COMMON GASTRO-

INTESTINAL &
HEPATOBILIARY
DISORDERS

ROLE OF THE
PHARMACIST
 BY
Dr AYMAN M SHAMSEYA

A. LECTURER OF INT MED

FACULTY OF MEDICINE
??Primary care…..WHO
Across most of Europe & North
America, primary care is a
specific specialty that exists
within a range of healthcare
systems & cultures
It is at the forefront of care of
most patients
??Primary care…..WHO
A primary care physician is
generally the first point of medical
input when a person chooses to
consult
In primary care, GI problems tend
to be undifferentiated &
management is largely symptom-
based
??Primary care…..WHO
An empiric approach in primary
care is often more appropriate
than the diagnostic model
generally used in secondary
care, where investigation rates
tend to be higher
Diseases of the gastrointestinal
tract & liver together account
for about 10% of the total
burden of illness, 50 million
office visits, and nearly 10
million hospital admissions
annually in the US
The cost of gastrointestinal
diseases depends on their
prevalence, direct costs (fees,
hospital charges,
pharmaceutical costs), and
indirect costs (time loss from
work)
Anatomic considerations
 GI overview
The major function of the
gastrointestinal tract is to
absorb water & nutrients while
food moves physically from
mouth to colon where non-
absorbable wastes are stored
for periodic elimination
 Clinical approach
The diagnosis of
gastrointestinal diseases
derives predominantly from the
patient’s history and, to lesser
extent, from the physician’s
examination
SYMPTOMATOLOGY
The cardinal symptoms of
gastrointestinal diseases are:
 Nausea & vomiting
 Weight loss
 Bleeding
CONSTIPATION
CONSTIPATION
DIARRHEA
Abdominal pain
BLOATING
NAUSEA & VOMITING
 Nausea is the unpleasant
feeling that one is about to
vomit
 Vomiting (emesis) is the
forceful ejection of contents of
the upper gut through the
mouth
NAUSEA & VOMITING
Causes of nausea & vomiting:
1. Local gastrointestinal disease:
 Gatritis
 Gastric ulcers
 Gastric neoplasms
 Cholecystitis
 pancreatitis
NAUSEA & VOMITING
2. Systemic causes:
 Elevated intra-cranial pressure (benign
or neoplastic)
 Inner ear disease
 Medications: (act locally on the stomach;
NSAIDs, erythromycin, or cardiac anti-
arrhythmics or systemically like
chemotherapeutics and opiates)
 pregnancy
NAUSEA & VOMITING
Antiemetic agents include:
5-HT3 antagonists: ondansetron & others
D-2 antagonists: domperidone &
metoclopramide
H-1 antagonists: diphenhydramine &
cyclizine
NAUSEA & VOMITING
Historical information concerning
the duration, precipitation, & pattern
of nausea & vomiting as well as the
nature of the vomitus are not
sufficient and one must also seek
signs of gastrointestinal diseases
&/or CNS diseases
 Abdominal pain
Pain is an
unpleasant
sensation that is
perceived by the
patient as
distressing; it is
the most common
cause for seeking
medical advice
 Abdominal pain
In addition to the location of pain,
the character of pain (burning,
steady, or colicky), its duration,
time to reach peak, &its relieving
and aggravating factors (such as
eating, passing stool or flatus)are
helpful components of the medical
history
 Abdominal pain
The most common causes of
abdominal pain are:
 Esophagitis
 Peptic ulcer
 Gall bladder colic
 Cholecystitis
 Pancreatitis
 Functional abdominal pain (IBS & non-ulcer
dyspepsia)
 GI bleeding
Bleeding from the gastrointestinal
tract may be gross & evident as
hematemesis, melena, or
hematochezia, or it may be occult;
presenting as unexplained anemia &
requiring testing of the stool to be
detected
 GI bleeding
 Itis always a serious symptom
that requires investigations
 Endoscopy is the most
effective way to diagnose the
cause of & to estimate the
severity of bleeding
 constipation
Constipation is so common a
complaint that it is often not
considered to be a symptom of a
disease
It may result from endocrine,
metabolic, neurological, or ano-
rectal causes, but more commonly it
is idiopathic
 constipation
The primary & usually empiric
treatment in the absence of an
evacuation disorder is the trial
of high fiber diet or fiber
medication
Functional GI disorders
In clinical practice, most
patients who present with
chronic or recurrent
gastrointestinal symptoms do
not have a structural or
biochemical explanation
identified by routine diagnostic
tests
Functional GI disorders
These patients are labeled as
having functional
gastrointestinal disorder
The word FUNCTIONAL does not
imply a psychiatric disturbance
or absence of disease but rather
a disorder of gut function
Functional GI disorders
Based on clinical &
epidemiologic studies, the most
widely recognized functional GI
disorders are irritable bowel
syndrome (IBS), functional (non-
ulcer) dyspepsia, and functional
(non-cardiac) chest pain
 IBS
Previously, ,most patients with
abdominal pain or dysfunction
of bowel were labeled as having
IBS, but now it is considered to
be characterized by:
Chronic or recurrent abdominal pain
Erratic disturbance of defecation
Bloating (very common)
 IBS
Symptoms consistent with IBS are reported
by one in six in America, Europe,
Australia, & Asia (women more than men
and similar in whites & blacks)
Only about one third of persons with IBS
consult a physician, but the condition still
accounts for 12% of primary care visits
Functional dyspepsia
Dyspepsia refers to persistent
or recurrent epigastric or
subjective upper abdominal
discomfort that may be
characterized by early satiety,
postprandial fullness, bloating,
or nausea.
Functional dyspepsia
Population-based studies from
around the world indicate that
the prevalence of dyspepsia is
about 25%, only 25% of them
(in the US) seek medical advice
Functional dyspepsia
Treatment of un-investigated NUD:
1. Dietary modifications
2. Antacids
3. Acid suppressing agents
4. Prokinetics
5. Cytoprotection
 Gastro-esophageal reflux
disease
GERD is one of the most prevalent
diseases in the western world (based
on the prevalence of heartburn)
Recurrent heartburn (which is the
hallmark of GERD) enables a
diagnosis of GERD to be made by
history alone
Gastro-esophageal reflux
disease
GERD, however, can induce
damage to the oro-pharynx,
larynx, & respiratory tract,
leading consequently to
recurrent cough, asthma,
earache, dental erosions, or
globus sensation
Gastro-esophageal reflux
disease
Empiric treatment with antacids
or acid-suppressing agents,
with positive response is
sometimes used to confirm the
diagnosis of GERD
 Gastro-esophageal reflux
disease
1. Life style modifications
2. Drug therapy
Peptic ulcer disease
The most common causes of
peptic ulcer disease are
infection with Helicobacter
Pylori and the use of non-
steroidal anti-inflammatory
drugs (NSAIDs)
Peptic ulcer disease
Classically, an ulcer was
considered likely when pain was
located in the epigastric area, was
burning in quality, occurred on an
empty stomach 2 to 4 hours after
meals &/or at night, was relieved
by antacids &/or meals
Peptic ulcer disease
This pattern of pain has been
called acid dyspepsia because
it occurs when acid is
unbuffered by food and is
relieved with neutralizing acid
or inhibiting acid secretion
Diarrhea & dysentery
Normal stool frequency ranges from
three times a week to three times a
day
A decrease in stool consistency
(increased fluidity) and stools that
cause urgency or abdominal
discomfort are likely to be termed
diarrhea
Diarrhea & dysentery
The most common causes of acute
diarrhea (lasting less than 4 weeks)
are infections (E coli, Vibrios,
campylobacter, …) while chronic
diarrhea (lasting 4 weeks or longer)
categorizes three important variants
(osmotic, secretory, & inflammatory)
Diarrhea & dysentery
The goal in evaluating a patient
with chronic diarrhea is to make
a definitive diagnosis as quickly
& inexpensively as possible
In only 25% to 50% of cases,
expert history & physical
examination may be sufficient
Diarrhea & dysentery
Dysentery refers to presence of
blood, mucus, or both in stool
The most important causes are:
1. Infections (Amoeba, Giardia,
Shigella, & S Mansoni)
2. IBDs (UC & CD)
3. Radiation & ischemic colitis
 Hepatology
The scope of practice of liver diseases
has expanded dramatically in the past
decade, primarily because of the
success of liver transplantation, the
development of effective treatment
regimens for viral hepatitis and safer
techniques for diagnosing liver diseases
and treating obstructive jaundice
 Hepatology
The current epidemic of hepatitis C,
which involves more than 4 million
people infected annually through
contaminated blood transfusion, and
injection-type drug addiction will
lead to the development of cirrhosis
or hepatocellular carcinoma in a
significant percentage
 Hepatology
The major function of the liver is
to synthesize and metabolize
proteins, carbohydrates, and
fats, as well as to detoxify
normal metabolic wastes and
ingested drugs and chemicals
 Hepatology
The major sequelae of cirrhosis
include portal hypertension,
variceal hemorrhage, ascites,
hepato-renal and hepato-
pulmonary syndromes, plus
hepatic encephalopathy
 Hepatology
Hemorrhage from gastro-
esophageal varices is often the
initial complication of portal
hypertension
Bleeding from varices accounts
for one third of all deaths in
patients with cirrhosis
 Hepatology
Ascites, which is the
accumulation of excess fluid in
the abdomen, is often among the
first signs of decompensation in
patients with chronic liver
disease
 Hepatology
Cirrhosis is the underlying cause of
ascites in at least 80% of patients,
but other causes (e.g., heart failure,
constrictive pericarditis, nephrotic
syndrome, tuberculous peritonitis,
peritoneal malignancy) must also
be considered
 Hepatology
Approximately 50% of patients with
cirrhosis develop ascites within 10 years,
and the development of ascites in the
sitting of cirrhosis is an important
landmark in the natural history of chronic
liver disease, because approximately
50% of patients usually die within 4 years
of ascites development
 Hepatology
Most patients with cirrhotic
ascites respond to dietary
sodium restriction (<2000
mg/day) and a diuretic
Treatment with diuretics may
result in dehydration, severe
muscle cramping,
hyponatremia, and hepatic
encephalopathy
Thank You