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__NOTOC__
__NOTOC__


{{CMG}}; {{AE}}


== Demographic / Medical history ==
* '''Demographic''': 77, M
* '''Past Medical History:''' HTN, BPH, CAD w CABG, MI, AVR
* '''Past Surgical History:'''
** AVR (#25 magna ease valve) on 12/14/17
** Stent on 10/10/2017
** CABG in 2007
** Appendectomy in 1957


==2017 ACG Guidelines for first-line treatment strategies of peptic ulcer disease for providers in North America==
* '''Medications:'''
{| class="wikitable"
** Metoprolol
|-
** DAPT
| colspan="1" style="text-align:center; background:LightGreen" |Strong recommendation
** Tamsulosin
|-
| bgcolor="LightGreen" |1.Bismuth quadruple therapy consisting of a PPI, bismuth, tetracycline, and a nitroimidazole for 10–14 days is a recommended fi rst-line treatment option.
Bismuth quadruple therapy is particularly attractive in patients with any previous macrolide exposure or who are allergic to penicillin


|-
== Procedure ==
| bgcolor="LightGreen" |2.Concomitant therapy consisting of a PPI, clarithromycin, amoxicillin and a nitroimidazole for 10–14 days is a recommended first-line treatment option
* '''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).


{| class="wikitable"
== Event(s) ==
|-
'''Event (1):'''
| colspan="1" style="text-align:center; background:LemonChiffon" |Conditional recommendation
* '''Site Reported Event Onset Date: 12/26/2017'''
|-
| bgcolor="LemonChiffon" |'''1.'''Patients should be asked about any previous antibiotic exposure(s) and this information should be taken into consideration when choosing an H. pylori
treatment regimen '''.'''
|-
| bgcolor="LemonChiffon" |2.Clarithromycin triple therapy consisting of a PPI, clarithromycin, and amoxicillin or metronidazole for 14 days remains a recommended treatment in regions
where H. pylori clarithromycin resistance is known to be <15% and in patients with no previous history of macrolide exposure for any reason.
|-
| bgcolor="LemonChiffon" |3.Sequential therapy consisting of a PPI and amoxicillin for 5–7 days followed by a PPI, clarithromycin, and a nitroimidazole for 5–7 days is a suggested first line


treatment option.
* '''Event summary''':
** Symptoms and sign: Subject presented with
*** Right leg collapse,
*** 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


|-
== Diagnostic tests ==
|-
* 01/03/2018 '''TTE'''
| bgcolor="LemonChiffon" |4.Hybrid therapy consisting of a PPI and amoxicillin for 7 days followed by a PPI, amoxicillin, clarithromycin and a nitroimidazole for 7 days is a suggested
** Mild left ventricular hypertrophy with normal systolic function and left ventricular diastolic dysfunction
 
** Moderate left atrial enlargement
first-line treatment option.
** Bioprosthetic aortic valve peak vel 2 m/s and mean grad 6.4 hg, no AI
|-
* 01/03/2018 '''MR Brain'''
| bgcolor="LemonChiffon" |5.Levofloxacin triple therapy consisting of a PPI, levofloxacin, and amoxicillin for 10–14 days is a suggested first-line treatment option.
** NO evidence of vascular occlusion
|-
** No evidence of restricted diffusion to suggest infarction
| bgcolor="LemonChiffon" |6.Fluoroquinolone sequential therapy consisting of a PPI and amoxicillin for 5–7 days followed by a PPI, fluoroquinolone, and nitroimidazole for 5–7 days is a
* 01/03/2018 '''MRA H/N'''
suggested first-line treatment option.
** Eccentric filling defect in the left internal carotid artery just distil to the bifurcation that may be from calcification / nonocclusive thrombus
|}
* 01/03/2018 '''Carotid US(Preliminary)'''
 
** Right: 1-49% stenosis of right internal carotid
 
** Left: 1-49% stenosis of left internal carotid
 
** Bilateral vrtebral arteries patent with antegrade flow
 
* 01/03/2018 '''EEG'''
== Initial assessment and risk stratification ==
** Normal awake EEG
{| class="wikitable"
** No epilitiform discharges, focal changes or other abnormalities
|-
==Consults==
| colspan="1" style="text-align:center; background:LightGreen" |'''Strong recommendation'''
*Neurology consult : 01/03/2018
|-
*Recommendations:  
| bgcolor="LightGreen" |1. Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed.
**CBC,CMP
|-
**Admission to neurology service
|}
**MRI brain with or without contrast
 
**MRA of the extracranial and intracranial circulation
{| class="wikitable"
**Carotid duplex US
|-
**EEG
| colspan="1" style="text-align:center; background:LemonChiffon" |'''Conditional recommendation'''
*Date and time of consult
|-
*Suggested treatments:  
| bgcolor="LemonChiffon" |1.Blood transfusions should target hemoglobin  ≥ 7   g / dl, with higher hemoglobins targeted in patients with clinical evidence of intravascular volume depletion or comorbidities, such as coronary artery disease.
**Aspirin 81mg chew tab
2. Risk assessment should be performed to stratify patients into higher and lower risk categories and may assist in initial decisions such as the timing of endoscopy, time of discharge, and level of care. 
**Clopidogrel 75 mg tab
 
**Enoxaparin 40mg inj
3. Discharge from the emergency department without inpatient endoscopy may be considered in patients with urea nitrogen < 18.2   mg / dl; hemoglobin ≥  13.0   g / dl for men (12.0   g / dl for women), systolic blood pressure  ≥  110   mm   Hg; pulse   100 beats / min; and absence of melena, syncope, cardiac failure, and liver disease, as they have  <1 %  chance of requiring intervention.
**Metoprolol succinate 25mg extended release
 
==Clinical course==
|-
*
|}
*Date and time of events,
== Pre-endoscopic medical therapy ==
*Patient condition got worse or better.
{| class="wikitable" style="width:82%"
==Treatment and outcome==
|-
*List of relevant medical treatments
| colspan="1" style="text-align:center; background:LemonChiffon" |'''Conditional recommendation'''  
**Aspirin 81mg chew tab
|-
**Clopidogrel 75 mg tab
| 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
**Enoxaparin 40mg inj
 
**Metoprolol succinate 25mg extended release
repeat endoscopy. However, erythromycin has not consistently been shown to improve clinical outcomes
*Out come - Discharged home
 
|-
| 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
 
higher risk stigmata of hemorrhage at endoscopy and who receive endoscopic therapy. However, PPIs do not improve clinical outcomes such as further
 
bleeding, surgery, or death
|-
| bgcolor="LemonChiffon" |3. If endoscopy will be delayed or cannot be performed, intravenous PPI is recommended to reduce further bleeding.
|-
|}
 
== Gastric lavage ==
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |'''Conditional recommendation'''
|-
| bgcolor="LemonChiffon" |1. Nasogastric or orogastric lavage is not required in patients with UGIB for diagnosis, prognosis, visualization, or therapeutic effect
|-
|}
 
== Timing of endoscopy ==
{| class="wikitable" style="width:82%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |'''Conditional recommendation'''
|-
| bgcolor="LemonChiffon" |Timing of endoscopy
1. Patients with UGIB should generally undergo endoscopy within 24 h of admission, following resuscitative efforts to optimize hemodynamic parameters and
 
other medical problems.
|-
| 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
setting to identify the substantial proportion of patients with low-risk endoscopic fi ndings who can be safely discharged.
|-
| 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
 
be considered to potentially improve clinical outcomes.
|-
|}
 
==Endoscopic diagnosis==
 
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |'''Strong recommendation'''
|-
| 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
risk of further bleeding, are active spurting, non-bleeding visible vessel, active oozing, adherent clot, fl at pigmented spot, and clean base .
|-
|}
 
== Endoscopic therapy ==
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |'''Strong recommendation'''
|-
| bgcolor="LightGreen" |1. Endoscopic therapy should be provided to patients with active spurting or oozing bleeding or a non-bleeding visible vessel.
|-
| 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 .
|-
| bgcolor="LightGreen" |3. Epinephrine therapy should not be used alone. If used, it should be combined with a second modality.
|-
| bgcolor="LightGreen" |4. Thermal therapy with bipolar electrocoagulation or heater probe and injection of sclerosant (e.g., absolute alcohol) are recommended because they
reduce further bleeding, need for surgery, and mortality.
|-
|}
{| class="wikitable" style="width:82%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |'''Conditional recommendation'''
|-
| 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
potentially associated with a higher risk of rebleeding (e.g., older age, concurrent illness, inpatient at time bleeding began).
|-
| 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
variable results and currently used clips have not been well studied .
|-
| 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
 
alone to achieve initial hemostasis .
|-
|}
 
== Medical therapy after endoscopy ==
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |'''Strong recommendation'''  
|-
| 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
patients who have an ulcer with active bleeding, a non-bleeding visible vessel, or an adherent clot.
|-
| 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).
|-
|}
 
== Repeat endoscopy ==
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |'''Conditional recommendation'''
|-
| bgcolor="LemonChiffon" |1. Routine second-look endoscopy, in which repeat endoscopy is performed 24 h after initial endoscopic hemostatic therapy, is not recommended.
|-
| bgcolor="LemonChiffon" |2.If further bleeding occurs after a second endoscopic therapeutic session, surgery or interventional radiology with transcathether arterial embolization is
generally employed
|-
|}
 
== Hospitalization ==
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |'''Conditional recommendation'''
|-
| 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
reason for hospitalization. They may be fed clear liquids soon after endoscopy.
|-
|}
 
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |'''Strong recommendation'''
|-
| 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
is stable, they have no other medical problems, and they have a residence where they can be observed by a responsible adult.
|-
|}
 
== Long-term prevention of recurrent bleeding ulcers ==
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |'''Strong recommendation'''
|-
| bgcolor="LightGreen" |1.Patients with H. pylori -associated bleeding ulcers should receive H. pylori therapy. After documentation of eradication, maintenance antisecretory
therapy is not needed unless the patient also requires NSAIDs or antithrombotics.
|-
| 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
patients who must resume NSAIDs, a COX-2 selective NSAID at the lowest effective dose plus daily PPI is recommended.
|-
|}
 
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |'''Conditional recommendation'''
|-
| 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
cardiovascular disease) then aspirin should be resumed as soon as possible after bleeding ceases in most patients: ideally within 1 – 3 days and certainly
 
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
 
therapy likely should not be resumed in most patients.
|-
| bgcolor="LemonChiffon" |2. In patients with idiopathic (non- H. pylori , non-NSAID) ulcers, long-term antiulcer therapy (e.g., daily PPI) is recommended.
|-
|}
 
__NOTOC__
 
{{CMG}}; {{AE}} {{MKK}}, {{SSW}}
==2017 ACG Guidelines for first-line treatment strategies of peptic ulcer disease for providers in North America==
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |Strong recommendation
|-
| bgcolor="LightGreen" |In patients with persistent H. pylori infection, every effort should be made to avoid antibiotics that have been previously taken by the patient.
 
|-
| bgcolor="LightGreen" |The following regimens can be considered for use as salvage treatment:
1.Bismuth quadruple therapy for 14 days is a recommended salvage regimen.
 
2.Levofloxacin triple regimen for 14 days is a recommended salvage regimen.
|-
|-
|-
|-
|}
 
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |Conditional recommendation
|-
| bgcolor="LemonChiffon" |Bismuth quadruple therapy or levofloxacin salvage regimens are the preferred treatment options if a patient received a first-line treatment containing
clarithromycin. Selection of best salvage regimen should be directed by local antimicrobial resistance data and the patient’s previous exposure to antibiotics.
|-
| bgcolor="LemonChiffon" |Clarithromycin or levofloxacin-containing salvage regimens are the preferred treatment options, if a patient received first-line bismuth quadruple therapy.
Selection of best salvage regimen should be directed by local antimicrobial resistance data and the patient’s previous exposure to antibiotics.
|-
| bgcolor="LemonChiffon" |The following regimens can be considered for use as salvage treatment:
1.Concomitant therapy for 10–14 days is a suggested salvage regimen.
 
2.Clarithromycin triple therapy should be avoided as a salvage regimen.
 
3.Rifabutin triple regimen consisting of a PPI, amoxicillin, and rifabutin for 10 days is a suggested salvage regimen.
 
4.High-dose dual therapy consisting of a PPI and amoxicillin for 14 days is a suggested salvage regimen.
 
|-
|}
 
 
===References===
{{Reflist|1}}

Latest revision as of 16:44, 18 June 2018


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Demographic / Medical history

  • Demographic: 77, M
  • Past Medical History: HTN, BPH, CAD w CABG, MI, AVR
  • Past Surgical History:
    • AVR (#25 magna ease valve) on 12/14/17
    • Stent on 10/10/2017
    • CABG in 2007
    • Appendectomy in 1957
  • Medications:
    • Metoprolol
    • DAPT
    • Tamsulosin

Procedure

  • 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).

Event(s)

Event (1):

  • Site Reported Event Onset Date: 12/26/2017
  • Event summary:
    • Symptoms and sign: Subject presented with
      • Right leg collapse,
      • 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

Diagnostic tests

  • 01/03/2018 TTE
    • Mild left ventricular hypertrophy with normal systolic function and left ventricular diastolic dysfunction
    • Moderate left atrial enlargement
    • Bioprosthetic aortic valve peak vel 2 m/s and mean grad 6.4 hg, no AI
  • 01/03/2018 MR Brain
    • NO evidence of vascular occlusion
    • No evidence of restricted diffusion to suggest infarction
  • 01/03/2018 MRA H/N
    • Eccentric filling defect in the left internal carotid artery just distil to the bifurcation that may be from calcification / nonocclusive thrombus
  • 01/03/2018 Carotid US(Preliminary)
    • Right: 1-49% stenosis of right internal carotid
    • Left: 1-49% stenosis of left internal carotid
    • Bilateral vrtebral arteries patent with antegrade flow
  • 01/03/2018 EEG
    • Normal awake EEG
    • No epilitiform discharges, focal changes or other abnormalities

Consults

  • Neurology consult : 01/03/2018
  • Recommendations:
    • CBC,CMP
    • Admission to neurology service
    • MRI brain with or without contrast
    • MRA of the extracranial and intracranial circulation
    • Carotid duplex US
    • EEG
  • Date and time of consult
  • Suggested treatments:
    • Aspirin 81mg chew tab
    • Clopidogrel 75 mg tab
    • Enoxaparin 40mg inj
    • Metoprolol succinate 25mg extended release

Clinical course

  • Date and time of events,
  • Patient condition got worse or better.

Treatment and outcome

  • List of relevant medical treatments
    • Aspirin 81mg chew tab
    • Clopidogrel 75 mg tab
    • Enoxaparin 40mg inj
    • Metoprolol succinate 25mg extended release
  • Out come - Discharged home
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