TOPIC D:

Topic Title: Gastro – Intestinal

GASTRO – INTESTINAL

Acid-Related Pathophysiology
 Hydrochloric Acid – an acid that aids digestion and also serves as a barrier to infection
o Secreted by the parietal cells when stimulated by food
o Maintains stomach at pH of 1 to 4
o Secretion also stimulated by:
 Large fatty meals
 Excessive amounts of alcohol
 Emotional stress
 Bicarbonate – a base that is a natural mechanism to prevent hyperacidity
 Pepsinogen – an enzymatic precursor to pepsin, an enzyme that digests dietary proteins
 Intrinsic factor – a glycoprotein that facilitates gastric absorption of vitamin B12
 Mucus – protects the stomach lining from both hydrochloric acid and digestive enzymes
 Prostaglandins – serve a variety of anti-inflammatory and protective functions

Acid-Related Diseases
• Caused by imbalance of the three cells of the gastric gland and their secretions
• Most common: hyperacidity
• Clients report symptoms of overproduction of HCl by the parietal cells as indigestion, sour
stomach, heartburn, acid stomach

Helicobacter pylori (H. pylori)

 Bacterium found in GI tract of 90% of patients with duodenal ulcers, and 70% of those with
gastric ulcers
 Combination therapy is used most often to eradicate H. pylori

Treatment for H. pylori

• Eight regimens approved by the FDA
• H. pylori is not associated with acute perforating ulcers
• It is suggested that factors other than the presence of H. pylori lead to ulceration

A common type of bacteria that

grows in the digestive tract and
has a tendency to attack the
stomach lining.

It infects the stomachs of

roughly 60 percent Trusted
Source of the world’s adult
population. 

H. pylori infections are usually

harmless, but they’re responsible
for the majority of ulcers in the
stomach and small intestine.

The “H” in the name is short

for Helicobacter. “Helico” means spiral, which indicates that the bacteria are spiral shaped.

H. pylori often infect your stomach during childhood. While infections with this strain of bacteria
typically don’t cause symptoms, they can lead to diseases in some people, including  peptic ulcers,
and an inflammatory condition inside your stomach known as gastritis.

H. pylori are adapted to live in the harsh, acidic environment of the stomach. These bacteria can
change the environment around them and reduce its acidity so they can survive. The spiral shape
of H. pylori allows them to penetrate your stomach lining, where they’re protected by mucus and
your body’s immune cells are not able to reach them. The bacteria can interfere with your immune
response and ensure that they’re not destroyed. This can lead to stomach problems.

What causes H. pylori infections?

 It’s still not known exactly how H. pylori infections spread.
 Have coexisted with humans for many thousands of years. The infections are thought to
spread from one person’s mouth to another.
  They may also be transferred from feces to the mouth.
 This can happen when a person does not wash their hands thoroughly after using the
bathroom. H. pylori can also spread through contact with contaminated water or food.

What are the symptoms of H. pylori infection?

 Most people with H. pylori  don’t have any symptoms.
 If the infection leads to an ulcer, symptoms may include abdominal pain, especially when
your stomach is empty at night or a few hours after meals. The pain is usually described as
a gnawing pain, and it may come and go. Eating or taking antacid drugs may relieve this
pain.

Other symptoms may be associated with H. pylori infection, includes:

 excessive burping
 feeling bloated
 nausea
 heartburn
 fever
 lack of appetite, or anorexia
 unexplained weight loss

See doctor immediately if you experience:

 trouble swallowing
 anemia
 blood in the stool

Who is at risk for H. pylori infection?

 Children are more likely to develop an H. pylori infection due to lack of proper hygiene.
 environment and living conditions.
o Your risk is higher if you:
 live in a developing country
 share housing with others who are infected with H. pylori
 live in overcrowded housing
 have no access to hot water, which can help to keep areas clean and free from
bacteria
 are of non-Hispanic Black or Mexican American decent

Gastroesophageal Reflux Disease (GERD)

- Backflow of stomach acid into the esophagus

- Esophagus is not equipped to handle stomach acid => scaring
- Usual symptom is heartburn, an uncomfortable burning sensation behind the breastbone
(MI often mistaken for GERD)
- More severe symptoms: difficulty swallowing, chest pain
- Reflux into the throat can cause sore throat
- Complications include esophageal erosions, esophageal ulcer and narrowing of the esophagus
(esophageal stricture)
 - In some patients (~10%), the normal esophageal lining or epithelium may be replaced with
abnormal (Barrett's) epithelium. This condition (Barrett's esophagus) has been linked to cancer of
the esophagus.

Precipitants:
 Food (fatty food, alcohol, caffeine)
 Smoking
 Obesity

Peptic Ulcer Disease

Types of Acid-Controlling Agents

• Antacids
• H2 antagonists
• Proton pump inhibitors

Mechanism of Action

• Promote gastric mucosal defense mechanisms

• Secretion of:
• Mucus: protective barrier against HCl
• Bicarbonate: helps buffer acidic properties of HCl
• Prostaglandins: prevent activation of proton pump which results in  HCl production
• Antacids DO NOT prevent the over-production of acid
• Antacids DO neutralize the acid once it’s in the stomach

Antacids: Drug Effects

• Reduction of pain associated with acid-related disorders

• Raising gastric pH from 1.3 to 1.6 neutralizes 50% of the gastric acid
• Raising gastric pH 1 point (1.3 to 2.3) neutralizes 90% of the gastric acid
• Reducing acidity reduces pain
• Used alone or in combination

Aluminum Salts
• Forms: carbonate, hydroxide
• Have constipating effects
• Often used with magnesium to counteract constipation
• Examples
• Aluminum carbonate: Basaljel
• Hydroxide salt: AlternaGEL
• Combination products (aluminum and magnesium): Gaviscon, Maalox, Mylanta, Di-Gel

Magnesium Salts

• Forms: carbonate, hydroxide, oxide, trisilicate

• Commonly cause diarrhea; usually used with other agents to counteract this effect
• Dangerous when used with renal failure —the failing kidney cannot excrete extra magnesium,
resulting in hypermagnesemia

• Examples
• Hydroxide salt: magnesium hydroxide (MOM)
• Carbonate salt: Gaviscon (also a combination product)
• Combination products such as Maalox, Mylanta (aluminum and magnesium)
Systemic Antacid: Sodium Bicarbonate
Nonsystemic Antacid:
Aluminum Hydroxide + Magnesium Hydroxide Combinations (Maalox and Mylanta)
Contraindicated in patients with impaired renal function

Magnesium may cause diarrhea

Calcium Carbonate (Tums)

Calcium may cause constipation

ANTACID NEUTRALIZING CAPACITY (ANC)

TOPIC E:

Topic Title: Endocrine System

Endocrine glands include:

 pituitary or (hypophysis),
 thyroid,
 parathyroid,
 adrenal,
 gonads, and
 pancreas

Hypothalamus & Pituitary are closely

related both anatomically and
functionally, together they help regulate all
bodily processes by using at least 15
hormones; both lobes of pituitary are
under control of the hypothalamus, the
hypothalamus communicates with
anterior pituitary by release-reg factors 
portal blood vessels; comm w/post. pit. is
neuronal
 • Pituitary Gland - Located at base of brain, 2 lobes
- Anterior (adenohypophysis) - master gland - secretes hormones that stimulate the release of
other hormones
- Posterior (neurohypophysis) - secretes antidiuretic hormone (ADH, vasopressin) & oxytocin

* Anterior Pituitary Gland secretes 6 various hormones targeting glands & tissues – controlled by
hypothalamus

1. growth hormone (GH) - stimulates growth of tissue/bone

2. thyroid-stimulating hormone (TSH) - acts on thyroid gland to promote synthesis and release of
thyroid hormones.
3. adrenocorticotropic hormone (ACTH) - stimulates adrenal cortex to release adrenocortical
hormones
4. follicle-stimulating hormone acts on ovary to promote follicular growth & development; In testes,
FSH promotes spermatogenesis.
5. luteinizing hormone (LH) – promotes ovulation in women, in men acts on the testes to promote
androgen production
6. prolactin – stimulates milk production

Growth hormone (GH) - Somatrem (Protropin) & somatropin (Humatrope) - If growth hormone deficiency
diagnosed and dwarfism can result - these drugs may be used. Very expensive therapy

Posterior Pituitary Gland – secretes 2 hormones

 1. antidiuretic hormone (ADH, vasopressin) &
2. oxytocin (ch. 47)

ADH promotes H2O reabsorption from the renal tubules to maintain H2O balance – Decrease ADH lg.
amts. H2O excreted called diabetes insipidus (DI)  fluid volume decrease & electrolyte imbalance

Thyroid Gland - Located anterior to the trachea, has 2 lobes (butterfly like), secretes 2 hormones:
Thyroxine (T4), & tri-iodothyronine (T3)

Thyroid hormones have 3 actions:

1) stimulation of energy use  increase basal metabolism rate;

2) stimulation of the heart leads to increase rate & force of contraction  increase cardiac output;
3) promotion of growth and development(brain & skeletal muscle).- Can be either a thyroid deficiency
(hypothyroidism), or an overabundance (Hyperthyroidism)

Hypothyroidism – a decrease in thyroid hormone secretion;

- primary cause is thyroid gland disorder

- or secondary cause is lack of TSH secretion = slow metabolic rate with s/s:
o lethargic
o weak
o edema
o slow pulse
o constipation
o weight gain
o emotional changes

- Drugs containing T4 & T3 are used to treat this:

Levothyroxine sodium (Levothroid, Synthroid) - drug of choice for replacement therapy, Used to treat
simple goiter & chronic lymphocytic thyroiditis

 Action – increase T3 & T 4, increase metabolic rate, increase cardiac output, PRO synthesis,
glycogen usage, O2 consumption, & body growth
Side Effects:
o Nausea & Vomiting
o diarrhea,
o cramps,
o nervousness

 Drug Interaction
increases effects of oral anticoagulants, with adrenergic agents (decongestant or vasopressor)
cardiac & CNS effects increase.
Liothyronine (Cytomel) – a synthetic T3 not for maintenance but for initial tx. of Myxedema, because of it’s
rapid onset of action

Hyperthyroidism - increase circulating T3 & T4 from overactive thyroid gland -

Signs and Symptoms:
 rapid metabolic rate
 increase heart rate
 palpitations,
 nervousness –
 symptoms mild to severe (Thyroid storm can cause death from vascular collapse).

Graves’ disease or thyrotoxicosis most common due to Increase function of thyroid

Rx = surgical removal of part of gland, radioactive iodine

therapy or anti-thyroid drugs

Signs and Symptoms: rapid pulse, palpitations, excessive

perspiration, heat intolerance, nervousness, irritability,
bulging eyes, and weight loss

• Purpose of Pharmacologic treatment: reduction of thyroid hormones T3 & T4 by inhibiting thyroid

secretion

• Propylthiouracid (PTU), & methylthiouracil (Tapazole) are affective thiomide anti-thyroid

drugs
 Use for hyperthyroidism (thyrotoxic crisis) and in preparation for
subtotal thyroidectomy

 Action

- it blocks the synthesis of T3 & T4 but does not destroy only but
prevents oxidation of iodide

Usually takes a period of a few days to 3 weeks before symptoms improve

*Ask MD about using iodized salt & eating shellfish - contain iodine and may alter the effectiveness of drug

Adrenal Glands - located at the top of each kidney & composed of 2 sections: adrenal medulla (inner
section) & adrenal cortex (surrounds the adrenal medulla)

- adrenal medulla releases epinephrine & norepinephrine & is linked to the sympathetic nervous
system
- adrenal cortex  2 major types of hormones called (corticosteroids) 1) glucocorticoids & 2)
mineralocorticoids

o main glucocorticoid = cortisol

o main mineralocorticoid = aldosterone

Corticosteroids promote Sodium retention & Potassium excretion. A Na ion is reabsorbed from the renal
tubules in exchange for a K ion; K ion then excreted.

- Influences electrolytes, carbohydrates, protein & fat metabolism - deficiency  serious illness or death

in corticosteroid secretion = Addison’s disease

in cotricosteroid secretion = Cushing’s Syndrome

Glucocorticoids - influenced by ACTH, released from the anterior Pituitary gland. Affect carbohydrate,
protein, & fat metabolism

- can cause Na absorption from the kidney = H2O retention, K loss & increase BP
 - Cortisol - main glucocorticoid = anti-inflammatory, anti-allergic & anti-stress effects
- Indications for therapy = trauma, surgery, infections, emotional upsets, anxiety
- Most of the wide variety of glucocorticoid drugs called cortisone drugs - synthetic
- Cortisone drugs can be given orally, parenteral (IM, IV), topical (creams, ointments), aerosol
(inhaler)
 Uses - inflammatory conditions (MS, rheumatoid arthritis, MG, ulcerative colitis), shock, head
trauma, asthma, contact dermatitis, anaphylaxis, debilitating conditions (malignancies), organ
transplant recipients
 Many glucocorticoids - some more potent than others
 Side Effects:
• fluid retention, muscle weakness, CV problems, hard on GI system , headache, increase ICP,
masks signs of infection, susceptibility to infection

Dexamethasone (Decadron) - PO, IV, IM

 Action - Not clearly defined. Decreases inflammation, suppresses immune response, stimulates
bone marrow
 Use - Cerebral edema, inflammatory conditions, allergic reactions, neoplasias
 Side Effect - Can affect all systems
 Do not discontinue (D/C) drug abruptly - rebound inflammation possibility
o Should be taken with food or milk,
 Signs and Symptoms of early adrenal insufficiency (fatigue, weakness, joint pain), warn about long
term therapy Cushing symptoms (moon face)

Prednisone (Deltasone, Orasone) – PO

 Action - Suppression of inflammation & adrenal function

 Use – Dec. severe inflammation, immunosuppression, dermatologic disorders
 Side Effect: Nausea, Vomiting, diarrhea, increase appetite, sweating, depression, mood changes,
HA, flushing
 Teaching - do not d/c abruptly - Best to start medication at lowest effective dose
 Contra Indication – psychosis, fungal infection, Caution w/ diabetes

Hydrocortisone (Cortef) - PO, IV, IM, enema

 Action - Decreases inflammation
 Use - Inflammation, adrenal insufficiency, ulcerative colitis

Glucocorticoid Inhibitors - Ketoconazole (Nizoral) - an antifungal drug, aminoglutethimide (Cytadren) an

antineoplastic hormone antagonist
- inhibit glucocorticoid synthesis

- Nizoral - Rx Cushing’s syndrome & adjunct to surgery or radiation

- high doses can cause fatal vent. Dysrhythmias
 - Cytadren – temporary RX of selected clients w/ Cushing’s syndrome, esp. clients w/ adrenal adenoma,
carcinoma, adrenal hyperplasia

Mineralocorticoids - secrete aldosterone

- maintains fluid balance by promoting reabsorption of Na from the renal tubules

- Na attracts H2O = H2O retention

 hypovolemia ( in circulating fluid)  more aldosterone secreted to Na and H2O retention 

restore fluid balance

 W/ Na reabsorption = K lost hypokalemia

 severe in aldosterone  hypotension & vascular collapse - Addison’s disease

Fludrocortisone (Florinef) - an oral mineralocorticoid given w/ a glucocorticoid

 Action - Increases Na+ reabsorption & K+ secretion

 Use - Addison’s disease (adrenocortical insufficiency)
 SE - hypertension, Na+ & H2O retention
 Alert - monitor clients BP & electrolytes ( esp. K+)
 Can cause a neg. nitrogen balance - a high-protein diet indicated