Gastroenterology

PCP submission

72 year old female with a past medical history of popliteal artery aneurysm, AAA without rupture, PAD, Hx of adenomatous polyp of colon, Hypertriglyceridemia, Obesity, Class II, BMI 35-39.9, tobacco use who was recently hospitalized for anemia requiring transfusions related to UGIB. Hgb was 5.8 on admit, baseline 13. IV iron 2 doses given-advised IV iron infusions after discharge. EGD reveals Roux-en-Y gastrojejunostomy for marginal ulcers with clean bases. There is LA grade reflux esophagitis. Recommendation: Zegerid or Prevacid with open capsules daily for a minimum of 3 months. Check stools for H. pylori. Avoid nonsteroidals. IV iron replacement therapy.

H Pylori breath test positive. Patient has listed allergies to ASA and erythromycin.Therefore I was planning to do quadruple therapy, however it calls for Bismuth subsalicylate and she is allergic to aspirin.

CBC 3/1/22: Hgb 9.2, HCT 32. 70, MCV 78, MCH 22.0, MCHC 28.10, RDW 21.6, platelet 418.

Creatinine 2/18/22 0.98l, GFR 58

Creatinine 2/21/22 0.87, GFR >= 60

Is it ok to do the PPI BID, tetracycline and metronidazole (250 mg) QID without the bismuth subsalicylate? Or other recommendations?

Also with initial creatinine and GFR readings that indicated slight renal insufficiency then was normal on repeat on 2/21/22, would you still recommend full dose tetracycline (500 mg) PO QID or every 8 hours?

She was given ferric gluconate 62.5 mg/5 mL (125 mg) in sodium chloride 0.9% 100 mL IVPB – 125 mg once daily on 2/20/22 and 2/22/22. How often should we continue these infusions outpatient? How often do we need to be monitoring CBC? What is our target goal?

Will we need to plan for a repeat EGD?

Specialist response

Thank you for this interesting consult question. If a patient like this came to see me in my GI clinic practice, here are some of my thoughts and recommendations: (Thank you for the detailed patient information.) With respect to treatment for Helicobacter pylori, your suggested regimen which excludes the bismuth, is reasonable to try. Given that her renal function has returned to normal or most recent check it is OK to use the full strength recommended antibiotic regimen. After completion of treatment, remember that it will be important to check for a successful eradication with either repeat still antigen or helicobacter breath testing. However, remember that testing should be performed at least four weeks after any exposure to antibiotics and after two weeks of stopping proton pump inhibitor therapy to ensure accuracy of test results. I think for now after her initial first two doses of intravenous iron, you can monitor to determine further need for infusions. I suspect that her anemia will significantly improve with treatment of H pylori and ulcer healing. You can repeat the CBC in about 2 to 3 months. After that you can return to checking with your routine labs. Given the findings on endoscopy which show marginal ulcer and findings of H pylori, the patient does not necessarily need to repeat EGD at this time. The most important thing is to evaluate for a successful eradication of H pylori. Thank you again for this consult. I hope that these thoughts and recommendations help improve the care of your patient.