NSAIDs - How to prevent GI bleed?

NSAIDs - How to prevent GI bleed?


I saw a young man today with likely ankylosing spondylitis. I started him on NSAIDs. He told me that he suffers from reflux, this brings up a question, how can I reduce the GI side effect?

How does it work ? (This is to remind myself, I seriously can't remember)

Key points:

1. No one NSAID is safer another. 

2. Use low dose NSAIDs for the shortest time possible. 

3. COX-2 NSAIDs seem to have less GI side-effects

4. Co-infection of H. Pylori and the use of NSAIDs increase the risk of GI ulcer by 60 folds and bleeding by 6 folds. 

5. Other drugs which can increase bleeding risks include: anti platelets, anti coagulants, anti depressants, corticosteroids, cigarette, smoking and excessive ETOH consumption.

6. Some other risk factors of GI bleed: 

7. Consider the use of PPI in high risk groups: 

Reference:

Australian therapeutic guideline 

Quick start of contraception

Quick start of contraception

Traditionally, contraception methods are started within the first 5 days of menstrual cycle. It becomes a problem when a woman comes to you for contraception during mid cycle. If you tell her to wait, she may become pregnant before she gets her next period. Quick start of contraception tries to tackle that.

Essentially, the process can be summarised in 3 steps:
1. Establish pregnancy status
2. Choose contraception method
3. Follow up

1. Establish pregnancy status 

• Pregnancy can be excluded if :
• -ve pregnancy test + no sex in the last 3 wks
• no sex since last period
• using contraception correctly and reliably
• within the first 5 days of menstrual period 
• < 21 days post part
• < 5 days post abortion or post miscarriage 
• Pregnancy cannot be excluded:
• needs follow up pregnancy testing, the current Australian guideline is in 4 weeks time

2. Choose contraception method 

• If pregnancy can be excluded: can choose any contraceptive method. Don't forget COCP, Vaginal ring, DMPA, LNG IUD and Levonorgestrel take 7 days to work. POP takes 3 days. Copper IUD effective immediately
• If pregnancy cannot be excluded
• tell her that there is a chance she could be pregnant, if it is appropriate, offer her emergency contraception 
• inform choices available for contraceptions: 
• Vaginal ring, COCP, POP, levonorgestrel have not shown to have teratogenic effects in babies. 
• DMPA injection is long acting, so it is less perferrable but also no evidence of teratogenicity
• IUD and Copper IUD not preferred as can cause miscarriage

3. Follow up 

• Women in whom the pregnancy status cannot be excluded: needs pregnancy test in 4 weeks. (This is the current Australian recommendation. Other guidelines have different timeframe)

Resources:

1. Flow chart for quick start contraception(American version, follow up testing time frame different)

2. Family planning victoria quick start guideline

Case study 2 - ? PUD

60 yr old M presented with 3 days history of epigastric pain.

3 days ago while he was watching TV, he developed severe abdominal. He said it was so severe that he almost called the ambulance. The pain was described as sharp and lasted for few hours. He still has some epigastric pain today but it is mild. He also complained of nausea and loss of appetite. He drinks 6-8 beers per day. In the last few days, he didn't drink more than what he normally would drink. There was no vomiting, diarrhoea, recent travelling or malaena.

On examination, his vitals were stable. Abdominal exam: tender epigastric region. PR: no malaena.

What do you think is going on? How would you manage this patient ?

My differential diagnoses were: peptic ulcer disease, pancreatitis, cholecystitis. Diagnoses that I didn't want to miss: MI and AAA.

I ended up ordering FBE, UEC, LFT, CRP and Lipase and started him on a PPI. I plan to refer him to a surgeon when he returns for the blood test results. I also try to advice him to cut down on his ETOH but I doubt he listened to me.

I will update the post once he comes back for his blood test results.

In addition, this case brought me to the attention of long term safety of PPI. According to eTG:
- PPI is safe long term, however, lack of data for the use > 20 years
- May increase risk of CAP, travellers' gastroenteritis and hospital and community acquired C. diff.
- Initial concern of increasing incident of enterochromaffin tumour has not been confirmed.

End

Ciprofloxacin

I prescribed ciprofloxacin today to a patient who has a background history of bladder TCC and received a neo bladder surgery in USA. He presented with rigor and dysuria. I ended up prescribing him ciprofloxacin which was what he was on in the past when he had an UTI.

Ciprofloxacin belongs to the Quinolone group. It has a broad spectrum of activity against Gram-negative bacteria, gram negative rods (P. Aeruginosa), gram negative cocci, some gram-positive cocci, and intracellular organisms including legionella and various species of mycobacteria. Quinolone have no clinical activity against anaerobic bacteria.

I am thinking that I should have covered him for anaerobic bacteria as well. Hopefully he gets better soon.

End.

GP Case study 1

I was on-call for GP this weekend. (Yes, I know. Don't ask me why GP needs to be on-call). The local ED was overflowing with patients. 90 % of them were inappropriate presentations. They should be sent home and present to their regular GP on Monday. The following was one of the cases I saw, not avcommon day to day presentation at GP clinic, however, still relevant.


Scenario 
21 F with b/g history of rheumatoid arthritis on Celebrex presented to ED after a dog bite. The dog bit her on the right thumb close to the 1st MCP. (Please see figure 1).



On examination, the patient's right thumb was neurovascularly intact. How would you manage this patient?

Answer: This wound is at high risk of getting infected. If you pay attention at the photo, you will also see a puncture wound on the palmer aspect of the thumb. It is likely that the puncture wound went through the 1st metacarpal phalangeal joint. It needs to debrided and washed out surgically. I contacted the local friendly plastic registrar to organise a surgical debridement the next day. I also organised a right thumb x-ray, IV Tazocin (Piperacillin + Tazobactam) and a right thumb superficial irrigation at ED with a ring block.

According to Australain therapeutic guideline 2015.

- The organisms associated with animal bites are Pasteurella species, S. aureus, Capnocytophaga canimorsus, Streptococcus species and anaerobic bacteria.
- Cat bites have a higher incidence of deep infection than dog bites.
- Postexposure rabies or lyssavirus prophylaxis is required for some bites, for example bat bites
- In all cases, the patient's tetanus immunisation status must be ascertained
- The recommended management of clenched fist injuries, and human and animal bites, is through cleaning, debridement, irrigation, elevation and immobilisation.

Antibiotic therapy is necessary for bites and clenched fist injuries with a high risk of infection. These include:
- wounds with delayed presentation ( 8 hours or more)
- Puncture wounds that cannot be derided adequately
- wounds on the hand, feet or face. (will usually require surgical consultation)
- Wounds involving deeper tissues (e.g. bones, joints, tendons)
- Wounds in immunocompromised patients

End.

Hepatitis B

Hepatitis B

key features:

1. Hepatitis affects 1 % of the population in Australia 
2. The main viral investigation for HBV is HBsAg (surface antigen), if detected, indicating hepatitis B positive or carrier, a full viral profile is then formed. 
3. Monitor progress with 6-12 monthly LFTs, HBeAg and HBV DNA
1. negative HBeAg and HBV DNA (with anti-HBe) = resolving, with anti-HBs = full recovery
2. Positive HBeAg and HBV DNA = replicating and infective - refer 
3. Monitor LFTs every 6 months. Refer if ALT elevated
4. Treatment: no specific treatment initially. Advise avoidance of ETOH, avoid certain drugs e.g. sedatives, NSAIDs, OCP, until recovery (normal LFTs). 
5. Treatment of chronic hepatitis B infection (abnormal LFTs) is with immunomodulatory and antiviral agents - pegylated interferon alpha and lamivudine. 
6. Refer any HBsAg positive patient with an abnormal ALT and/or signs of chronic liver disease to a specialist since the evaluation of chronic hepatitis B can be complex
7. 
8. 

Reference:

http://crmpub.ashm.org.au/product/Decision%20Making%20in%20HBV%202015_71497B8BAFEDE211AB9F984BE173A384/HBV_DecisionMaking_Jan2015.pdf

Hepatitis C

Hepatitis C

key features:

1. Hepatitis C virus is responsible for most cases of viral hepatitis in Australia. 
2. there are at least 6 major genotypes of HCV and treatment decisions are based n the genotype
3. Diagnosis and progress:
1. HCV Ab (Anti HCV) +ve = exposure (current or past)
2. HCV RNA + ve = chronic viraemia, -ve spontaneous clearance
3. HCV/CD4= Viral load
4. ALTs on LFTs indicate disease activity (tested 3 times over 6 months)
5. ALTs persistently normal = good prognosis
6. ALT increases = referral for treatment
7. If PCR +ve + significant viral load + ALT increases perform HCV genotype - determines treatment
4. current treatment is ribavirin orally daily and pegylated alpha-interferon. At present the determination of the genotype and the viral load will identify those groups most likely to respond to therapy. e.g. genotype 1 will have a good response, genotype 2 and 3 have excellent response
5. Patients with hepatitis c should be tested for hepatitis A and B 
6. They should avoid ETOH
7. Factors associated with faster disease progression include significant ETOH ingestion, co-infection with hepatitis B or HIV, age over 40 years at acquisition, marijuana use and obesity
8. Those at increased risk of having hepatitis c
1. Blood transfusion recipients (prior to HBV and HCV)
2. Intravenous drug users 
3. Male homosexuals who have practised unsafe sex
4. kidney dialysis patients
5. sex industry workers
6. those with abnormal LFTs with no obvious cause
7. Tattooed people/body piercing
9. Advice to those who are positive for HCV
1. Do not donate blood or any body organs or tissues
2. Do not share needles
3. Advise health care workers, including your dentist
4. Do not share intimate equipment such as tooth brushes, razors, nail files and nail scissors
5. Wipe up blood spills in the home with household bleach
6. Cover up cuts or wounds with an adequate dressing
7. Dispose of blood stained tissue, sanitary napkins and other dressings safely
8. Use safe sex practices such as condoms 
9. Avoid tattooing

References:

1. John Murtagh
2. http://www.racgp.org.au/afp/2013/july/hepatitis-c/

H. Pylori

H. Pylori 

Key features: 

1. H. pylori is a gram negative bacillus that has naturally colonised the human stomach for at least 50,000 years. Usually acquired in childhood, it colonises the gastric mucosa of about 50% of the world’s population at some time in their life. 
2. Infection with H. pylori induces a persistent immune response. Because the organism has numerous adaptions to prevent immune detection, clearance by the body is never complete. The resulting sustained inflammatory processes in the stomach cause a reduction in the population of somatostatin-producing D cells. This causes a subsequent rise in gastrin secretion followed by an increase in gastric acid release which may lead to peptic ulceration in some patients. 
3. Most patients colonised with H. Pylori do not develop peptic ulcers. 
4. It would not be appropriate to investigate for H. pylori initially in the presence of alarm symptoms such as weight loss, bleeding, dysphagia or symptoms in a patient above the age of 55 years. In this context, investigations should first be directed at excluding malignancy, for example with a gastroscopy.
5. Current Therapeutic Guidelines in Australia, revised in July 2013, recommend PPI-based triple therapy as the first line measure for eradication of H.pylori. (Esomeprazole 20 mg twice daily, amoxicillin 1 g twice daily and clarithromycin 500 mg twice daily)
6. The conclusion to be drawn from the Swedish study is that in all traditionally prescribed regimens, eradication is only partially successful. 

Reference:

http://www.racgp.org.au/afp/2014/may/helicobacter-pylori-eradication/

Diverticular disorder

Key points:

1. 90 % in descending colon, mostly asymptomatic and is related to lack of fibre in the diet.
2.

• Typical clinical features: middle aged or elderly - over 40 years. 
• Increases with age
• Present in one in three people over 60 years
• Diverticulitis - infected diverticula and symptomatic 
• Constipation or alternating constipation/diarrhoea
• Intermittent cramping lower abdominal pain in LIF
• Tenderness in LIF
• Rectal bleeding -- may be profuse 
• May presente as acute abdomen or subacute obstruction 
• Usually settles in 2-3 days 

3. Complications include

• Abscess 
• Perforation 
• Peritonitis
• Obstruction 
• Fistula - bladder, vagina

4. Management

• It usually responds to a high fibre diet: plenty of fluids, cereals, wholemeal, multigrain bread, fresh or stewed fruits and vegetables
• Avoidance of constipation 

References:

- John Murtagh's general practice 8th edition 

Ingrown toenail (onychocryptosis)

Key points on ingrown toenail management:

1. Common presentation to primary care, especially in adolescent boys. It is typically located along the lateral edges of the great toenail and represents and imbalance between the soft tissues of the nail fold and the growing nail edge.

2. It is exacerbated by faulty nail trimming, constricting shoes and poor hygiene. Other risk factors include: male, 14-25 age group, isotretinoin use and thickening of the nail plate.

3. All patients should be instructed on correct foot and nail care. Foot hygiene includes foot baths, avoiding nylon socks and frequent changes of cotton or wool socks. It is important to fashion the toenails so that the corners project beyond the skin. (Figure 1)

4. Surgical nail excision is an easy procedure. GPs should learn how to do it.

5. There are many different ways of removing the lateral toenail. The principles are the same. Remove the part of the nail that is digging into the skin and prevent it from happening again. The following youtube video showed a technique that we use in our GP practice

6. https://youtu.be/XVDYb6ubt7I

7. The following video gives a good illustration of how to do a digital block: https://youtu.be/l2Zl15LFQWQ

8. I use the phenol ablative technique and it is well described in reference 2

9. The first time when you do it, it is better to have someone there to supervise. Once you have done it for a few times, you will be able to do it. It is not a difficult procedure.

Reference:
1. John Murtagh's General practice 5th edition
2. http://www.racgp.org.au/afp/2015/march/ingrown-toenails-the-role-of-the-gp/