GASTROINTESTINAL TRACT

DISORDERS
KALANDA ALOYSIUS
B. PHARM, …….
 SCOPE
• PUD
• GERD
• IBD
• IBS
• TYPHOID FEVER
• DYSENTRY
• AMEBIASIS
• HELMINTHIC DISEASES
• CONSTIPATION
• DIARRHEA
• NUASEA AND VOMITING
 PEPTIC ULCER DISEASE
• Defects in gastric (gastric ulcer) or duodenal mucosa (duodenal ulcers) as a result
of gastric acids and other enzymes.
• Caused mainly by Helicobacter pylori, NSAIDS, cancer and stress
• Other causes; hyper secretory states, viral infections
• Risk factors; alcohol, cigarette smoking, diet, stress, drugs
• Signs and symptoms
Epigastric pain, abdominal discomfort, fullness, cramping and burning
• Complications; upper GI bleeding, gastric obstruction, gastric perforations
• Gastric ulcers involves pain after meals and not relieved by antacids
• Duodenal ulcers involve pain when no meals taken but relieved with meals
 Management of PUD
• Non Pharmacologic Therapy
1. Discontinue NSAIDs
2. Dietary modifications
3. Reduce stress
4. Smoking cessation
5. Surgery
6. Stop alcohol drinking
 Mgnt cont
• Pharmacologic therapy
1. Antacids and Alginic acids (sodium, magnesium, alminium, calcium salts)
2. H2 receptor anatagonists (cimetidine, ranitidine, famotidine )
3. Proton pump inhibitors PPIs (omeprazole, lansoprazole, esomeprazole,
rabeprazole, pantoprazole)
4. Sucralfate (Antepsin)
5. Misoprostol
6. Bismuth salts (bismuth subsalicylate)
7. Anticholinergic (hyoscine, phenelzine)
 Oral regimens to eradicate H.pylori
• For H.pylori infection is treated with a combination of antibiotics and PPIs(
triple therapy) or plus antacids( quadruple therapy).
• PPI + Clarithromycin + amoxicillin/metronidazole/tinidazole for 14 days
• Bismuth + metronidazole + tetracycline/amoxicillin/clarithromycin + PPI/H2
receptor antagonist
• Available brands (heligokit, pylokit )
• Amoxicillin doses; 1g bd
• The drugs are given twice daily except Esomeprazole 40mg and rabeprazole
20mg
 GASTROESOPHAGEAL REFLUX DISEASE
GERD
• Retrograde passage of gastric contents from the stomach into the esophagus
• Mostly associated with heart burn and acid regurgitation.
• Causes; Transient les relaxation, increased gastric pressure and anatomic abnormalities,
• Risk factors; delayed gastric emptying, poor esophageal acid clearance and buffering, diet,
lifestyle, drugs, medical conditions
• Signs and symptoms
heartburn, regurgitation of gastric contents, belching, hiccups, nausea and vomiting, early satiety
• Complications
erosive esophagitis, esophageal strictures, GI bleeding, malignancy
NB; Amount and composition of the refluxing substances affects the prognosis of the disorder.
 GERD MANAGEMENT
• Non pharmacologic; lifestyle, dietary modifications and surgery for
anatomic abnormalities.
• Pharmacotherapy
1. Antacids
2. H2 receptor antagonists
3. PPIs
4. Prokinetics e.g domperidone, metoclopramide
5. Sucralfate
 INFLAMMATORY BOWEL DISEASE
IBD
• Group of chronic, idiopathic relapsing inflammatory disorders of the GIT
• Divided into; Ulcerative colitis & Chron’s Disease.
• UC is inflammation of mucosal layer of the colon and rectum characterized
with chronic diarrhea, abdominal pain and rectal bleeding
• CD is inflammation of the distal end of the small intestines characterized with
abdominal pain, diarrhea, weight loss
• Cause of IBD is unclear but involves perpetuated and autoimmune disorders
• Signs and symptoms; abdominal pain, tenesmus, fever, diarrhea etc
Comparison between CD and UC

Chron’s disease Ulcerative colitis

Affects the entire GIT but especially distal ileum and Affects the distal part of the colon and the rectum
proximal colon

Traverses the entire thickness of the GIT Localized to the surface mucosa of the GIT

More bloody and poorly formed loose stool Less bloody loose stool

Associated with weight loss and malnutrition Associated with dehydration majorly
 IBD MGT
• Aminosalicylates ; mesalazine 2.4g daily, sulfasalazine 0.5-2g QID,
osalazine1g daily
• Corticosteroids ; prednisolone, budesonide 3g Tds, cortisone
• Immunomodulators ; azathioprine, cyclosporine, methotrexate, 6-
mercaptopurine
• Monoclonal antibodies; infliximab, adalimumab
• Antibiotics; metronidazole and ciprofloxacin (in case of bacteria
induced disease)
• Pro-biotics
 IRRITABLE BOWEL SYNDROME
IBS
• Abdominal pain is associated with a change in bowel habit involving disordered
defecation and distension.
• Possible Causes; altered neurotransmitters, altered colonic motility
• Risk factors; food intolerances, genetics, stress, sexual abuse, infections.
• Signs and symptoms; weight loss, diarrhea, constipation, abdominal bloating
• Based on the symptoms, IBS is further classified into;
 Constipation predominant IBS
 Diarrhea predominant IBS
 Pain predominant IBS
 IBS MGT
• Reassure patient that their symptoms are real
• Help patient discover triggering factors
• Counsel on diet
• Pharmacotherapy for constipation predominant IBS
linaclotide 300mcg and laxatives for symptomatic relief
• Pharmacotherapy for pain predominant IBS
antispasmodics ( hysocine, propatheline, drotaverine, mebeverine, tizanidine)
antidepressants (esp TCAs due to their analgesic effects e.g amitriptyline,
imipramine, nortriptyline)
• Pharmacotherapy for diarrhea predominant IBS
loperamide, cholestyramine ( if bile malabsorption suspected), probiotics, bulking
agents
• Others
anti-biotics especially the local intestinal ones e.g. rifaximin
 DIARRHEA
• Increased frequency and decreased consistency of fecal discharge as
compared to an individual normal bowel pattern
• Diarrhea can be classified as secretory, excudative, osmotic and altered
transient depending on the cause and the characteristics of the stool.
• Diarrhea can also be acute, persistent or chronic depending on the
duration of the condition
• Can be caused by virus, bacteria or protozoa. Viral diarrhea is usually self
limiting while that caused by the other micro-organisms requires
antibiotic therapy.
• An increase in body temperature and smell of the stool or presence of
blood in the stool can be used to determine the need for antibiotics.
NB; blood stained watery stool is referred to as dysentery.
Management of diarrhea
Non pharmacological;
•Dietary
•Water and electrolytes replacement
•Zinc supplementation
Pharmacological;
• Anti-motility (loperamide, diphenoxylate)
• Adsorbents; kaolin, activated charcoal, polycarbophils
• Anti-secretory; bismuth subsalicylate
• Pro-biotics and pre-biotics
 TRAVELLER’S DIARRHEA
• Develops during or shortly after travel abroad.
• Caused by eating food or drinking water contaminated by microbes
including bacteria, viruses and parasites
Signs and symptoms;
abdominal cramps, nausea, fever, bloating etc
Treatment
• Oral replacement therapy
• Antimotility agents (loperamide ),
• Antibiotics (fluoroquinolones, cotrimoxazole, rifaximin, azithromycin)
 TYPHOID/ENTERIC FEVER
• Acute systemic illness caused by typhoidal salmonellae
• Incubation period of 7-14days
• Classic signs and symptoms; high fever, abdominal pain, anorexia, diarrhea, headache,
splenomegaly
• Complications; GI bleeding, encephalopathy, shock, bacteremia
• Treatment
chloramphenicol, ampicillin, cotrimoxazole for 14-21 days
ceftriaxone 3-4g for 3-5days (75mg/kg)
azithromycin 20mg/kg for 5-10 days
cefixime for 12-14days
• Uncomplicated cases can be treated with oral antibiotics while parenteral is used for the
severe cases
 ENTERIC FEVER MGT CONT
Chronic typhoid carriers (1-3%) excrete salmonella from stool or urine
for 1 year after infection and usually asymptomatic
• Treatment involves prolonged course of antibiotics
amoxicillin 2g tds for 28days
ampicillin 1g qid for 90days
CTX 960mg bd
ciprofloxacin 500mg-750mg bd for 3-4wks
• Patient education; good food hygiene
 DYSENTERY
• Severe manifestation of inflammatory diarrhea characterized by bloody
stools, abdominal cramps and tenesus
• Common in children and is transmitted through the fecal-oral route.
• Signs and symptoms;
Abdominal pain, fever, initially watery then later bloody stools.
• Treatment
oral fluid and electrolyte replacement
antibiotics; CTX, ciprofloxacin, norfloxacin, azithromycin, ceftriaxone
NB; Anti-motility agents worsen disease thus not recommended
 AMEBIASIS
• Caused by Entamoeba histolytica
• Can be asymptomatic or present as colitis or dysentery
• Transmission is via fecal-oral route
• Clinical presentation
1. Intestinal disease; vague abdominal discomfort, malaise, flatulence,
bloody diarrhea with mucus
2. Amebic liver abscess; high fever, hepatomegaly, liver tenderness
Adjunctive treatment;
• electrolyte replacement, nutritional support, antibiotic therapy, surgery
 AMEBIASIS MGT
Luminal amebicides;
• iodoquinol 650mg tds 20days
• paramomycin (amminosidine) 25-30mg/kg tds for 7days
• diloxanide furoate 500mg tds for 10 days
Tissue amebicides;
• Metronidazole and tinidazole
• Nitazoxanide 500mg BID
• Nifuroxanide 200mg QID
• OTHERS; chloroquine, dihydroemetine
Prevention measures;
• sanitation,
• food hygiene
NB; available combinations e.g metronidazole + diloxanide
 HELMINTHIC DISEASES
• Broadly classified as
1. Nematodes (HEATS)
2. Cestodes (tapeworm)
3. Trematodes
• Signs and symptoms; mild epigastric pain, fatigue, malnutrition,
abdominal obstruction, perianal itch (enterobiasis), pruritis, fever,
coughing.
 TREATMENT OF HELMINTHIC DISEASE
• Drugs used to treat luminal nematodes (HEATS)
mebendazole, albendazole, pyrantel pamoate, piperazine citrate,
levamisole, ivermectin
• Drugs that act on tissue nematodes
ivermectin, diethyl carbamazine, levamisole, albendazole
• Drugs that act on cestodes/tapeworm
niclosamide, praziquantel, albendazole.
• Drugs that act on trematodes (schistosomiasis)
praziquantel, albendazole,
 CONSTIPATION
• Period of more than 3 days without a bowel movement coupled with
passing out of hard solid stool.
• Can be due to poor dietary behaviors, psychogenic causes, pregnancy or
due to medicines.
Signs and symptoms
• Difficulty and painful passing out waste, unproductive urges, small
amounts, incomplete evacuation
Management
Non pharmacologic;
•Dietary modification
•Light frequent exercises
•Avoid postponing the defecation reflex
•Discontinue the causative medicines if possible.
Management continued….
Pharmacologic;
1. Emollient laxatives; docusates
2. Lubricants; mineral oil, liquid paraffin,
3. Osmotic; lactulose, sorbital, glycerin, mono and dibasic sodium
phosphate.
4. Stimulants; bisacodyl, senna, castor oil
5. Bulk forming; ispaghula, methylcellulose, bran, polycarbophil.
6. Secretory agents; lubriprostone
7. Others; methylnaltrexone
NB; the agents can also be used in people with hernias, hemorrhoids and
the elderly to reduce straining during defecation.
NAUSEA AND VOMITING
Vomiting is the forceful expulsion of gastric contents through the mouth
following simultaneous contraction of the abdominal and chest muscles
Nausea is the feeling or urge to vomit.
Causes;
• Motion sickness, irritation of the intestinal mucosa, pathological,
psychological causes.
Mediated through the CTZ, afferent impulses from the GI plexus, vestibular
system to the vomiting center.
Non pharmacological management
• Dietary modification
• Counselling for psychological causes
• Physical position
Pharmacological management…
• Antacids; magnesium and aluminium hydroxide
• Anti-cholinergics and anti-histamines; scopolamine, hyoscine,
meclizine
• Dopamine antagonists; metoclopramide, domperidone,
promethazine, haloperidol
• Serotonin antagonist; ondansetron, granisetron, etc
• Neurokinin 1 antagonist; apriptant
 MISCELLANEOUS
• Anti-flatulance agents; simethicone (disflatyl) , activated charcoal,
ENO, Andrews
• These are sometimes co-formulated with antacids preparations
• Other preparations to note; Unienzyme, Eucarbon,
• HEAMORRHOIDS..........