A CASE ON GERD.

Patient Demographic Details

Patient Name -

Age - 42 years

Sex - Female

Height - Not Taken

Weight - 55 Kg

MRD No - 2320515

Date Of Admission - 24th october 2015

Date Of Discharge - 26th october 2015

COMPLAINTS ON ADMISSION:

1.Severe abdominal pain for 1 week.

2. Abdominal distension.

3.Altered bowel habits.

4.Vomiting and nausea.

5.Abdominal discomfort provoked by stress.

MEDICAL HISTORY

Nil
 SOCIAL HISTORY

1.Non vegetarian.

2.Non alcoholic.

3.Non smoker.
FAMILY HISTORY

No relevant family history

PREVIOUS DRUG ALLERGIES

Nil
MEDICATION HISTORY

Nil
 PHYSICAL EXAMINATION

1.Anxious.

2.General physical: diffuse mild tenderness P/A :

3.Epigastric tenderness .

4.Hypochondral tenderness.Rebound tenderness seen,.

5.Peri umbilical tenderness seen,

6.No mcBurney s tenderness

PROVISIONAL DIAGNOSIS

1.Acute abdomen?

2.Appendicitis?
 ROUTINE BIOCHEMICAL
INVESTIGATIONS
1.Urea: 19mg/dl.

2.S.Cr : 0.8mg/dl.

3.Na: 141 meq/l.

4.K: 4.1 meq/l .

5.T Bili:0.4 mg/dl.

6.D Bili:0.2 mg/dl.

7.T. Prot:6.8 g/dl

8. Alb:3.8 gm/dl.

9.Glob:3.1 gm/dl.

10.AST:45 u/l.

11.ALT:69 u/l.

12.ALP:180u/l
 HAEMATOLOGY
1.RBC : 5.02 million/cu.

2.WBC: 6.5*1000c/cu.

3.Hb:13.2 gm/dl.

4.N: 66%.

5.PCV:40%.

6.L: 20%.

7.MCV:80fl.

8.M: 3%.

9.MCH:26.2pg.

10.E:17%.

11.MCHC: 32.8%.

12.B:0%.

13.ESR:25mm/hr

14.RDW:15.4%

15.193*1000c/cu APTT:
 URINE ANALYSIS
1.Protein: Nil.

2.Sugars: Trace.

3.Blood:Nil.

4.Ketones:Nil

5.WBC:Nil.

6.RBC: Nil

7.Casts:Nil.

8.Crystals: Nil
 OTHERS

1.Upper GI Endoscopy : Normal

 FINAL DIAGNOSIS

1.Gastro Esophageal Reflux Disease.

2.Functional dyspepsia.
 Drugs Administered
On Day 1
1. IVF NS - Normal Saline 500 ml IV STAT.

2. Inj. CYCLOPAM - Dicyclomine hydrochloride 20 mg IM QID.

3. Inj. PAN - Pantaprazole 40mg IV OD.

4. Inj. EMESET - Ondansetron 8mg IV BD.

5. Tab. SHINE - Amitryptyline 10 mg P/O HS.

6. Tab. LONAZEP -Clonazepam 0.25 mg P/O 12- 12-1.

 INVESTIGATIONS Day 1

1.Vomiting and Pain in Abdomen.

2.All vital signs were stable.

PR 82 b/min .
RR 22 b/min.
BP 110/80 .
Temp 98.6 F.
 Drugs Administered
On Day 2
1. Inj. PAN - Pantaprazole 40mg IV OD.Inj.

2. EMESET - Ondansetron 8mg IV BD.

3. Tab. SHINE - Amitryptyline 10 mg P/O HS.

4. Syp. CREMMAFFIN PLUS - {Magnesium hydroxide(3.75ml)

+ liquid paraffin(1.25ml) + sodium picosulphate(3.3mg)}/5 ml
3tsp HS}.

5. Cap. RAZO D -Rabeprazole + Domperidone (20mg + 30 mg)

P/O OD.
 INVESTIGATIONS Day 2
1.No vomiting.

2.Pain in Abdomen.

3.Constipation and Drowsiness.

4.All vital signs were stable.

PR 86 b/min.

RR 22 b/min.
BP 120/70.

Temp 98.6
 Drugs Administered
On Day 3

1. Tab. LONAZEP -Clonazepam 0.25 mg P/O 12- 12-1.

2. Cap. RAZO D -Rabeprazole + Domperidone ( 20mg +

30 mg ) P/O OD.
 INVESTIGATIONS Day 3

1.Patient well ; Pain free.

2.All vital signs were normal.

PR 88b/min.

RR 22 b/min.

BP 120/80.

Temp 98.6.
 DISCHARGE MEDICATIONS

1.C.Razo D ( Rabeprazole + Domperidone ) 1-0-0. x 2 Weeks

2.T.Depsonil 25 mg 0-0-1. x 2 Weeks

3..T.Lonazep ( clonazepam ) 12- 12- 1. x 2 Weeks

4.Syp Cremaffin plus 0-0-2 tsp. x 2 Weeks

FOLLOW UP/REVIEW:

Review after 2 weeks in Gastro Enterology Department.

INSTRUCTIONS/ ADVICES
1.Follow Strict Diet Control

- Avoid spicy and fatty

foods

- Avoid carbonated
drinks.

- Avoid caffeinated
beverages.
SOAP ANALYSIS
 SUBJECTIVE EVIDENCE

A 42 year old female patient having weight of 55 kg was admitted in

the department of gastroenterology with the signs and

symptoms of abdominal pain for 7 days,abdominal distension ,

vomiting , anxiety ,decreased sleep.
OBJECTIVE EVIDENCE

1.P/A Rebound tenderness.

2.Elevated eosinophils.

3.Elevated ESR.

4.Elevated SGOT and SGPT

 ASSESSMENT
Etiology:
Intake of fatty foods, fried foods, pickles, chilli, peppers and hot
spicy sauces.
Caffeinated beverages like tea & coffee.
Fruit juice like Orange juice, tomato juice.
Oesophageal distension.
Stress and anxiety associated with functional dyspepsia.
 Assessment of Current Therapy -
Rationality of each drug
1. PPIs such as pantaprazole and rabeprazole were used for the treatment
of GERD. The most recent meta analysis by Moayyedi et al. (2006)
from 10 RCTs evaluating 3347 participants compared PPIs with
placebo. The average response to PPI therapy was 34 %,( with a 25%
response to placebo). Overall studies suggested significant benefit of
PPI over placebo in patients with functional dyspepsia. Five trials found
that PPI therapy was more effective in non ulcer dyspepsia participants
with reflux like symptoms while three trials did not find any association
with symptom subgroup.
 Assessment of Current Therapy -
Rationality of each drug
2. Domperidone is a D2 receptor antagonist .it provides relief
from nausea by blocking receptors at the chemo receptor trigger
zone at the floor of the fourth ventricle. The Cochrane Meta
analysis suggested the beneficial effects of domperidone 10-20
mg three times daily versus placebo on a global rate of dyspeptic
symptoms (V eldhuyzen van zanten et al 2001).
 Assessment of Current Therapy -
Rationality of each drug
3. Meta analysis studies of ,(Hojo et al.2005), of anti depressant
and anti anxiety agents such as clonazepam of 13 studies found
that in 11 studies participants showed symptom
improvement.Among 13 studies on 1717 patients , 11 studies
showed the evidence on improvement of dyspeptic
symptoms .statistical analysis of 4 trials showed a significant
benefit of treatment with antianxiety or antideppressive agents.
 Assessment of Current Therapy -
Rationality of each drug

4. Amitryptyline was used for the treatment of stress and anxiety

associated with functional dyspepsia,Tricyclic antidepressant like
Amitryptyline have been found to be effective in variety of
functional disorders as cited in the Meta analysis of, (Jackson et
al.2000)
 Assessment of Current Therapy -
Rationality of each drug

5. In the Meta analysis on demand use of rabeprazole for the

management of NERD incurred the least cost in comparison with
the other PPIs evaluated. Utility gains were comparable for all on
demand PPIs.(Hughes DA et al).
 Assessment of Current Therapy -
Rationality of each drug
6. The newer PPI rabeprazole and omeprazole were of similar
efficacy to omeprazole in terms of heartburn control , healing rates
and relapse rates. All the PPIs were superior to ranitidine and
placebo in healing erosive esophagitis and decreased relapse rates,
(Caro JJ et al).In this,55 studies were identified of which 38
involved acute therapy and 15 maintanence therapy.the newer PPIs
were of similar efficacy to omeprazole in terms of heartburn
control and relapse rates.
 Assessment of Current Therapy -
Rationality of each drug

7.Dicyclomine is an anti cholinergic drug used as an antispasmodic

agent to prevent the abdominal spasm.In a study of 42 patients with
dyspepsia as in the Randomized controlled trial of,(Kagan G et al),
has been demonstrated to be effective in the control of the
symptoms in functional dyspepsia.
 Response To Therapy

1. Patient responded well to the therapy.

2. Abdominal pain and discomfort was relieved.

3. Nausea and vomiting were absent at time of discharge.

4. She was started on anxiolytics and tricyclics with good relief.

5. Patient was pain free upon discharge.

 ADRs / Drug Interactions

The administration of Anticholinergics drug Dicyclomine Hcl with

Amitryptyline resulted in potentiated Anticholinergics side effects.
Side effects included Dry mouth, Drowsiness, Weakness, Dizziness
and Constipation.
ADRs / Drug Interactions

Significant
Intensity of
S.No Drug 1 Drug 2 Effects On
Interaction
Patient

Drymouth,drowsi
ness,weakness,
1 Dicyclomine Hcl Amitryptyline Moderate dizziness and
constipation
 Patient Compliance

Patient was found to be compliant to the medications given.

 Alternative therapy (if any)
The treatment provided for the patient was in accordance with the
guidelines of American college of Gastroenterology. H2 receptor
antagonists can be used for the treatment of mild to moderate
GERD.

Prokinetic agent like Metochlopromide is also indicated in the

treatment of GERD.
PLAN
 Goals Of Therapy
1. To control signs and symptoms of GERD

2. To prevent complications of GERD.

3. To prevent recurrence of GERD.

4. To improve quality of life.

 Goals Achieved

1. Reduced abdominal pain and reflux episodes.

2.Anxiety and sleep disturbances were reduced.

3.Abdominal discomfort was relieved

 Monitoring Parameters
1.Rabeprazole

- Assess for bloody or coffee ground emesis and black tarry stools.

- Assess for symptoms of esophageal reflux (e.g., heart burn, acid regurgitation) or peptic ulcer activity
(e.g.,
indigestion, abdominal pain, nausea).

2.Clonazepam

- Assess renal studies: urinalysis, BUN, urine creatinine.

- Assess blood studies (CBC and platelets) prior to and regularly throughout therapy.

- Evaluate hepatic studies: ALT, AST, bilirubin, creatinine, and alkaline phosphatase.
 Monitoring Parameters
3. Amitryptyline

- Assess patient's mental status, affect, energy level, sleeping, and eating habits and
suicidal tendencies.

- Record I&O, noting bowel elimination pattern.

4. Ondansetron

- Ensure that baseline hepatic studies have been performed before beginning therapy.

- Assess patient for nausea, vomiting, and bowel sounds.

 Drugs/ OTC To Be Avoided

1.NSAIDS leads to decreased LES pressure leading to increased reflux.

2.Iron is a direct irritant to oesophageal mucosa.

3.Theophylline, Anticholinergics, Nicotine, Dopamine, Barbiturates,

Phentolamine leads to decreased LES pressure
leading to increased reflux.

4.Alendronate leads to direct mucosal irritation.

Clinical Pharmacist Interventions

1.The drug interaction between dicyclomine and Amitryptyline

was reported to the physician.

2.Accordingly the drugs were discontinued on day 2.

Patient counselling carried out
A. On disease

- GERD refers to any symptomatic clinical condition or

histological alteration those results from episodes of
gastro esophageal reflux.

- When the oesophagus is repeatedly exposed to refluxed

materials for prolonged period, inflammation of the
oesophagus occurs.
 Patient counselling carried out
B. On diet

- Avoid foods that may decrease lower esohageal sphincter

pressure (fatty foods, chocolate, alcohol, peppermint
& spearmint.

- Avoid fatty foods, orange juice , tomato juice & coffee.

- Avoid eating prior to sleeping immediately.

 Patient counselling carried out
C. On lifestyle modifications

- Elevate the head on the bed (increases esophageal clearance).

Use 6-8 inch blocks under the head of the bed.

- Avoid tight clothes

- Discontinue if possible drugs that may promote reflux.

 Patient counselling carried out
(On Drugs)
1. Rabeprazole

- Take half an hour before food.

- Do not chew,crush or split the tablet

- Tablet should be swallowed as whole.

2. Clonazepam

- Do not administer with antacids. Give at least one hour apart.

- Give with food or milk to decrease GI upset

 Patient counselling carried out
. 3. Amitryptyline
(On Drugs)
- Give drug with or immediately after food or fluid and in late afternoon or at
bedtime because of sedative effect. - Tablets may be crushed.

4. Ondansetron

- Advise patient that headache is a common side effect.

- Advise patient that medication will greatly reduce likelihood of nausea and
vomiting, but that these are still
possible
 Follow Up Details

. On review after 2 weeks in the gastroenterology department the

patient was found to be free of GERD symptoms. No symptoms
of vomiting and abdominal pain were present. The patient was
completely relieved from constipation. The patient showed
functional improvement. Patient was less anxious and slept well.
 THANKYOU

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