Case حلوة Flashcards
(13 cards)
57-year old male patient presented with hematemesis and melena. He has a history of
MI with cardiac catheter with insertion of 2 coronary stents 6 months ago. He does not
have chronic liver disease. His medications include Acetyl Salicylic Acid, Clopidogril,
Rosuvastatin, and Olmesartan. Upper GI endoscopy showed duodenal bulb ulcer.
A-Illustrate your decision regarding antiplatelet treatment to continue or to stop.
الخلاصة
Temporarily discontinue both aspirin and clopidogrel during the acute GI bleeding episode. Resume aspirin first once bleeding is controlled, and consider permanent discontinuation or delayed reintroduction of clopidogrel depending on risk stratification.
*Consider PPI to prevent recurrence of bleeding
التفصيل بقي
1-Dual antiplatelet therapy (DAPT) (Aspirin + Clopidogrel) is typically recommended for at least 6-12 months post-stenting.
2-He is now at the 6-month mark, a threshold where DAPT may be de-escalated if bleeding risk is high.
3-The active GI bleed (hematemesis and melena) suggests a high bleeding risk at this moment.
4- temporary stop both asprin and clopidogril till hemostasis of bleeding.
5-Resume antiplatelet therapy as soon as bleeding is controlled:
Restart aspirin first, as soon as it is safe (usually within 3-5 days if no rebleeding).
Reintroduce clopidogrel later or consider stopping it altogether based on:
Bleeding resolution +
Risk assessment (e.g., type of stent, ongoing ischemic risk)
4 A 56-years old lady presented with melena. She is known case of IHD on baby aspirin for secondary cardiovascular prophylaxis. An upper GI endoscopy was done after initial assessment and risk stratification and revealed a single Forrest III prepyloric peptic ulcer and initial testing for H. pylori infection was positive despite history of 10 days course of Pantoprazole + Clarithromycin + Amoxicillin, twice daily, 3 months ago. Her cardiologist contacts you to: resume her aspirin, explain the still positive H pylori testing and plan the treatment regimen. A-How would you answer his 3 questions? .
When to Resume Aspirin?
Answer:
Aspirin can generally be resumed within 3–5 days after a bleeding stopped
Why is H. pylori Still Positive Despite Previous Treatment?
Answer:
There are several possible reasons for persistent H. pylori positivity:
1-Antibiotic resistance, especially to clarithromycin, is increasingly common.
2-Non-adherence to treatment or inappropriate dosing/timing.
3-Reinfection is rare but possible.
4-Testing too soon after treatment (within 4 weeks or while still on PPI) can give false results, but in this case, the test was done months after.
What Is the Next Step in Treatment?
Since the patient failed clarithromycin-based triple therapy, a second-line regimen is needed.
Recommended next steps:
*Stop any PPI for 2 weeks if planning urea breath test for confirmation.
*Use a bismuth-based quadruple therapy for 14 days:
PPI twice daily
Bismuth subsalicylate or subcitrate
Metronidazole
Tetracycline
*Alternative (if bismuth unavailable): Levofloxacin-based triple therapy
*Follow-up testing (urea breath or stool antigen) should be done ≥4 weeks after completing therapy and off PPI for ≥2 weeks.
A:You are asked to place a PEG in a 76-year-old woman with a mechanical mitral valve
and atrial fibrillation complicated by a stroke 4 weeks ago now with persistent
oropharyngeal dysphagia. She is taking long-term warfarin. What do you do?
السؤال الاول…هوPEG2
(percutaneous endoscopic gastrostomy)ده High risk ولا لا؟
الاجابة high risk
كلمة السر
5,2,يوم بليلة
1-stop warfarin 5 days before procedure
2-Start LMWH 2 days after stoppage warfarin
3-Stop LMWH at the day of procedure
4-Restart warfarin at the night of procedure
5-Continue LMWH till reaching the target level of INR
مين المريض
High risk
1- prothetic metal valve in mitral or aorta
2- AF + prothetic valve
3-AF +mitral stenosis
4-AF +stroke within 3 months
5-AF + high rik CHAD ≥3
Congestive heart failure
HTN
Age >75 years old
DM
طب لو العيان
Low risk
وهيعمل High risk
Warfarin
قانون 5,1.5
1-stop warfarin 5 days before procedure
2-Check inr before procedure to make sure it is below 1.5
3-Restart warfarin at the night of procedure
4-check for INR 1 week after procedure
طب لو العيان هيعمل Low rik
يكمل عادي علي warfarin
ويعمل INR قبلها باسبوع
طب بالنسبة لل DOACS
لو هيعمل Low risk
يوقف يومها الصبح
لو هيعمل High risk
قانون 3,3
يوقف قبلها ب ٣ أيام ويكمل بعدها ب ٣ أيام
ايه هي الحاجات ال low risk
1- منظار بعينة أو بدون
٢- stent… panceriatic,enteral,colonic,gastric, esophygeal,billiary
3-eus من غير عينة
4- اي حاجة من غير polipoctomy
A 68-year-old man is referred by his primary care physician for a colonoscopy because of a positive fecal immunohistochemistry test for blood. The patient’s last colonoscopy was 5 years ago and was normal. Eight months ago, he had 3 drug-eluting coronary stents placed. He has not experienced angina since then. He takes ramipril, aspirin 325 mg daily, clopidogrel 75 mg daily, and esomeprazole 40 mg daily. How do you want to proceed, both with l the timing of colonoscopy and the dua antiplatelet therapy?
محبكتش يعني
1-colonoscopy due to positive fit isn’t urgent,ptn can delay colonoscopy till complete 12 months on dual antiplatlets
2-If colonoscopy is urgent, clopidogril can stopped 6 months after stent (here, the patient had stent 8 months ago,so he can stop but after cardiologist consultation) and aspirin is continoued unless there is bleeding
Cyanosis with normal oxygen saturation after using Hurricaine Topical
Anesthetic Spray (benzocaine spray) before endoscopy
*Methemoglobinemia occurs when iron in hemoglobin is oxidized from Fe²⁺ to Fe³⁺, which cannot bind oxygen.
*This leads to a functional hypoxia despite normal PaO₂
*Treatment…Iv methyline blue
