GASTROINTESTINAL

DISORDER

Content
Introduction about GI disorder.
Peptic Ulcer

Constipation
Diarrhea

Introduction about GI
disorder
The gastrointestinal (GI) tract is
composed esophagus, stomach,
small intestine, large intestine,
colon, rectum, biliary tract,
gallbladder, liver, and pancreas.
Disorder related to any of this
organ are called Gastro Intestinal
Disorder.
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Disease under GI disorder

Gastroesophageal Reflux Disease.
Peptic Ulcer Disease
Inflammatory Bowel Disease
Nausea and Vomiting
Diarrhea, Constipation
Irritable Bowel Syndrome
Portal Hypertension and Cirrhosis
Drug-Induced Liver Disease
Pancreatitis
Viral Hepatitis

Peptic Ulcer
A
peptic
ulcer,
also
known
as PUD or peptic ulcer disease, is the
most common ulcer of an area of
the gastrointestinal tract that is usually
acidic and thus extremely painful. It is
defined as mucosal erosions equal to
or greater than 0.5 cm.

 TYPES:
Duodenum (called duodenal ulcer)
Esophagus (called esophageal ulcer)
Stomach (called gastric ulcer)

 ETIOLOGY
Common causes
Helicobacter pylori infection
Nonsteroidal anti-inflammatory drugs
Critical illness (stress-related mucosal damage)
Uncommon causes
Hypersecretion of gastric acid (e.g., ZollingerEllison syndrome)
Viral infections (e.g., cytomegalovirus)
Vascular insufficiency (crack cocaineassociated)
Radiation
Chemotherapy (e.g., hepatic artery infusions)
Rare genetic subtypes
Idiopathic
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 PATHOPHYSIOLOGY
Gastric and duodenal ulcers occur
because of an imbalance between
aggressive factors (gastric acid and

pepsin) and mechanisms that maintain

mucosal integrity (mucosal defense and

repair) i.e. defensive factor.

SIGNS & SYMPTOM:

Symptoms
Abdominal pain that is often epigastric and described as
burning, abdominal fullness, or cramping
A typical nocturnal pain that awakens the patient from
sleep (especially between 12 AM and 3 AM)
The severity of ulcer pain varies from patient to patient,
and may be seasonal, occurring more frequently in the
spring or fall.
Changes in the character of the pain may suggest the
presence of complications
Heartburn, belching, and bloating often accompany the
pain
Nausea, vomiting, and anorexia, are more common in
patients with gastric ulcer than with duodenal ulcer, but
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may also be signs of an ulcer-related complication

 SIGNS:
Weight loss associated with nausea,
vomiting, and anorexia
Complications, including ulcer bleeding,
perforation, penetration, or obstruction
DIGNOSIS:
Laboratory tests
Gastric acid secretory studies
Fasting serum gastrin concentrations are only
recommended for patients unresponsive to therapy,
or for those in whom hypersecretory diseases are
suspected.
The hematocrit and hemoglobin are low with
bleeding, and stool hemoccult tests are positive
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Tests for Helicobacter pylori

Other diagnostic tests

Esophagogastroduodenoscopy detects more
than 90% of peptic ulcers and permits direct
inspection, biopsy, visualization of superficial
erosions, and sites of active bleeding.
Routine single-barium contrast techniques
detect 30% of peptic ulcers; optimal doublecontrast radiography detects 60% to 80% of
ulcers.

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DRUGS USED FOR PEPTIC ULCER

H2 RECEPTOR ANTAGONISTS:
The H2 receptor antagonists inhibit
acid production by reversibly competing with
histamine for binding to H2 receptors on the
basolateral membrane of parietal cells. E.g.
Ranitidine,
Famotidine,
Cimetidine,
Nizatidine,
PROTON PUMP INHIBITORS:
They act on H+-K+ ATPase pump to
block the secretion of Gastric acid. E.g.
Omeprazole, Pantoprazple, Esmoprazole,
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Rabeprazole.

Cont...

Prostaglandin Analogs:
They bind to the EP3 receptor on
parietalcells and stimulate the Gi pathway,

thereby decreasing intracellular cyclic AMP

and gastric acid secretion. PGE2 also can
prevent gastric injury by cytoprotective effects
that include stimulation of mucin and
bicarbonate secretion and increased mucosal
blood flow. E.g. Misoprostol.
Anticholinergics:
They are mainly M1 anticholinergics,
which decrease the gastric acid secretion by
blocking the Muscarinic receptor present in
the stomach. E.g. Piperazine.
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Cont...

Antacids:
Systemic: Sodium bicarbonate.
Nonsystemic: Magnesium hydroxide,
Alluminium hydroxide gel.
Ulcer Protective: Sucralfate.
Anti H. pylori drugs : Amoxicillin,
Clarithromycin,
Metronidazole,
Tinidazole, Tetracyclin.

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Constipation
Constipation include infrequent bowel action twice a
week or less, that involves straining to pass hard
faeces & which may be accompanied by a sensation
of pain or incomplete evacuation
Functional constipation is defined as two or more of
the following complaints present for at least 12
months in the absence of laxative use:
straining at least 25% of the time;
lumpy or hard stools at least 25% of the time;
a feeling of incomplete evacuation at least 25% of
the time;
two or fewer bowel movements in a week.
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PHYSIOLOGY OF STOOL FORMATION:

The undigested food are swept along the GI Tract

by waves of muscular contractions called peristalsis
These peristaltic waves eventually moves the faeces
from the colon to rectum & induce the urge to
deficit
By the time stool reaches the rectum it generally
has a solid consistency because most of the water
has been reabsorbed
Normally there is a net uptake of fluid in the
intestine in response to osmotic gradient involving
the absorption & secretion of ions, & absorption of
sugars & amino acids
This process is under the influence of Sympathetic
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& Parasympathetic nervous system

ETIOLOGY:
Extent of absorption & secretion of fluid from
GIT generally parallels transit time --- a slower
transit time will lead to formation oh hard stool
& constipation
Agents altering the intestinal motility either
directly or by acting on ANS affect the transit
time of food along the GIT
Motility is largely under cholinergic control --anticholinergics or drug with anticholinergic
side effect Motility
Constipation
Opoid cause tone of smooth muscle,
suppress forward peristalsis, rais
sphincter tone at ileocaecal valve & anal
sphincter
Constipation.
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Cont...

Causes directly affecting Colon or Rectum include--Obstruction from neoplasm

Hirschspungs disease
During child birth
Causes of Constipation out side the Colon --Poor diet
Inadequate fibre intake
Inadequate water intake
Excessive intake of caffeine
Drugs induced constipation include Drugs for--Hypothyroidism
Diabetic autonomic neuropathy
Spinal cord injury
Cerebrovascular accident
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Multiple sclerosis or Parkinsons disease

CLINICAL MENIFESTATION:
Signs and symptoms
Infrequent bowel movements, stools of insufficient
size, a feeling of fullness, or difficulty and pain on
passing stool.
Hard, small or dry stools, bloated stomach,
cramping abdominal pain and discomfort, straining
or grunting, sensation of blockade, fatigue, headache,
and nausea and vomiting

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DIAGNOSIS:
Laboratory tests
A series of examinations, including proctoscopy,
sigmoidoscopy, colonoscopy, or barium enema,
may be necessary to determine the presence of
colorectal pathology.
Thyroid function studies may be performed to
determine the presence of metabolic or
endocrine disorders.
With laxative abuse, fluid and electrolyte
imbalances (most commonly hypokalemia),
protein-losing
gastroenteropathy
with
hypoalbuminemia may be present.
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TREATMENT ALGORITHM

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TREATMENT:
NONPHARMACOLOGIC THERAPY
Dietary modification to increase the amount of
fiber consumed.
Include at least 10 g of crude fiber in their daily
diets
Encourage patients to exercise (achieved even by
brisk walking after dinner)
To adjust bowel habits so that a regular and
adequate time is made to respond to the urge to
defecate
To increase fluid intake

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Cont...
PHARMACOLOGICAL TREATMENT:
By using laxative or purgative.
Different types of laxative or purgative used
Laxative or Purgative

Bulk forming.
E.g.Dietary fibre

Stool softener.
E.g. DOSS

Stimulant Purgatives

Diphenyl methanes
e.g. Bisacodyl

5-HT4 agonists.
e.g. Tegasarod

Osmotic Purgative
e.g. Lactulose

Anthraquonones
Senna

Fixed oil
e.g. castor oil

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DEFINATION & TYPES:

Diarrhoea is defined as the increased passage of
loose or watery stools relative to the persons usual
bowel habit, usually more than 3 times a day
It is of two types.
Acute Diarrhoea (<3 days)
Chronic Diarrhoea (>14 days)
ETIOLOGY:
Various virus & bacteria
Campylobacter, followed by rota virus
E.coli,
Shigella,
Salmonella,
Clostrodium
perfringens,
Viruses such as adenovirus & astrocytes
S. aureus, Bacillus cereus produce enterotoxin wich
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on ingestion cause diarrhoea & vomiting

Cont...

Travellers diarrhoea occurs due to ingestion of

contaminated food & water.
Involved organism in descending order are
o Enterotoxigenic bacteria E.coli, Shigella, Salmonella,
Campylibacter, Vibrio, Yersinia species
o Virus & parasites such as Giardia, Cryptosporidium,
Entameoba.
Broad spectrum antibiotic on long time therapy cause
Diarrhoea
PATHOPHYSIOLOGY:
Four general pathophysiologic mechanisms disrupt
water and electrolyte balance, leading to diarrhea
a change in active ion transport by either
decreased sodium absorption or increased
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chloride secretion

Cont...

change in intestinal motility

increase in luminal osmolarity;
increase in tissue hydrostatic pressure.
Secretory diarrhea occurs when a stimulating substance
either increases secretion or decreases absorption of large
amounts of water and electrolytes
vasoactive intestinal peptide (VIP) from a pancreatic
tumor unabsorbed dietary fat in steatorrhea, laxatives,
hormones (such as secretin), bacterial toxins, and
excessive bile salts
These agents stimulate intracellular cyclic adenosine
monophosphate and inhibit Na+/K+-ATPase, leading
to increased secretion
Poorly absorbed substances retain intestinal fluids,
resulting in osmotic diarrhea
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Cont...
Altered intestinal motility produces diarrhea by three
mechanisms:
o reduction of contact time in the small intestine
o premature emptying of the colon
o bacterial overgrowth

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SIGNS AND SYMPTOMS:

Abrupt onset of nausea, vomiting, abdominal pain,
headache, fever, chills, and malaise.
Bowel movements are frequent and never bloody, and
diarrhea lasts 12 to 60 hours.
Intermittent periumbilical or lower right quadrant pain
with cramps and audible bowel sounds is characteristic
of small intestinal disease.
When pain is present in large intestinal diarrhea, it is a
gripping, aching sensation with tenesmus (straining,
ineffective and painful stooling). Pain localizes to the
hypogastric region, right or left lower quadrant, or sacral
region.
In chronic diarrhea, a history of previous bouts, weight
loss, anorexia, and chronic weakness are important
findings.
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DIAGNOSIS:
Laboratory tests
Stool analysis studies include examination for
microorganisms, blood, mucus, fat, osmolality, pH,
electrolyte and mineral concentration, and cultures.
Stool test kits are useful for detecting gastrointestinal
viruses, particularly rotavirus.
Occasionally, total daily stool volume is also determined.
Direct endoscopic visualization and biopsy of the colon
may be undertaken to assess for the presence of
conditions such as colitis or cancer.
Radiographic studies are helpful in neoplastic and
inflammatory conditions.

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TREATMENT:
NONPHARMACOLOGICAL :
Dietary management is a first priority in the
treatment of diarrhea
Most clinicians recommend discontinuing
consumption of solid foods and dairy
products for 24 hours
Rehydration and maintenance of water and
electrolytes are primary treatment goals until
the diarrheal episode ends
Oral or i.v infusion of WHO-ORS.

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 PHARMACOLOGICAL TREATMENT:

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DRUGS

Loperamide is antisecretory; it inhibits the calciumbinding protein calmodulin, controlling chloride

secretion. Loperamide, available as 2-mg capsules or
1 mg/5 mL solution
Adsorbents are used for symptomatic relief. These
products, are nontoxic, nonspecific in their action;
they adsorb nutrients, toxins, drugs, and digestive
juices. Coadministration with other drugs reduces
their bioavailability
Bismuth subsalicylate appears to have antisecretory,
antiinflammatory, and antibacterial effects relievs
abdominal cramps, and controlling diarrhea,
including travelers diarrhea
Octreotide, a synthetic octapeptide analog of
endogenous somatostatin, is prescribed for the
symptomatic treatment of carcinoid tumors and
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vasoactive intestinal peptidesecreting tumors

References
Joseph T Dipiro et al. Rosemary R. Berardi,
Lynda S. Welage Peptic Ulcer Disease;
Pharmacotherapy; Page : 629
Joseph T Dipiro et al; William J. Spruill;
William E. Wade l; Diarrhoea, Constipation,
and
Irritable
Bowel
Syndrome;
Pharmacotherapy; Page 677.
Roger Walker, Cate Whittlesea; S. E. Ghosh,
M. Kinnear; Peptic Ulcer Disease; Clinical
Pharmacy & Therapeutics; Page: 149
Roger Walker, Cate Whittlesea; P. Rutter;
Constipation & Diarrhoea; Clinical Pharmacy &
Therapeutics; Page: 187
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