Peptic Ulcer

ANTACIDS
Mechanism of action
Neutralization of gastric acidity
Low doses promote gastric mucosal defensive
mechanisms
Common examples include
CaCO3
NaHCO3
Al(OH)3
Mg(OH)2
 SIDE EFFECTS AND ADVERSE EFFECTS

Magnesium : diarrhea
Aluminum : constipation
Calcium : constipation
 NURSING INTERVENTIONS
Monitor for side effects
Nausea, vomiting, abdominal pain, diarrhea
With calcium-containing products: constipation, acid
rebound
Monitor for therapeutic response
Notify heath care provider if symptoms are not relieved.
 H2 BLOCKERS
H2 blockers impede acid production in the stomach by
blocking the actions of histamine, a substance produced by
the body that encourages acid secretion in the stomach.
These drugs cannot cure ulcers, but in certain cases they are
useful in reducing inflamation allowing the stomach to heal

8
 H2 BLCOKER

Four H2 blockers are currently available as over the

counter drugs in the Indonesia :
Famotidine
Cimetidine
Ranitidine
Nizatidine
Anderson et al. Handbook of Clinical Drug Data 10th edition. 2002 . New York :McGraw
Hill Inc
Anderson et al. Handbook of Clinical Drug Data 10th edition. 2002 . New York :McGraw
Hill Inc
Anderson et al. Handbook of Clinical Drug Data 10th edition. 2002 . New York :McGraw
Hill Inc
 PROTON PUMP INHIBITORS (PPI)

Proton Pump Inhibitors reduce the production of acid

by blocking the enzyme in the wall of the stomach that
produces acid.
Inhibitors do not neutralize excess acid but inhibit the
initial production of hydrochloric acid
The reduction of acid prevents ulcers and allows any
ulcers that exist in the esophagus, stomach and
duodenum to heal.

14
 PROTON PUMP INHIBITORS
Proton Pump Inhibitors are generally available only by
prescription but low doses of some products are now
approved for over the counter use
Commonly prescribed Proton Pump inhibitors include
Rabeprazole
Lansoprazole
Omeprazole
Esomeprazole
Pantoprazole

15
 OTHER DRUGS
SUCRALFAT
Cytoprotective agent.
Used for stress ulcers, erosions, PUD.
Attracted to and binds to the base of ulcers and erosions, forming a protective
barrier over these areas.
Little absorption from the gut.

Use
Dosage Forms. Tab 1 g; Susp 100 mg/mL.
Patient Instructions. Take this drug with water on an empty stomach 1 hr before
each meal and at bedtime.
Misoprostol
Synthetic prostaglandin analogue.

Prostaglandins have Cytoprotective activity:

Protect gastric mucosa from injury by enhancing local production of mucus
or bicarbonate.
Promote local cell regeneration.
Help to maintain mucosal blood flow.

Used for preventation of NSAID-induced gastric ulcers.

Doses that are therapeutic enough to treat duodenal ulcers often produce
abdominal cramps and diarrhea.
Motility & Secretion
 ETIOLOGY OF DIARRHEA
Rotavirus
Enterotoxigenic Escherichia coli
Shigella
Campylobacter jejuni
cryptosporidium
Vibrio cholera
salmonella (Non thyphoid )
Entropathogenic Escherchia coli
 PHATOGENIC MECANISM
PATHOGENIC MECHANISMS (
VIRUSES)
Replicate within the villous
epithelium of small bowel
Patchy epithelial cell
destruction and villous
shortening
The Loss of normally
absorptive villous cells
Replacement immature ,
secretary ,crypt- like cells
Loss of disaccharides ,
especially lactose
PATHOGENIC MECHANISMS
)PROTOZOA)
Mucosal adhesion and
cause shortening of the villi
G,lambelia ,
cryptosporidum
Mucosal invasion in the
colon or ileum and causing
micro absess and ulcer
E, histolitica
 PATHOGENIC MECHANISMS )BACTERIA)

Mucosal adhesion to avoid being swept away

Entrotoxicogenic E.coli ,vibrio .cholera
Toxins that cause secretion that reduce the absorption of Na
and increase the secretion of chloride
Entrotixigenic E.coli , v.cholera
Mucosal invasion occurs in the colon and distal ileum and
destroying mucosal epithelial cells and cause bloody diarrhea
Shigella ,C.jejuni ,entroinvasive E. coli and salmonella
 PREVENTION OF DIARRHEA

Give only breast milk for first 4-6 month

Do not use feeding bottle
Prepare and store food safely
Use clean water for drinking
Wash hands when soiled
Dispose of faeces safely
 PRINCIPLES OF MANAGEMENT
1. Prompt replacement of fluids & electrolytes
2. Maintenance of nutrition
3. Use of anti-microbials only for those with bloody
diarrhea, suspected cholera or serious non-intestinal
infections & avoidance of anti-diarrheal agent
4. Patients or caretakers should be taught about
feeding & hygiene practices that reduce diarrhea
morbidity. Emphasize prevention & follow-up.
 TREAT DIARRHEA
CHILD ADULT
REHYDRATION REHYDRATION
ADSORBENT ADSORBENT
PROBIOTIC PROBIOTIC
ZINC ANTIBIOTIC !!!
VITAMIN A LOPERAMID
 COMPOSITION OF ORS
Ingredient Amount (g/liter)
Sodium chloride 3.5
Trisodium citrate or 2.9 or
Sodium bicarbonate 2.5
Potassium chloride 1.5
Glucose 20.0

Home-made ORS: Sugar or molasses (40 g) can be used as a substitute for glucose to prepare home-
made ORS. Common salt (5 g) will be added to it and dissolved in one liter of clean water.
Rice-ORS: Rice powder (50 g) can replace the sugar or glucose. The amount of the other salts will
remain the same. These will be dissolved in one liter of clean water to prepare rice-based ORS. Studies
showed that rice-based ORS can reduce vomiting and diarrhea more in some cases compared to the
conventional ORS prepared with glucose.
 PREVENT OF TREAT DEHYDRATION
Choose the treatment plan that corresponds with the patients
degree of dehydration
No Signs of Dehydration follow Treatment Plan A at home to
prevent dehydration & malnutrition
Some Dehydration follow Treatment Plan B to treat dehydration
Severe Dehydration follow Treatment Plan C to treat
dehydration urgently
 REHYDRATION
Treatment Plan A
Home ORS: Mix the in a 1 liter of water:
How much fluids to give after each loose stool:
Children < 2 yrs: 50 100 mL of fluid
Children 2 10 yrs: 100 200 mL
Older children & adults: as much fluid as they want
What foods to give
Milk
Breast milk as often & as long as child wants
Milk formula every 3 hrs, if possible by cup
Infants < 4 months: on mixed feeding should receive increased breastfeeding. If
possible, breastfeed exclusively
 REHYDRATION
Treatment Plan B
Patients with Some Dehydration should receive oral
rehydration therapy (ORT) with ORS solution in a health
facility following treatment plan B
Adults can consume up to 750mL/hr while still
dehydrated
Children can consume up to 20mL/kg BW/hr
 REHYDRATION
Treatment Plan C
For patients with SEVERE dehydration
Patients should be brought to the hospital so that IV
fluids can be started immediately
Usual fluid given is Lactated Ringers solution
If not available, Normal Saline solution may be used
 ADSORBENT
Coat the walls of the GI tract
Bind to the causative bacteria or toxin, which is then
eliminated through the stool
Examples:
BISMUTH SUBSALICYLATE
KAOLIN-PECTIN
ACTIVATED CHARCOAL
ATTAPULGITE
 PROBIOTIC
Intestinal flora modifiers
Bacterial cultures of Lactobacillus organisms
work by:
Supplying missing bacteria to the GI tract
Suppressing the growth of diarrhea-causing bacteria
Example: L. acidophilus
 ZINC
Zinc-supplemented children had:
24% lower probability of continuing diarrhoea
42% lower rate of treatment failure or death
Conclusion: zinc supplementation reduces the duration and
severity of persistent diarrhoea
Provide children with 20 mg per day of zinc supplementation
for 10-14 days (10 mg per day for infants under six months
old)
 OPIATES
Decrease bowel motility and relieve rectal spasms
Decrease transit time through the bowel, allowing more time for water
and electrolytes to be absorbed
Examples:
LOPERAMIDE

Administration and Adult Dosage. PO for acute diarrhea or travelers

diarrhea, to a maximum of 16 mg/day (8 mg/day for no more than 2
days with OTC product).
Dosage Forms. Cap 2 mg; Chew Tab 2 mg; Tab 2 mg; Liquid 0.2, 1
mg/mL; Chew Tab 2 mg plus simethicone
Adverse Reactions. Abdominal cramping, constipation, distention,
headache, rash.
 DEFINITIONS
Nausea
Unpleasant feeling that often precedes vomiting
Emesis (vomiting)
Forcible emptying of gastric, and occasionally, intestinal
contents
Antiemetic agents
Used to relieve nausea and vomiting
 VOMITING - ANTIEMETICS
The CTZ receives most of the
impulses from drugs, toxins, and the
vestibular center. The
neurotransmitter dopamine
stimulates the CTZ, which stimulates
the vomiting center, when
triggered, motor neuron responds
contraction of diaphragm,
anterior abdominal muscles, & the
stomach. the glottis closes, the
abdominal wall moves, upward &
vomiting occurs.
 ANTIEMETICS
Nonprescription antiemetics : used to prevent motion sickness -
minimal effect on severe vomiting from anticancer agents,
radiation, and toxins.
take 30 min before traveling
DIMENHYDRINATE, DIPHENHYDRAMINE
 ANTIEMETICS
METOCLOPRAMIDE, DOMPERIDONE
Blocks dopamine & serotonin receptors in the CTZ
Use : post-op emesis, chemo & radiation therapy
SE : sedation & diarrhea w/ high doses
 ANTIEMETICS
Serotonin Antagonists ONDANSETRON, GRANISETRON
Action :
Suppress 5HT3 by blocking the serotonin receptors in the CTZ &
afferent vagal nerve terminals in upper GI tract - Do not cause
EPS symptoms
Use : chemo induce emesis - PO & IV
SE : headache, diarrhea, dizziness, fatigue
OVERVIEW OF PROKINETIC DRUGS

Masaoka T, et al: Update on Gastroparesis. Gut and Liver, Vol. 3, No. 3,

September 2009, pp. 166-173
 CONSTIPATION
Abnormally infrequent and difficult passage of feces through
the lower GI tract
Symptom, not a disease
Disorder of movement through the colon and/or rectum
Can be caused by a variety of diseases
or drugs
 MECHANISM OF ACTION

Bulk forming
Emollient
Hyperosmotic
Saline
Stimulant
 BULK FORMING
High fiber
Absorbs water to increase bulk
Distends bowel to initiate reflex bowel activity
Examples:
PSYLLIUM
METHYLCELLULOSE
POLYCARBOPHIL
 EMOLLIENT

Stool softeners and lubricants

Promote more water and fat in the stools
Lubricate the fecal material and intestinal walls
Examples:
STOOL SOFTENERS: DOCUSATE SALTS
LUBRICANTS: MINERAL OIL
 HYPEROSMOTIC
Increase fecal water content
Result: bowel distention, increased peristalsis, and
evacuation
Examples:
POLYETHYLENE GLYCOL
SORBITOL
GLYCERIN
LACTULOSE
 SALINE
Increase osmotic pressure within the intestinal tract,
causing more water to enter the intestines
Result: bowel distention, increased peristalsis, and
evacuation
Examples:
MAGNESIUM SULFATE
MAGNESIUM HYDROXIDE
MAGNESIUM CITRATE
SODIUM PHOSPHATE (FLEET ENEMA)
 STIMULANT

Increases peristalsis via intestinal nerve

stimulation
Examples:
CASTOR OIL
SENNA
CASCARA
BISACODYL
Masaoka T, et al: Update on Gastroparesis. Gut and Liver, Vol. 3, No. 3,
September 2009, pp. 166-173