Pharmacotheraphy

Gastrointestinal Tract
Liza Yudistira Yusan,S.Farm.,M.Farm-Klin.,Apt.
Prodi Farmasi FK UHT Surabaya
Gasal-2016
 OUTLINE

Dyspepsia
Diarrhoea
Peptic Ulcer Disease
GERD
H.pylori
 DYSPEPSIA-Definition

A group of symptoms which alert clinicians to

consider disease of the upper gastrointestinal
tract: upper abdominal discomfort, retrosternal
pain, vomiting, heartburn, upper abdominal
fullness and feeling full earlier than expected
when eating.
 DYSPEPSIA

Popularly known as indigestion

Meaning hard or difficult digestion, is a medical
condition characterized by chronic or recurrent
pain in the upper abdomen, upper abdominal
fullness and feeling full earlier than expected
when eating.
 ETIOLOGY

● Dyspepsia may be caused by a number of

foods, medications, systemic disorders, and
diseases of the luminal GI tract .
● An organic cause is found, however, in only
40% of patients with dyspepsia, usually peptic
ulcer disease, Gastroesophageal Reflux
Disease (GERD), or gastric cancer, IBS
(Irritable Bowel Syndrome).
● In over half of patients, no obvious cause is
found, and the dyspepsia is labeled as
idiopathic or functional dyspepsia.
 Dyspepsia:
Sample Breakdown

Total
Sample
No Dyspepsia
dyspepsia 29%
71%
Acute* dyspepsia Chronic dyspepsia
6.5% 22.5%
* Less than 1 Month (DIGEST, 1996)
 Causes

Reflux oesophagitis 12%

Duodenal ulcer 10%
Gastric ulcer 6%
Gastric carcinoma 1%
Oesophageal carcinoma 0.5%

Non-erosive GERD
Functional (non-ulcer) dyspepsia
 Gastroscopy RSCM 591 cases

Normal 168 28.4 %

Oesophagitis 35 5.9 %
Chronic Gastritis 295 49.9 %
Gastric Ulcer 13 2.2 %
Duodenal Ulcer 21 3.5 %
Oesophagus tumor 1 0.16 %
Gastric tumor 6 1.01 %
Etc 52 8.8 %
 Major Causes of Dyspepsia
Williams 1988 Stanghellini 1996 Heikkinen 1996
(n=1386) (n=1057) (n=766)

60
% of Patients with

50
Diagnosis

40

30

20

10

0
Gastric Cancer Peptic Ulcer Esophagitis/ Functional
GERD Dyspepsia
 Dyspepsia

Functional Non-GI
Dyspepsia Causes of Symptoms
(cardiac disease,
muscular pain, etc.)

Structural Dyspepsia
(GERD, PUD, pancreatic
disease, gallstones, etc.)
 Symptoms of Functional
Dyspepsia
Dysmotility-like Dominant Ulcer-like Dominant

Nocturnal
pain Nausea
Localized Heartburn Bloating
epigastric Retrosternal Early
burning burning satiety
Better Worse
with food with food
Defining Clinical Pathways for
Dyspepsia
 Pathophysiology
● The pathophysiology of dyspepsia is notwell
understood

● Researchers have focused on several key

factors:
(Motility Disorders) vs (Nonmotility Disorders)
Psychosocial factors
UPPER GI MOTILITY IN ALTERED
MOTILITY DYSPEPSIA
Pathomechanisms Functional
Dyspepsia
 Nonmotility Disorders
● With motility disorders, there is little correlation
between symptoms and severity of duodenitis,
and no relationship between treatment and
improvement of mucosal appearance on
endoscopy

● One of the most prevalent theories currently

being evaluated is the possible involvement of
H.pylori infection in non-ulcer dyspepsia (as in
ulcer disease)
Management Therapy
Dyspepsia
 Clarification; Explanation
●Nature of the problem
●What is ulcer & non-ulcer dyspepsia
●Prognosis
●Ulcer dyspepsia can be treated effectively
●Non-ulcer remains recurrent since the
cause is unclear
 Interview and Examination –
Symptoms and Signs
Suggest Suggest Ulcer-like Suggest Dysmotility Suggest
GERD Dyspepsia like Dyspepsia Structural Disease
Heartburn Burning pain Nausea Weight loss
Regurgitation Bloating Dysphagia

Reflux Relief of pain

with food
Localized Early satiety Vomiting
epigastric Pain worse Bleeding
pain with food
Nocturnal/
fasting pain
Management Tx Uninvestigated
Dyspepsia
 Suggested Approach for
Management of Dyspepsia
Dyspepsia

Initial interview and examination

Functional dyspepsia Structural disease or alarm symptoms

Dysmotility-like symptoms dominant

Ulcer-like symptoms dominant

Education/lifestyle modification Test Hp Education/lifestyle modification

+ -
Eradicate
Trial of acid Trial of prokinetic medication
suppression

Success Fail Success Fail Fail Success

Investigate/refer
 SKEMA PENATALAKSANAAN PASIEN
DI PELAYANAN KESEHATAN LINI PERTAMA
DISPEPSIA

Umur < 45 tahun tanpa Usia > 45 atau < usia 45 tahun
tanda-tanda bahaya dengan tanda-tanda bahaya

Terapi empiris selama 2 minggu DISPEPSIA (-) Terapi dihentikan

- Antasid
- H2 antagonis
Penghambat Pompa Proton (PPI) DISPEPSIA (+)
-Obat-obat prokinetik

SEROLOGI (Tervalidasi secara lokal)

ENDOSKOPI Hasil (+) Hasil (-)

Tidak ada sarana RUJUK

Internis, internis plus,
UBT/HpSA Gastroenterologist atau
dokter anak dengan fasilitas
endoskopi
Hasil (-) Hasil (+) Terapi Eradiksi

Gagal
 SKEMA PENATALAKSANAAN PASIEN DISPEPSIA OLEH
GASTROENTEROLOGIS/INTERNIS DENGAN FASILITAS ENDOSKOPI

DISPEPSIA

Umur > 45 tahun Tanda

Tidak bahaya/alarm YA
Gagal terapi
Riwayat ulkus peptikum +
komplikasi
ENDOSKOPI
UBT/HpSA Permintaan pasien
Pengguna aspirin / NSAID

Ha Ha Gastroeshopageal Reflux Pemeriksaan Rapid Urease Test

Disease (GERD) (CLO, MIO, Prontodry*)
sil sil
Histopatology
(-) (+)
Hasil (+) Hasil (-)

Terapi Eradikasi Terapi Simtomatik

Reevaluasi diagnostik

Terapi Simtomatik Gagal

 Choice of Investigation for Ulcer-
like Dyspepsia

Endoscopy UGI Series

More expensive
Issues of access/waiting
lists can be a problem
Allows for biopsy
endoscopy
(cancer, Hp)
Allows diagnosis of
lesions
mucosal lesions (erosions)
Preferred investigation for
dyspepsia
Less expensive
Easy access, usually short
waiting time
If cancer is found,
will be needed
Often misses mucosal
Alternative, especially if
access is a concern
 Investigation of
Dysmotility-like Dyspepsia

Investigations are frequently normal

Reserved for patients with severe symptoms,
vomiting dominant, unresponsive to therapy
Solid-phase gastric emptying test may be useful
Suspected Functional Dyspepsia -
Who to Investigate? –
Alarm symptoms

Over 50 years of age, with new onset of

symptoms
Failed therapy
Cancer fear
Symptoms that are severe as perceived by
patient or physician
 Alarm Symptoms/ Signs*
GI bleeding
 Persistent vomiting
Weight loss (progressive unintentional)
 Dysphagia
 Epigastric mass
 Anaemia due to possible GI blood loss
Age > 50 y.o
NSAID use
Thus all patients with new-onset dyspepsia should have
abdominal examination and FBC
Refer if dyspepsia in 50+* year old

Alarm symptoms/signs (2 week referral)

Unexplained and persistent recent-onset

dyspepsia without alarm symptoms
– Unexplained means no cause known
– Persistent implies present for a length of time
– Recent-onset implies new-not a recurrent
episode.
 First Approach to Dyspepsia

Consider possible causes outside upper GI tract

-Heart, lung, liver, gall bladder, pancreas, bowel

 Consider drugs and stop if possible

- Aspirin / NSAIDs, calcium antagonists, nitrates,
theophyllines, etidronate, steroids
 Referral for Endoscopy

Review medications for possible causes of dyspepsia

(calcium antagonists, nitrates, theophyllines,
bisphosphonates, corticosteroids and non-steroidal
anti-inflammatory drugs [NSAIDs]).

 In patients requiring referral, suspend NSAID use.

 Urgent specialist referral
Endoscopic investigation is indicated for patients of any
age with dyspepsia when presenting with any of the
following:
chronic gastrointestinal bleeding,
progressive unintentional weight loss,
progressive difficulty swallowing,
persistent vomiting,
Iron deficiency anaemia,
epigastric mass
suspicious barium meal
Management of simple dyspepsia
in those aged < 50 years

Stress benign nature of dyspepsia

 Lifestyle advice
– Healthy eating
– Weight reduction
– Stop smoking
– Use of antacids
 Interventions for uninvestigated
dyspepsia

Initial therapeutic strategies for dyspepsia are

empirical treatment with a proton pump inhibitor
(PPI) or testing for and treating H. pylori.
There is currently insufficient evidence to guide
which should be offered first.
A 2-week washout period following PPI use is
necessary before testing for H. pylori with a breath
test or a stool antigen test
 Rx of H. Pylori
One week triple therapy *
 PPI (full dose) e.g. omeprazole 20mg bd
 Clarithromycin 500mg bd
 Amoxycillin 1g bd
(or Metronidazole 400mg bd)

Use urea breath test, stool antigen test or, when

performance has been validated, laboratory based
serology.

If re-testing for H. pylori use urea breath test.*

 Dyspepsia - Therapy

 1. Lifestyle
 2. Farmakologis:
- Acid inhibition: antacids, H2-blocker, PPI
- Cytoprotection: sucralfate, PG analogues
(misoprostol), bismuth
- Prokinetics: metochlorpamide,domperidone,cisapride
- H.pylori eradication: PPI+Antibiotics+bismuth
- Visceral analgetics: opiate agonists
- Tricyclic antidepressants: amitriptyline, mianserin
- Spasmolytics: butylscopolamine
- Antiemetics: Phenotiazine
- psychological intervension
 Lifestyle Modification

●Small frequent meals

●Stop smoking
●Reduce alcohol
●Reduce caffeine
●Avoid irritating food
●Maintain an ideal weight
●Review medication
 Summary

Dyspepsia is common
On clinical grounds, functional dyspepsia can
be separated into ulcer-like and dysmotility-like
Patients with ulcer-like functional dyspepsia
should be tested for Helicobacter pylori, and
treated accordingly
For patients with dysmotility-like functional
dyspepsia, prokinetic drugs are effective
THANK YOU