and twelve days after starting the study (P=0.001). Current research results also show that the prevalence of stress ulcers occurs in men more than women. The risk of stress ulcers increases among older patients. People with stress ulcers also lose more hemoglobin, and finally, patients with more trauma and more extended hospital stays have a higher chance of developing stress ulcers.

Pantoprazole-induced Thrombocytopenia: Unresponsive to Corticosteroid and Thrombocyte Concentrate Transfusion

Introduction Pantoprazole is a proton pump inhibitor (PPI) class drug that is widely used in the treatment of SRMD (stress-related mucosal disease in critical ill patients. PPI are one class of drugs used commonly both for treatment and prophylactic therapy for stress ulcers in intensive care unit (ICU). Case We report a case of a 51-year old male who was referred to PKU Hospital. He was admitted to ICU with diagnosis of Hyperosmolar Hyperglymic State and bronchopneumonia. Thrombocytopenia was noted in admission. There was more than 70% decrease in platelet count after initiation of pantoprazole. Patient received Thrombocyte Concentrate (TC) transfusion and corticosteroid iv for several days, but only had minor increase in platelet count. The platelets recovered after stopping pantoprazole. Discussion In the present case report, another exposures to parenteral pantoprazole in a dose of 40 mg once daily reproduced the same adverse drug reaction. In comparison to lansoprazole, thrombocytopenia from pantoprazole is more severe that necessitate TC transfusion and corticosteroid trial. However, in the present case, TC transfusion and corticosteroid fail to escalate platelet count. This finding suggests probability of non-immune mechanism of pantoprazole-induced thrombocytopenia. Conclusion Pantoprazole may induce thrombocytopenia with new features that were immediately developed, resulting a decrease in platelet count >70%. The mechanism found in this case may be non-immune. Drug-induced thrombocytopenia is one of the rare complications that has to be kept in mind with the use of pantoprazole.

MORPHOLOGICAL CHANGES IN THE MUCOUS MEMBRANE OF THE STOMACH AND DUODENUM IN ACUTE EROSIVE - ULCERATIVE LESIONS OF VARIOUS ETIOLOGICAL ORIGIN.

The article considers morphological disorders of cellular renewal of the stomach and duodenal mucosa in acute erosive-ulcerative lesions of various etiological origins (stress ulcers)

Unusual cause of gastrointestinal bleeding in an 84-year-old woman: a miraculous survival from an aortoduodenal fistula repair

An 84-year-old woman presented acutely with dizziness, fatigue and a total of 800 mL of fresh per rectum (PR) bleeding. The significant history of abdominal aortic aneurysm repair 5 years ago included multiple episodes of endovascular leak around the stent associated with abscess of left psoas major, left abdominal wall abscess with sinus formation, appendicitis with abscess formation, and acute pancreatic and chronic cholecystitis with multiple gallstones in the 7 months prior to this presentation. During the preceding 7 months, the patient was stabilised with an intravenous proton pump inhibitor, blood transfusions and Intensive Care Unit (ICU) management for the assumed diagnosis of stress ulcers over multiple hospital admissions. Imaging with CT scan of the abdomen made the more accurate diagnosis of acute gastrointestinal haemorrhage caused by a fistula between the distal duodenum and aorta, which was later surgically confirmed. Removal of infected stents and axillobifemoral bypass were performed with a successful recovery.

Proton pump inhibitors: important information for cardiologists

Thromboembolic disorders occupy an important place in the structure of cardiovascular pathologies. Anticoagulants and antiplatelet agents proved to be the most efficient preventive medications for this group of patients, they enable reduction of the risk for both primary and secondary thromboembolic complications. However, their main shortcoming is the high potential of serious adverse events, basically related to gastrointestinal tract. That’s why, to prevent stress ulcers and bleedings in these patients, administration of antiplatelet agents, thrombolysis and heparin therapy is obligatory combined with the proton pump inhibitors. The authors presented data of evidence‑based medicine regarding one of the proton pump inhibitors, Ezolong, that contains esomeprazole (branded generic of Organosyn company). This combined medication is a modern formulation with the improved properties and more prolonged and predictable effect. Apart from its high protective efficacy, Ezolong is well tolerated, which is explained by the peculiarities of its pharmacodynamics and pharmacokinetics. Based on the complex of its clinical effects and safety profile, it is the drug of choice for patients with cardiovascular diseases. Ezolong is marketed in various formulations. Availability of its injectable formulation allows to achieve a quick intake of the active substance into the body, which is important for the therapy of acute pathologies and in case of impossibility of oral administration of the drug. Capsulated Ezolong provides easy administration, dosing accuracy, high adherence to the therapy of patients receiving outpatient treatment.

The Effects of Ranitidine Treatment on the Risk of Necrotizing Enterocolitis in Preterm Infants: A Case-Control Study

Introduction: Gastric acidity plays an important role in the protection of infants against various pathogens from the environment. The histamine-2 receptor blockers (H2-blockers) are off-labeled drugs that are frequently prescribed in preterm neonates to prevent stress ulcers. The impact of the H2-blockers on the development of the necrotizing enterocolitis (NEC) in preterm infants is still controversial, particularly in the developing world. Materials and Methods: One hundred twenty-two preterm infants were enrolled in the study. The multivariate logistic regression model was used to identify potential postnatal risk factors associated with NEC. Results: Preterm infants (n = 51) with total NEC, medical NEC, and surgical NEC had the highest rate of receiving ranitidine compared with controls (n = 71) (39.2%, 19.6%, and 47.6%, p < 0.05). Logistic regression analysis revealed that ranitidine use and nosocomial infections were significantly associated with NEC development (odds ratios 1.55 and 3.3). Conclusions: We confirm that ranitidine administration was associated with an increased risk of NEC in preterm infants. H2-blockers use should be only administered in very strictly selected cases after careful consideration of the risk-benefit ratio.

Analysis of the use and cost of stress ulcer prophylaxis for surgical inpatients

BackgroundStress ulcer is a superficial and asymptomatic lesion and causes bleeding. As many as 50% of death cases are reported as the result of stress ulcer bleeding. Stress ulcer prophylaxis (SUP) is a drug used to prevent gastrointestinal tract injuries due to stress ulcers. The inappropriate use of SUP drugs can cause adverse drug reactions, and thus SUP drugs are only given to patients in accordance with guidelines in order to avoid the overuse of SUP drugs. The aim of this present study is to analyse the suitability of SUP drug usage based on the criteria from the American Society of Health-System Pharmacists (ASHP) and the drug costs of SUP overuse.MethodsAn observational descriptive study was conducted from April 24, 2019, to May 17, 2019, in the inpatient surgical ward of Dr. Soetomo General Hospital. Data were obtained from patient medical health records.ResultsOne hundred fifty-two patients used 1404 SUP drugs. Approximately 48% of usage did not suit the ASHP criteria and was considered as medication overuse. The cost of excessive SUP usage during the study period was more than US $65, which is 30.08% of the total drug cost of prescribed stress ulcer drugs.ConclusionsThe present study suggests that the relatively high excessive drug costs for SUP show a need for monitoring of the application of SUP therapy guidelines.

Therapeutic Roles of Goji Berry and Ginseng in Traditional Chinese

Background: Goji berries (Lycium barbarum), widely used in traditional Chinese medicine, can be applied as a dietary supplement. They are classified as nutraceutical food due to their long and safe traditional use. Ginseng has been increasingly used in the last decades and has become well known for its significant role in preventing and treating many diseases. Methods: The keywords of Goji berry, Ginseng, Traditional Chinese medicine were searched in Google Scholar, Scopus, Research Gate, and PubMed in both English and Chinese languages. Results: Goji berry significantly inhibited the generation and spread of cancer cells, improved eyesight, and increased reserves of muscle glycogen and liver glycogen, which may increase human energy and has anti-fatigue effect. Usage of Goji berries improved brain function and enhanced learning and memory. It had positive effects on anti-cancer, anti-oxidant activities, retinal function preservation, anti-diabetes, immune function, and anti-fatigue. Pharmacological activities of ginseng extracts affected the central nervous system, antipsychotic action, tranquilizing effects, protection from stress ulcers, increase of gastrointestinal motility, anti-fatigue action, endocrinological effects, enhancement of sexual behavior, acceleration of metabolism, or synthesis of carbohydrates, lipids, RNA, and proteins. In Traditional Chinese Medicine, ginseng helps to maintain a healthy immune system. Conclusions: In this review article we found that Goji berries and Ginseng were sources of compounds with valuable nutritional and bioactive properties. Therefore, they could be incorporated into foods with functional properties. More clinical studies are necessary to uncover the numerous substances and their effects in goji berries and ginseng that contribute to public health.

Gastrointestinal drugs

This chapter discusses gastrointestinal drugs and includes discussion on H2 blockers and proton pump inhibitors (including discussion on physiology of acid secretion, pharmacology, pathophysiology of stress ulcers, stress ulcer prophylaxis, and treatment of acute bleeding after endoscopy), antiemetics (including discussion on mechanisms of nausea and vomiting, antiemetic drugs, and clinical approach), gut motility agents (indications, erythromycin, erythromycin versus metoclopramide, metoclopramide, domperidone, cisapride, neostigmine, and alternative treatment strategies), antidiarrhoeals (risk factors and causes of diarrhoea, antidiarrhoeal drugs, and enteral supplements), and constipation in critical care. This includes pathophysiology of and risk factors for constipation, treatments including bulk-forming, stimulating, osmotic, and emollient laxatives, as well as suppositories and enemas, motility agents, and opioid antagonists. It also outlines special circumstances, including palliative care, spinal cord injury, and liver failure patients.