CLINICAL PHARMACY in CLINICAL PHARMACY in GASTROENTEROLOGYGASTROENTEROLOGY

DDigestive diseasesigestive diseases

All diseases that pertain to the All diseases that pertain to the gastrointestinal tract are labelled as gastrointestinal tract are labelled as digestive diseasesdigestive diseases. This includes . This includes diseases of the esophagus, stomach, diseases of the esophagus, stomach, first, second and third part of the first, second and third part of the duodenum, jejunum, ileum, the ileo-duodenum, jejunum, ileum, the ileo-cecal complex, large intestine cecal complex, large intestine (ascending, transverse and descending (ascending, transverse and descending colon) sigmoid colon and rectum. colon) sigmoid colon and rectum.

GastritisGastritisGastritis means inflamation of the stomach. It means that Gastritis means inflamation of the stomach. It means that

white blood cells move into the wall of the stomach as a white blood cells move into the wall of the stomach as a response to some type of injury. Gastritis does not mean response to some type of injury. Gastritis does not mean that there is an ulcer or cancer. It is simply inflammation–that there is an ulcer or cancer. It is simply inflammation–either acute or chronic. What are the causes of gastritis?either acute or chronic. What are the causes of gastritis?Helicobacter PyloriHelicobacter Pylori

This is the name of a bacteria that has learned to live in the This is the name of a bacteria that has learned to live in the thick mucous lining of the stomach. Although it doesn't thick mucous lining of the stomach. Although it doesn't actually infect the underlying tissue, it does result in acute actually infect the underlying tissue, it does result in acute and chronic inflammation. It probably occurs early in and chronic inflammation. It probably occurs early in childhood and remains throughout life unless antibiotics childhood and remains throughout life unless antibiotics cure it. The infection can lead to ulcers and, in later life, cure it. The infection can lead to ulcers and, in later life, even to stomach cancer in some people. Fortunately, there even to stomach cancer in some people. Fortunately, there are now ways to make the diagnosis and treat this disorder.are now ways to make the diagnosis and treat this disorder.Autoimmune Gastritis - Pernicious AnemiaAutoimmune Gastritis - Pernicious Anemia

The stomach lining also may be attacked by the The stomach lining also may be attacked by the immune system leading to loss of the stomach cells. immune system leading to loss of the stomach cells. This causes acute and chronic inflammation which This causes acute and chronic inflammation which can result in a condition called pernicious anemia. can result in a condition called pernicious anemia. The anemia occurs because the body no longer can The anemia occurs because the body no longer can absorb vitamin B12 due to a lack of a key stomach absorb vitamin B12 due to a lack of a key stomach factor, destroyed by the chronic inflammation. factor, destroyed by the chronic inflammation. Stomach cancer can even occur later in life.Stomach cancer can even occur later in life.

GastritisGastritisAspirin & NSAID GastritisAspirin & NSAID Gastritis NSAID stands for non-steroidal anti-inflammatory NSAID stands for non-steroidal anti-inflammatory

drug. These are arthritis and pain relievers and drug. These are arthritis and pain relievers and include the over-the-counter drugs Advil, Naprosyn, include the over-the-counter drugs Advil, Naprosyn, Motrin and ibuprofen as well as many prescription Motrin and ibuprofen as well as many prescription arthritis medicines such as Voltaren, Feldene, Lodine arthritis medicines such as Voltaren, Feldene, Lodine and Relafen. Along with aspirin, they reduce a and Relafen. Along with aspirin, they reduce a protective substance in the stomach called protective substance in the stomach called prostaglandin. These drugs usually cause no prostaglandin. These drugs usually cause no problems when taken for the short-term. However, problems when taken for the short-term. However, regular use can lead to a gastritis as well as a more regular use can lead to a gastritis as well as a more serious ulcer condition.serious ulcer condition.

AlcoholAlcohol Alcohol and certain other chemicals can cause Alcohol and certain other chemicals can cause

inflammation and injury to the stomach. This is inflammation and injury to the stomach. This is strictly dose related in that a lot of alcohol is usually strictly dose related in that a lot of alcohol is usually needed to cause gastritis. Social or occasional needed to cause gastritis. Social or occasional alcohol use is not damaging to the stomach although alcohol use is not damaging to the stomach although alcohol does stimulate the stomach to make acid.alcohol does stimulate the stomach to make acid.

GastritisGastritis (cont’d) (cont’d)Hypertrophic GastritisHypertrophic Gastritis At times, the folds in the stomach will At times, the folds in the stomach will

become enlarged and swollen along become enlarged and swollen along with the inflammation. There is not a with the inflammation. There is not a great deal known about why this great deal known about why this occurs. A variation of this type of occurs. A variation of this type of gastritis is called Ménétrier's disease gastritis is called Ménétrier's disease where the gastric folds become where the gastric folds become gigantic. With this condition, there is gigantic. With this condition, there is often protein loss into the stomach often protein loss into the stomach from these weeping folds.from these weeping folds.

GastritisGastritis (cont’d) (cont’d)SSymptomsymptoms The symptoms of gastritis depend on how acute it The symptoms of gastritis depend on how acute it

is and how long it has been present. In the acute is and how long it has been present. In the acute phase, there may be pain or gnawing in the upper phase, there may be pain or gnawing in the upper abdomen, nausea and vomiting. In the chronic abdomen, nausea and vomiting. In the chronic phase, the pain may be dull and there may be loss phase, the pain may be dull and there may be loss of appetite with a feeling of fullness after several of appetite with a feeling of fullness after several bites of food. Very often, there are no symptoms bites of food. Very often, there are no symptoms at all. If the pain is severe, there may be an ulcer at all. If the pain is severe, there may be an ulcer as well as gastritis.as well as gastritis.

TreatmentTreatment The treatment of gastritis will depend on its cause. The treatment of gastritis will depend on its cause.

For most types of gastritis, reduction of stomach For most types of gastritis, reduction of stomach acid by medication is often helpful. Beyond that, a acid by medication is often helpful. Beyond that, a specific diagnosis needs to be made. Antibiotics specific diagnosis needs to be made. Antibiotics are used for infection. Elimination of aspirin, are used for infection. Elimination of aspirin, NSAIDs or alcohol is indicated when one of these NSAIDs or alcohol is indicated when one of these is the problem. For the more unusual types of is the problem. For the more unusual types of gastritis, other treatments may be needed. gastritis, other treatments may be needed.

Peptic ulcer disease (PUD) is a very common Peptic ulcer disease (PUD) is a very common ailment, affecting one out of eight persons in the ailment, affecting one out of eight persons in the United States. The causes of PUD have gradually United States. The causes of PUD have gradually

become clear. With this understanding have come become clear. With this understanding have come new and better ways to treat ulcers and even cure new and better ways to treat ulcers and even cure

themthem

PEPTIC ULCER DISEASEPEPTIC ULCER DISEASEHelicobacter pylori (H. pylori)Helicobacter pylori (H. pylori)

This funny-sounding name identifies the basic cause of most This funny-sounding name identifies the basic cause of most peptic ulcers, excluding those caused by aspirin or arthritis peptic ulcers, excluding those caused by aspirin or arthritis drugs. This bacteria has a twisted spiral shape and infects drugs. This bacteria has a twisted spiral shape and infects the mucous layer lining of the stomach. This infection the mucous layer lining of the stomach. This infection produces an inflammation in the stomach wall called produces an inflammation in the stomach wall called gastritis. The body even develops a protein antibody in the gastritis. The body even develops a protein antibody in the blood against it. The bacteria is probably acquired from blood against it. The bacteria is probably acquired from contaminated food or from a drinking glass. It ims only after contaminated food or from a drinking glass. It ims only after H. pylori bacteria injure the protective mucous layer of the H. pylori bacteria injure the protective mucous layer of the stomach, allowing damage by stomach acid, that an ulcer stomach, allowing damage by stomach acid, that an ulcer develops. develops.

Arthritis medications include ibuprofen (Advil), Feldene, Arthritis medications include ibuprofen (Advil), Feldene, Naprosyn, Voltaren, Indocin, Aleve, Lodine, and many others. Naprosyn, Voltaren, Indocin, Aleve, Lodine, and many others. As with aspirin, they can damage the mucous layer of the As with aspirin, they can damage the mucous layer of the stomach, after which the stomach acid causes the final injury. stomach, after which the stomach acid causes the final injury.

So, H. pylori and certain drugs are the two major factors that So, H. pylori and certain drugs are the two major factors that cause ulcers. In rare cases, a patient will produce very large cause ulcers. In rare cases, a patient will produce very large amounts of acid and develop ulcers. This condition is called amounts of acid and develop ulcers. This condition is called Zollinger -Ellison syndrome. Finally, some people get ulcers Zollinger -Ellison syndrome. Finally, some people get ulcers for unknown reasons. for unknown reasons.

PEPTIC ULCER DISEASEPEPTIC ULCER DISEASE SymptomsSymptoms

Ulcers cause gnawing, burning pain in the upper Ulcers cause gnawing, burning pain in the upper abdomen. These symptoms frequently occur abdomen. These symptoms frequently occur several hours following a meal, after the food several hours following a meal, after the food leaves the stomach but while acid production is leaves the stomach but while acid production is still high. The burning sensation can occur during still high. The burning sensation can occur during the night and be so extreme as to wake the the night and be so extreme as to wake the patient. Instead of pain, some patients patient. Instead of pain, some patients experience intense hunger or bloating. Antacids experience intense hunger or bloating. Antacids and milk usually give temporary relief. Other and milk usually give temporary relief. Other patients have no pain but have black stools, patients have no pain but have black stools, indicating that the ulcer is bleeding. Bleeding is a indicating that the ulcer is bleeding. Bleeding is a very serious complication of ulcers.very serious complication of ulcers.

PEPTIC ULCER DISEASEPEPTIC ULCER DISEASE Therapy of PUD has undergone profound changes. Therapy of PUD has undergone profound changes.

There are now available very effective medications to There are now available very effective medications to supress and almost eliminate the outpouring of stomach supress and almost eliminate the outpouring of stomach acid. These acid-suppresssing drugs have been dramatically acid. These acid-suppresssing drugs have been dramatically effective in relieving symptoms and allowing ulcers to heal. effective in relieving symptoms and allowing ulcers to heal. If an ulcer has been caused by aspirin or an arthritis drug, If an ulcer has been caused by aspirin or an arthritis drug, then no subsequent treatment is usually needed. Avoiding then no subsequent treatment is usually needed. Avoiding these latter drugs, should prevent ulcer recurrence. these latter drugs, should prevent ulcer recurrence.

The second major change in PUD treatment has been the The second major change in PUD treatment has been the discovery of the H. pylori infection. When this infection is discovery of the H. pylori infection. When this infection is treated with antibiotics, the infection, and the ulcer, do not treated with antibiotics, the infection, and the ulcer, do not come back. Increasingly, physicians are not just come back. Increasingly, physicians are not just suppressing the ulcer with acid-reducing drugs, but they are suppressing the ulcer with acid-reducing drugs, but they are also curing the underlying ulcer problem by getting rid of also curing the underlying ulcer problem by getting rid of the bacterial infection. If this infection is not treated, the the bacterial infection. If this infection is not treated, the ulcers invariably recur. ulcers invariably recur.

There are a number of antibiotic programs available to treat There are a number of antibiotic programs available to treat H. pylori and cure ulcers. Working with the patient, the H. pylori and cure ulcers. Working with the patient, the physician will select the best treatment program available physician will select the best treatment program available

TreatmentTreatment of peptic ulcer of peptic ulcer Antimicrobial agents (tetracycline, bismuth subsalicylate, Antimicrobial agents (tetracycline, bismuth subsalicylate,

and metronidazole) to eradicate and metronidazole) to eradicate H. pyloriH. pylori infection infection Misoprostol (a prostaglandin analog) to inhibit gastric acid Misoprostol (a prostaglandin analog) to inhibit gastric acid

secretion and increase carbonate and mucus production, to secretion and increase carbonate and mucus production, to protect the stomach lining protect the stomach lining

Antacids to neutralize acid gastric contents by elevating the Antacids to neutralize acid gastric contents by elevating the gastric pH, thus protecting the mucosa and relieving pain gastric pH, thus protecting the mucosa and relieving pain

Avoidance of caffeine and alcohol to avoid stimulation of Avoidance of caffeine and alcohol to avoid stimulation of gastric acid secretion gastric acid secretion

Anticholinergic drugs to inhibit the effect of the vagal nerve Anticholinergic drugs to inhibit the effect of the vagal nerve on acid-secreting cells on acid-secreting cells

H2 blockers to reduce acid secretion H2 blockers to reduce acid secretion Sucralfate, mucosal protectant to form an acid-impermeable Sucralfate, mucosal protectant to form an acid-impermeable

membrane that adheres to the mucous membrane and also membrane that adheres to the mucous membrane and also accelerates mucus production accelerates mucus production

Dietary therapy with small infrequent meals and avoidance Dietary therapy with small infrequent meals and avoidance of eating before bedtime to neutralize gastric contents of eating before bedtime to neutralize gastric contents

Insertion of a nasogastric tube (in instances of Insertion of a nasogastric tube (in instances of gastrointestinal bleeding) for gastric decompression and gastrointestinal bleeding) for gastric decompression and rest, and also to permit iced saline lavage that may also rest, and also to permit iced saline lavage that may also contain norepinephrine contain norepinephrine

Gastroscopy to allow visualization of the bleeding site and Gastroscopy to allow visualization of the bleeding site and coagulation by laser or cautery to control bleeding coagulation by laser or cautery to control bleeding

Surgery to repair perforation or treat unresponsiveness to Surgery to repair perforation or treat unresponsiveness to conservative treatment, and suspected malignancy. conservative treatment, and suspected malignancy.

Ranitidine (Ranitidin) Forms of production: 0,15 g and 0,3 g tablets and ampoules with 2 ml of

2,5 % solution.

RECOMMENDATIONS OF

HELICOBACTER PYLORI ERADICATION • omeprazole 20mg • amoxicillin 1000mg • clarithromycin 500mg, all twice daily for 7 days. • An alternative regimen with a similar eradication

rate of around 90% is:• omeprazole 20mg • clarithromycin 250mg • metronidazole 400mg, again all twice daily for 7

days.

A typical quadruple therapyA typical quadruple therapy

a PPI twice a day a PPI twice a day bismuth 120 mg four times a day bismuth 120 mg four times a day metronidazole 400 mg three times a day metronidazole 400 mg three times a day oxytetracyclineoxytetracycline 500 mg four times a day, all 500 mg four times a day, all

for 7 days. for 7 days.

Ulcers associated with NSAIDsUlcers associated with NSAIDs

omeprazole 20mg daily is preferable to omeprazole 20mg daily is preferable to ranitidineranitidine 150mg 150mg twice daily as the respective rates of healing are 80% and twice daily as the respective rates of healing are 80% and 63%. 63%.

H2RAs are slow to heal the ulcers if the offending drug is H2RAs are slow to heal the ulcers if the offending drug is not stopped and so, under these conditions, a PPI is not stopped and so, under these conditions, a PPI is preferred. preferred.

H pylori eradication is no more effective than omeprazole H pylori eradication is no more effective than omeprazole alone to heal ulcers, but if the infection is present, then alone to heal ulcers, but if the infection is present, then eradication will reduce the rate of relapse. eradication will reduce the rate of relapse.

H pylori is not associated with an increased risk of ulcer H pylori is not associated with an increased risk of ulcer with NSAIDs in the elderly but there is an increased risk of with NSAIDs in the elderly but there is an increased risk of bleeding. bleeding.

MotiliumMotiliumForm of production: Form of production: 0,0,001 1 g tabletsg tablets

LAXATIVES AND CATHARTICSLAXATIVES AND CATHARTICSConstipationConstipation can be defined can be defined as infrequent or hard pellet as infrequent or hard pellet stools, or difficulty in stools, or difficulty in evacuating stool. Passing evacuating stool. Passing one or more soft, bulky one or more soft, bulky stools every day is a stools every day is a desirable goal. While desirable goal. While troublesome, constipation is troublesome, constipation is not usually a serious not usually a serious disorder. However, there disorder. However, there may be other underlying may be other underlying problems causing problems causing constipation and, therefore, constipation and, therefore, testing is often testing is often recommended. recommended.

ConstipationConstipation

Constipation is often caused by a lazy colon that does not Constipation is often caused by a lazy colon that does not contract properly and fails to move the stool to the rectum. contract properly and fails to move the stool to the rectum. The colon also can become spastic and remain contracted The colon also can become spastic and remain contracted for a prolonged time. In this case, stool cannot move along. for a prolonged time. In this case, stool cannot move along. Too much water is absorbed and hard pellet-like stool Too much water is absorbed and hard pellet-like stool develops. Constipation also can result from a mechanical develops. Constipation also can result from a mechanical obstruction, such as tumors or advanced diverticulosis, a obstruction, such as tumors or advanced diverticulosis, a disorder which can distort and narrow the lower-left colon. disorder which can distort and narrow the lower-left colon. Other conditions that can produce a sluggish, poorly Other conditions that can produce a sluggish, poorly contracting bowel include: pregnancy, certain drugs, thyroid contracting bowel include: pregnancy, certain drugs, thyroid hormone deficiency, the chronic abuse of laxatives, travel, hormone deficiency, the chronic abuse of laxatives, travel, and stress. and stress.

Indications for UseIndications for Use 1. To relieve constipation in pregnant women, elderly1. To relieve constipation in pregnant women, elderly clients clients

whose abdominal and perineal muscles havewhose abdominal and perineal muscles have become weak and become weak and atrophied, children with megacolon,atrophied, children with megacolon, and clients receiving and clients receiving drugs that decrease intestinaldrugs that decrease intestinal motility (eg, opioid analgesics, motility (eg, opioid analgesics, drugs with anticholinergicdrugs with anticholinergic effects)effects)

2. To prevent straining at stool in clients with coronary2. To prevent straining at stool in clients with coronary artery artery disease (eg, postmyocardial infarction), hypertension,disease (eg, postmyocardial infarction), hypertension, cerebrovascular disease, and hemorrhoids andcerebrovascular disease, and hemorrhoids and other rectal other rectal conditionsconditions

3. To empty the bowel in preparation for bowel surgery or3. To empty the bowel in preparation for bowel surgery or diagnostic procedures (eg, colonoscopy, barium enema)diagnostic procedures (eg, colonoscopy, barium enema)

4. To accelerate elimination of potentially toxic substances4. To accelerate elimination of potentially toxic substances from the GI tract (eg, orally ingested drugs or toxicfrom the GI tract (eg, orally ingested drugs or toxic compounds)compounds)

5. To prevent absorption of intestinal ammonia in clients5. To prevent absorption of intestinal ammonia in clients with with hepatic encephalopathyhepatic encephalopathy

6. To obtain a stool specimen for parasitologic examination6. To obtain a stool specimen for parasitologic examination 7. To accelerate excretion of parasites after anthelmintic7. To accelerate excretion of parasites after anthelmintic drugs drugs

have been administeredhave been administered 8. To reduce serum cholesterol levels (psyllium products)8. To reduce serum cholesterol levels (psyllium products)

LaxativesLaxatives

There are two main types of laxatives: There are two main types of laxatives: stimulants (chemical)stimulants (chemical) and and saline (liquid or salt).saline (liquid or salt). They occasionally help temporary constipation They occasionally help temporary constipation problems. However, chronic use of laxatives, problems. However, chronic use of laxatives, especially stimulant laxatives is discouraged especially stimulant laxatives is discouraged because the bowel becomes dependent upon because the bowel becomes dependent upon them. Bowel regularity should occur without them. Bowel regularity should occur without laxatives. laxatives. An occasional enema is preferrable over An occasional enema is preferrable over the chronic use of laxatives.the chronic use of laxatives.

Contraindications to UseContraindications to Use

Laxatives and cathartics should not be Laxatives and cathartics should not be used in the presenceused in the presence of undiagnosed abdominal of undiagnosed abdominal pain. The danger is that the drugspain. The danger is that the drugs may cause an may cause an inflamed organ (eg, the appendix) to ruptureinflamed organ (eg, the appendix) to rupture and spill and spill GI contents into the abdominal cavity with GI contents into the abdominal cavity with subsequent peritonitis, a life-threatening condition. subsequent peritonitis, a life-threatening condition. Oral drugsOral drugs also are contraindicated with intestinal also are contraindicated with intestinal obstruction and fecalobstruction and fecal impaction.impaction.

DietDietThe following foods should be eaten daily in The following foods should be eaten daily in

adequate amountsadequate amounts Whole grain breads (whole wheat)Whole grain breads (whole wheat)Bran cerealsBran cereals VegetablesVegetables -- Root (potatoes, carrots, turnips), leafy green (lettuce, celery, -- Root (potatoes, carrots, turnips), leafy green (lettuce, celery,

spinach), or cooked high residue (cabbage) spinach), or cooked high residue (cabbage) FruitFruit -- Cooked or stewed (prunes, applesauce) or fresh fruit (skin and pulp) -- Cooked or stewed (prunes, applesauce) or fresh fruit (skin and pulp) Bulking AgentsBulking Agents -- Fiber is the undigested part of plant food that passes into -- Fiber is the undigested part of plant food that passes into

the colon. Certain types of fiber can absorb and hold large amounts of water. the colon. Certain types of fiber can absorb and hold large amounts of water. This, in turn, results in a larger, bulkier stool which is soft and easier to pass. This, in turn, results in a larger, bulkier stool which is soft and easier to pass. Adequate fiber in food or from supplements is recommended daily. This type of Adequate fiber in food or from supplements is recommended daily. This type of water-retaining fiber generally is easily obtained each day by one of the water-retaining fiber generally is easily obtained each day by one of the following: following:

Food branFood bran -- This is available as wheat, oat or rice bran. Processing of wheat -- This is available as wheat, oat or rice bran. Processing of wheat and other grains removes this valuable fiberous part of the food so these and other grains removes this valuable fiberous part of the food so these processed products should be avoided. processed products should be avoided.

Psyllium branPsyllium bran -- The psyllium plant is remarkable because its ground seeds -- The psyllium plant is remarkable because its ground seeds can retain so much water. This product is available as Metamucil, Konsyl, can retain so much water. This product is available as Metamucil, Konsyl, Effersyllium, Per Diem Fiber, or the less expensive generic preparation in drug Effersyllium, Per Diem Fiber, or the less expensive generic preparation in drug and health food stores. Although labeled a laxative, it really is not a laxative. and health food stores. Although labeled a laxative, it really is not a laxative.

MethylcelluloseMethylcellulose -- This is another fiber derived from wood which also retains -- This is another fiber derived from wood which also retains water. It is available as Citrucel. water. It is available as Citrucel.

Antidiarrheals

Antidiarrheal drugs are indicated in the following circumstances:

• 1. Severe or prolonged diarrhea (>2 to 3 days), to prevent severe fluid and electrolyte loss

• 2. Relatively severe diarrhea in young children and older adults. These groups are less able to adapt to fluid and electrolyte losses.

• 3. In chronic inflammatory diseases of the bowel (ulcerative colitis and Crohn’s disease), to allow a more nearly normal lifestyle

• 4. In ileostomies or surgical excision of portions of the ileum, to decrease fluidity and volume of stool

• 5. HIV/AIDS-associated diarrhea• 6. When specific causes of diarrhea have been determined

Contraindications to UseContraindications to Use

Contraindications to the use of antidiarrheal drugs Contraindications to the use of antidiarrheal drugs include diarrheainclude diarrhea caused by toxic materials, caused by toxic materials, microorganisms that penetratemicroorganisms that penetrate intestinal mucosa (eg, intestinal mucosa (eg, pathogenic pathogenic E. coli, Salmonella,E. coli, Salmonella, ShigellaShigella), or antibiotic-), or antibiotic-associated colitis. In these circumstances,associated colitis. In these circumstances, antidiarrheal antidiarrheal agents that slow peristalsis may aggravateagents that slow peristalsis may aggravate and prolong and prolong diarrhea. Opiates (morphine, codeine) usuallydiarrhea. Opiates (morphine, codeine) usually are are contraindicated in chronic diarrhea because of possible contraindicated in chronic diarrhea because of possible opiateopiate dependence. Difenoxin, diphenoxylate, and dependence. Difenoxin, diphenoxylate, and loperamide areloperamide are contraindicated in children younger than contraindicated in children younger than 2 years of age.2 years of age.