Gastrointestinal Conditions-1 PDF

Gastrointestinal conditions-1 Ass. Prof. Dr. Mona Magdy Saber| Associate Professor – Clinical Pharmacy Department 1. Dyspepsia (indigestion) - Epidemiology Very common Little difference in incidence between men and women Only 25% of sufferers will consult GP High potential for OTC managem...

Gastrointestinal conditions-1 Ass. Prof. Dr. Mona Magdy Saber| Associate Professor – Clinical Pharmacy Department 1. Dyspepsia (indigestion) - Epidemiology Very common Little difference in incidence between men and women Only 25% of sufferers will consult GP High potential for OTC management refers to discomfort or pain that occurs in the upper abdomen, often after eating or drinking. It is not a disease but a symptom Dr. Mona Magdy 2  3. Dyspepsia-Symptoms Group of symptoms ▪ Heartburn ▪ Flatulence, bloating ▪ Feeling of fullness quickly during or after eating ▪ Nausea ▪ Occur in bouts (come and go) ▪ Related to eating A person can have symptoms even if they have not eaten a large amount. Dr. Mona Magdy 3 4. Dyspepsia – Aetiology a) Disease/condition Ulcers GERD Stomach cancer (rare) Gastroparesis (a condition where the stomach doesn't empty properly; this often occurs in people with diabetes) Stomach infections IBS Chronic pancreatitis Thyroid disease Pregnancy ▪Hormones affect sphincter muscle tone ▪Size of baby pressing on stomach (pressure) Dr. Mona Magdy 4 b) Medications ▪ NSAIDs ▪ Aspirin ▪ Steroids ▪ Calcium antagonists ▪ Nitrates ▪ Theophyllines ▪ Estrogen ▪ Bisphosphonates ▪ Thyroid medications Dr. Mona Magdy 5  c) Lifestyle Smoking ▪ Chemicals in smoke relax sphincter muscles Heavy drinkers ▪ Alcohol irritates mucosal lining Posture ▪ Bending over ▪ Sitting hunched up ▪ Lying down Overweight ▪ Obesity puts pressure on stomach Eating too much (increases pressure in the stomach) , eating too fast, eating high-fat foods (relaxant effect on the sphincter), or eating during stressful situations Psychological anxiety, depression, stress Foods that cause dyspepsia are ▪ peppermint, tomato, chocolate, spices, hot drinks, coffee, alcohol Dr. Mona Magdy 6  Sometimes people have persistent indigestion that is not related to any of these factors. This type of indigestion is called functional, or non-ulcer dyspepsia. Dr. Mona Magdy 7 5. Red Flag Symptoms ▪ Unintentional weight loss ▪ Recurrent vomiting ▪ Dysphagia ▪ Evidence of gastrointestinal bleeding ▪ Loss of appetite ▪ Severe abdominal pain Dr. Mona Magdy 8 Dyspeptic Symptoms – Questions & Relevance Always ask of family history and medication use. Age ▪ Dyspepsia – young adults ▪ >50s – other pathology more likely Location of the pain ▪ Dyspepsia – above umbilicus/central (epigastric) ▪ Heartburn – behind the sternum ▪ Below umbilicus – IBS, diverticulitis etc Pain radiation ▪ Cardiovascular (MI) ▪ Angina ▪ Biliary colic Dr. Mona Magdy 9 Dyspeptic Symptoms – Questions & Relevance How severe is the pain? ▪ Dyspepsia – mild to moderate Other symptoms present? ▪ Persistent vomiting (+/- blood) – ulcer/cancer ▪ Black/tarry stools – GI bleed Factors which aggravate/relieve symptoms? - ulcers ▪ Food ▪ Antacids ▪ Caffeine/alcohol Social factors ▪ Fast food, excess alcohol, stress Dr. Mona Magdy 10 Peptic Ulcer 1- Epidemiology Most common in 30-50 year olds Over 60s accounts for 15% but leads to 80% fatality H.pylori ▪ 25% of population infected at some time ▪ 3/20 infected develop ulcer ▪ In others it lives harmlessly Dr. Mona Magdy 11 2. Peptic Ulcer Gastric or Duodenal? Characteristic pain of each ▪ Intermittent upper abdominal pain ▪ Many patients experience a feeling of hunger Does pain move in to the back? ▪ Duodenal ulcer pain radiates to back When does it occur? ▪ May wake you up at night (more duodenal than with gastric ulcers) ▪ Ulcer-related pain generally occurs 2-3 hours after meals and often awakens the patient at night. Also felt before meal as acid passes into duodenum ▪ Pain increases with eating (gastric ulcer) What is it relieved by? ▪ Improved by food, Eased by antacids What is it aggravated by? ▪ Exacerbated by food, pain increases during meal Is there any weight loss? ▪ Loss of appetite, weight loss Is there any evidence of bleeding? ▪ Perforated or bleeding ulcer Dr. Mona Magdy 12 Gastric/Oesophageal Cancer Alarm Symptoms - Learn ▪ Dark/tarry stools (GI bleeding) ▪ Persistent vomiting ▪ Loss of weight ▪ Altered bowel habit Dysphagia ▪ Early sign ▪ May indicate stricture (scaring/narrowing of oesophagus) Fatigue Barrett’s Oesophagitis Cell changes in appearance due to long standing acid reflux- potentially cancerous Dr. Mona Magdy 13  Gastroesophageal reflux disease GERD Def: Backward regurgitation of gastric contents into esophagus Symptoms: Heart Burn: Burning sensation felt in the upper abdomen (retrosternal) radiates to left shoulder and side of the neck , the pain increased by bending forward and recumbent position , relieved by standing. Coughing Causes: Relaxation of the Lower Esophageal sphincter (LOS) by : 1- Gastric distension 2- Meals containing high fat, chocolate, smoking 3-Pregnancy 4-Obesity 5-Hiatus Hernia Dr. Mona Magdy 14 Dyspepsia - Treatment Because indigestion is a symptom rather than a disease, treatment usually depends upon the underlying condition Lifestyle Measures (non-pharmacological) Avoid precipitating factors Bending, alcohol, tea, coffee, fatty foods, spicy foods, chocolate, onion, garlic, citrus fruits Eating smaller meals Not eating before bedtime Weight reduction Reduce stress Eat slowly, avoid gulping air Avoid tight belts (+clothing) Avoid smoking (reflux) Sleeping with head raised (reflux) Dr. Mona Magdy 15 Dyspepsia - Treatment OTC treatments Alginates ▪ Floats on top of stomach contents like a raft ▪ E.g. Gaviscon Antacids ▪ Neutralise stomach acid (alkalis) ▪ Relatively fast-acting (1 hour) ▪ Absorption interactions Dr. Mona Magdy 16 Dyspepsia Treatment - Antacids ▪ Magnesium salts (hydroxide) e.g. Rennie, Epicogel, Maalox Diarrhoea, sodium content ▪ Aluminium salts (hydroxide e.g. Maalox, Epicogel SE: Constipation ▪ Calcium salts (carbonate) e.g. Rennie, Glycodal SE: Constipation ▪ Bismuth salts SE: Constipation ▪ Sodium bicarbonate e g Pharocola, Fawar Fruit High sodium content therefore used with caution in people with hypertension, CHF or kidney disease. Dr. Mona Magdy 17 Dyspepsia - Treatment H2 antagonists ▪ Block action of histamine which usually signals cells in stomach to release HCl acid ▪ Relatively fast-acting (1 hour) ▪ Ranitidine, famotidine, cimetidine Dr. Mona Magdy 18 Dyspepsia - Treatment PPIs ▪ Inhibit H/K-ATPase enzyme of parietal cells which usually secret HCl acid ▪ Potent ▪ For recurrent symptoms ▪ Omeprazole, pantoprazole, esomeprazole Dr. Mona Magdy 19 Dyspepsia - Treatment Simethicone ▪ Reduces surface tension of gas bubbles ▪ Defoaming agent in many antacid preparations E g Simethicone caps & syrups Dr. Mona Magdy 20 Dyspepsia - Treatment How do we decide on what is appropriate? Simple antacids + alginates are 1st line Omeprazole+Tinidazole+Clarithromycin H2-antagonists – 2nd line PPIs – 2nd line Dr. Mona Magdy 21 H.Pylori treatment - ulcers Triple therapy PPI + 2 antibiotics Amoxicillin, clarithromycin, metronidazole See BNF or USP-NF for details Post lecture reading: Read up on Helicobacter Pylori Dr. Mona Magdy 22 Role of community Pharmacist Offer simple lifestyle advice: healthy eating, weight reduction, smoking cessation Help with prescribed medicines and give advice when to consult a doctor especially with Red Flags Office advice on the use of OTC medicines and educate patients about their condition Provide patients with access to educational materials to support the care they receive. Dr. Mona Magdy 23 Thank you Dr. Mona Magdy 24