Internal and emergency medicine
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Malabsorption encompasses dysfunctions occurring during the digestion and absorption of nutrients. A small proportion of patients presents with chronic diarrhoea. A clinical history supportive of malabsorption may guide investigations toward either the small bowel or pancreas. ⋯ Measurement of protein absorption is difficult and unreliable; it is, therefore, rarely advocated in clinical settings. No single biological marker confirming a diagnosis of small bowel malabsorption or small bowel integrity is presently available in clinical practice. Plasma citrulline concentration, an amino acid not incorporated into endogenous or exogenous proteins, has been extensively used in research studies and supportive results are establishing its concentration as a reliable quantitative biomarker of enterocyte absorptive capacity.
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Dual antiplatelet therapy with aspirin and clopidogrel reduces cardiovascular events following an acute coronary syndrome or stent implantation, but the associated increased risk of gastro-intestinal bleeding often leads to the co-administration of proton pump inhibitors (PPIs). PPIs have been shown to decrease antiplatelet effects of clopidogrel ex vivo, raising concerns about the cardiovascular safety of this drug combination. Clinical trials investigating PPI-clopidogrel interactions have provided conflicting results and are all subject to methodological critiques. ⋯ Indeed, the Clopidogrel and the Optimization of GI Events Trial, which would have had such characteristics, was stopped prematurely. As a consequence, the question of the PPI-clopidogrel interaction is still unresolved, and clinical consequences cannot be excluded. At this time such combination therapy should, therefore, be provisionally advocated only for patients at high risk of bleeding (prior upper gastro-intestinal bleeding, advanced age, concomitant use of warfarin, steroidal or non-steroidal anti-inflammatory drugs and Helicobacter pylori infection) and avoiding PPIs with strong affinity for cytochrome CYP2C19, such as omeprazole and esomeprazole.
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Angioedema attacks, characterized by the transient swelling of the skin and mucosae, are a frequent cause of visits to the emergency department. Swellings of the oral cavity, tongue, or larynx can result in life-threatening airway obstruction, while abdominal attacks can cause severe pain and often lead to unnecessary surgery. The underlying pathophysiologic process resulting in increased vascular permeability and plasma extravasation is mediated by vasoactive molecules, most commonly histamine and bradykinin. ⋯ The low awareness among physicians of the existence of rare forms of angioedema with different aetiologies and pathogenesis, considerably adds to the problem. Also poorly appreciated by emergency personnel may be the recently introduced bradykinin-targeted treatments. The main objective of this consensus statement is to provide guidance for the management of acute angioedema in the emergency department, from presentation to discharge or hospital admission, with a focus on identifying patients in whom new treatments may prevent invasive intervention.