This document discusses the role of proton pump inhibitors (PPIs) in treating upper gastrointestinal bleeding. It begins by defining upper GI bleeding and noting that the majority of GI bleeds originate in the upper GI tract. It then discusses the differential diagnosis of upper GI bleeding and lists common causes such as esophageal varices, gastric ulcers, and duodenal ulcers. The document emphasizes that maintaining a stomach pH above 6 is important for preventing rebleeding because it allows blood clots to form stabilly. Proton pump inhibitors are the treatment of choice for raising gastric pH and preventing rebleeding because they more effectively suppress acid secretion compared to histamine-2 receptor antagonists.
Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
This presentation is about peptic ulcer disease , including:Pathomorphology,etiology,symptoms,complications,diagnosis and pharmacotherapy,asurgical intervention and prevention...
Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
This presentation is about peptic ulcer disease , including:Pathomorphology,etiology,symptoms,complications,diagnosis and pharmacotherapy,asurgical intervention and prevention...
G I bleeding with radiological interventions(ACR Appropriateness Criteria).Tc-99m RBC scintigraphy,Catheter-directed Angiography,Pharmacological control,Embolization,Arterial interventions,Endoscopy,CT Angiography
What may have seemed like science fiction, surgery without an incision, is now a reality that is making lives better for patients suffering from chronic acid reflux also known as gastroesophageal reflux disease (GERD). Peter Janu, MD, a general surgeon, provides basic information about GERD as well as common treatment options including the new TIF (transoral incisionless fundoplication) procedure for the treatment of GERD.
G I bleeding with radiological interventions(ACR Appropriateness Criteria).Tc-99m RBC scintigraphy,Catheter-directed Angiography,Pharmacological control,Embolization,Arterial interventions,Endoscopy,CT Angiography
What may have seemed like science fiction, surgery without an incision, is now a reality that is making lives better for patients suffering from chronic acid reflux also known as gastroesophageal reflux disease (GERD). Peter Janu, MD, a general surgeon, provides basic information about GERD as well as common treatment options including the new TIF (transoral incisionless fundoplication) procedure for the treatment of GERD.
Upper Gastrointestinal Bleeding (UGIB) - General ApproachMohamed Badheeb
What does the science & evidence say about UGIB ?
Introduction & Background on Upper GI Bleeding.
- Incidence and Epidemiology
- Etiologies
2. Guidelines on UGIB
- Resuscitation, Risk assessment
- Diagnostic Modalities
- Treatment Options
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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The Role of PPIS Which One is The Best for Acute Upper GI Bleeding?
1. The Role of PPIs in
Upper Gastrointestinal Bleeding;
Which one is The Best?
Mangatas SM Manalu
Internal Medicine Department
Mayapada Hospital – South Jakarta
2. Definitions
• Upper GI bleed – arising
from the esophagus,
stomach, or proximal
duodenum
• Mid-intestinal bleed –
arising from distal
duodenum to ileocecal
valve
• Lower intestinal bleed –
arising from colon/rectum
3. Upper GI Tract
◦ Proximal to the Ligament of Treitz
◦ 65 - 70% of GI Bleeds
Mid Intestinal GI Tract
2-3 % of GI Bleeds
Lower GI Tract
◦ Distal to the Ligament of Treitz
◦ 25 -30% of GI Bleeds
4.
5. Differential Diagnosis of
Upper GI bleeding
Esophageal varices
Gastric varices
Erosive gastritis
Mallory Weiss tear
Reflux esophagitis
Gastric malignancy
Vascular malformations
Nose bleed
Aorto-enteric fistula
Gastric ulcer
Duodenal ulcer
Consider the following
6. Tabel 1. Penyebab Tersering Perdarahan SCBA
pada Pasien yang menjalani Endoskopi
di Pusat Endoskopi RSCM selama tahun 2001-2005
Konsensus Nasional Perdarahan Saluran Cerna Bagian Atas, PB-PGI, 2012
7. Initial Assessment and Resuscitation
History and Physical Examination
Assessment of the bleeding source
Differential Diagnosis
Investigations
Management
◦ Conservative
◦ Therapeutic
8. Airway, Breathing and Circulation
Vital Signs:
◦ Pulse, BP, Temperature, Respiratory
Rate
Fluid and Resuscitation Plan
◦ Co-morbidities
9. RR, HR, and BP can be used to estimate
degree of blood loss/hypovolaemia
Class I Class II Class III Class IV
Volume Loss
(ml)
0-750 750-1500 1500-2000 >2000
Loss (%) 0-15 15-30 30-40 >40
RR 14-20 20-30 30-40 >40
HR <100 >100 >120 >140
BP Unchanged Unchanged Reduced Reduced
Urine Output
(ml/hr)
>30 20-30 5-15 Anuric
Mental State Restless Anxious Anxious/conf
used
Confused/
lethargic
10. Confirm the GI Bleed - Hemoptysis or
Hemetemesis ???
Manner of Presentation of a GI Bleed
◦ Hemetemesis
◦ Malena
◦ Hematochezia
◦ Occult Blood loss
◦ Symptoms of Blood loss
Is it only the GI Bleed ??
Assessment of the bleed
◦ Dizziness, Syncope, Chest Pain, SOB
11. Bleeding etiology Leading History
Mallory -Weiss tear Multiple Emesis before hematemesis, alcoholism
Esophageal ulcer Dysphagia, Odynophagia, GERD,
Peptic ulcer Epigastric pain, NSAID or aspirin use
Stress gastritis Patient in an ICU, gastrointestinal bleeding occurring
after admission, respiratory failure, multiorgan failure
Varices, portal
gastropathy
Alcoholism, Cirrhosis
Gastric antral
vascular ectasia
Renal failure, cirrhosis
Malignancy Recent involuntary weight loss, dysphagia, cachexia,
early satiety
Angiodysplasia Chronic renal failure, hereditary hemorrhagic
telangiectasia
Aortoenteric fistula Known aortic aneurysm, prior abdominal aortic
aneurysm repair
12. Anticoagulation (warfarin/heparin)
Use of Drugs NSAIDs,Steroids,Bisphosphonates
Similar episodes before
H/o Jaundice in past
H/o Abdominal Surgery
H/o Alcoholism
H/o Smoking or Tobacco abuse
H/o Cocaine abuse
14. Alopecia, Pallor, Icterus, Fetor Hepaticus,
Glossitis, Parotid Swelling
Leukonychia, Clubbing, Palmar Erythema,
Dupuytren’s Contracture, Asterexis
Loss of Axillary hair, Spider naevi,
Gynaecomastia,
Ascites, Splenomegaly, Caput Medusae
Testicular Atrophy, Loss of Pubic Hair
Pedal Edema
15. Stool color and origin/pace of bleeding
• Guaiac positive stool
– Occult blood in stool
– Does not provide any localizing information
– Indicates slow pace, usually low volume bleeding
• Melena
– Very dark, tarry, pungent stool
– Usually suggestive of UGI origin (but can be small
intestinal, proximal colon origin if slow pace)
• Hematochezia
– Spectrum: bright red blood, dark red, maroon
– Usually suggestive of colonic origin (but can be UGI origin
if brisk pace/large volume)
18. Complete Blood count, ESR,
Liver and Renal Function Tests, Electrolytes
Prothrombin Time and INR
BUN / Creatinine – ratio > 30 sensitivity of
68% and a specificity of 98%
Stool Occult Blood Test
Grouping and Cross Matching
ECG, Cardiac enzymes(if essential)
HIV, HbsAg, AntiHCV Markers
19. ABC’s
Fluid Resucitation
NG Tube insertion and Lavage
Hemodynamically Unstable – Hypotension,
Tachycardia, Postural Changes Urgent
Endoscopy
Hemodynamically Stable Plan Early
Endoscopy
Tranexamic Acid I.V (+ Vit K in Liver Cirrochis)
IV PPI Therapy
20. A grossly bloody aspirate in the atraumatic NG insertion
CONFIRMS a UGI Bleed
The type of bleed
Red blood - active bleeding
Coffee ground - recently active bleeding.
Continued aspiration of red blood - severe, active
hemorrhage.
Clears the field for endoscopic visualization
Prevent aspiration of gastric content
However, lavage may not be positive if bleeding has
ceased or arises beyond a closed pylorus.
21. An algorithm in the management of acute nonvariceal GI bleeding
Acute upper GI bleeding
Initial resuscitation, airway, volume restoration, nasogastric tube,
empiric high-dose PPI, risk stratification using clinical factors
Signs of on-going bleeding; such as shock
and fresh hematemesis or hematochezia
Urgent endoscopy
Stable patient
Endoscopy next morning
Epinephrine injection + Thermocoagulation to
actively bleeding ulcers and ulcers with NBW
Clots elevated and treatment to underlying vessel
Bleeding stopped
Unable to control bleeding, access
or localize bleeding point in the
presence of massive bleeding.
Second re-bleed
Consider
early discharge
Low-risk ulcers; flat
pigments and clean base
22. Treatment in Harisson’s PIM (18 th ed-2012)
1. Laine L. Gastrointestinal Bleeding. In Longo DL, Kasper DL, Jameson JL, Fauci AS, Hauser SL, Loscalzo J, editors. Harrisons Princ Intern Med.
18th ed. New York: The McGraw-Hill Companies; 2012.
23.
24. Age > 60 yrs
Comorbidities (Renal failure, Liver failure, CHF,
Malignancy)
Variceal bleeding (as compared with nonvariceal
bleeding)
Shock or hypotension on presentation
Increasing number of units of blood transfused
Active bleeding on Endoscopy
Bleeding Ulcer of >2cm or a Spurting vessel
Need for emergency surgery
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36. Peran dari obat penekan asam
lambung
• Terapi farmakologis menggunakan obat yang mampu
menekan sekresi asam lambung merupakan pilihan yang
paling banyak digunakan sebagai standar pengobatan untuk
kasus perdarahan. Termasuk didalamnya untuk pencegahan
perdarahan ulang 1-5
• Tujuan terapi pada pasien tersebut adalah mencapai pH
dalam lambung (intragastric) diatas 6, sebuah kondisi dimana
proses pembentukan bekuan darah dapat stabil 1,6-7
1. Lin H-J, et al. Arch Intern Med 1998; 158: 54-8. 2. Lau JWY, et al. N Eng J Med 2000; 343: 310-6. 3. Liontiadis
GI, et al. Aliment Pharmacol ther 2005; 22: 169-74. 4. Sung JJ, et al. Ann Intern Med 2003; 139: 237-43. 5.
Barkun A, et al. Gastroenterology 2004; 126: A78 (Abstract). 6. Vorder Bruegge WF, et al. J Clin Gastroenterol
1990; 12: (Suppl 2): S35-40. 7. van Resburg, et al. Am J Gastroenterol 2003; 98: 2635-41
37. Tingkatan pH lambung yang disarankan pada
berbagai kasus penyakit asam lambung
pH lambung Indikasi
3.5
Penurunan kejadian perdarahan karena
stress mukosa lambung
4.5
Pepsin tidak aktif sebagai faktor agresif
mukosa lambung
=5 99.9% netralisasi asam
< 6
Pencegahan koagulasi dan aggregrasi
platelet darah
6 Penurunan kejadian perdarahan ulang
8 Penghancuran pepsin
Stress-
Related
Mucosal
Disease
Prevention
of Ulcer
Rebleeding
Adapted from Vorder Bruegge WF, et al. J Clin Gastroenterol. 1990;12:S35–S40.
38. Stress Related Mucosal Disease perlu
pH>3.5
pH lambung Indikasi
3.5
Penurunan kejadian perdarahan karena
stress mukosa lambung
4.5
Pepsin tidak aktif sebagai faktor agresif
mukosa lambung
=5 99.9% netralisasi asam
< 6
Pencegahan koagulasi dan aggregrasi
platelet darah
6 Penurunan kejadian perdarahan ulang
8 Penghancuran pepsin
Stress-
Related
Mucosal
Disease
Prevention
of Ulcer
Rebleeding
Adapted from Vorder Bruegge WF, et al. J Clin Gastroenterol. 1990;12:S35–S40.
39. • Stress-related mucosal disease
(SRMD) merupakan kondisi
berkesinambungan dari
kerusakan mukosa (superficial
mucosal damage) hingga
stress ulcer (focal deep
mucosal damage).
• Disebabkan iskemi mukosa,
SRMD biasanya dilihat pada
pasien yang dirawat di
Intensive Care Unit (ICU).
Stress-related mucosal disease dan
pH>3
Multiple ulcers of the stomach, occurring in a
chronically debilitated patient.
41. Faktor Risiko perdarahan lambung karena
Stress Ulcer
• Respiratory failure
• Coagulopathy
• Increased risk with increased
severity of illness
• Multiple trauma
• Age >65
• Corticosteroids
• Prolonged NG tube placement
• NSAIDs
• Major surgery
• Respiratory failure
• Renal failure
• Acute hepatic failure
• Multiple organ failure
• Alcoholism
• Increase IgA antibody to HP
• Head injury
• Sepsis
• Burns >30–35% BSA
Curr Med Res Opin. 2005;21(1):11-18.
42. Terapi pada kasus Stress Ulcer
Curr Med Res Opin. 2005 Jan;21(1):11–18.
• Current preventative treatment strategies
o Histamine 2 receptor antagonists (H2RAs) – Suppressing acid secretion
o Proton pump inhibitors (PPIs) - Suppressing acid secretion
o Sucralfate - provides a protective barrier against acid in the GI tract.
• In the past, H2RAs have been preferentially used over PPIs-available in liquid
and intravenous formulations.
• Currently, PPI are preferable-availability of suspension and IV formulations.
Penelitian membuktikan bahwa PPI memberikan efikasi yang
lebih baik pada pencegahan stress Ulcer dibandingkan H2RA
43. pH>6 dibutuhkan untuk pencegahan
perdarahan berulang
pH lambung Indikasi
3.5
Penurunan kejadian perdarahan karena
stress mukosa lambung
4.5
Pepsin tidak aktif sebagai faktor agresif
mukosa lambung
=5 99.9% netralisasi asam
< 6
Pencegahan koagulasi dan aggregrasi
platelet darah
6 Penurunan kejadian perdarahan ulang
8 Penghancuran pepsin
Stress-
Related
Mucosal
Disease
Prevention
of Ulcer
Rebleeding
Adapted from Vorder Bruegge WF, et al. J Clin Gastroenterol. 1990;12:S35–S40.
44. pH intragastric >=6
dibutuhkan untuk
mencegah disagregasi
platelet pada kasus
perdarahan
gastrointestinal yang
diebabkan oleh ulkus
Target pH intragastrik pada
kasus perdarahan ulkus
peptikum
Green FW, et al. Gastroenterology 1978;74:38–43
48. Efektivitas PPI dalam
menurunkan kejadian
perdarahan berulang pada
pasien dengan perdarahan non
variceal
Barkun AN, et al. Ann Intern Med. 2010;152:101-113
49. Percentage of time pH>6 during first 3 hours
with esomeprazole iv (healthy volunteers)
0
20
40
60
80
100
Mean fraction of first 3 hours (%)
*p<0.05 versus 80 mg + 8 mg/hour
Baseline 40 mg
+ 8 mg/hour
80 mg
+ 4 mg/hour
80 mg
+ 8 mg/hour
120 mg
+8 mg/hour
120 mg (2hours)
+ 8 mg/hour
2%
23.3%*
36.7%*
46.7% 46.7% 43.3%
Röhss K, et al. Intl J Clin Pharm Ther 2007;45:345–54
n=25 n=23 n=24 n=24 n=22 n=20
50. Comparison of acid control
between PPIs;
Which one is the best???
http://www.ncbi.nlm.nih.gov/pubmedhealt
h/PMH0008767/#summary.t1
56. Intragastric pH with high-dose iv PPI
therapy (Eso Vs Panto)
• Clinical pharmacology studies
• H. pylori-negative healthy volunteers
• 24 hour iv infusion
1Röhss K, et al. Intl J Clin Pharm Ther 2007;45:345–54; 2Metz DC, et al. Aliment Pharmacol Ther 2006;23:985–95
n Median/mean Time pH>6
24-hour pH (0–24 hours)
Esomeprazole
80 mg + 8 mg/hour1 25 5.8 12.6
Pantoprazole
80 mg + 8 mg/hour2 36 5.0 5.5–6.7
* This is not “ a head to head” study
57. Day #1 Day #5
Once-daily dosing with esomeprazole 40 mg i.v. provides
faster and more pronounced intragastric acid control than
pantoprazole 40 mg
58. Esomeprazole 40 mg IV satu kali sehari lebih cepat dan lebih efektif mengontrol
keasaman lambung dibandingkan pantoprazole 40 mg IV
59. Rata Rata Lama Pengontrolan pH Intragastric ( Jam )
Esomeprazole i.v 40 mg
Pantoprazole i.v 40 mg
Esomeprazole 40 mg i.v. lebih mampu mempertahankan pH > 4
lebih lama dibandingkan pantoprazole 40 mg i.v
Grafik pH 24-jam intragastrik
60.
61. Prosentase lama Pengontrolan Asam Lambung selama
monitoring 24 Jam (Eso Vs Lanso)
Esomeprazole 40 mg i.v mempertahankan pH > 4 lebih lama
dibandingkan lansoprazole 30mg i.v.
62.
63.
64.
65.
66.
67. ESOMEPRAZOLE
pada pencegahan perdarahan ulang ulkus Peptikum
Pasien perdarahan ulkus peptikum yang mengalami perdarahan ulang,
yang diterapi dengan esomeprazol secara signifikan lebih sedikit
dibandingkan plasebo, baik dalam waktu 7 hari ataupun 30 hari
pemberian.
n= 375 n= 389
73. Safety
Tolerability
Effectivity
Cost
Availability
International Pharmaceutical Society, Council Statement, 2012
74.
75.
76. Esomeperazole : Some Drug interactions and side effects
Initially, there was some worry that PPIs might increase the risk of
developing stomach cancer. Those concerns were unfounded, but
others have taken their place, partly because people often take PPIs
on a daily basis for years, so the total exposure to the drug ends up
being quite significant. Here’s a rundown of the some of the drug
interactions and side effects that are causing concern:
Interaction with clopidogrel. Clopidogrel (sold as Ceruvin, Clopilet,
and Plavix) is a drug that discourages the formation of artery-
clogging blood clots and is often taken by people with heart disease
to prevent heart attacks and stroke. But clopidogrel has a significant
downside: it’s hard on the lining of the stomach and intestines, so it
increases the risk of gastrointestinal bleeding. To keep those bleeds
from happening, doctors have often prescribed a PPI with
clopidogrel, especially if the patient is also taking aspirin. Like
clopidogrel, aspirin makes blood clots less likely to form, and dual
clopidogrel-aspirin therapy is recommended after placement of an
artery-opening coronary stent. But aspirin, too, is rough on the
gastrointestinal lining.
The trouble is that PPIs — and omeprazole in particular — inhibit an
enzyme called CYP2C19 that’s crucial to one of the metabolic steps
that activates clopidogrel and its effects. In 2009, the FDA issued a
strong warning that said patients taking clopidogrel should avoid
taking omeprazole (and, secondarily, the related drug Nexium)
because they may cut clopidogrel’s effectiveness in half.
77. Fracture risk. Some studies have shown an association between PPIs and the risk of fracture
— particularly hip fracture — while others have not. The FDA decided in 2010 that there was
enough evidence of fracture risk to warrant a warning about it. Calcium is absorbed in the
small intestine, not the stomach. But low stomach acid levels can have downstream effects,
especially in the duodenum, and some research shows that one of them could be reduced
absorption of calcium, which could lead to osteoporosis, weaker bones, and, consequently,
a greater chance of breaking a bone. The fracture risk is probably pretty small, but it’s
another reason for not taking a PPI unless necessary.
Pneumonia risk. Several studies have shown that people taking PPIs seem to be more likely
to get pneumonia than those who aren’t. The association has been documented among
people living in the community and hospital patients alike. Normally, stomach acid creates a
fairly inhospitable environment for bacteria, but if acid levels are reduced by PPIs, the
bacteria count can go up. The thinking is that in people with GERD who take PPIs, bacteria-
laden stomach contents may travel up the esophagus and then get inhaled into the windpipe
and lungs, where the bacteria cause pneumonia.
C. difficile risk. People typically develop Clostridium difficile infections in the hospital after
taking antibiotics that have disrupted the natural bacterial ecology of the large intestine.
The infections cause diarrhea but can also become a lot more serious, even life-threatening.
Studies have shown a fairly strong statistical correlation between PPI use and C. difficile
infection, although it’s still just a correlation and not proof of direct cause and effect. Some
experimental evidence suggests that PPIs may change conditions in the gut to be more
favorable to C. difficile bacteria.
Iron and B12 deficiency. Stomach acid helps render the iron and vitamin B12 from food into
forms that are readily absorbed. So there was worry that an unintended consequence of PPIs
would be deficiencies of this vitamin and mineral because of lower stomach acid levels. But
research has shown that if there is any effect, it’s mild, so those concerns have been
largely allayed.