Intravenous Proton Pump Inhibitors Research Articles

Predictive Factors Associated with Inappropriate Intravenous Proton Pump Inhibitors Use in Hospitalized Patients: A Case-Control Study.

Background and Objectives: Proton Pump Inhibitors (PPIs) are the most effective agents for treating acid-related gastrointestinal disorders. The prescription of an intravenous (IV) formulation of PPIs has increased dramatically. The aims of this study were to assess the appropriateness of IV PPI use and to define the risk factors and outcomes associated with its inappropriate use. Materials and Methods: A case-control retrospective study included all the hospitalized patients who received IV PPIs was conducted. Patient health records were reviewed, data were collected covering the period of the individual patients' admission to the hospital until discharge or death, and over the 3-month post-discharge period. The appropriateness of the IV PPI use and the resulting clinical outcomes were analyzed. Results: Overall, 540 patients were analyzed. Among them, 130/540 (24%) had inappropriate PPI use in terms of indication, dosage, and duration of treatment vs. 410 patients who had appropriate indications. Two parameters were associated with inappropriate use: congestive heart failure (OR 1.77; p = 0.02) and prescription of IV PPIs by surgeons vs. internists (OR 1.53; p = 0.05). Conclusions: Inappropriate IV PPI use is still common in daily clinical practice. Significant predictors of inappropriate use were the presence of congestive heart failure, elderly age, current use of anticoagulants and antithromotics, and the cases managed by surgeons, naturally due to suspected upper gastrointestinal bleedings.

Risk factors for gastric mucosa lesion in critically ill patients undergoing endoscopy for percutaneous gastrostomy: a case-control study

BackgroundPharmacologic prophylaxis for gastric ulcer is commonly prescribed in patients hospitalized in the intensive care unit (ICU). The aim of the study was to assess the current prevalence and risk factors for gastric mucosa lesion in ICU patients receiving standard pharmacologic prophylaxis undergoing endoscopy for percutaneous gastrostomy implantation.MethodsPatients hospitalized in the mixed medical-surgical ICU undergoing percutaneous endoscopic gastrostomy (PEG) were analyzed. We excluded patients receiving either no or high doses of intravenous proton pump inhibitor (PPI), only patients receiving standard doses of PPI were included. Data retrieved from the electronic medical records included: demographics, risk factors for gastric mucosa lesion (use of stimulants, comorbidities, medications, treatment methods in the ICU, laboratory derangements) and endoscopic findings. The study compared a group of patients with gastric mucosa lesions (cases) vs. patients without gastric mucosa lesions (controls). Inter-group comparisons between cases and controls were performed. Depending on the type of distribution continuous variables were assessed using two-sample t-test or Mann-Whitney test, whereas categorical variables with Chi-squared or Fisher exact test. Odds ratio (OR) with 95% confidence interval (95% CI) were calculated. Statistical significance was assumed at p < 0.05.ResultsPatients with no prophylaxis (n = 8) or receiving high doses (> 40 mg per day) of proton pump inhibitor (n = 2) were excluded. There were 182 patients receiving standard intravenous dose of PPI, 63 (34.6%) women and 119 (65.4%) men, with median age 61.5 (interquartile range IQR 46.0–70.0) years. Majority of patients (n = 169, 92.9%) were receiving pharmacological prophylaxis for venous thromboembolism. There were 53 (29.1%) patients with gastric mucosa lesion. The only risk factor that was significantly different between cases and controls was history of gastric ulcer (p = 0.04) with OR 3.8 (95% CI 1.1–12.5; p = 0.03).ConclusionsMajority of various risk factors for gastric ulceration may not predict gastric mucosa lesion in ICU patients receiving standard pharmacological prophylaxis undergoing endoscopy for PEG implantation. We found that history of gastric ulcer may be a risk factor for gastric ulceration in the ICU patients. Patients with history of gastric ulcer might benefit from higher than standard doses of anti-ulcer medication when hospitalized in the ICU.

Unique EPIYT motif CagA gene Helicobacter pylori Bali 01 isolate as the cause of hematemesis in a male gastric ulcer patient in Wangaya General Teaching Hospital Denpasar Bali: a case report

Background: Helicobacter pylori (H. pylori) infection is related with a number of gastrointestinal disorders, including gastritis, peptic ulcer disease, gastric cancer, and gastric mucosa-associated lymphoid tissue (MALT) lymphoma. This case report aims to present an unique EPIYT motif CagA gene H. pylori Bali 01 isolate as the cause of hematemesis in a male gastric ulcer patient Case Presentation: A 70-year-old male Balinese patient came to the hospital due to hematemesis. Esophagogastroduodenoscopy was performed after stabilizing patient condition with prompt treatment and intravenous proton pump inhibitor. Esophagogastroduodenoscopy revealed a solitary giant ulcer in the gastric antrum. Gastric biopsy was performed and histopathology examination revealed a spherical-like organism, confirmed as H. pylori. Biopsy was sent to the Biomedical Laboratory at West Nusa Tenggara, Mataram, Lombok Island. Culture of biopsy and polymerase chain reaction revealed H. pylori, then named H. pylori Bali 01 isolate. Standard protocol of H. pylori eradication is conducted by administration of triple drug therapy consisting of omeprazole, amoxicillin, and clarithromycin for 14 days. Patient was discharged from hospital in stable condition. Helicobacter pylori was successfully eradicated and revealed completely normal gastric antrum in reperformance of esophagogastroduodenoscopy 3 months later. Conclusion: The EPIYA-ABD motif on this H. pylori Bali 01 isolate is distinctively unique from the EPIYT motif on the second EPIYA sequence.

Efficacy of Vonoprazan vs. Intravenous Proton Pump Inhibitor in Prevention of Re-Bleeding of High-Risk Peptic Ulcers: A Randomized Controlled Pilot Study.

Background: Proton pump inhibitor (PPI) therapy is well-established for its effectiveness in reducing re-bleeding in high-risk peptic ulcer patients following endoscopic hemostasis. Vonoprazan (VPZ) has demonstrated the capacity to achieve gastric pH levels exceeding 4, comparable to PPIs. This study aims to evaluate the comparative efficacy of intravenous PPI infusion versus VPZ in preventing re-bleeding after endoscopic hemostasis in patients with high-risk peptic ulcers. Methods: A randomized, double-blind, controlled, and double-dummy design was employed. Patients with peptic ulcer bleeding (Forrest class IA/IB or IIA/IIB) who underwent endoscopic hemostasis were randomly assigned to either the PPI group or the VPZ group. Re-bleeding rates at 3, 7, and 30 days, the number of blood transfusions required, length of hospitalization, and ulcer healing rate at 56 days were assessed. Results: A total of 44 eligible patients were enrolled, including 20 patients (PPI group, n = 11; VPZ group, n = 9) with high-risk peptic ulcers. The mean age was 66 years, with 70% being male. Re-bleeding within 72 h occurred in 9.1% of the PPI group versus 0% in the VPZ group (p = 1.000). There was no significant difference in re-bleeding rates within 7 days and 30 days (18.2% vs. 11.1%, p = 1.000). Additionally, the ulcer healing rate did not significantly differ between the groups (87.5% vs. 77.8%). Conclusions: This pilot study demonstrates comparable efficacy between oral vonoprazan and continuous PPI infusion in preventing recurrent bleeding events among high-risk peptic ulcer patients following successful endoscopic hemostasis.

Concomitant use of lansoprazole and ceftriaxone is associated with an increased risk of ventricular arrhythmias and cardiac arrest in a large Japanese hospital database

To determine whether concomitant use of ceftriaxone and oral or intravenous lansoprazole increases the risk of ventricular arrhythmia and cardiac arrest in the real-world setting in Japan. The data analyzed were obtained from the JMDC hospital-based administrative claims database for the period April 2014 to August 2022. Patients who received a proton pump inhibitor (PPI) while receiving ceftriaxone or sulbactam/ampicillin were identified. The frequency of ventricular arrhythmia and cardiac arrest was analyzed according to whether oral or intravenous PPI was concomitant with ceftriaxone or sulbactam/ampicillin. Estimates of the incidence of ventricular arrhythmia and cardiac arrest were then compared among the groups, using the Fine-Gray competing risk regression model. The results showed that the risk of ventricular arrhythmia and cardiac arrest was significantly higher with concomitant ceftriaxone and oral lansoprazole (hazard ratio 2.92, 95% confidence interval 1.99-4.29, P<0.01) or intravenous lansoprazole (hazard ratio 4.57, 95% confidence interval 1.24-16.80, P=0.02) than with concomitant sulbactam/ampicillin and oral or intravenous lansoprazole. Oral and intravenous lansoprazole may increase the risk of ventricular arrhythmia and cardiac arrest in patients who are receiving ceftriaxone.

Non-variceal Upper Gastrointestinal Bleeding and Its Endoscopic Management.

Upper gastrointestinal bleeding (UGIB) is a major cause of morbidity and mortality. Clinical symptoms that patients may present with include: hematemesis, coffee-ground emesis, melena, and hematochezia. Clinical signs can range from tachycardia to shock. The anatomical landmark that differentiates upper gastrointestinal (GI) bleeds from lower bleeds is the ligament of Treitz. The first steps of treating a patient who presents with signs of UGIB are resuscitation with appropriate fluids and blood products as necessary. The consideration of endoscopy and the urgency at which it should be performed is also vital during initial resuscitation. Endoscopic therapy should ideally be performed within 24 hours of presentation after initial stabilization with crystalloids and blood products. Intravenous proton pump inhibitors are the mainstay in the initial management of upper GI bleeding from a non-variceal etiology, and they should be administered in the acute setting to decrease the probability of high-risk stigmata seen during endoscopy. Pro-kinetic agents can be given 30 minutes to an hour before endoscopy and may aid in the diagnosis of UGIB. There are 3 broad categories of endoscopic management for UGIB: injection, thermal, and mechanical. Each endoscopic method can be used alone or in combination with others; however, the injection technique with epinephrine should always be used in conjunction with another method to increase the success of achieving hemostasis. In this review article, we will review the steps of triage and initial resuscitation in UGIB, causes of UGIB and their respective management, several endoscopic techniques and their effectiveness, and prognosis with a primary focus limited to non-variceal bleeding.

Comparison of Vonoprazan Versus Intravenous Proton Pump Inhibitor for Prevention of High-Risk Peptic Ulcers Rebleeding After Successful Endoscopic Hemostasis: A Multicenter Randomized Noninferiority Trial

High-dose proton pump inhibitor (PPI) therapy has been recommended to prevent rebleeding of high-risk peptic ulcer (PU) after hemostasis. Vonoprazan has been proven to be noninferior to PPIs in various acid-related diseases. This study aimed to compare the efficacy of vonoprazan vs PPI for preventing high-risk PU rebleeding after hemostasis. A multicenter, randomized, noninferiority study was conducted in 6 centers. Pre-endoscopic and endoscopic therapy were performed according to standard protocol. After successful hemostasis, patients with high-risk PU bleeding (Forrest class Ia/Ib, IIa/IIb) were randomized into 1:1 to receive vonoprazan (20 mg twice a day for 3 days, then 20 mg once a day for 28 days) or high-dose PPI (pantoprazole intravenous infusion 8 mg/h for 3 days, then omeprazole 20 mg twice a day for 28 days). The primary outcome was a 30-day rebleeding rate. Secondary outcomes included 3-and 7-day rebleeding rate, all-cause and bleeding-related mortality, rate of rescue therapy, blood transfusion, length of hospital stay, and safety. Of 194 patients, baseline characteristics, severity of bleeding, and stage of ulcers were comparable between the 2 groups. The 30-day rebleeding rates in vonoprazan and PPI groups were 7.1% (7 of 98) and 10.4% (10 of 96), respectively; noninferiority (within 10% margin) of vonoprazan to PPI was confirmed (%risk difference,-3.3; 95% confidence interval,-11.2 to 4.7; P < .001). The 3-day and 7-day rebleeding rates in the vonoprazan group remained noninferior to PPI (P<.001 by Farrington and Manning test). All secondary outcomes were also comparable between the 2 groups. In patients with high-risk PU bleeding, the efficacy of vonoprazan in preventing 30-day rebleeding was noninferior to intravenous PPI. (ClinicalTrials.gov, Number: NCT05005910).

THERAPEUTIC APPROACHES FOR ACID REDUCTION IN PATIENTS ADMITTED TO INTENSIVE CARE UNITS WITH A HISTORY OF GASTROESOPHAGEAL REFLUX DISEASE AT A TERTIARY CARE HOSPITAL IN PAKISTAN.

Introduction: Although the prevalence of gastroesophageal reflux disease (GERD) in intensive care units is still unknown, the condition is on the rise all over the world. Patients in critical condition are especially susceptible to gastroesophageal reflux disease (GERD) because of the many procedures and underlying illnesses they undergo. Pepsin levels in oral secretions, ambulatory monitoring, and pH measurement are among procedures that can be utilized in the diagnostic process. The most popular treatment methods consist of adjusting one's lifestyle and using medicine, mainly proton pump inhibitors (PPIs). Methodology: An analysis of data collected from 96 critically sick patients who were getting acid-lowering medication was carried out in retrospective research that was carried out at a tertiary care hospital in AJK, Pakistan between June and December 2023. Results: Most patients were being treated in medical intensive care units (MICU), and the medications that were prescribed the most frequently were omeprazole and esomeprazole. Omeprazole and antacids were the primary maintenance medications that were administered at the time of discharge. Patients who were diagnosed with gastroesophageal reflux disease (GERD) and those who were undergoing mechanical ventilation made up a sizeable share, with most of them receiving intravenous proton pump inhibitors (PPIs). Both potassium-competitive acid blockers and omeprazole were shown to have equivalent levels of treatment efficacy, according to the findings. Conclusion: Most of trials in past have established esomeprazole being highlighted as having superiority in certain studies. On the other hand, newer possibilities such as GABA-B agonist baclofen and P-CABs offer potential lines of investigation. Even though developing medicines require more exploration for routine management, intravenous proton pump inhibitors (PPIs) continue to be the primary emergency treatment for gastroesophageal reflux disease (GERD) in critical care.

Comparison between intermittent and continuous intravenous proton pump inhibitors infusion in treatment of bleeding peptic ulcer

Comparison between intermittent and continuous intravenous proton pump inhibitors infusion in treatment of bleeding peptic ulcer

Prevention of Gastrointestinal Bleeding in Patients Operated on Coronary Arteries for Acute Coronary Syndrome

Introduction. Acute coronary syndrome is a collective concept that reflects any form of exacerbation of coronary heart disease from unstable angina to acute myocardial infarction. Modern principles for the diagnosis and treatment of this syndrome are coronary angiography and urgent stenting of the affected coronary artery. These patients, having survived a life-threatening condition and surgical treatment, have a high probability of acute erosive and ulcerative gastroduodenal lesions and dependent gastrointestinal lesions. As a result, conservative treatment of acute ulcers and erosions complicated by bleeding remains unsatisfactory, mortality ranges from 36.4 to 50-80%.The aim of the study was to evaluate effectiveness of the proposed measures to prevent erosive and ulcerative lesions of the stomach and duodenum and gastrointestinal bleeding in patients with acute coronary syndrome who underwent coronary artery stenting.Materials and methods. The study included 614 patients who underwent percutaneous coronary intervention and stenting of the arteries of the heart due to the development of acute coronary syndrome. The patients were divided into two groups. The first group included 284 patients treated in 2018. Prevention of acute erosive and ulcerative gastroduodenal lesions was not routinely performed in this group. The second group included 330 patients treated in 2019. All patients in this group underwent prophylaxis and included omeprozole 40 mg per day from the first hours of the patient's stay in the hospital.Results. During the entire study period, 31 patients died in the early and late postoperative period in the first group, 18 of them during the first hospitalization. In the second group, 35 patients died during the entire study period in the early and late postoperative period, 21 of them during the first hospitalization. With the development of gastrointestinal bleeding, the probability of a full recovery in a patient with acute coronary syndrome is extremely low, and the system of preventive measures avoids this problem.Conclusion. Prevention of stressful acute erosive and ulcerative gastroduodenal lesions due to use of intravenous proton pump inhibitors in increased dosages (omeprozole 40 mg per day) is indicated to the patients of the studied group; in the presence of additional risk factors, the prophylactic dosage of proton pump inhibitors is doubled (omeprozole 40 mg 2 times a day). Mandatory non-invasive diagnosis of Helicobacter pylori for all patients is also indicated; if the condition is detected, eradication therapy is to be carried out. It is also required to apply proton pump inhibitors for the entire period of dual antiplatelet or anticoagulant therapy.

Investigating potential confounding by indication when considering the association between proton pump inhibitor use, infection, hepatic encephalopathy and mortality in hospitalised decompensated cirrhosis: a post-hoc analysis of the ATTIRE trial

Proton pump inhibitors (PPIs) are commonly prescribed to prevent and treat upper gastrointestinal ulceration and bleeding. Studies have identified increased incidence of spontaneous bacterial peritonitis and hepatic encephalopathy (HE) in cirrhosis patients taking PPIs. However, results are conflicting, and as PPIs are prescribed for variceal bleeding, a major risk factor for infection and HE, it is challenging to discern whether these associations are causal. In this post-hoc analysis of the ATTIRE trial, we pooled all patient data to investigate the effects of PPI use on clinical outcomes. ATTIRE was a multicentre, open-label, randomised trial of targeted 20% human albumin solution (HAS) daily infusions versus standard care involving 777 adults with decompensated cirrhosis hospitalised with acute complications and albumin <30g/L. Study recruitment was between Jan 25, 2016, and June 28, 2019, at 35 hospitals across England, Scotland, and Wales. Key exclusion criteria were advanced hepatocellular carcinoma with life expectancy <8 weeks and patients receiving palliative care. In ATTIRE, patients were grouped by PPI use at trial entry. We studied infection and HE at baseline and incidence of hospital acquired infection, new onset HE, renal dysfunction and mortality. We attempted with propensity score matching to account for differences in disease severity. Overall PPI use at baseline was not associated with increased incidence of infection, renal dysfunction or mortality, but was associated with significantly increased incidence of grade III/IV HE during hospital stay (P=0.011). This was only significant for those taking intravenous PPIs and these patients had >10 times the incidence of variceal bleeding and near double the 28-day mortality compared to non-PPI patients. However, propensity score matching was not possible as there was such a strong selection of patients for PPI use, that we could not find sufficient non-PPI patients to match to. We found no impact of PPI use on plasma markers of bacterial translocation, infection or systemic inflammation. Our real-world data from a completed randomised trial show that PPIs are widely prescribed in the UK and judicious use appears safe in patients hospitalised with decompensated cirrhosis. However, patients prescribed PPIs had fundamentally different phenotypes to those not prescribed PPIs, a form of confounding by indication, which should be strongly considered when interpreting studies and making recommendations about their use. Wellcome Trust and Department of Health and Social Care.

Overuse of Intravenous Proton Pump Inhibitors in General Medicine and Surgery Wards.

Overuse of stress ulcer prophylaxis is prevalent globally despite guidelines leading to the added cost, especially the intravenous proton pump inhibitor (IVPPI). This study aims to analyze the prevalence of such overuse and be aware of rational use which may help develop local guidelines. This study analyzed the prospectively collected data on IVPPI use in adult patients in general wards of medicine and surgery at Patan Hospital, Patan Academy of Health Sciences, Nepal, from April-Jun 2022. Ethical approval was obtained. Variables analyzed were the patient's age, gender, history of peptic ulcer disease, risk for stress ulcer and gastrointestinal bleeding, the status of nil per os (NPO ≥12 hours), appropriate use of IVPPI, and cost. Prevalence of IVPPI use was 36.24% (274/756 admissions), surgery 39.45(189/479), medicine ward 30.68% (85/277). The mean age was 43.1 ±18.6 years, males 113(41.2%), surgery 189 (69%). Inappropriate overuse in 253(92.3%, significantly more in surgery-182 than medicine-7, p=0.001. Appropriate use was in 21 (7.7%, i.e., NPO-15, NPO + gastrointestinal bleed, and NPO + non steroid anti-inflammatory drugs each 3). Prevalence of IVPPI use was 36.24%. Inappropriate overuse of IVPPI was high (92.2%, 253/274), more in surgery. The nil per os status was the main reason for appropriate use of IVPPI.

Peptic Ulcer Disease and Its Implications

Peptic ulcer disease (PUD) is one of the commonest diseases seen throughout the world. Peptic ulcers are open sores that develop on the inside lining of your stomach and the upper portion of your small intestine. The most common symptom of a peptic ulcer is stomach pain. There are various risk factors for the development of peptic ulcer disease, but the most important ones are Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs (NSAIDs). Patients generally present with dyspepsia or peptic ulcer bleeding. Acid suppressant therapy, H. pylori eradication, and avoidance of nonsteroidal anti-inflammatory drugs are the cornerstones of treatment of peptic ulcer disease. Peptic ulcer bleeding could be life-threatening. It is managed by appropriate supportive care, intravenous proton pump inhibitor therapy, and endoscopic homeostasis. Trans arterial embolization (TAE), Herbal treated and surgery are rarely required if endoscopic therapy fails.

Evaluation of Proton Pump Inhibitors Prescribing Among Hospitalized Patients: A Cross-Sectional Study.

Proton pump inhibitors (PPIs) are the most effective agents for managing acid-related disorders. However, inappropriate prescribing of PPIs is becoming an issue of concern. This study aimed to assess the appropriate utilization of PPIs in terms of indication, dose, frequency, and route of administration during admission and discharge. Furthermore, direct costs associated with inappropriate PPI use were calculated. A descriptive cross-sectional study was conducted at the internal medicine department of a tertiary hospital in Palestine from January 1, 2021, to June 30, 2021. The medical records of patients aged 18 years or older, hospitalized for 48 hours or more, and receiving oral or intravenous (IV) PPIs during their stay were collected and evaluated for the appropriateness of PPIs prescribed according to clinical guidelines. Of 262 patients, 80.2% had an appropriate indication for prophylaxis (67.6%) or treatment (12.6%). A total of 230 patients were prescribed IV pantoprazole.182 (79.1%) had an appropriate indication, whereas 122/182 (67%) received IV PPI instead of oral without an appropriate indication. Of the 32 patients who received 20 mg of oral omeprazole, 28 (87.5%) had an appropriate indication, dose, and route of administration, whereas 16/28 (57.1%) had an inappropriate frequency. At discharge, 32.5% of patients were discharged with unnecessary PPI prescriptions. The total direct cost of inappropriate PPI Indications and route of administration in 188 patients over six months was $1518. This study showed that most patients received a PPI for an appropriate indication with the correct dose. However, a high prevalence of inappropriate IV pantoprazole administration was observed, resulting in the highest costs, demonstrating the importance of correctly ordering IV medications. Adherence to clinical guidelines, such as those of the American College of Gastroenterology (ACG), will improve the appropriateness of PPI prescribing, prevent complications, and reduce healthcare costs.

Medical Management of Emphysematous Gastritis

A 95-year-old man presented to the hospital with altered mental status, sepsis, and coffee-ground emesis. His chest radiograph showed gas along the lesser curvature of the stomach, prompting abdominal computed tomography, which demonstrated intramural gastric air. This patient's clinical presentation and computed tomography findings were suggestive of emphysematous gastritis (EG). He was successfully managed with an intravenous proton-pump inhibitor and broad-spectrum antibiotics. Details of the case are presented to encourage the early diagnosis of EG, which may make conservative management more successful.

Gastric ultrasound-assisted diagnosis of undifferentiated shock

Rationale: Peptic ulcer disease and variceal bleeding are two of the most common causes of gastrointestinal (GI) bleeding. GI bleeding can present with symptoms of hemodynamic instability such as tachycardia and shock. Patient’s Concern: A 33-year-old man with confusion and hypotension (blood pressure: 70/40 mmHg and pulse rate: 140/min) was brought by emergency medical services from home to the emergency department without any companion. The patient was in undifferentiated shock. His hypotension was assessed with inferior vena cava (IVC) size and collapsibility, and rapid ultrasound in shock and hypotension (RUSH) protocol was used to investigate the cause of his shock. Following the RUSH protocol when scanning the IVC, parts of the stomach were seen in its vicinity and suspended heterogeneous particles were observed in the fluid. After seeing these particles, we suspected GI bleeding. Diagnosis: Endoscopy confirmed GI bleeding. Interventions: After placing an orogastric tube and suction, about 2 L of coffee-ground fluid with clots was removed. We started intravenous proton-pump inhibitors 80 mg bolus, followed by a continuous infusion of 8 mg/h. The patient received about 2 L of normal saline and 2 units of packed red blood cells to correct his hypotension. Outcomes: After being admitted to the GI ward and treated for three days, the patient was discharged from the hospital with a hemoglobin level of 11 g/dL and continued to have an outpatient follow-up at the clinic. Lessons: The use of gastric ultrasound in conjunction with the RUSH protocol can help to diagnose undifferentiated hypotensive shock. The components of the RUSH exam are the heart (H), IVC (I), Morrison’s/FAST abdominal views with the aorta (MA), and pulmonary and pipes scanning (P), and can be memorized with the mnemonic: HI-MAP. We would like to introduce a new mnemonic: Hi-MAPS, adding stomach (S) to the RUSH protocol in undifferentiated hypotension and shock to evaluate upper GI bleeding.

Pharmacoeconomics and Utilization of Intravenous Proton Pump Inhibitors in a Tertiary Care Hospital

Background: Proton pump inhibitors (PPIs) are one of the most frequently prescribed class of drugs worldwide contributing to the increase in economic burden on the healthcare system. To study the utilization of intravenous proton-pump-inhibitors (PPIs) according to its indications, comorbidities and related pharmacoeconomics in a tertiary care teaching hospital&#x0D; Methods: A prospective-observational study was conducted over 3 months. Case-records of 300 indoor patients were reviewed for IV (intravenous) pantoprazole prescription, as it was the only PPI available at the hospital in IV as well as oral formulations and relevant data was procured.&#x0D; Results: Amongst 300 patient records, 72% were males whereas 28% were females and mean age was 41.18 years (S.D. ± 15.91). 37.33% of the patients were prescribed PPIs for Stress ulcer prophylaxis and 62.66% for non-stress ulcer prophylaxis. 62.66% patients were prescribed IV PPIs inappropriately and 74% were found to be potential candidates for oral pantoprazole therapy without affecting patient outcomes. Utilisation of PPIs was found to be 0.87 defined daily dose (DDD)/100 bed days. The cost of administration for intravenous pantoprazole therapy per patient per day accounted to INR 64.34 and that for oral formulation of the same summed up to INR 1.36. The percentage reduction in the cost of administration of PPI therapy per patient in potential candidates for oral PPI therapy was found to be 97.8%. Antimicrobials (36%) were the most common drugs prescribed concomitantly followed by antiemetics (25%).&#x0D; Conclusion: Subtle changes like shifting the patient to oral formulations when clinically permissible can make a significant positive contribution in resource limited settings without negatively impacting patient outcomes. This will effectively reduce the economic burden on the patients and the healthcare system which is of utmost importance in a resource limited setting like tertiary care hospitals.

S2598 Gastric Kaposi Sarcoma Presenting as Acute Upper Gastrointestinal Hemorrhage in a Heart Transplant Patient

Introduction: Kaposi sarcoma (KS), a multifocal neoplasm of lymphatic cells, occurs more often in organ transplant patients, and its pathogenesis is related to use of immunosuppressive (IS) medications. Acute gastrointestinal hemorrhage due to KS is exceedingly rare and has never been reported in a heart transplant patient. We report a case of KS presenting as gastrointestinal hemorrhage in a heart transplant patient whose bleeding resolved with supportive care and treatment of his underlying KS. Case Description/Methods: A 63-year-old man originally from Sudan with a history of non-ischemic cardiomyopathy requiring heart transplant on IS presented with melena and acute anemia. Medical history included cutaneous KS of the right leg diagnosed 1 year following transplant previously treated with paclitaxel and in clinical remission. He was treated with intravenous proton-pump inhibitor and blood transfusions. EGD showed a patch of nodular mucosa on the lesser curvature of the stomach. Pathology of the nodule showed dilated capillaries with spindle cells in the lamina propria, and staining for human herpesvirus-8 (HHV-8) was positive in the spindled cells, supporting a diagnosis of recurrent KS. He had no further bleeding, hemoglobin stabilized, and he was discharged. He was resumed on paclitaxel for recurrent KS after discharge and had no further bleeding (Figure 1). Discussion: We report a case of KS presenting with GI bleeding in a patient on chronic IS following heart transplant. While GI bleeding from KS has been reported in renal transplant recipients, this is the first such report we are aware of in a heart transplant patient. The GI tract is a common site of visceral involvement in KS, and presentation can include vomiting, diarrhea, and occult blood loss. Overt GI bleeding in KS is rare. Endoscopic appearance varies from flat lesions to polypoid or nodular growths, and histopathology shows spindle cells positive for HHV-8. Management of GI bleeding in KS depends on severity, and in less severe cases, the role of endoscopy is to confirm the visceral spread of KS with biopsy. Thereafter, management includes IS reduction and chemotherapy for refractory disease. Though KS is a rare cause of overt GI bleeding, it should be considered in patients with immunodeficiency or on chronic IS, and biopsy for suspicious lesions should be performed to confirm diagnosis.Figure 1.: Lesser curvature gastric nodule.

S2327 Gurvits Syndrome in Setting of Uncontrolled Diabetes and Acute Gastrointestinal Bleeding Successfully Treated with Extended Duration PPI Despite Continuing DOAC

Introduction: A young male with past medical history (PMH) of severely uncontrolled non-insulin dependent diabetes mellitus (NIDDM) with recurrent admissions for diabetic ketoacidosis (DKA) and hypertriglyceridemia-induced pancreatitis, both secondary to medication non-adherence, presented via emergency medical services (EMS) after being found unresponsive at home and subsequently developed acute esophageal necrosis (AEN) during a prolonged stay in the intensive care unit (ICU) for acute respiratory failure. He was successfully treated with extended duration of proton pump inhibitor (PPI) therapy and control of underlying risk factors despite being continued on anticoagulation. Case Description/Methods: A 39-year-old male with PMH of uncontrolled NIDDM presented was admitted for acute respiratory failure secondary to DKA and pneumonia. He was intubated and admitted to ICU, while continued on DKA protocol including antibiotics. GI was consulted for hematemesis and melena 2 weeks into hospitalization. EGD revealed circumferential black esophageal mucosa in the distal esophagus abruptly ending at the gastroesophageal junction (GEJ) and hiatal hernia. Recommendations included Intravenous (IV) proton pump inhibitor (PPI) and strict avoidance of naso/orgastric (NG/OG) tube. Follow up EGD few months after discharge showed remarkable improvement of mucosa as noted in Figures A and B, despite continuation of DOAC as per patient wishes for DVT developed during the stay. Discussion: AEN is a rare syndrome disproportionately reported in men which is characterized by circumferential black esophageal mucosa in the distal 2 thirds of the esophagus, abruptly ceasing at the GEJ. Ischemia is postulated to be an inciting event. Conditions associated with AEN are antibiotics, sepsis, gastric volvulus, hernia, DKA, malignancy, and prolonged vomiting. Symptoms of upper gastrointestinal bleeding (UGIB) and shock are common presentations. Although biopsy establishes diagnosis and rules out other causes, EGD finding is generally sufficient. Initial management consists of IV fluids and treatment of the underlying cause. IV PPI and nil per os (NPO) is recommended. NG/OG tubes are avoided unless vomiting or obstruction is present. Mortality is largely due to underlying disease rather than directly from AEN, hence supportive care results in resolution in most cases, as seen in our patient. Our case demonstrates the importance of addressing underlying causes, as well as PPI therapy, which can overcome continued anticoagulation.Figure 1.: A. Acute esophageal necrosis discovered on endoscopy while undergoing EGD for acute GI bleeding during ICU admission for DKA and acute respiratory failure requiring mechanical ventilation B. Resolution of acute esophageal necrosis with grossly normal mucosa on follow up endoscopy conducted after extended duration PPI therapy and relatively controlled diabetes.

S2451 Acute Esophageal Necrosis: A Rarely Encountered Clinical Entity

Introduction: Acute Esophageal Necrosis (AEN), otherwise known as black esophagus for its remarkable appearance during endoscopy, is a rather rare entity in the gastroenterology field. Case Description/Methods: A 51-year-old male with a past medical history of diabetes complicated by peripheral neuropathy presented to the hospital with left lower extremity swelling and pain after a fall. On admission he underwent lower extremity x-ray with subcutaneous air concerning for necrotizing fasciitis. He was taken emergently to the operating room where he underwent 3 compartment exploration with irrigation and drain placement. On day 7 of hospitalization he developed persistent nausea and vomiting for which we were consulted. The following morning he was taken to the endoscopy suite. He was noted to have circumferential black appearance of the esophagus from 28 to 40 cm with abrupt transition to normal-appearing gastric mucosa at the GE junction. This was endoscopically consistent with acute esophageal necrosis He was placed on high-dose intravenous proton pump inhibitor (PPI) therapy as well as sucralfate suspension. Transfer was facilitated to a tertiary care center where repeat endoscopy confirmed the diagnosis. He had a gastrostomy tube placed and ultimately underwent repeat endoscopy 8 weeks later at the same tertiary care center which revealed severe benign appearing esophageal stricturing with inability to pass adult endoscope. It was recommended to continue on PPI therapy with repeat endoscopic evaluation with possible dilation the following month. Unfortunately, in the meantime the patient expired due to unknown causes (Figure). Discussion: AEN is defined by a circumferential, necrotic appearance that almost always affects the distal esophagus with abrupt cessation of the black contour at the GE junction. Incidence is 0.28%, affects men over 4 times more often than women with a mortality near 32%. AEN is usually multifactorial and affects people with many comorbidities. Presenting symptoms varied greatly, with the most prevalent being hematemesis (34%). Injury is related to esophageal ischemia and topical injury. AEN is almost always diagnosed by endoscopy. Biopsy can rule out other similarly appearing pathologies. Management of AEN typically involves treating the underlying cause. Empirical treatment includes IV fluids, PPI, sucralfate, NPO, and TPN in patients with poor nutritional status after 24 hours.Figure 1.: Multiple images showing diffuse esophageal necrosis with abrupt transition to normal mucosa at the GE junction.