Pharmacotherapy Case Study 4: Stress Ulcer Prophylaxis/Upper GI Hemorrhage By: Dr. Nehad Ahmed

 

Pharmacotherapy Case Study 4: Stress Ulcer Prophylaxis/Upper GI Hemorrhage By: Dr. Nehad Ahmed

 

Chief Complaint:

A 68-year-old male is admitted to the hospital following a recent surgery for hip fracture repair. He is presenting with gastrointestinal symptoms, including dark stools and a drop in hemoglobin, noted during routine post-surgical monitoring. He is also experiencing mild epigastric discomfort.

Subjective Data:

History of Present Illness (HPI):

·        The patient was admitted for hip fracture surgery 5 days ago and has been recovering post-operatively.

·        For the past 2 days, the patient has reported mild, intermittent epigastric discomfort, which he describes as a dull ache that worsens after meals and with certain positions (e.g., lying flat).

·        The patient denies nausea or vomiting, although he notes occasional dizziness and fatigue. He also reports passing dark, tarry stools over the past 24 hours.

·        The patient has a history of chronic stress and anxiety, often exacerbated by medical procedures, and has been under significant stress since his recent surgery.

Past Medical History (PMH):

·        Hypertension: Controlled with amlodipine 10 mg daily.

·        Osteoarthritis: Chronic knee and hip pain, managed with NSAIDs before surgery (ibuprofen 400 mg daily).

·        Gastroesophageal reflux disease (GERD): Long-standing, treated with over-the-counter antacids as needed.

·        No history of peptic ulcer disease (PUD) or upper gastrointestinal (GI) bleeding prior to this admission.

·        Recent hip fracture due to a fall.

Medications:

·        Amlodipine 10 mg orally once daily.

·        Omeprazole 20 mg orally once daily (started post-surgery for stress ulcer prophylaxis).

·        Acetaminophen 500 mg every 6 hours as needed for pain management (post-surgery).

·        Ibuprofen 400 mg daily (discontinued on hospital admission due to risk of GI bleeding).

Allergies:

·        No known drug allergies (NKDA).

Social History:

·        Retired office worker, lives alone.

·        Smokes half a pack of cigarettes daily for 40 years.

·        Drinks alcohol socially (2-3 drinks per week).

·        Denies illicit drug use.

·        Significant stress related to his recent surgery and recovery process.

Family History:

·        Father had a history of hypertension and stroke.

·        Mother had a history of peptic ulcers and passed away from complications related to gastrointestinal bleeding.

Review of Systems (ROS):

·        Gastrointestinal: Dark stools, mild epigastric discomfort. Denies nausea or vomiting.

·        Cardiovascular: No chest pain or palpitations.

·        Respiratory: No shortness of breath, cough, or wheezing.

·        Neurological: Mild dizziness and fatigue; no headaches or syncope.

·        Musculoskeletal: Recent hip fracture with post-surgical pain.

Objective Data:

Vital Signs:

·        Blood Pressure: 110/68 mmHg

·        Heart Rate: 92 bpm

·        Respiratory Rate: 18 breaths/min

·        Temperature: 98.4°F (36.9°C)

·        Weight: 185 lbs (83.9 kg)

·        Height: 5'10" (178 cm)

Physical Exam:

·        General: Alert, oriented, appears slightly fatigued, but in no acute distress.

·        Abdomen: Soft, non-distended, mild epigastric tenderness on palpation. No rebound tenderness or guarding. Bowel sounds are normal.

·        Cardiovascular: Regular rate and rhythm, no murmurs or gallops.

·        Respiratory: Clear to auscultation bilaterally.

·        Musculoskeletal: Surgical site on right hip with dressing intact. No obvious swelling or deformity.

Labs and Imaging:

·        Complete Blood Count (CBC):

o   Hemoglobin: 10.2 g/dL (down from baseline of 13.5 g/dL pre-surgery).

o   Hematocrit: 31% (decreased).

o   Platelets: 250,000/mm³.

o   White Blood Cell Count: 7,000/mm³.

·        Basic Metabolic Panel (BMP):

o   Normal electrolytes and renal function.

·        Liver Function Tests (LFTs): Normal.

·        Stool Occult Blood Test: Positive for occult blood.

·        Upper GI Endoscopy (EGD): Findings consistent with superficial gastric erosions and small active bleeding in the fundus of the stomach, likely stress-related.

Assessment:

The patient is at risk for stress ulcer-related upper GI hemorrhage, particularly given his recent surgery, use of NSAIDs prior to admission, and significant stress levels. The presence of dark stools and a drop in hemoglobin suggests ongoing gastrointestinal bleeding. The findings from the upper GI endoscopy confirm superficial gastric erosions with active bleeding.

Stress ulcers are common in critically ill patients, and given the patient's recent surgery, history of chronic stress, and the use of NSAIDs prior to hospitalization, this patient is at increased risk for this complication.

Plan:

Pharmacologic Treatment:

1.     Proton Pump Inhibitor (PPI):

o   Pantoprazole 40 mg IV once daily for 72 hours, then transition to oral form (Pantoprazole 40 mg once daily) for 4-6 weeks to promote ulcer healing and prevent further bleeding.

2.     Stress Ulcer Prophylaxis:

o   Continue Omeprazole 20 mg orally once daily as stress ulcer prophylaxis.

3.     Blood Transfusion:

o   Due to the drop in hemoglobin (10.2 g/dL), consider a blood transfusion if the patient remains symptomatic (dizziness, fatigue) or if hemoglobin continues to decline.

4.     Antacids:

o   For mild symptom relief, use calcium carbonate (500 mg) after meals if needed.

Non-pharmacologic Treatment:

·        Monitor Hemoglobin and Hematocrit: Recheck CBC every 24 hours to monitor for further bleeding or improvement.

·        Dietary modifications: Start with a bland diet once the patient is stable. Avoid spicy, acidic, or highly caffeinated foods that could exacerbate irritation.

·        Stress management: Provide relaxation techniques, encourage deep breathing, and consult with hospital support services for stress reduction during recovery.

·        Smoking cessation: Strongly recommend smoking cessation to reduce ulcer risk.

Patient Education:

·        Instruct the patient on the importance of completing the prescribed PPI regimen.

·        Educate on the signs of gastrointestinal bleeding (e.g., dark stools, vomiting blood) and the need to report any of these immediately.

·        Discuss the potential complications of NSAID use and the need to avoid NSAIDs for pain management during recovery.

·        Counsel the patient on stress reduction strategies and encourage participation in relaxation techniques or counseling if needed.

Follow-Up:

·        Monitor the patient's response to therapy daily and adjust based on clinical symptoms and laboratory values.

·        Follow-up after discharge for continued management of stress ulcer prophylaxis and GI symptom resolution.

·        Repeat endoscopy if symptoms persist or if there is continued evidence of active bleeding.