Patient information
The patient under review is a 42 year old female Indian who is admitted into the emergency room presenting with acute gastrointestinal bleeding. Prior patient diagnosis reveals the patient had suffered from dental abscess and also a fractured tooth, which was subsequently treated with antibiotics. However, a tooth extraction procedure was carried out for the extraction of the tooth. Ensuing dental ache was treated with drugs purchased over the counter (OTC) including ibuprofen and acetaminophen before the medical prescription of Vicoprofen. The patient complains of nausea and headache in addition to vomiting copious amounts of a dark brown liquid which were followed by diarrhea. The patient also reports prior episodes of bleeding, including incidences of epistaxis in childhood, which called for frequent visits to the emergency department. She also reports an episode of epistaxis in pregnancy at 26 years of age, which called for an ED visit and led to a complicated delivery. Hemorrhage occurred during the pregnancy warranting a hysterectomy. The patient also suffers from depression of which she is under medication. The patient reports no history of drug usage, including smoking, drinking or taking in of banned substances. The patient is originally from India and relocated to America a decade ago. She lives with her husband and the couple has an only child aged 16 years.
Pathophysiology
The patient condition presents with gastrointestinal bleed. According to Srygley, et al., (2012) gastrointestinal bleed is divided in two, upper and lower gastrointestinal bleed. Causes of the upper form of gastrointestinal hemorrhage (UGIB) include peptic ulcer disease, esophageal varices, which emanate from liver cirrhosis and cancer (Cheng, et al., 2012). Peptic ulcer results from either the breakage of the stomach lining or the first parts of the ileum, or breakage in the esophagus lining. In this case, the mucosal lining of the digestive tract becomes eroded, leading to damage to the blood vessels which marks the onset of bleeding (Srygley, et al., 2012). Additionally, inflammation of the lining wall of the stomach stems from the incapacity of the gastric lining to protect itself from the produced acid in the region. In which case, gastritis ensues.
The use of NSAIDs continues to cause UGIB (Upper Gastrointestinal bleeding). According to Villanueva, et al., (2013) some NSAIDs and associated ulcers are asymptomatic and do not lead to bleeding. However, elderly patients such as the case in this case study, who have a history of bleeding have a higher risk of continued bleeding with a continued use of nonsteroidal anti-inflammatory drugs. Other associated risk factors that come with NSAID use include higher dosages of NSAIDs, a history of PUD (Peptic Ulcer Disease) which is linked with H. pylori and the use of corticosteroids and anticoagulants. Although the correlation between H. pylori (Helicobacter pylori) infection in patients using nonsteroidal anti-inflammatory drugs are hitherto controversial, anecdotal evidence suggests that using NSAIDs predisposes one to a PUD or to developing gastrointestinal (GI) bleeding and complications. The risk of gastrointestinal (GI) bleeding is also compounded by a history of drug use and abuse, including a history of smoking, drinking, nicotine use and the use of caffeine. According to Cheng, et al., (2012) persons with Blood group O are at higher risk of gastrointestinal (GI) bleeding compared to other blood types.
In this regard, the patient under review is highly predisposed to gastrointestinal (GI) bleeding due to multiple factors. As documented, intake of NSAIDs equally predisposes one to gastrointestinal (GI) bleeding. With the patients’ intake of both ibuprofen and vicoprofen, this risk is augmented. Having migrated from India a decade ago, the patient may have been a high spicy food intake person, a fact that predisposes on to GI bleed. The patient also has epitaxies episodes coupled with a history of hemorrhage dating back to when she was young and during her pregnancy. The intake of Nonsteroidal anti-inflammatory drugs alongside antidepressants such as sertraline in the case of the patient, augments the risk of bleeding (Laine & Jensen, 2012). Finally, with a blood O + type, the patient has a higher likelihood of contracting gastrointestinal complications.
The patient’s physical assessment revealed that she was pale and fatigued. Furthermore, a nasogastric tube is positioned in her right nostril with the purpose of draining a pink tingled fluid. She has diarrhea and vomits copious amounts of a dark brown liquid. Her vital signs include a blood pressure reading of 102/55, an increased heart rate of 110 beats per minute and an increased respiratory rate of 26-28 breath per minute. This shows the body is trying to compensate the drop in blood pressure and oxygen saturation by raising the heart and respiration rate. These are all signs and symptoms of upper GI bleeding and complications such as gastritis and peptic ulcer. With these high readings above normal, the patient’s body is making an effort in compensating for the dip in blood pressure levels and oxygen levels. The patient’s signs are pointers of gastrointestinal (GI) bleed. Additionally, it is plausible that comorbid conditions may be present.
With the presented conditions, varied treatment options and interventions have been instituted for the patient. They include the daily administration of Sertraline 50 mg and multivitamins. She also reports to have taken Vicoprofen, and has also began medication on Omeprazole, which is effectual in suppressing gastric acid in the stomach. Omeprazole is effectual in treating adverse stomach acidity as well as treating gastro esophageal reflux disease (GERD) (Goldstein, et al., 2016). Additionally, she is scheduled to commence on 2 units of leukoreduced packed red blood cells, which are effectual in replenishing her red cells as well as hematocrit. The connected nasogastric that is linked to low intermittent suction tube also plays a vital role in the monitoring and the drainage of gastric secretions. By being placed under Nil Per Os (NPO), the patient is kept from a plausible aspiration pneumonia as she undergoes observation (Leder & Lerner, 2013).
In order to ensure she receives proper care, a close monitoring of her vitals is imperative. The responsible nurse, for instance, has to ensure that the prescribed medications and the intravenous fluids are administered as prescribed. The patient’s vital signs including her BP, HR among other vitals need regular checkup in tandem with set regulations. In so doing, the high BP and HR will be reduced as well as the incidence of the gastrointestinal (GI) bleeding checked. Assessment of the patient’s bowel is equally essential in order to prevent adverse effects. This assessment includes checking for signs of bloating, bowel movement, tenderness among other tests. This checkup must be routine based on the hospital guidelines on acute patient assessment.
In case the patients' pain persists, the location of the pain should be identified and analysis of the pain done including its cause, severity and longevity. In this case, appropriate pharmacological interventions must be provided to alleviate the pain. The Nasogastric (NG) intubation process should be done gently and proper caution needs to be taken, including lubrication of the NG tube and maintain aseptic conditions in the oral cavity. The patient also has to be educated over the purchase of OTC drugs and the dangers of self-medication. Obtaining and self-prescribing Ibuprofen, a Nonsteroidal anti-inflammatory drug (NSAID) and acetaminophen over the counter should be discouraged. Additionally, the patient’s need to be taught on the coping mechanisms of stress management other than medication such as the sertraline which she was on. Psychosocial support can be encouraged. Finally, the healthcare professionals have to assess the patient’s lab test results in order to guide on appropriate interventions to be used.
With a Hematocrit value of 19.4%, the patient records extremely low readings considering normal adult values range from 37.0 -47.0%. Hemoglobin levels of 7.2g/dl is equally low. Hemolysis, hemorrhage or anemia are plausible causes since the patient registered huge losses of blood and has a history of blood loss. By the patients vomiting of large quantities of dark brown liquid followed by dark brown liquid diarrhea, water loss is also inevitable. A combination of these factors including the intake of NSAIDs are plausible cause of the recorded hematocrit and hemoglobin levels. Consequentially, close monitoring is needed because of the close correspondence between the hematocrit and hemoglobin level and the level of blood that circulates as Ignatavicius & Workman, (2015) documents.
Blood urea nitrogen (BUN) levels are often checked against that of creation in order to establish renal function (Wu, et al., 2013). In the case of the patient where the BUN levels are high (27 mg/ml) whereas the creatine levels are normal, various explanations can surface. According to Wu, et al., (2013) age plays a significant role in this observation. However, higher BUN levels may also be attributed to urinary tract obstruction, the use of medications such as corticosteroids or NSAIDs, dehydration and gastrointestinal (GI) bleeding. All these plausible reasons apply to the patient. Other explanations for higher BUN levels included high protein intake and the effects of severe burns. A Direct Coombs test is one of the two blood tests. Segel & Lichtman (2014), document its application in hematology and immunology. Both the direct Coombs test (DAT) and the antiglobulin test (IAT) achieve this purpose. The test has the ability to also detect immune hemolysis (Segel & Lichtman, 2014). The test searches for antibodies which link to erythrocytes resulting in hemolysis. Specifically, the direct Coombs test, tests for autoimmune hemolytic anemia, such as the presence of low blood count. The indirect Coombs test on the other hand tests pregnant women before a blood transfusion. In this regard, antibodies against the RBC which bound the serum are detected. A positive Coombs test is a pointer to the presence of antibodies (Yoshimi, 2016).
With regard to the patient, since she consents to having used antibiotics recently, the antibiotics need to be established and classified. This will prevent plausible drug interactions and improve the efficacy of administered drugs. The patient records episodes of epistaxis during childhood requiring multiple ED visits. The presence of an autoimmune disorder may be more likely.
Medications
The patient is under omeprazole (40mg) which is administered intravenously twice in a day. This dosage is higher than the allowable requirements. Adverse patient symptoms are plausible causes for this measure. As a proton pump inhibitor, the action of omeprazole is both selective and permanent (Angiolillo, 2011). By inhibiting the H+/K+-ATPase system, secretion of stomach acids such as gastric acid is suppressed from the parietal cells. This inhibition is achieved because as an enzyme system, the H+/K+-ATPase is considered as the proton pump in the gastric mucosa (Angiolillo, 2011). Omeprazole thus functions to inhibit the production of acid in the parietal cells. The patient prescribed omeprazole dosage of 40mg Intravascular (IV) taken twice daily will thus be effective for the patient in preventing peptic ulcers and other UGIB (Upper Gastrointestinal bleeding). Clostridium difficile infection is similarly associated with taking omeprazole at a higher dose. Albeit a higher than recommended dosage at 40mg, the adverse condition warrant this dosage intake.
Adverse effects such as dermatological rashes, headaches, dizziness, hypomagnesaemia, regurgitation, flatulence, back pain, nausea, constipation and vomiting are expected. Drug interactions are not expected in the patient’s case since omeprazole contraindications are rare (Angiolillo, et al., 2011). Effectual administration of omeprazole is expected to prevent adverse effects of Upper Gastrointestinal bleeding. Consequentially, the bleeding should stop since inhibition of the production of acid in the parietal cells will be achieved. Diarrhea, nausea, headaches and abdominal pain are thus expected to cease. However, constant monitoring of vital signs such as HB, Hematocrit, White blood count, Platelet and Blood urea nitrogen (BUN) must be ensured. Monitoring is effectual in determining the patient’s response to medication (Angiolillo, et al., 2011).
Sertraline, an antidepressant, is effectual in treating depression (Porth, 2015). It is mainly a serotonin reuptake inhibitor, which has a high affinity towards serotonin. Consequentially, uptake of sertraline results in more than 90% inhibition of SERT (serotonin transporter).The drug was thus prescribed to reduce episodes of stress and cognitive issues including headaches in the patient. Additional side effects include potential sexual disorders and difficulties in having sexual desire, suicidal tendencies and withdrawal.
Vicoprofen can cause adverse gastrointestinal effects (Porth, 2015). Some of the symptoms of the reaction to the drug include bleeding, inflammation, and ulceration and can cause fatal effects on the stomach, small intestines and large intestines by causing perforations in their lining. The danger of these serious side effects can occur any time without warning in the patient who is using vicoprofen. Moreover, the adverse reaction is symptomatic in every one in five patients and this only occurs in 1% of the patients who have been treated with the drugs. Additionally, the condition is more likely to occur with persistent use of the drugs for three to six months and the prevalence rises to 2 to 4% in patients who have continually used the drugs in more than one year. Therefore, while using Vicoprofen it is important to take extreme precaution, especially if one has a history of ulcers or any form of gastro intestinal bleeding. Additionally, these drugs have increased chances of causing side effects when they interact with other drugs like corticosteroids and some anticoagulants. Additionally, poor health, smoking, and older age increase the chances of developing adverse reactions. To minimize these effects it is important to consult with a physician before taking vicoprofen as Ignatavicius & Workman (2015) document. Ibuprofen is a milder alternative to vicoprofen. Therefore, taking it, may be ineffectual due to the presenting adverse effects.
References
Angiolillo, D. J., Gibson, C. M., Cheng, S., Ollier, C., Nicolas, O., Bergougnan, L., & Dubar, M. (2011). Differential effects of omeprazole and pantoprazole on the pharmacodynamics and pharmacokinetics of clopidogrel in healthy subjects: randomized, placebo‐controlled, crossover comparison studies. Clinical Pharmacology & Therapeutics, 89(1), 65-74.
Cheng, D. W., Lu, Y. W., Teller, T., Sekhon, H. K., & Wu, B. U. (2012). A modified Glasgow Blatchford Score improves risk stratification in upper gastrointestinal bleed: a prospective comparison of scoring systems. Alimentary pharmacology & therapeutics, 36(8), 782- 789.
Goldstein, J. L., Whellan, D. J., Scheiman, J. M., Cryer, B. L., Eisen, G. M., Lanas, A., & Fort, J. G. (2016). Long‐Term Safety of a Coordinated Delivery Tablet of Enteric‐Coated Aspirin 325 mg and Immediate‐Release Omeprazole 40 mg for Secondary Cardiovascular Disease Prevention in Patients at GI Risk. Cardiovascular therapeutics.
Ignatavicius, D. & Workman, L., M. (2015). Medical-surgical nursing: Patient-centered collaborative care (8th ed.). St. Louis, MO: Elsevier Saunders.
Laine, L., & Jensen, D. M. (2012). Management of patients with ulcer bleeding. The American journal of gastroenterology, 107(3), 345-360.
Leder, S. B., & Lerner, M. Z. (2013). Nil per os except medications order in the dysphagic patient. QJM, 106(1), 71-75.
Porth, C.M. (2015). Essentials of pathophysiology (4th ed.). Philadelphia, PA. Lippincott Williams & Wilkins.
Segel, G. B., & Lichtman, M. A. (2014). Direct antiglobulin (“Coombs”) test-negative autoimmune hemolytic anemia: a review. Blood Cells, Molecules, and Diseases, 52(4), 152-160.
Srygley, F. D., Gerardo, C. J., Tran, T., & Fisher, D. A. (2012). Does this patient have a severe upper gastrointestinal bleed?. JAMA, 307(10), 1072-1079.
Villanueva, C., Colomo, A., Bosch, A., Concepción, M., Hernandez-Gea, V., Aracil, C., & Guarner-Argente, C. (2013). Transfusion strategies for acute upper gastrointestinal bleeding. New England Journal of Medicine, 368(1), 11-21.
Wu, B. U., Bakker, O. J., Papachristou, G. I., Besselink, M. G., Repas, K., van Santvoort, H. C., & Banks, P. A. (2011). Blood urea nitrogen in the early assessment of acute pancreatitis: an international validation study. Archives of internal medicine, 171(7), 669- 676.
Yoshimi, M., Kadowaki, Y., Kikuchi, Y., & Takahashi, T. (2016). Coombs-negative Autoimmune Hemolytic Anemia Followed by Anti-erythropoetin Receptor Antibody- associated Pure Red Cell Aplasia: A Case Report and Review of Literature. Internal Medicine, 55(5), 511-514.
