gastroparesis / chronic abdominal pain

[dotcb]

Just curious if any others have useful approaches to these patients... Cyclic vomiting syndrome, etc.

My intial approach was to look at prior visits and repeat what has worked in the past.

Then I switched to 2 rounds of meds and if not ready to go home - I admit you to the hospital.

Well, my department got an observation unit and there is more pressure for us to keep these patients out of inpatient beds. I don't need to mention they are infuriating. The last one felt well enough to go home, but refused to, stating she was too afraid her pain would return and would have to come right back. She wanted a prescription for pain medicine.

I explained to her analgesics worsen nausea and gut motility - and she burst into tears.... Ugh.

Any novel ideas for success?

I think I may go back to admitting them all again...

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[brk81144]

Thorazine or haldol seem to work well. Try to avoid the narcs because it just "feeds the animals" and they always come back looking for more

 

[RustedFox]

1.) Reglan.
2.) Haldol.
3.) Aggressive IV hydration.
4.) GTFO.

I don't see a lot of these in my current practice setting because my average patient is a 70 year old retiree that fought several wars, lived through several recessions, underwent and overcame outstanding hardships, and understands that life is not without discomfort, pain, or difficulty.

Its largely a disease of the young entitled wuss-crowd that has always thought that they could destroy themselves with cigarettes, alcohol, narcotics, high-fructose corn syrup, fast-food, and never have to deal with the consequences.

I like to tell them. Listen, I have (autoimmune disease). I am in daily 4/10 abdominal pain, yet you don't see me in here bargaining for narcotics and applying for disability. I get over it.

Get back to work, kids.

 

[USCDiver]

I don't give them a choice most of the time. I just walk in after their fluids and/or labs are done and say "Everything looks fine, I'm gonna give you one more dose of meds before you go home."

 

[cyclohexanol]

I am a big fan of droperidol, except for that our P&T committee decided that we aren't allowed to use it anymore and got rid of it in our pharmacy...

If you have it, its awesome

 

[deleted547339]

I have some attendings that say "2 or 3 doses of anti-emetics --> admit."

Having recently been on the inpatient wards, I realize that assuming the patient is not profoundly dehydrated or malnourished, there is nothing more the inpatient team has to offer.

 

[gutonc]

I have some attendings that say "2 or 3 doses of anti-emetics --> admit."

Having recently been on the inpatient wards, I realize that assuming the patient is not profoundly dehydrated or malnourished, there is nothing more the inpatient team has to offer.

Sure there is. Dispo and another name on the chart. And then the hospitalist will do the same by getting GI on board.

 

[EM4life]

Where I trained in New York it was common place to attempt 2-3 doses of antiemetics, analgesics and admit for pain control. I practice in WI now, I'm not sure if it's just the climate of practice here, but I do not find myself admitting chronic abdominal pain like ever, unless there is truly intractable vomiting, severe dehydration/electrolyte disturbance. But if not, it's a regimen of nonnarcotics/antiemetics, max 2 doses of pain meds, and outpatient fu with PMD/GI. I'm not really negotiating at this point, I just walk into the room like USCdriver and say it all looks okay and that we'd be sending them home - if there's any attempt at negotiation, especially if it's the usual "I'm in too much pain to go home" blah, I emphasize close fu and that there's no indication for admission. I find that the majority of patients who have this problem don't argue when you state outright that if their labs look okay, we'll be sending them home - make eye contact, don't get emotionally involved, I feel like patients can smell fear or smell a provider's ability to be swayed so to speak haha. I save this treatment for chronic abdominal pain/chronic pain stuff only - usually I'm a pretty nice person!

 

[Arcan57]

The real question to ask the patient is "How long will it take whatever psychsocial **** storm that is keeping you from coping with your chronic pain to die down?"

1. Less than a day (ie fight with coworker, needs work note to return) - discharge
2. 1-3 days (rent money due, dealer out of town for weekend) - admit
3. >3 days (impending incarceration, evicted by SO, oxy stash stolen) - discharge

 

[EctopicFetus]

We have a bunch of these cases. I rarely admit. I rarely give narcs. I try to "ride them out" meaning no narcs until later. Fluids, hydration, antiemetics. If i give pain meds I tell them after that if their labs are normal they go home.

 

[Hamhock]

I strongly second droperidol. Droperidol. Droperidol.

However, I am now moonlighting in an ED without it and have found enough success with plenty of haldol. Gotta knock up down with haldol and a little narcotic. Only one dose of narcotic.

After a sufficient dose of droperidol (sometimes twice), they don't complain much and usually agree to the discharge.

HH

 

[Akail]

Haldol? Seriously? Maybe it's unique to my program but I think my attendings would flip if I gave a chronic abd painer that...How much do you guys usually give?

 

[Khaos]

I gave it at my old place all the time. Haldol, bentyl, zofran, fluids. As for the dose anywhere from 5 to 10 mg based on age. If younger, than no problems. I usually start off by telling them my plan. I explain that I will not fix them today and what they have is chronic and won't ever be fixed. I will explain that I don't treat with narcotics secondary to decease motility and worsening of symptoms. I will tell them if labs are abnormal I will admit to have them help the dehydration. Usually between the meds and the realization that I'm not going to give them narcs they are wanting to leave after a little while.

I've started it at my new place and the nurses are just giving me weird looks but are amazed when it "works."

 

[deleted109597]

Haldol? Seriously? Maybe it's unique to my program but I think my attendings would flip if I gave a chronic abd painer that...How much do you guys usually give?

Between 2.5 and 5mg IV. Nausea is an FDA indication (well, chemotherapy induced, but that's splitting hairs), so they can't be intellectually honest about not giving haldol for nausea if they're ok with giving droperidol.
It treats both causes of their problems.

Be sure and tell the nurses why you're giving it though, so they don't go in and say "this is haldol, it's for psychosis", since they're apparently required by the JC to tell patients what meds they're giving and why, even if they don't know.

 

[n2b8me]

I'm curious about what the length of stay is for these patients. How long is the patient stay with haldol? How long do you observe before making a call to admit?

 

[WilcoWorld]

Butyrophenones are a great discharge medication with provider-percieved LOS much shorter (or at least less painful) than the opiate-titration visit. When your nurses complain that the patient has to be on monitor for the arbitrary X number of hours after these meds, just remind him that the rule doesn't apply if the patient decides to leave.

ED doses (0.625-1.25 droperidol, 2-4 mg haldol) are safe in uncomplicated patients and they're more effective than most of our alternatives.

 

[EM Junkie]

We have a bunch of these cases. I rarely admit. I rarely give narcs. I try to "ride them out" meaning no narcs until later. Fluids, hydration, antiemetics. If i give pain meds I tell them after that if their labs are normal they go home.

Exactly my approach. We also have a "No Dilaudid Policy" that helps tremendously. I never admit unless labs abnormal (and a K of 3.4 ain't cutting it).

 

[Khaos]

Butyrophenones are a great discharge medication with provider-percieved LOS much shorter (or at least less painful) than the opiate-titration visit. When your nurses complain that the patient has to be on monitor for the arbitrary X number of hours after these meds, just remind him that the rule doesn't apply if the patient decides to leave.

ED doses (0.625-1.25 droperidol, 2-4 mg haldol) are safe in uncomplicated patients and they're more effective than most of our alternatives.

Studies have shown that up to 100 mg of Haldol can be used safely within a very short amount of time. Now, those doses were for extreme psychosis but is the reason why I don't hesitate giving 5 to 10 mg.

 

[Apollyon]

Studies have shown that up to 100 mg of Haldol can be used safely within a very short amount of time. Now, those doses were for extreme psychosis but is the reason why I don't hesitate giving 5 to 10 mg.

I thought at even 20mg, all the receptors were soaked. 100mg? That's nuts! (Pun intended.)

Oh, and I DID use Haldol for nausea just less than one hour ago (2.5mg), and made sure to tell staff to tell pt that it was for nausea (and I DID say for chemo nausea, but that is splitting hairs). It worked wonderfully, and pt is being discharged right now.

 

[Rendar5]

2 patients this week with clear psych component to their vomiting. Both even thanked me after the haldol helped

 

[Substance]

1.) Reglan.
2.) Haldol.
3.) Aggressive IV hydration.
4.) GTFO.

I don't see a lot of these in my current practice setting because my average patient is a 70 year old retiree that fought several wars, lived through several recessions, underwent and overcame outstanding hardships, and understands that life is not without discomfort, pain, or difficulty.

Its largely a disease of the young entitled wuss-crowd that has always thought that they could destroy themselves with cigarettes, alcohol, narcotics, high-fructose corn syrup, fast-food, and never have to deal with the consequences.

I like to tell them. Listen, I have (autoimmune disease). I am in daily 4/10 abdominal pain, yet you don't see me in here bargaining for narcotics and applying for disability. I get over it.

Get back to work, kids.

I want to work where you work.

 

[RustedFox]

I want to work where you work.

Really? we're hiring. We need 2 FT docs. PM me if you want more details.

 

[Apollyon]

Feel better? And is that a nom de plume, like Indiana Jones? And props for wishing us ill. One good turn deserves another!

 

[gutonc]

I really liked this part:

I don't take Reglan because I don't like pills. They are damaging.

So...there's a drug that might help you (and might not, I'm not naive), but you won't take it because you don't like pills and it's "damaging"?

How did you even find this thread?

I applaud you for your internet trolling skills as well as your internet medical degree and training. Good show.

 

[goodoldalky]

Still trying to figure this one out...

 

[deleted128562]

I'm confused. You don't like reglan because you don't like pills, but you took motrin after your c-sections?

And don't worry, my future in medicine probably will in fact be *******. I have to deal with people like you all day.

 

[WilcoWorld]

Thank you for the lesson in compassion.

 

[spyderdoc]

Thread locked to prevent a troll storm. I also deleted troll posts and the quotes in responses.