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| ===Recommendation for Revascularization for CLI:===
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| {| class="wikitable" | | {{CMG}}; {{AE}} |
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| | colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| | bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.'''In patients with CLI, [[revascularization]] should be performed when possible to minimize tissue loss.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
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| | bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.'''An evaluation for [[revascularization]] options should be performed by an interdisciplinary care team before amputation in the patient with CLI.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''<nowiki>"</nowiki>
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| == Pre-endoscopic medical therapy == | | == Demographic / Medical history == |
| {| class="wikitable" style="width:82%"
| | * '''Demographic''': 77, M |
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| | * '''Past Medical History:''' HTN, BPH, CAD w CABG, MI, AVR |
| | colspan="1" style="text-align:center; background:LemonChiffon" |Conditional recommendation ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]])
| | * '''Past Surgical History:''' |
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| | ** AVR (#25 magna ease valve) on 12/14/17 |
| | bgcolor="LemonChiffon" |1. Intravenous infusion of erythromycin (250 mg ~ 30 min before endoscopy) should be considered to improve diagnostic yield and decrease the need for
| | ** Stent on 10/10/2017 |
| | ** CABG in 2007 |
| | ** Appendectomy in 1957 |
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| repeat endoscopy. However, erythromycin has not consistently been shown to improve clinical outcomes
| | * '''Medications:''' |
| | ** Metoprolol |
| | ** DAPT |
| | ** Tamsulosin |
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| | == Procedure == |
| | bgcolor="LemonChiffon" |2. Pre-endoscopic intravenous PPI (e.g., 80 mg bolus followed by 8 mg / h infusion) may be considered to decrease the proportion of patients who have
| | * '''Index Procedure Date/Time''': |
| | ** mm/dd/YYYY at xx:xx [insert date and time] |
| | * '''Index Procedure Detail''': |
| | ** On mm/dd/YYYY at xx:xx [insert date and time] the subject underwent a [select surgical correction] for [select etiology]. |
| | ** Access site details |
| | ** The site reported that there were/were not procedural complication(s). |
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| higher risk stigmata of hemorrhage at endoscopy and who receive endoscopic therapy. However, PPIs do not improve clinical outcomes such as further
| | == Event(s) == |
| | '''Event (1):''' |
| | * '''Site Reported Event Onset Date: 12/26/2017''' |
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| bleeding, surgery, or death
| | * '''Event summary''': |
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| | ** Symptoms and sign: Subject presented with |
| | bgcolor="LemonChiffon" |3. If endoscopy will be delayed or cannot be performed, intravenous PPI is recommended to reduce further bleeding.
| | *** Right leg collapse, |
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| | *** Right arm and right leg weakness |
| |}
| | ** Episodes lasted approximately 2 -10 minutes and ranged from 1-4/day |
| | ** No visual or speech difficulties, no headache or neck pain |
| | ** No history of vertigo, syncope, loss of consciousness or seizures |
| | ** Other important symptoms related to the chief complaint. |
| | ** Physical assessment: |
| | *** Normal neurological exam |
| | *** BP: 124/66 |
| | *** HR: 96 |
| | == Laboratory data == |
| | * '''Lab studies list: ('''Date/ name/ value) |
| | ** 01/04/2018 / HDLC / 31 |
| | ** 01/03/2018 / INR / 1.2 |
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| == Gastric lavage == | | == Diagnostic tests == |
| {| class="wikitable"
| | * 01/03/2018 '''TTE''' |
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| | ** Mild left ventricular hypertrophy with normal systolic function and left ventricular diastolic dysfunction |
| | colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Conditional recommendation (Class IIa)]]
| | ** Moderate left atrial enlargement |
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| | ** Bioprosthetic aortic valve peak vel 2 m/s and mean grad 6.4 hg, no AI |
| | bgcolor="LemonChiffon" |1. Nasogastric or orogastric lavage is not required in patients with UGIB for diagnosis, prognosis, visualization, or therapeutic effect
| | * 01/03/2018 '''MR Brain''' |
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| | ** NO evidence of vascular occlusion |
| |}
| | ** No evidence of restricted diffusion to suggest infarction |
| | | * 01/03/2018 '''MRA H/N''' |
| == Timing of endoscopy ==
| | ** Eccentric filling defect in the left internal carotid artery just distil to the bifurcation that may be from calcification / nonocclusive thrombus |
| {| class="wikitable" style="width:82%"
| | * 01/03/2018 '''Carotid US(Preliminary)''' |
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| | ** Right: 1-49% stenosis of right internal carotid |
| | colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Conditional recommendation (Class IIa)]]
| | ** Left: 1-49% stenosis of left internal carotid |
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| | ** Bilateral vrtebral arteries patent with antegrade flow |
| | bgcolor="LemonChiffon" |Timing of endoscopy
| | * 01/03/2018 '''EEG''' |
| 1. Patients with UGIB should generally undergo endoscopy within 24 h of admission, following resuscitative efforts to optimize hemodynamic parameters and
| | ** Normal awake EEG |
| | | ** No epilitiform discharges, focal changes or other abnormalities |
| other medical problems.
| | ==Consults== |
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| | *Neurology consult : 01/03/2018 |
| | bgcolor="LemonChiffon" |2. In patients who are hemodynamically stable and without serious comorbidities endoscopy should be performed as soon as possible in a non-emergent
| | *Recommendations: |
| setting to identify the substantial proportion of patients with low-risk endoscopic fi ndings who can be safely discharged.
| | **CBC,CMP |
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| | **Admission to neurology service |
| | bgcolor="LemonChiffon" |3. In patients with higher risk clinical features (e.g., tachycardia, hypotension, bloody emesis or nasogastric aspirate in hospital) endoscopy within 12 h may
| | **MRI brain with or without contrast |
| | | **MRA of the extracranial and intracranial circulation |
| be considered to potentially improve clinical outcomes. | | **Carotid duplex US |
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| | **EEG |
| |}
| | *Date and time of consult |
| | | *Suggested treatments: |
| ==Endoscopic diagnosis==
| | **Aspirin 81mg chew tab |
| | | **Clopidogrel 75 mg tab |
| {| class="wikitable"
| | **Enoxaparin 40mg inj |
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| | **Metoprolol succinate 25mg extended release |
| | colspan="1" style="text-align:center; background:LightGreen" |Strong recommendation ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]])
| | ==Clinical course== |
| |-
| | * |
| | bgcolor="LightGreen" |1. Stigmata of recent hemorrhage should be recorded as they predict risk of further bleeding and guide management decisions. The stigmata, in descending
| | *Date and time of events, |
| risk of further bleeding, are active spurting, non-bleeding visible vessel, active oozing, adherent clot, fl at pigmented spot, and clean base .
| | *Patient condition got worse or better. |
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| | ==Treatment and outcome== |
| |}
| | *List of relevant medical treatments |
| | | **Aspirin 81mg chew tab |
| == Endoscopic therapy ==
| | **Clopidogrel 75 mg tab |
| {| class="wikitable"
| | **Enoxaparin 40mg inj |
| |-
| | **Metoprolol succinate 25mg extended release |
| | colspan="1" style="text-align:center; background:LightGreen" |Strong recommendation [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| | *Out come - Discharged home |
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| | bgcolor="LightGreen" |1. Endoscopic therapy should be provided to patients with active spurting or oozing bleeding or a non-bleeding visible vessel.
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| | bgcolor="LightGreen" |2. Endoscopic therapy should not be provided to patients who have an ulcer with a clean base or a fl at pigmented spot .
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| | bgcolor="LightGreen" |3. Epinephrine therapy should not be used alone. If used, it should be combined with a second modality.
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| | bgcolor="LightGreen" |4. Thermal therapy with bipolar electrocoagulation or heater probe and injection of sclerosant (e.g., absolute alcohol) are recommended because they
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| reduce further bleeding, need for surgery, and mortality.
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| |}
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| {| class="wikitable" style="width:82%"
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| | colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Conditional recommendation (Class IIa)]]
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| | bgcolor="LemonChiffon" |1. Endoscopic therapy may be considered for patients with an adherent clot resistant to vigorous irrigation. Benefi t may be greater in patients with clinical features
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| potentially associated with a higher risk of rebleeding (e.g., older age, concurrent illness, inpatient at time bleeding began).
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| | bgcolor="LemonChiffon" |2. Clips are recommended because they appear to decrease further bleeding and need for surgery. However, comparisons of clips vs. other therapies yield
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| variable results and currently used clips have not been well studied .
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| | bgcolor="LemonChiffon" |3. For the subset of patients with actively bleeding ulcers, thermal therapy or epinephrine plus a second modality may be preferred over clips or sclerosant
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| alone to achieve initial hemostasis .
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| |}
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| == Medical therapy after endoscopy == | |
| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LightGreen" |Strong recommendation ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]])
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| | bgcolor="LightGreen" |1. After successful endoscopic hemostasis, intravenous PPI therapy with 80 mg bolus followed by 8 mg/h continuous infusion for 72 h should be given to
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| patients who have an ulcer with active bleeding, a non-bleeding visible vessel, or an adherent clot.
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| | bgcolor="LightGreen" |2. Patients with ulcers that have fl at pigmented spots or clean bases can receive standard PPI therapy (e.g., oral PPI once daily).
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| |}
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| == Repeat endoscopy ==
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| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon" |Conditional recommendation ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa)]]
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| | bgcolor="LemonChiffon" |1. Routine second-look endoscopy, in which repeat endoscopy is performed 24 h after initial endoscopic hemostatic therapy, is not recommended.
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| | bgcolor="LemonChiffon" |2.If further bleeding occurs after a second endoscopic therapeutic session, surgery or interventional radiology with transcathether arterial embolization is
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| generally employed
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| |}
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| == Hospitalization ==
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| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon" |Conditional recommendation ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa)]]
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| | bgcolor="LemonChiffon" |1.Patients with high-risk stigmata (active bleeding, visible vessels, clots) should generally be hospitalized for 3 days assuming no rebleeding and no other
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| reason for hospitalization. They may be fed clear liquids soon after endoscopy.
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| |}
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| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LightGreen" |Strong recommendation [[ACC AHA guidelines classification scheme#Classification of Recommendations|(Class I]])
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| | bgcolor="LightGreen" |1.Patients with clean-based ulcers may receive a regular diet and be discharged after endoscopy assuming they are hemodynamically stable, their hemoglobin
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| is stable, they have no other medical problems, and they have a residence where they can be observed by a responsible adult.
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| |}
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| == Long-term prevention of recurrent bleeding ulcers == | |
| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LightGreen" |Strong recommendation ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]])
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| | bgcolor="LightGreen" |1.Patients with H. pylori -associated bleeding ulcers should receive H. pylori therapy. After documentation of eradication, maintenance antisecretory
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| therapy is not needed unless the patient also requires NSAIDs or antithrombotics.
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| | bgcolor="LightGreen" |2. In patients with NSAID-associated bleeding ulcers, the need for NSAIDs should be carefully assessed and NSAIDs should not be resumed if possible. In
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| patients who must resume NSAIDs, a COX-2 selective NSAID at the lowest effective dose plus daily PPI is recommended.
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| |}
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| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon" |Conditional recommendation ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa)]]
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| | bgcolor="LemonChiffon" |1.In patients with low-dose aspirin-associated bleeding ulcers, the need for aspirin should be assessed. If given for secondary prevention (i.e., established
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| cardiovascular disease) then aspirin should be resumed as soon as possible after bleeding ceases in most patients: ideally within 1 – 3 days and certainly
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| within 7 days. Long-term daily PPI therapy should also be provided. If given for primary prevention (i.e., no established cardiovascular disease), anti-platelet
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| therapy likely should not be resumed in most patients.
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| | bgcolor="LemonChiffon" |2. In patients with idiopathic (non- H. pylori , non-NSAID) ulcers, long-term antiulcer therapy (e.g., daily PPI) is recommended.
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| |}
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| ===References===
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| {{Reflist|1}}
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