GASTRO-INTESTINAL OESOPHAGEAL DX.
(GERD)
Pharmacotherapy
Etiology GIT Disorders
Incompetence of gastro-oesophageal sphincter STEP 1
and reflux of gastric contents. Mild cases, <40 yrs, no complications and previously responded
Incomplete clearance of refluxed gastric well to antacid treatment.
contents due to gravity, decreased esophageal
motility, anchoring of distal esophagus in abdomen. Non-absorbable antacids: Al(OH) and/or Mg(OH)
Persistent gastric reservoir liquid or tabs 1 and 3 hours after food and at night.
Increased exposure of lower esophagus to acid Combination of Al and Mg will decrease
unwanted effects of constipation (Aluminium) and
Contributing factors diarrhea (Magnesium)
PEPTIC ULCERS Metoclopramide tabs if nausea, spasm and
Treatment delayed gastric emptying.
Etiology
Step 1 Increased acid secretion and STEP 2
Symptomatic treatment for 6 weeks decreased mucosal resistance If duodenal ulceration is confirmed
OR. H.Pylori infection.
Non-pharmacological treatment H2 blockers: Cimetidine or Ranitidine tabs at
Contributing factors night for 4 weeks.
Decreased intra-abdominal pressure through:
Ulcerogenic drugs: NSAID’s Proton pump blockers: Omeprazole or
Reduction in body mass
or Biphosphonates. Lanzoprazole or Pantoprazole
Head elevation by 20 cm
Lifestyle: Alcohol, Smoking,
Stop intake of food/fluid 2hrs before bed
Stress. Ulcer protectors
Avoid excess alcohol
Stop smoking Bismuth trioxide tabs on empty stomach, 30
Treatment min before meals, 4-8 weeks.
Pharmacotherapy Eliminate causative factors if possible. Avoid Sucralfate tabs, 30 min before meals and at
Antacids: ( Al(OH)/ Mg(OH) ) foods causing dyspepsia, limit eating between night. Antacids should not be taken 30 min before or
Antacid/Anti-flatulent combination: Alginic acid, meals and before bedtime. after sucralfate.
Al(OH), Mg trisilicate – (1-2 tabs after meals and Misoprostol – stimulates mucus production, can
before bedtime) be given with NSAIDS, also used for TOP.
H2 receptor blockers (4-12 wks): Cimetidine or
Ranitidine – Not 1st choice. STEP 3
Proton pump blockers (4-12 wks): Omeprazole,
Lanzoprazole or Pantoprazole. For H. Pylori
Endoscopy, biopsies, urea breath test.
Surgery Triple therapy – One for acid, Two for infection
For severe gastric ulcers Omeprazole 20mg-40mg if needed
Carcinoma in 4% of Gastric ulcers daily/Ranitidine
AND
Amoxycillin 1g 12hrly, 7days +
NAUSEA, VOMITING AND MOTION SICKNESS ANTI-EMETICS ClarythromycinAntimuscarinics:
500mg 12hrlyHyoscine
+/-
(scopolamine)
Metronidazole 400mg 12hrly, 7 days
Causes Dopamine antagonist OR
Toxicity, food poisoning, infection, medication, motion Use: Motion sickness,
Omeprazole anti-emetic
20mg daily +
Blocks D2 receptors in CTZ (medulla) Metronidazole
Systemic 400mgeffects:
anticholinergic 12hrly, 14 days
How does it work? A/E: Extrapyramidal effects (dyskinesia) Tetracycline
Dry 500mg
mouth, blurred tabGI-disturbances,
vision, 6hrly, 14 days orthostatic
AND
Brain stem sites in vomiting reflex pathway: Uses: Bismuth
hypotension, urinary retention, sedation
EMETICS
Drugs that causes vomiting – used to empty stomach from toxic
substances.
Cautions: ASPIRATION
Examples
Irritants of stomach mucosa – CuSO4 1%
A/E: Convulsion – NOT ADVISED
Stimulants of CTZ chemoreceptors –
Emetine (Ipecachuana syrup)
Stimulation of CTZ D2 receptors –
Apomorphine
A/E: Respiratory depression
Motility enhancers
Dopamine D2 antagonists
Increase contractions in stomach
Combine to speed-up transit of contents form
stomach
Mainly used to reduce vomiting induced by
drug/surgery and to enhanceDIARRHEA GI motility CONSTIPATION
Metoclopramide
Domperidone
Many due to infections Abdominal discomfort
– Prokinetic action
Usually is as result–ofrehydration
self-limiting Ach is enough Laxatives used in Surgery Prep
Loss of appetite & malaise
Antimicrobials for specific infections Hard dry feaces – ( Fe++ supplements)
Avoid offending agents Improve diet, Increase exercise, Increase Movicol
Correct underlying malabsorption fluid intake Kleen Prep
Management: DON’T USE LAXATIVE BEFORE Colo-prep
Electrolyte imbalance – rectify with oral or IV LIFESTYLE MODIFICATIONS
rehydration.
Traditional medications
To clean blood
“Go tlhatswa madi”
To clean stomach
“Go berekisa mala”
Anti-diarrheals LAXATIVES
Inhibitors of GI motility, increased tone & constrict Irritants and stimulants
sphincter: Opioids and derivatives Senna
Absorbents: Koalin & Pectin (Pectrolyte) and Bismuth Bisacodyl
salts Castor oil
Bulk-forming laxatives
Inhibitors of GI motility, increased tone and constrict Indigestible parts of fruits and veggies
sphincters Bran
Opioids, Codeine, Chlorodyne, Diphenoxylate Psyllium seeds
Lomotil (Diphenoxylate & atropine) Methylcellulose
Loperamide: Synthetic opioid with no central effect. Saline and osmotic laxatives
Magnesium citrate
Absorbents for ‘other’ toxicities Magnesium hydroxide
Koalin & Pectin Polyethylene glycol (PEG)
Bismuth salts Lactulose
Cholestyramine – may absorb drugs Stool softeners – emollients
Activitated charcoal – for unknown toxicity or overdose Docusate sodium
Docusate calcium
Antispasmodics DON’T TAKE WITH MINERAL OIL
Atropine&Scopolamine Lubricant laxatives
Mebeverine Mineral oil
Dicyclomine Glycerin suppositories
Irritable bowel syndrome (spastic colon/IBS)
Propantheline Inflammatory Chloride
bowel disease
channel activators
Lubiprostone
Dysmotility of bowel giving intermittent Glucocorticosteroids: for Acute attacks
constipation & diarrhea Aminosalicylates: Sulfasalazine & Mesalazine
30% females % 15% males have IBS Azathioprine, Mercaptopurine, Methotrexate
Treat symptomatically Cyclosporin (Immunosuppressant) – monitor renal
Mebeverine (antispasmodic) & function
anticholinergics, decrease bowel motility by Infliximab (TNF alpha antibody) - Inhibits action of
reducing peristalsis inflammatory cytokine tumor necrosis factor A
Motility enhancers increase bowel motility
GIT infections
E.coli, Bacillary dysentery, Cholera, Pseudomembranous enterocolitis,
Amoebiasis, Giardiasis, Trichomoniasis, Intestinal worms, Necrotizing
ulcerative gingivitis, Candidiasis, Periodontitis, Herpes simplex, Coxsackie
viruses (Enteral diarrhea)
Diarrhea
V-cholera: Rice water stools – Ciprofloxacin,
Tetracycline, Doxycycline
Salmonellae typhi: Bloody – Ciprofloxacin
E.coli – Tetracycline, Erythromycin, Amoxicillin
Listeriotis – Ampicillin
