1) Proton Pump Inhibitors - potential side effects
Proton pump inhibitors have revolutionized the treatment of UGIB. An acidic environment inhibits platelet aggregation and promotes fibrinolysis of formed clot by the enzyme pepsin. Bringing the gastric pH to above 6 is thought to promote clot formation. Studies have shown that treatment with a PPI signficantly reduces recurrent bleeding secondary to PUD.
- PPIs are often started for various reasons, i.e. to promote healing of peptic and duodenal ulcers, symptom relief from GERD etc. They are very effective, however many forget to reassess the need to continue on PPI therapy and patients may continue them indefinitely. This has led to long term complications of PPI use.
- Nutritional:
- Protein bound dietary Vitamin B12 requires acid and pepsin for its initial absorption. Vitamin B12 then binds to haptocorrin, found in the saliva. It is then liberated in the higher pH environment of the duodenum, where it binds to intrinsic factor and is absorbed in the terminal ileum.This may be more important for people who have low Vit B12 intake (i.e. Vegans) or the elderly. Therefore it may be reasonable to measure Vit B12 levels in these populations of people who are on PPIs.
- There is a theoretical possibility of iron deficiency, as gastric acid is needed to reduce non heme iron (Ferric iron) to the more soluble Ferrous iron.
- Osteoporosis: Gastric acid secretion is important for dietary calcium absorption.
- Infections:
- Pneumonia: By changing the gastric flora and seeding of the lungs from the upper alimentary tract.
- C. difficile and other enteric infections: Also due to changes in the gastric flora
- Cancer:
- Theoretically the hypergastrinemia resulting from chronic acid suppression can lead to hyperplasia of the gastric enterochromaffin-like cells and lead to gastric carcinoid tumours. Gastrin is also trophic for colonic mucosa, and may also lead to colorectal carcinoma.
2) Treatment of bacteriuria in the Elderly
- There is no evidence for treatment of asymptomatic bacteriuria in the elderly. The only cases where asymptomatic bacteriuria should be treated is in pregnant patients and prior to urologic procedures.
- Bottom line, a positive urinalysis in an obtunded elderly patient does not mean the patient has urosepsis! Look for other signs of infection: Fever, white blood cell count, imaging findings of pyelonephritis, lower urinary tract symptoms.
3) When to suspect Legionella?
- Fever >39C
- Neurologic findings, confusion
- Gastrointestinal findings: Nausea/Vomiting/Diarrhea
- Transaminitis
- Leukocytosis, thrombocytopenia
- Hematuria
- Hyponatremia
- Failure to respond to beta-lactams or aminoglycocide
- CXR: can show anything from lobar consolidation to interstitial pulmonary inflitrates
No comments :
Post a Comment