GIT Prepared by

DR/ MOHAMMAD ABDUL BASET BADR

 TOPICS
❑GERD & Peptic ulcer
❑Nausea & Vomiting
❑Diarrhea
❑Constipation
❑Irritable bowel syndrome
❑Ulcerative colitis & Chron’s disease
❑Hemorrhoids ( piles )
PEPTIC ULCER
• Peptic ulcer disease is a condition in which painful sores or ulcers
develop in the lining of the stomach or the first part of the small
intestine (the duodenum).

• Causes
• Helicobacter pylori is a gram- Negative bacillus responsible for 90%
of duodenal ulcers And 70% to 90% of gastric ulcers.
Causes of peptic ulcer
Symptoms of peptic ulcers
Non pharmacological treatment
Pharmacological treatment of peptic ulcer

A- Antacids :
Aluminium hydroxide- Calcium carbonate – Sodium bicarbonate
– Magnesium hydroxide
• Neutralize gastric acid and reduce pepsin activity .
• Magaldrate ( hydroxy magnesium aluminate)

• Advantages : Rapid onset of action – low price

• Disadvantages : short duration – several interactions
Drug interactions :
• Antacids interfere with the absorption of :
• 1- Tetracyclines
• 2- Quinolones
• 3- Azoles antifungals
• 4- Digoxin
• 5- Iron supplements
• Antacids should be spaced at least 2 hours apart from the
administration of the interacting drugs .
GAVISCON different types :
GAVISCON GAVISCON GAVISCON GAVISCON GAVISCON Gaviscon
tablets Extra Double Double Advance syrup
strength tab action tab action syrup syrup

500 mg sodium 500 mg sodium 250mg sodium 500 mg sodium 1000mg 500 mg sodium
alginate & alginate,267mg alginate,106 mg alginate, 213 mg Sodium alginate alginate,267mg
100mg sodium hydrogen sodiumbicarbon sodium and 200mg sodiumhydrogen
potassium carbonate and ate and 187mg bicarbonate and Potassium carbonate and
bicarbonate 160 mg calcium calcium 325 mg calcium Hydrogen 160 mg calcium
carbonate carbonate carbonate Carbonate carbonate
• B- H2-Receptor Antagonists:

Famotidine Nizatidine Ranitidine

( FAMODAR ) ( FIXIT ) ( ZANTAC )

• Used for GERD and peptic ulcer.

• Used 1-2 times daily before meal.
•Pregnancy Category B
• C- Proton pump inhibitors :
• Omeprazole Esomeprazole Lanzoprazole

• Pantoprazole Rabeprazole
• Taken 30 minutes before the meal once or twice daily.
• Bioavailability decreased by 50% when taken with food .
• Formulated as acid resistant enteric coated to protect them from degradation by
gastric acid .
• What are Proton Pump Inhibitors used for?
• 1- Gastroesophageal reflux disease (GERD)
• 2- Conditions characterized by an overproduction of stomach acid (such
as Zollinger-Ellison syndrome)
• 3- Duodenal or stomach ulcers including those caused by NSAIDs.
• 4- In combination with certain antibiotics for the eradication of Helicobacter
pylori, a bacteria associated with duodenal ulcer recurrence.
Side effects of PPIs :
Drug interactions :
Except for omeprazole, all proton pump inhibitors (PPIs) are
classified as category B drugs by the US Food and Drug
Administration (FDA).

It is interesting that omeprazole should perhaps be the PPI of

choice in pregnancy, even though it is a category C drug.
Treatment of H. pylori –Associated Ulcers:
PPI +
amoxicillin 1gm BID +
levofloxacin 500 mg once daily
for 10 days.
• 4- Prokinetic Agents :
• As Dopamine antagonists. Metoclopramide and Domperidone
• Prokinetics help strengthen the lower esophageal sphincter (LES) and cause the
contents of the stomach to empty faster. This allows less time for acid reflux to
occur.
• Uses :
• 1- Delayed gastric emptying in GERD , diabetes and following syrgery.
• 2- Vomiting
• 3- Indigestion and dyspepsia .
MANUKA HONEY AND PEPTIC ULCER :

• Manuka honey significantly decreased the ulcer index,

completely protected the mucosa from lesions .
• Manuka honey with high MGO content has proven anti-ulcer
activities, due to its non-peroxide antibacterial component.
NAUSEA AND VOMITING
Causes of nausea and vomiting :
• Symptoms for referral:
• -Duration is longer than 2 days.
• - Children under 2 years.
• - Presence of blood.
Treatment :
• 1- Remove or treat the cause.
• 2- Correction of dehydration and
electrolyte disturbances with Oral Rehydration Solutions ( ORS ).
• 3- ANTIEMETIC DRUGS :
• Anti histamine: Diphenhydramine & Dimenhydrinate & Meclizine.
• Dopamine antagonists: Metoclopramide & Domperidone.
• 5-HT 3 antagonists : Ondansetron
• Corticosteroids: Dexamethasone
1- ANTIHISTAMINES
• Diphenhydramine - Meclizine - Dimenhydrinate
• Help prevent nausea & vomiting caused by motion sickness and
morning sickness .
• Block H1 & M1 ( anti cholinergic action ) in vestibular system .
• Not used in children younger than 5 years ( may cause CNS toxicity )
• Pregnancy category B ( The first choice )
2- Dopamine antagonists:
Metoclopramide (Primperan – Premosan) Domperidone ( Motilium – Dompy )
act centrally & peripherally. Act peripherally only .
Used 30 min. before meals 3 times daily. Used 30 min. before meals 3 times
Dose in children 0.1–0.2 mg/kg/dose tid. Dose in children 0.25-0.5mg/kg/dose tid
Side effects : Side effects :
EPS ( extrapyramidal symptoms ) QT prolongation
Pregnancy category B Pregnancy category C
3- 5-HT 3 antagonists : Ondansetron
Used to prevent nausea and vomiting that may be caused by surgery,
pregnancy, chemotherapy, or radiation treatment.

Ondansetron can be taken with or without food.

• Common side effects may include:

• QT prolongation
• Increase serotonin level (do not used with SSRIs or drugS increase
serotoin level )
• pregnancy category: B
• Use with caution during Breastfeeding
4- Ginger : Antimetil

• The best available evidence demonstrates that ginger is an effective

and inexpensive treatment for nausea and vomiting and is safe.

• consuming up to 1 gram of ginger extract per day appears to be safe

to treat nausea and vomiting during pregnancy .

• According to one study, this amount is equal to 1 teaspoon (5 grams)

of freshly grated ginger, 4 cups (950 ml) of tea .
DIARRHEA
• Diarrhea is characterized by loose, watery stools or a frequent need
to have a bowel movement.

• Normal stool frequency ranges from three times a week to three

times a day.
CAUSES OF DIARRHEA
80% of acute diarrhea cases are due to infections with viruses,
bacteria, helminthes, and protozoa.
TREATMENT OF DIARRHEA :
• A) Patient education:
• Drink plenty of water.
• Avoid milk and drinks high in sugar.
• B) Pharmacologic management:
• Non infected diarrhea Infected diarrhea
• 1- ANTI MOTILITY DRUG 1- ANTI INFECTIVE
• 2- ORS (ORAL REHYDRATION SOLUTION)
• 3- ADSORBENT
• 4- PROBIOTICS
• 5- ZINC
1- ORS (Oral Rehydration Solution):
• It contains sodium , potassium & Glucose.

• Maintain the fluid & electrolyte balance.

• Dose :
• A child under 2 years : 60 – 125 ml of the ORS after each watery stool.
• A child aged 2 years or older : 125 – 250 ml of the ORS drink after each
watery stool.
2- Anti motility drug : ( Loperamide )

• works by slowing down the movement of the gut.

• Adults and children 13 years of age and older—At first, 4 milligrams

(mg) (2 capsules) after the first loose bowel movement, then 2 mg
(1 capsule) after each loose bowel movement.

• Max. dose : 8 mg ( 4 cap ) in 24 hours if self-treating, or 16 mg ( 8

cap ) in 24 hours if under a doctor's direction.
• Loperamide may cause (QT prolongation).

• It is not recommended for use in children under 2 years.

• Not recommended during breast feeding.

• Pregnancy category B .

• Not used in infectious diarrhea or bloody stool.

3- Adsorbents (kaolin & pectin ) :

• It adsorbs toxins, bacteria and water.

• It must be taken ≥ 2 hours before or after other medications &

shake well before use.

• Pectin may decrease stool softness and increase viscosity .

4- Probiotics :
• probiotics may help prevent and treat diarrhea by repopulating
beneficial gut bacteria and correcting an imbalance in the gut.

• Probiotics decrease the duration of infectious and antibiotic induced

diarrhea .

• Dose :
• 2 Cap after the main meal.
• Drops : 5 drops once daily .
• Safe in pregnancy and breast feeding.
5- Zinc

• Reduce the duration and severity of diarrhea.

• The World Health Organization (WHO) recommend daily 20 mg zinc

supplements for 10 – 14 days for children with acute diarrhea, and
10 mg per day for infants under six months old .
6- Anti infective:
• A) Bacterial infection :
• Cefixime
• Metronidazole
• Azithromycin 500 mg single dose .
• Levofloxacin and ciprofloxacin for acute watery diarrhea (single
dose 500 mg and 750 mg, respectively ).

• B) parasitic infection:
• Metronidazole
• Secindazole
•Refer
• 1- PERSISTENT DIARRHEA

• 2- BLOODY DIARRHEA

• 3- INFANTS LESS THAN 3 MONTHS

CONSTIPATION
• Constipation is infrequent bowel movements or difficult passage of stools
that persists for several weeks or longer ( less than 3 times per week ) .
• Causes of constipation
Drugs cause constipation :
Non pharmacological management of constipation
Pharmacological management of constipation
• 1) BULK FORMING LAXATIVES :
• Absorb liquid in the intestines. This creates a bulky, more liquid-like
stool that’s softer and easier to pass.
• Also swell or expand in the gut and activate the muscles to pass stools .
• Common bulk-forming laxatives include :
• Psyllium ( Ispaghula ) as Agiolax
• Wheat dextrin ( Benfiber )
BULK FORMING LAXATIVES :
• Onset of action : 12 – 72 h
• Uses:
• Help in chronic constipation due to diet, lifestyle, recent surgery,
or medication.
• Require adequate water intake to be effective. Not drinking enough
fluid can cause blockage in the gut, and make constipation worse.

• Safe in pregnancy , geriatrics .

2) OSMOTIC LAXATIVES :
• They pull water from the surrounding tissues using a process known
as osmosis. Excess moisture in the intestine results in softer stools
that are easier to pass.
• They include:
• A- lactulose 10g/15mL
• ( Duphalac – lactulose – Ezilax )
• Onset of action : 1-2 days
• Used for chronic constipation
• Dose :
• Adults : 15-30 mL (10-20 g) PO once daily
• Pediatrics : (1 to 3 mL/kg/day) orally in divided doses
OSMOTIC LAXATIVES :
• Safe in pregnancy
• Side effects :
• Abdominal discomfort
• Sugary taste .

• B- Glycerin supp
• Onset of action : 30 min.
• Used for acute constipation
• Pregnancy category C
3) STIMULANT LAXATIVES :
• They irritate the intestinal cells causing the intestine to contract,
which is responsible for the laxative action.
• Stimulant laxatives also promote water influx to the intestine, which
in turn promotes bowel movement.
• Examples :
• 1- Bisacodyl ( Dulcolax )
• 2- Senna ( A-lax – Senne )
• 3- Sodium picosulfate ( Pico )
• 4- Castor oil : : is hydrolyzed in upper small intestine to
ricinoleic acid a Local irritant that increases Intestinal motility.
STIMULANT LAXATIVES :
• Used for acute constipation
• Precaution :
• Chronic, long-term use of stimulant laxatives can lead to:
• loss of colon function .
• Onset of action : 6-12 h
• Administration orally at bed time .
• Sodium picosulfate is pregnancy category B
• Bisacodyl is not recommended during first trimester. and safe in lactation.
• Senna is pregnancy category C and safe in lactation.
• Castor oil should not used during pregnancy .
STIMULANT LAXATIVES :
• Side effects :
• Diarrhea
• Abdominal pain
• Electrolyte imbalance
Irritable bowel syndrome
(IBS)
Irritable bowel syndrome (IBS)
• Is a common condition that affects the digestive system.
• It causes symptoms like stomach cramps, bloating, diarrhea or
constipation.
• Symptoms tend to come and go over time , and can last for days,
weeks or months at a time.
• Women may tend to have symptoms around the time of
menstruation, or they may have more symptoms during this time.
• It's usually a lifelong problem.
• There's no cure, but diet changes and medicines can often help
control the symptoms.
Causes of Irritable bowel syndrome (IBS)
• Types of IBS:
• 1- IBS-D (diarrhea predominant)
• 2- IBS-C (constipation predominant)
• 3- IBS-M (mixed diarrhea and constipation)
• Refer to doctor if the patient has a persistent change in bowel habits or
other signs or symptoms of IBS. They may indicate a more serious
condition, such as colon cancer.
• More-serious signs and symptoms include:
• Weight loss
• Rectal bleeding
• Iron deficiency anemia
• Unexplained vomiting
• Persistent pain that isn't relieved by passing gas or a bowel movement
Treatment of IBS
• Treatment focuses on relieving symptoms so that the patient can live as
normally as possible.
• A- Patient education :
• 1- Eating smaller meals with high-fiber content
• 2- Drink plenty of fluids
• 3- Exercise regularly
• 4- Minimizing stress
• 5- Probiotics to help relieve gas and bloating ( cross selling ) 2cap after
the main meal.
• 8- Limit the intake of caffeine, alcohol, dairy products , artificial
sweeteners and spicy foods .
B- Pharmacologic management
• 1- Fiber supplements : Taking a supplement such as psyllium with
fluids may help control constipation.

• 2- Laxatives : If fiber doesn't help constipation

• 3- Anti-diarrheal medications : as loperamide (Imodium ) can help

control diarrhea.
Pharmacologic management
• 4- Anti flatulence as simethicone ( Disflatyl – Salinal )
or Charcoal ( Eucarbon – Neocarbon )

• 5- Antispasmodic medications : as Hyoscine ( buscopan ) or

Mebeverine ( verine ) can help relieve painful bowel spasms.
Pharmacologic management
• 5- Tricyclic antidepressants : can help relieve depression as well as
inhibit the activity of neurons that control the intestines to help
reduce pain

• 6- SSRI antidepressants ; as fluoxetine ( Prozac ) or paroxetine

( Seroxat ) may help if the patient depressed and have pain.
Hemorrhoids
• Hemorrhoids (piles ) are swollen blood vessels in the lower rectum.

• Sometimes, the walls of these blood vessels stretch so that the veins
bulge and get irritated, especially when defecation.

• These swollen veins inside the rectum or outside the anus can cause
pain, anal itching and rectal bleeding.
Hemorrhoids symptoms :
Hemorrhoids causes :
Hemorrhoids degrees :
Non pharmacological treatment of hemorrhoids:
Non pharmacological treatment of hemorrhoids:
• Weight reduction.

• Apply ice packs or cold compression on the anus. ( Cross selling )

• Soaking anal area in sitz bath tube 10-15 min 2-3 times
daily to decrease discomfort. ( Cross selling )

• Avoid spicy food

Pharmacological treatment of hemorrhoids:
• 1- Topical medications containing lidocaine , witch
hazel or hydrocortisone to the affected area. Decrease inflammation .
• e.g. lupinus albus, hamamelis, calendula, menthol and aloe vera.
Pharmacological treatment of hemorrhoids:
3- Soften stool by taking laxatives.

• 4- (NSAIDs) for pain and inflammation.

• 5- Oral Vein tonic : ( Diosmin & horse chestnut).

CROSS SALE :

Donut cushion
Anuice Sitz bath tub
•MIND MAP
• Refer to the doctor when:

• Severe rectal bleeding and pain.

• Abdominal pain - Fever and chills.
• Chronic constipation or diarrhea.
• What is the primary difference between piles and fissure?
• Piles are swollen blood vessels while fissures are cuts, tears or cracks of the anal skin.

PILES ANAL FISSURES

Swollen veins in the anal canal, rectum or anus Tear or cut of anal skin
Painless during the initial phase and increases as Very painful and uncomfortable with little or
the swelling becomes more prominent more bleeding
Piles are a result of prolonged constipation, This occurs during pregnancy, as a result of
pregnancy or chronic cough, physical strain obesity or an injury to the anal cavity, to
people with Crohn’s disease, passing hard
stools and chronic diarrhea