Gastrointestinal haemorrhag

AVP is mainly used in the replacement therapy in congenital diabetes insipidus (CDI), but has only a short effect of 4-6 h. It is also used in the therapy of gastrointestinal haemorrhage, as a local vasoconstrictor,... 

The value of pharmacological interventions is not as firmly established as is desirable. Control of pre-cipitants notably gastrointestinal haemorrhage, systemic infection, constipation and electrolyte, particularly potassium imbalance is important. Despite lack of consistent evidence, use of synthetic sugars by mouth and oral antibiotics (neomycin or metronidazole) remains standard. Oral neomycin, though poorly absorbed, can still cause eighth cranial nerve damage. 

British Society of Gastroenterology Endoscopy Committee (2002) Non-variceal upper gastrointestinal haemorrhage guidelines. Cut 51 (Suppl IV) iv1-iv6. Available at http //www.bsg.org.uk/pdf word docs/nonvar3.pdf [Accessed 7 July 2008],... 

Nausea, vomiting and abdominal pain. Excessive doses may cause profuse diarrhoea, gastrointestinal haemorrhage, rashes, renal and hepatic damage... 

Intestinal cleansing effects the removal of nitrogenous substances and toxins from the intestine, particularly in cases of gastrointestinal haemorrhaging, increased intake of animal protein and obstipation. In HE, intestinal cleansing is always indicated, modified according to the respective degree of severity, (s. tab. 15.6). 

Spontaneous haemostasis Some 60-80% of all upper gastrointestinal haemorrhages cease spontaneously. Early diagnosis with simultaneous stabilization of the circulation facilitates such spontaneous haemostasis without further therapeutic measures being called for. In 10-15% of cases, the bleeding persists. 

Gastrolavage using a double-lumen tube may be of both diagnostic and therapeutic value in upper gastrointestinal haemorrhage. Endobronchial intubation is strongly recommended for disturbances of consciousness. 

The basic treatment of bleeding oesophageal varices is carried out under intensive care conditions. It essentially corresponds to the procedures for upper gastrointestinal haemorrhage, (s. pp 350, 351) The therapy has three main objectives ... 

Lower gastrointestinal haemorrhage shows a frequency of 10-15% some 3-5% develop in the small bowel. Intestinal bleeding as a result of liver disease is rare. The initial problem consists in the fact that (7.) numerous and different causes of bleeding must be clarified by differential diagnosis and (2.) severe blood loss together with a concurrent liver disease is always particularly hazardous. 

In lower gastrointestinal haemorrhage, the bleeding site is distal to the duodenojejunal ligament (Treitz s ligament) or the duodenojejunal recessus (i.e. the passage of the duodenum retroperitoneally and its transition to the intraperitoneal jejunum). 

All these diagnostic measures, when implemented specifically and step-by-step, yield a reliability of over 90% in lower gastrointestinal haemorrhage. 

Rockall, T.A., Logan, R.F., Devlin, H.B., Northfield, T.C. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996 38 316-321... 

Simpson, K.J., Chalmers, N., Redhead, D.N., Finlayson, N.D.C., Bonch-ier, I.A.D., Hayes, P.C. Transjugular intrahepatic portasystemic stent shunting for control of acute and recurrent upper gastrointestinal haemorrhage related to portal hypertension. Gut 1993 34 968 -973... 

There are a number of causes including (I.) well-known hepatotoxic factors (e.g. superimposed viral infection, alcohol consumption, hepatotoxic drugs, intoxication) and (2.) endogenous factors (e.g. sepsis, variceal bleeding, gastrointestinal haemorrhage, diarrhoea, hypoxia). Acute liver failure is frequently the result of a chain of damaging events, like a vicious circle. 

Derry S, Loke YK. Risk of gastrointestinal haemorrhage with long term use of aspirin meta-analysis. BMJ 2000 321(7270) 1183-7. 

Pahor M, Guralnik JM, Furberg CD, Carbonin P, Havlik R. Risk of gastrointestinal haemorrhage with calcium antagonists in hypertensive persons over 67 years old. Lancet 1996 347(9008) 1061-5. 

Diflunisal is a fluorinated salicyhc acid derivative, which is absorbed unchanged from the gastrointestinal tract, reaching peak concentrations after about 2 hours, and is metabolized by glucuronidation (1). Its adverse effects and other characteristics are those of aspirin, although gastrointestinal haemorrhage may be less common (2). 

Henry DA, O Connell DL. Effects of fibrinolytic inhibitors on mortality from upper gastrointestinal haemorrhage. BMJ 1989 298(6681) 1142-6. 

On admission, some 36 h after the incident, local necrotic lymphadenopathy was present and gastrointestinal haemorrhage ensued with hypo-volaemic shock and renal failure death occurred on the third day. At autopsy, there was evidence of pulmonary oedema and haemorrhagic necrosis of the small bowel haemorrhages were observed in the lymph nodes local to the injection site, in the myocardium, testicles and pancreas. 

Needham CD, Kyle J, Jones PF, Johnston SJ, Kerridge DF. Aspirin and alcohol in gastrointestinal haemorrhage. Gm (1971) 12, 819-21. 

Alcohol may increase the risk of gastrointestinal haemorrhage associated with NSAIDs. The skills related to driving are impaired by indometacin and phenylbutazone and this is made worse if patients drink alcohol while taking phenylbutazone, but this does not appear to occur with indometacin. A few isolated reports attribute acute renal failure to the concurrent use of NSAIDs and acute excessive alcohol consumption. 

One pharmaeodynamic study in healthy subjeets found that gastric instillation of a solution of diflunisal before an indometacin solution prevented the fall in transmucosal potential difference seen with indometacin alone. This was interpreted as evidence that diflnnisal protects the human gastric mucosa against the damaging effects of indometacin. However, the relevance of this test to the adverse effects of NSAIDs used clinically is unknown. Note that fatal gastrointestinal haemorrhage has been reported in a patient taking diflnnisal and indometacin. ... 

Coumarins. Six out of 20 patients taking warfarin had an increase in their prothrombin ratios (to about 4 to 6) within 2 to 6 days of starting to take eo-trimoxazole 960 mg twiee daily. One patient had a gastrointestinal haemorrhage and needed to be given vitamin K. The warfarin was temporarily withdrawn from 5 patients and the dosage was reduced in one patient to eontrol exeessive hypoprothrombinaemia. ... 

Combined use ofNSAnis and coumarin anticoagulants increases the risk of gastrointestinal haemorrhage. Care is needed with the combination. Some individual NSAIDs also alter the pharmacokinetics of warfarin, and these effects are covered in specific monographs that follow. 

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