1. Sector of Gastroenterological Disorder Munzur Morshed, Pharm D. candidate 2011Arnold & Marie Schwartz College of Pharmacy and Health SciencesInternal Medicine-Advanced Pharmacy PracticeMaimonides Medical Center
2. Objectives Provide brief overview of the patients case Discuss the disease state, presentation and signs and symptoms Explain pharmacological management options that are available Display the place in therapy of each medications Provide a synopsis of a major landmark trial Discuss the patient’s appropriate management options
3. Case PresentationHistory of Present Illness LZ is a 49 y/o male, PMH significant of mild chronic gastritis, who came in to the ER, complaining of abdominal pain of moderate severity in the epigastric and RUQ that had started while the patient was sleeping last night. He subsequently had two episodes of nausea and vomiting and was brought in to the ER for further evaluation.
4. Case presentation-History of present illness cont… PMH: Gastritis FH: Unknown SH:Unknowm NKDA VS: Temp: 98 ° F, BP: 139/76 mm Hg, HR: 58 BPM, RR:21 BPM, Pain scale: 10/10-Terrible pain to the abdomen
5. Case presentation- Physicals Physical Findings: ABW: 63.2 kg, Height: 5’5, IBW: 57 kg Mental status: alert awake and oriented x 3; PERRL HEENT: Normocephalic, atraumatic, normal oropharynx Lungs: Normal chest excursion, respiration breath sounds are clear and equal bilaterally. No wheezes, rhonchi, or rales. CV: Normal S1, S2, no murmur, rubs or gallops Extremities: Normal range of motion (ROM) in all four extremeties, non-tender to palpitation, distal pulses are intact. GI:Tender abdomen, nausea, and vomitting CXR: Not Performed EKG: Normal sinus rhythym and elevation of the ST-segment. Abdominal Ultrasound: Distended gall bladder with thickening of the wall. This could represent cholecystitis. No stones were seen. If clinical suspicion is high, recommend HIDA scan
9. Abdominal Pain Perceived location of pain not necessarily to its site of origin,which may be remote from the abdominal cavity Caused by Inflammation (e.g.- appendicitis, colitis) Organs being stretched or distended (e.g.- Hepatitis, gallstones) Lack of blood supply to the organs (e.g.- Ischemic colitis) Abnormal contractions of the intestinal muscles (IBS)
10. Epidemiology Nearly 5 million American patients presents to the ED with complaints of abdominal pain per year Accounts for 5-10% of all ED visits 50% were hospitalized Contributing to overall mortality of 10% American College of Emergency Physicians. Clinical policy:critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumaticacute abdominal pain. Ann Emerg Med. October 2000;36:406-415 Powers RD, Guertler AT. Abdominal pain in the ED: stability and change over 20 years. AmJEmerg Med. 1995;13:301-303. McCaig LF, Stussman BJ. National Hospital Ambulatory Medical Care Survey: 1996 EmergencyDepartment Summary. Advanced data from Vital and Health Statistics, No. 293. Hyattsville,MD: National Center for Health Statistics; 1997.
18. Approach to treatment Ascertain urgent surgical intervention is required Provide pain and other symptomatic relief Initiatate empiric ABX therapy if intraabdominal infection is suspected Decrease the risk of developing serious complications such as dehydration, shock, etc
27. Empiric Antimicrobial Initiate empiric antibiotic therapy if intra-abdominal infection is suspected Second generation cephalosporin PLUS metronidazole is the corner stone of therapy
28. Monitoring Parameter Monitor closely every hour for improvement in pain Toxicity such as decrease blood pressure, respiratory rate, and symptoms of GI constipation Follow-up with frequent re-examination as soon as possible
30. Landmark Trial cont… Pace S., Burke ET. Intravenous Morphine for Early Pain Relief in Patients with Acute Abdominal Pain. Academic Emergency Medicine. 1996:3 (12,); 1086–1092.
31. Conclusion Definitive therapy is dependent on the etiology of the pain Mainstays of therapy include providing adequate analgesia and symptomatic relief Prescribe empiric antibiotic if only suspecting intra-abdominal infection Monitor patient very closely for symptomatic pain
32. Patient Case: Findings pertaining to the problem Patient came in to the ED complaining of mid upper abdominal pain that is at a scale of 10/10 On admission, abdominal ultrasound had shown a distended gall bladder with thickening of the gall bladder wall Lab work had shown that the patient has an anion gap of 8.0-suggesting a serious intra-abdominal process Has an elevated neutrophil count, suggesting possible inflammation
34. Patient Case: Treatment Morphine sulfate 5 mg IV STAT Morphine is indicated for the treatment of moderate to severe pain No contraindications present No asthma, low blood pressure, or any reports of hypersensitivity Appropriate to use to control the pain according to the package insert and clinical trials Other alternative are meperidine (Demerol), fentanyl citrate (Sublimaze). The dose is also appropriate to use at time Some toxicities that can occur are Respiratory depression Bradycardia Hypotension. No drug-interactions present Not on any benzos, cimitedine, chlorpromazine, codeine, etc. Patient should be monitored for improvement in the pain level for efficacy Monitor respiratory rate and symptoms of GI Nausea, vomiting, constipation and hypotension
It is one of the most common problem in the field of emergency medicine.
Many intra-abdominal disorders cause abdominal painSome are trivial while others may be life threatning, requiring rapid diagnosis and possible surgery
Patients who arehemodynamically unstable are at risk for having had a catastrophe such as ruptured aortic aneurysm and will require immediate surgery
