VIGNAN INSTITUTE OF PHARMACEUTICAL TECHNOLOGY

Pharm-dPharmacotherapeuticsCase presentation on epigastric herniaM.SAI NAVYA15AC1T0015

Epigastric Hernia

• It occurs in the middle of the body between the breast bone & the belly button or naval.

Epigastric hernia

Causes• Lesser strength of connective tissue of

stomach(due to heavy lifting,etc.)• Obesity• Pregnancy• Accumulation of fluid in the stomach cavity.• Sometimes persistent coughing can cause

epigastric hernia.

Signs & Symptoms

Abdominal bulge

Pain Nausea

Pathophysiology

Complication• A lot of complications may pop up if the epigastric hernia is not

treated properly or on time. There may be loops of bowel when the weakness in the muscle wall enlarges. Due to this a blockage may cause which will result in vomiting and stomach ache.

• Strangulation is one serious complication observed in epigastric hernia.

Diagnosis• Physical examination: Epigastric hernia is often small or barely visible.• To take an internal look at the abdominal

wall between the breast bone & naval: 1) USG 2) CT Scan

TreatmentPharmacological• Antibiotics : Cefoxitin Gentamicin Ampicillin• Antianxiety Agents : These agents are indicated for

patients who may experience significant anxiety before a surgery – Lorazepam

Midazolam• NSAIDs : Diclofenac Ibuprofen Naproxen

Non pharmacological : • Surgery – Epigastric hernia repair Procedure: Anesthesia is given (general) Surgery begins with an incision on either side of the hernia A laproscope is inserted into one incision, the other incision

is used for additional surgical instruments The surgeon then isolates the portion of the abdominal lining

that is pushing through the muscle. This tissue is called hernia sac. The surgeon returns the

hernia sac to its proper position , then begins to repair the muscle defect.

If the defect in the muscle is small , it may be sutured closed. For large defects , a mesh graft will be used to cover the

hole. Once the mesh is in place or the muscle has been sewn , the

laproscope is removed & the incision can be closed It is closed with sutures .

Repair with mesh

Soap note on epigastric pain

SUBJECTIVE FINDINGS• A male patient of age 66 years admitted in the

hospital with the complaints of pain & swelling over epigastric region since 15 years.• He has H/O hypertension since 2 years.• His past medication history include intake of

analgesics , but the medications are not available. • He consumes caffeine.• He has neither surgical nor family history.• He has no drug allergies.

OBJECTIVE FINDINGSPhysical examination• All the vitals were tested for 6 days.• His temperature was high on 1st & 6th day.• His blood pressure was abnormal (high).• His was pulse rate was high.• His respiratory rate was high.

Objective findings• Hemoglobin was decreased.• Lymphocytes were increased slightly.• Monocytes were decreased slightly.• ESR was increased

Specialized diagnostic tests• USG: 7.8cm defect noted in the parietal layer of anterior abdominal wall in

epigastric region with herniation of bowel & omentum Impression: epigastric hernia.

ASSESSMENT• Based on patient’s complaints (pain

&swelling over epigastric region)& USG(epigastric hernia), the patient is confirmed with epigastric hernia.• Chronic use of NSAIDs (analgesics) lead

to ulcers.

PLAN Non pharmacological:Surgery – lap hernia repair prolene mash

PHARMACOLOGICALDrug Composition Dose Route Frequency DaysTab CYRA-D Domperidone

Rabeprazole1 tab P/O OD 5

Tab Telmisartan

Telmisartan 40mg P/O OD 5

Inj NOSOCEF Ceftriaxone 1gm P/O BD 2

Inj TRAMADOL

Tramadol 1 amp IV BD 2

Inj PANTOP Pantoprazole 40mg IV OD 2

Tab DOLO Paracetamol 650mg P/O SOS -

Inj FEBRINIL Paracetamol 1amp IV SOS -

Inj VOVERAN Diclofenac 1 amp IM SOS -

10RL Ringer lactate solution

1 pint IV SOS -

Pre operation

Post operation

SOS Medication

Drug / Composition

Indication Contraindication Monitoring parameters

ADRs

CYRA –D / Domperidone, Rabeprazole

Acidity Concomitant use with rilpivirine & alazanavir

Monitor Mg levels prior to initiation

Diarrhoea, headache, pruritus, dizziness

TELMIKIND/ Telmisartan

HTN Severe hepatic impairment

Monitor BP , serum creatinine levels , electrolytes

Dizziness, fatigue , headache , sinusitis

NOSOCEF / Ceftriaxone

Susceptible Bacterial infection

Hypersensitivity to ceftriaxone or other cephalosporin

Perform CBC at regular intervals during prolonged treatment. Observe for signs &symptoms of anaphylaxis

Diarrhoea, nausea, vomiting.

TRAMADOL / Tramadol

Post operative pain

Suicidal patients , acute intoxification of hypnotics

Monitor pain relief , resp. rate , BP , pulse rate , abuse

Resp. depression, seizure , dizziness , headache.

Drug / Composition

Indication Contraindication Monitoring parameters

ADRs

PANTOP / Pantoprazole

Ulcers Concomitant use with rilpivirine , atazanavir

Monitor Mg levels prior to initiation

Diarrhoea, headache, pruritus, dizziness

DOLO/ Paracetamol

Pain reliever/ fever reducer

Not to be used if allergic to acetaminophen or paracetamol

Monitor serum paracetamol levels when acute over dosage is expected

Nausea, loss of appetite

FEBRINIL/ Paracetamol

Pain reliever/ fever reducer

Not to be used if allergic acetaminophen or paracetamol

Monitor serum paracetamol levels when acute over dosage is expected

Nausea , loss of appetite

VOVERAN / Diclofenac

Post operative pain

Hypersensitivity , asthma , urticaria

Periodically monitor serum transaminase values , CBC , BP

Edema , CHF, HTN, Tachycardia, nausea , diarrhoea

RINGERS LACTATE SOLUTION

Replacement of fluid & electrolytes

- Monitor fluid balance , electrolytes , acid base balance

Allergic reactions

DRUG INTERACTIONS• They are no major or moderate drug interactions.

MINOR INTERACTION: Ceftriaxone × Diclofenac

FOOD DRUG INTERACTIONS:

Interaction Mechanism Management Tramadol × Alcohol

Result in additive CNS depression

Avoid taking alcohol

Telmisartan × food

Moderate to high dietary intake of K+, especially salt substitutes may increase the risk of hyperkalemia

Avoid eating potassium containing salt substitutes

PHARMACIST INTERVENTIONDOSE ADJUSTMENT : No dose adjustment is requiredPATIENT COUNSELLING : • Do not drive or operate machinery.• Avoid drinking alcohol , soft drinks & grape fruit juice.• Do not crush or chew the tablets.• Take PANTOP immediately before a meal.AFTER DISCHARGE:• Rest for few days. • Have a pillow handy to over abdomen for support.• Do not lift heavy objects.

MY TREATMENTPRE SURGERY

Drug Dose Frequency RoutePANTOPRAZOLE 40 mg OD P/O

TELMISARTAN 40 mg OD P/O

POST SURGERYDrug Dose Frequency Route

AMPICILLIN 500 mg BD P/O

PARACETAMOL 650 mg SOS P/O

RL 1 Pint SOS IV

PANTOPRAZOLE 40mg OD P/O

REFERENCES• http://www.webmd.com/digestive-disorders/tc/common-types-

of-hernias-epigastric-hernia• https://www.verywell.com/epigastric-hernia-diagnosis-

treatment-and-surgery-3157222• https://www.epainassist.com/abdominal-pain/what-is-

epigastric-hernia• http://emedicine.medscape.com/article/189563-medication#6• https://image.slidesharecdn.com• http://californiahernia.com/wp-content/uploads/2015/09/

hernia-illustration.jpg• http://www.mims.com/india