ANTI-DIARRHEAL DRUGS

the

frequent passage of loose, watery, soft stools with or without abdominal bloating, pressure, and cramps commonly referred to as gas. Diarrhea can come on suddenly, run its course, and be helped with home care to prevent complications such as dehydration.

 Viral

infections cause most cases of diarrhea and are typically associated with mild-to-moderate symptoms with frequent, watery bowel movements, abdominal cramps, and a low-grade fever. Diarrhea generally lasts approximately 3 to 7 days.

 Rotavirus

is a common cause of diarrhea in

infants; Norovirus (for example, Norwalk virus, caliciviruses) is the most common cause of epidemics of diarrhea among adults and school age children (for example, cruise ship infection, schools, nursing homes, day care facilities, and restaurants); and Adenovirus infections are common in all age groups.

 Bacterial

infections cause the more serious cases of diarrhea. Typically, infection with bacteria occurs from contaminated food or drinks (food poisoning). Bacterial infections also cause severe symptoms, often with vomiting, fever, and severe abdominal cramps or abdominal pain Bowel movements occur frequently and may be watery.

In more serious cases, the stool may contain mucus, pus, or blood. Most of these infections are associated with local outbreaks of disease. Family members or others eating the same food may have similar illnesses. Foreign travel is a common way for a person to contract travelers diarrhea. Campylobacter, salmonellae, and shigella organisms are the most common causes of bacterial diarrhea. Less common causes are Escherichia coli (commonly called E coli) Yersinia, and Iisteria. Use of antibiotics can lead to an overgrowth of Clostridium difficile (C diff) bacteria in the intestines.

 Parasites

cause infection of the digestive system by the use of contaminated water. Common parasitic causes of diarrhea include Giardia lamblia, Entamoeba histolytica, and Cryptosporidium. Intestinal disorders or diseases including inflammatory bowel disease, irritable bowel syndrome (IBS), diverticulitis, microscopic colitis, and celiac disease can cause diarrhea

 Reaction

to certain medications can cause diarrhea. Common medications include antibiotics, blood pressure medications, cancer drugs, and antacids (especially ones containing magnesium). Intolerance to foods such as artificial sweeteners and lactose (the sugar found in milk) can cause diarrhea.

Watery, liquid stools: The stools may be any color. The passage of red stools suggests intestinal bleeding and could be a sign of a more severe infection. The passage of thick, tarry black stools suggests significant bleeding in the stomach or upper portions of the intestine and is not usually caused by acute infections. Abdominal cramps: Occasionally diarrhea is accompanied with mild-to-moderate abdominal pain. Severe abdominal or stomach pain is not common and, if present, may suggest more severe disease.

 Fever:

A high fever is not common. If present, the affected person may have a more severe illness than acute diarrhea. Dehydration: If diarrhea leads to dehydration, it is a sign of potentially serious disease.

Replenishing water loss (due to diarrhea) is important. Avoid milk as it can make diarrhea worse. Sports beverages (for example, Gatorade or Powerade) can be beneficial because they replenish electrolytes in addition to providing hydration. If the affected person is able to eat, avoid greasy or fatty foods. Adults, infants, toddlers, and children should be encouraged to follow the "BRAT" diet (bananas, rice, applesauce, and toast). The BRAT diet (diarrhea diet) is a combination of foods used for decades to treat diarrhea. If diarrhea is accompanied by nausea, have the person suck on ice chips until the nausea stops. After the diarrhea subsides, avoid alcoholic beverages and spicy foods for two additional days.

 Individuals

should continue their usual activities if they are mildly ill with diarrhea; however, strenuous exercise should be avoided until they feel better because exercise increases the risk of dehydration. Pregnant women with diarrhea should make sure to rehydrate to avoid dehydration, and should consult their physician.

Infants and toddlers pose special problems because of their increased risk of dehydration. They should be offered a bottle frequently. Solutions such as Pedialyte may be more appealing than water. These fluids also contain necessary electrolytes lost with diarrhea. Never use salt tablets as they may worsen diarrhea. Children with frequent stools, fever, or vomiting should stay at home and avoid school and daycare until these symptoms go away. This allows the child to rest and recover and prevents other children from being exposed to the infection.

 As

mentioned previously, infants, toddlers, and children should be encouraged to follow the "BRAT" diet (bananas, rice, applesauce, and toast). The BRAT diet (diarrhea diet) is a combination of foods used for decades to treat diarrhea.

 Opiates

and Opiate-related Drugs Decrease intestinal motility, thereby decreasing peristalsis LOPERAMIDE HYDROCHLORIDE (Diatabs, Imodium, Diar-Aid Caplets, Pepto Diarrhea Control, Neo-Diaral) Pregnancy category B MOA: slows intestinal motility and affects water and electrolyte movements through the bowel by inhibiting peristalsis through direct effects on the circular and longitudinal muscles of the intestinal wall

SIDE/ADVERSE EFFECTS: abdominal fullness, nausea, vomiting, dry mouth, dizziness INDICATIONS: for control and symptomatic relief of acute non-specific diarrhea and chronic diarrhea; for reduction of volume of discharge from ileostomies; OTC use for diarrhea including travelers diarrhea CONTRAINDICATIONS: persons with allegy to loperamide; patients who must avoid constipation; diarrhea associated with organism that penetrate intestinal mucosa; persons with hepatic impairment, acute ulcerative colitis, pregnancy and lactation

OPIUM PREPARATIONS (Paregoric, Opium tincture) Pregnancy category C MOA: inhibits peristalsis and diarrhea by producing spasm of GI tract smooth muscle SIDE/ADVERSE EFFECTS: nausea, loss of appetite, constipation, dizziness, sedation, drowsiness, impaired visual activity, shortness of breathing or DOB

INDICATIONS: for acute nonspecific diarrhea. To treat withdrawal symptoms in neonates of mothers who are addicted to opiates. Avoid taking alcohol and CNS depressant CONTRAINDICATIONS: diarrhea cause by poisoning, pregnancy, labor or delivery, COPD, respiratory depression, anoxia, lactation, increased intracranial pressure, bronchial asthma

DIFENOXIN and ATROPINE (Motofen, Lomotil) Pregnancy category C MOA: to treat diarrhea by slowing intestinal motility, inhibition of gastric motility SIDE/ADVERSE EFFECTS: drowsiness, constipation, dizziness, dry mouth, weakness, flush, rash, blurred vision, mydriasis, urine retention, angioneurotic edema, severe allergic reaction, paralytic ileus, toxic megacolon

INDICATIONS: for acute nonspecific and chronic diarrhea. CONTRAINDICATIONS: severe hepatic or renal disease, glaucoma, severe electrolyte imbalance; children <2 years old

 Somatostatin

Analog -Octreotide (sadostatin) is a somastatin analogue that is prescribed to inhibit gastric acid, pepsinogen, gastrin, cholecystokinin and serotonin secretions and intestinal fluid. It decreases smooth muscle contractility. It is frequently prescribed for severe diarrhea resulting from metastatic cancer

OCTREOTIDE ACETATE (sadostatin, sadostatin LAR depot) Pregnancy Category B MOA: mimics the natural hormone somatostatin; suppresses secretion of serotonin, gastrin, vasoactive intestinal peptide, insulin, glucagon, secretin, motilin, and pancreatic polypeptide; it also suppresses groeth hormone and decreases splanchnic blood flow

SIDE/ADVERSE EFFECTS: headaches, dizziness, light-headedness, fatigue, nausea, abdominal pain, flushing, dry skin, flaking of skin INDICATIONS: for severe diarrhea resulting from metastatic carcinoid tumors CONTRAINDICATIONS: use caustiously with renal impairment, thyroid disease, diabetes mellitus, pregnancy, lactation; persons with hypersensitivity with octreotide

Adsorbents -Acts by coating the wall of the GI Tract and adsorbing bacteria or toxins that cause diarrhea BISMUTH SUBSALICYLATE (Bismatrol, Bismatrol extra strength, Kao- Tin, Kaopectate, peptobismol, peptic relief, Maalox total stomach, pink bismuth) Pregnancy category C MOA: adsorbents actions remove irritants from the intestine, forms a protective coating over the mucosa and soothes the irritated bowel lining

SIDE/ADVERSE EFFECTS: report for fever or diarrhea that does not stop after 2 days, ringing in the ears, rapid respirations INDICATIONS: for diarrhea , gastric distress; to reduce the number of bowel movements and help firm stool CONTRAINDICATIONS: persons with allergy to this drug, use cautiously with pregnancy, lactation

Miscellaneous Antidiarrheals RIFAXIMIN (xifaxan) Pregnancy category C MOA: binds to bacterial DNA-dependent RNA polymerase; inhibits bacterial synthesis SIDE/ADVERSE EFFECTS: dizziness, flatulence, abdominal pain, nausea; report for bloody diarrhea, fever, worsening diarrhea INDICATIONS: for treatment of travelers diarrhea caused by noninvasive strains of E. coli CONTRAINDICATIONS: persons with allergy to this drug; use cautiously with pregnancy

VOMITING AND EMETICS

Expulsion

of gastric contents Has a multitude of causes, including motion of sickness, viral and bacterial infection, food intolerance, surgery, pregnancy, pain, shock, effects of selected drugs, radiation, and disturbances of the middle ear that affect equilibrium

 Nausea,

a queasy sensation, may or may not precede the expulsion. Antiemetics can mask the underlying cause of vomiting and should not be used until the cause has been determined, unless the vomiting is so severe as to cause dehydration and electrolyte imbalance.

 Two

major cerebral centers: Chemoreceptor trigger zone(CTZ) lies near the medulla : Vomiting center in the medullacause vomiting when stimulated *the neurotransmitter Dopamine stimulates the CTZ, which in turn stimulates the vomiting center. *the neurotransmitter Acetylcholine is also a vomiting stimulant

 When

vomiting center is stimulated, the motor neuron responds by causing contraction of diaphragm, the anterior muscles, and the stomach. The glottis closes, the abdominal wall moves upward and vomiting occurs Nonpharmacologic measures should be used first when nausea and vomiting occur

 Two

major groups of antiemetics are: nonprescription: antihistamines, bismuth, subsalicylate, phosphorated carbohydrate solution prescription: antihistamines, dopamine antagonists, benzodiazepines, serotonin antagonists, glucocortisoids, cannabinoids, and miscellaneous antiemetics

 Methods

to decrease nausea and vomiting Includes: administration of weak tea, flattened carbonated beverage, gelatin, Gatorade, and Pedialyte( for children) Crackers and dry toast may be helpful * When dehydration becomes severe, intravenous fluids are needed to restore body fluid balance*

 Antivomiting

agents Can be purchased as over-the-counter drugs These drugs are frequently used to prevent motion sickness but have minimal effect on controlling severe vomiting resulting from anticancer agents ( antineoplastics), radiation, and toxins Should be taken 30minutes before travel, to prevent motion sickness

 Selected

antihistamine antiemetics such as: - dimenhydrinate(Dramamine) -cyclizine hydrochloride(Marezine) -meclizine hydrochloride(Antivert) -diphenhydramine hydrochloride(Benadryl)[ also used to prevent/alleviate allergic reactions to drugs, insects, and food by acting as an antagonist to H1 receptors Can be purchased over the counter to prevent nausea, vomiting, and dizziness(vertigo) caused by motion

 The

side effects of antihistamine antiemetics are similar to those of anticholinergics: drowsiness, dryness of the mouth, and constipation Several nonprescription drugs such as bismuth subsalicylate(Pepto-Bismol) act directly on the gastric mucosa to suppress vomiting; may be in liquid and chewable tablet forms; can be taken for gastric discomfort or diarrhea

 Phosphorated

carbohydrate solution(Emetrol)- hyperosmolar carbohydrate; decreases nausea and vomiting by the contraction of the stomach. *clients with diabetes should avoid this drug because of its high sugar contant* Antiemetics are no longer recommended to pregnant women because they may cause harm to the fetus; *if vomiting becomes severe and threatens the well being of the fetus, Trimethobenzamine(Tigan) can be administered. *

 Common

prescription antiemetics are classified into following groups:

Antihistamines Anticholinergics Dopamine antagonists Benzodiazepines Serotonin antagonists Glucocorticoids

Cannabinoids(Clients

with cancer)

 Miscellaneous *Cannabinoids act on the cerebral cortex; *Phenothiazines and the miscellaneous antiemetics act on CTZ center Drug combination theraphy is commonly used to manage chemotheraphy-induced nausea and vomiting *Lorazepam(Ativan), glucocorticoids, and Serotonin receptor antagonists are quite effective in combination theraphy. Lorazepam, haloperidol, and glucocorticoids are not approved by FDA

 Only

few prescription of these drugs are used in the treatment of nausea and vomiting Side and adverse Effects: Drowsiness, dry mouth, blurred vision( caused by papillary dilation), tachycardia, and constipation * These drugs should not be used by clients with glaucoma

 Suppress

emesis by blocking dopamine2 receptors in the CTZ. Categories include: phenothiazines, butyrophenones, and metoclopramide Common side effects of dopamine antagonists are extrapyrimidal symptoms(EPS) which are caused by blocking dopamine receptors, and hypotension

Selected piperazine phenotiazines are used to treat nausea and vomiting resulting from surgery , anesthetics, chemotheraphy, and radiation sickness They act by inhibiting CTZ Not all phenothiazinesn are effective antiemetic agents; *when prescribed for vomiting, the drug dose is usually smaller than when used in psychiatric patients Chlorpromazine(Thorazine) and prochlorperazine edisylate(Compazine) were the first phenothiazines used for both psychosis and vomiting

Promethazine(Phenergran)- phenothiazine, introduced as an antihistamine (1940) has a sedative effect and can also be used for motion sickness and management of nausea and vomiting Promethazine is the most frequent prescribed antiemetic drug CNS depression increases when promethazine is taken with alcohol, narcotics, sedative-hypnotics, and general anesthetics Anticholinergic effects increase when promethazine is combined with antihistamines, anticholinergics such as atropine, and other phenothiazines

 Promethazine

may interfere with urinary pregnancy tests, producing false results Side effects:
moderate sedation

hypotension EPS CNS effects Mild anticholinergic symptoms

 Haloperidol(Haldol) and droperidol(Inapsine), like phenothiazine, block the dopamine2 receptors in the CTZ They are used to treat postoperative nausea and vomiting and emesis associated with toxins, cancer chemotheraphy and radiation theraphy. *cause EPS id used for and extended time; Hypotension may also be a result

Metoclopramide(Reglan) suppresses emesis by blocking the dopamine receptors in the CTZ Used in the treatment of postoperative emesis, cancer chemotheraphy, and radiation theraphy High doses can cause sedation and diarrhea *should not be given if the client has GI obstruction, hemorrhage, or perforation

 Indirectly

control nausea but may occur with cancer chemotheraphy Lorazepam(Ativan) -drug of choice -provides emesis control,sedation, anxiety reduction, and amnesia when used in combination with a glucocorticoid and serotonin

Suppress nausea and vomiting by blocking serotonin receptors( 5-HT3) in the CTZ and afferent vagal nerve terminals in the upper GI tract Ondansetron(Zofan), granisetron(Kytril), dolasetron(Anzamet), and palonosetron(Aloxi) are most effective of all antiemetics in suppressing nausea and vomiting caused by cancer chemotheraphy-induced emesis or emetogenic anticancer drugs

These drugs can be administered orally and IV Ondasetron(Zensana) form tha is available in an oral spray delivery system; they are also effective in preventing nausea and vomiting before and after surgery Common side effects include: headache, diarrhea, dizziness and fatigue

 Dexamethasone(Decardon)

and methylprednisolone(Solu-Medrol) are two agents that are effective in suppressing emesis associated with cancer chemotheraphy

 Active

ingredient in Marijuana. May be prescribed to clients receiving chemptherapy who do not respond to or unable to take other antiemetics. Contraindicated for clients with psychiatric disorder Used as an appetite stimulant for patient with AIDS

 Diphenidol

(Vontrol) and Trimethobenzidine (Tigan) are in the class of miscellaneous antiemetics because they do not act strictly as antihistamines, anticolinergics, or phenothiazines. Suppress impulses to the CTZ. Diphenidol alos prevent vertigo by inhibiting impulses to the vestibular area.

 Side

effects and Adverse reaction: drowsiness and anticholinergic symptoms( dry mouth, increased heart rate, urine retention, constipation, blurred vision) Trimethobenzamide can cause hypotension, diarrhea, and EPS (abnormal involuntary movements, postural disturbance and alteration in muscle tone)

Drugs used to induce vomiting Vomiting should not be induced if caustic substances such as ammonia, chlorine bleach, lye, toilet cleaners, and battery acids have been ingested. Regurgitating this substance can cause additional injury to the esophagus. Activated charcoal is given when emesis is contraindicated.

Ipecac syrup should not be administered routinely in the management of poisoned individuals. It can be appropriate for the client who is alert and if administered within 60 minutes of poisoning. Instruct client to get Ipecac syrup and not Ipecac fluid extract, which is more potent and may cause fatalities if the client is going to purchase Ipecac. Keep out of the reach of children in house.

Ipecac syrup induce vomiting by stimulating the CTZ in the medulla and acting directly on the gastric mucosa. It should be taken with a glass of water( do not give with milk or carbonated beverage) The onset of emesis production following administration of ipecac syrup is usually 15 to 30 minutes when vomiting is induced, client should be treated with an absorbent, such as activated charcoal or gastric lavage individuals with bulimia and anorexia nervosa often abuse ipecac, which may lead to cardiomyopathy, ventricular fibrillation, death.

ANTI-ULCER DRUGS

CONSTIPATION

Is a relatively common complaint and a major problem for older adults. Insufficient water intake and poor dietary habits are contributing factors. Other causes include (1) fecal impaction, (2) bowel obstruction, (3) chronic laxative use, (4) neurologic disorders (paraplegia), (5) ignoring the urge to defecate, (6) lack of exercise, and (7) selected drugs, such as anticholinergics, narcotics, and certain antacids.

Nonpharmacologic management includes diet (high fiber), water , exercise, and routine bowel habits. A normal number of bowel movements ranges between one to three a day to three a week. At times a laxative may be needed, but the client should also use nonpharmacologic measures to prevent constipation.

Laxatives and cathartics are used to eliminate fecal matter. Laxatives promote a soft tool, cathartics result in a soft to watery tool with some cramping, and frequently dosage determines whether a drug acts as a laxative or cathartic. Purgatives are harsh cathartics that cause watery stool with abdominal cramping. Four types of laxatives: (1) osmotic (saline) , (2) stimulants (contact or irritants) , (3) bulk forming, and (4) emollients (stool softeners).

Osmotics (hyperosmolar laxatives) include salts or saline products, lactulose, and glycerin. Saline products consist of sodium or magnesium, and a small amount is systematically absorbed. Hyperosmolar salts pull water into the colon and increase water in the feces to increase bulk, which stimulates peristalsis. Saline cathartics cause a semiformed to watery stool according to low or high doses. Saline cathartics are contraindicated for clients with heart failure. Osmotic laxatives contain three types of electrolyte salts, including sodium salts, magnesium salt, potassium salts.

Clients who have renal insufficiency should avoid magnesium salts. Hypermagnesemia can result from continuous use of magnesium salts, causing symptoms such as drowsness, weakness, paralysis, complete heart block, hypotension, flush, and respiratory depression. The side effects of excess lactulose use include flatulence, diarrhea, abdominal cramps, nausea, and vomiting. Clients who have diabetes mellitus should avoid lactulose, because it contains glucose and fructose.

Stimulant (contact or irritant) laxatives increase peristalsis by irritating sensory nerve endings in the intestinal mucosa. Bisacodyl and phenolphthalein are two of the most frequently used and abused laxatives and can be purchased OTC. Results usually occur to 6 to 12 hours after ingestion. Castor oil is a harsh laxative (purgative) that acts on the small bowel and produces a watery stool. The action is quick, within 2 to 6 hours, so the laxative should not be taken at bedtime.

Pharmacokinetics The contact laxative bisacodyl is minimally absorbed from the GI tract. It is excreted in feces, but because of the small amount of bisacodyl absorption, a portion is excreted in urine. Pharmacodynamics Bisacodyl promotes defecation. Bisacodyl irritates the colon, causing defecation, and psyllium compounds increase fecal bulk and peristalsis. The onset of action of oral bisacodyl occurs within 6 to 12 hours and with suppository (rectal administration) , within 15 to 60 minutes.

 Side

Effects and Adverse Reactions Side effects include nausea, abdominal cramps, weakness, and reddish brown urine caused by excretion of phenolphthalein, senna, or cascara. Mild cramping and diarrhea are side effects of bisacodyl. Castor oil should not be used in early pregnancy, because it stimulates uterine contraction. Spontaneous absorption may result.

Bulk-forming laxatives are natural fibrous substances that promote large, soft stools by absorbing water into the intestine, increasing fecal bulk and peristalsis. These agents are nonabsorbable. Defecation usually occurs within 8 to 24 hours; however, it may take up to 3 days after drug therapy is started for the stool to be soft and well formed. Powdered bulk-forming laxatives, which sometimes com in flavored and sugar-free forms should be mixed in a glass of water or juice, stirred, drunk immediately, and followed by a half to a full glass of water. Insufficient fluid intake can cause the drug to solidify in the GI tract, which can result in intestinal obstruction. Calcium polycarbophil (Fibercon) methylcellulose (Citrucel), fiber granules (Perdiem), and psyllium hydrophilic mucilloid (Metamucil) are examples of bulk-forming laxatives.

 BISACODYL

Drug class Laxative: Stimulant Trade names: Dulcolax; Apo-Bisacodyl, Bisacolax Pregnancy Category: C Contraindications Hypersensitivity, fecal impaction, intestinal/biliary obstruction, appendicitis, abdominal pain, nausea, vomiting, rectal fissures

Dosage A: PO: 5-15 mg in Am or PM PRN; max: 30 mg C: >6 y: PO: 5-10mg; 0.3 mg/kg/d A & C: >2 y: Rectal supp: 5-10 mg/d C <2 y, infants: 5mg Drug-Lab-Food interactions Drug: Decrease effects with antacids, histamine blockers, milk

Pharmacokinetics Absorption: Minimal (5% - 15%) Distribution: PB UK Metabolism: t1/2: UK Excretion: In bile and urine Pharmacodynamics PO: Onset: 10-15 min Peak: UK Duration: 6-12 hours PR: Onset: 15-60min Peak: UK Duration: 6-12 hr

Therapeutic Effects/Uses Short term treatment or constipation; bowel preparation for diagnostic tests Mode of Action: Increases Peristalsis by direct effect on smooth muscle of intestine Side Effects Anorexia, nausea, vomiting, cramps, diarrhea Adverse Reactions Dependence, hypokalemia Life-threatening: Tetany

 A,

Adult; C, child ; d , day; h, hour; max, maximum; min, minute; PB, proteinbinding; PO, by mouth; PR, per rectum;PRN, as needed Supp, suppository; t1/2, halflife; UK, unknown; y, year; >,greater than; <less than;

Pharmacokinetics The bulk-forming laxative metamuccil is a nondigestable and nonabsorbent substance that, when mixed with water, becomes a viscous solution. Because it is not absorbed, there is no problem-binding or half life for the drug. Metamuccil is excreted in the feces. Pharmacodynamics The onset of action for Metamuccil is 10 to 24 hours. Peak action is 1 to 3 days. The duration of action is unknown. Side effects and Adverse Reactions Bulk-forming laxatives are not systematically absorbed; therefore there is no systemic effect. If bulk-forming laxatives excessively used, nausea, vomiting, flatus, or diarrhea may occur. Abdominal cramps may occur of the drug is used in dry form.

Selective chloride channel activators are a new category of laxatives used to treat idiopathic constipation in adults. The first drug in this category is lubiprostone, manufactured by Sucampo Pharmaceuticals. Lubigprostone was approved by the FDA in January 2006. This drug activates chloride channels in the lining of the small intestine, leading to an increase in intestinal fluid secretion and motility. Lubiprostone is contraindicated for clients with a history of mechanical GI obstruction. Adverse effects of lubiprostone include nausea, which seems to be dosedependent, diarrhea headache, abdominal distention, and flatulence.

 Emollients

are lubricants and stool softeners (surface acting or wetting drugs) used to prevent constipation. These drugs decrease straining during defecation. Lubricants such as mineral oil increase water retention in the stool. Mineral oil absorbs essential fat-soluble vitamins A, D, E and K. some of the minerals can be absorbed into the lymphatic system.

 Stool

softeners work by lowering surface tension and promoting water accumulation in the intestine and stool. Docusate calcium (SurFak), dicusate potassium (Dialose) , docusate sodium (Colace), and docusate sodium with casanthranol (Pero-Colace) are examples of stool softeners.

Side effects of mineral oil include nausea, vomiting, diarrhea, and abdominal cramping. This laxative is not indicated for children, older adults, or clients with debilitating diseases , because they might aspirate the mineral oil, resulting in lipid pneumonia.

circumscribed inflammatory and often suppurating lesion on the skin or an internal mucous surface resulting in necrosis of tissue There are three most common types of stomach ulcer: esophageal ulcer, gastric ulcer and duodenal ulcer

 The

hydrochloric acid (HCl) from the parietal cells of the stomach is influenced by histamine, gastrin and acetylcholine. Peptic ulcer occurs when there is hypersecretion of hydrochloric acid and pepsin, which erode the GI mucosal lining The gastric secretions in the stomach strive to maintain a pH of 2-5 for the activation of Pepsin (a digestive enzyme which is activated at pH 2)

 The

gastric mucosalbarrier is the property of the stomach that allows it to contain acid. If the barrier is broken, acid diffuses back into the mucosa where it can cause damage to the stomach itself.

 An

esophageal ulcer results from reflux of acidic gastric secretions into the esophagus as a result of defective or incompetent cardiac sphincter. A gastric ulcer results from the breakdown of the gastric mucosal barrier A duodenal ulcer is caused by hypersecretion of acid from the stomach passing into the duodenum

 Insufficient

buffers to neutralize gastric acid in the stomach A defective or incompetent pyloric sphincter Hypermotility of the stomach

 Mechanical

Hypersecretion

of acid

disturbances

and pepsin; inadequate GMB mucous secretion; impaired GMB resistance; hypermotility of the stomach; incompetent (defective) cardiac and pyloric sphincter

Genetic influences

Increased number of parietal cells in the stomach; susceptibility of mucosal lining to acid penetration; susceptibility to excess acetylcholine and histamine; excess hydrochloric acid caused by external stimuli

 Environmental

Food

influences

and liquids containing caffeine; fatty, fried and highly spiced foods; alcohol; nicotine, especially from cigarette smoking; stressful situations; pregnancy; massive trauma; major surgery

 Helicobacter

pylori

gram negative bacterium H. pylori infects gastric mucosa and can cause gastritis, gastric ulcer, and duodenal ulcer. If not eradicated, H. pylori can return as frequently as every year.

 Drugs

Non-steroidal

antiinflammatory drugs (NSAID), including aspirin and aspirin compounds, ibuprofen and indomethacin; corticosteroids; potassium salts; antineoplastic salts

 H.

pylori evades attack by the host immune system and causes chronic, indolent inflammation by several mechanisms. H. pylori can damage the mucosal defense system by reducing the thickness of the mucus gel layer, diminishing mucosal blood flow, and interacting with the gastric epithelium throughout all stages of the infection. H. pylori infection can also increase gastric acid secretion; by producing various antigens, virulence factors, and soluble mediators,

 H.

pylori induces inflammation, which increases parietal-cell mass and, therefore, the capacity to secrete acid. The H. pylori cytotoxin-associated gene CagA also has an important role: it interferes with gastric epithelial cell-signalling pathways, thereby regulating cellular responses and possibly contributing to apical junction barrier disruption, interleukin-8 secretion and phenotypic changes to gastric epithelial cells.

 chronic

symptoms for mucosal damage caused by stomach acid coming up from the stomach into the esophagus An inflammation of the esophageal mucosa Drugs used in treatment include H2 blockers such as ranitidine (Zantac), and PPIs such as omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix), or esomeprazole (Nexium).

PPI relieves symptoms faster and maintains healing better than an H2 blocker. Effective management of GERD keeps the esophageal mucosa healed and the client free of symptoms, but GERD is a chronic disease that needs continuous care.

 Avoid

tobacco and alcohol With obesity, weight loss is helpful in decreasing symptoms Avoid hot, spicy, and greasy foods NSAID drugs should be taken with food or in a decreased dosage. To relieve symptoms of GERD, the client should raise the head of the bed, not eat before bedtime and wear loose-fitting clothing

 There

are 7 groups of anti-ulcer agents: (1) tranquilizers, which decrease vagal activity; (2) anticholinergics, which decrease acetylcholine by blocking the cholinergic receptors; (3) antacids which neutralize gastric acid; (4) H2 blockers, which block the H2 receptors;

 (5)

PPIs which inhibit gastric acid secretion, regardless of acetylcholine or histamine secretion; (6) the pepsin inhibitor sucralfate and (7) the prostaglandin E1 analogue misoprostol, which inhibits gastric acid secretion and protects the mucosa

 Have

minimal effect in preventing and treating ulcers; however reduce vagal stimulation and decrease anxiety Librax, a combination of the anxiolytic chlordiazepoxide (Librium) and the anticholinergic clidinium bromide (Quarzan may be used in the treatment of ulcers.

 Was

the DOC for peptic ulcers until the introduction of H2 blockers in 1975. They relieve pain by decreasing GI motility and secretion They inhibit acetylcholine and block histamine and hydrochloric acid. Delay gastric emptying so are more used frequently for duodenal ulcers than gastric ulcers.

 Anticholinergics

should be given prior to meals because of the acid secretion that occurs with eating. Antacids can slow the absorption of anticholinergics therefore these should be taken 2 hrs after anticholinergic administration.

Dry mouth Decreased secretions Headache Blurred vision Drowsiness Dizziness Lethargy Palpitations Bradycardia, tachycardia Urinary retention Constipation Because gastric emptying is delayed, gastric secretions are stimulated therefore aggravating ulcerations

 Promote

ulcer healing by neutralizing hydrochloric acid and reduce pepsin action Two types of antacids: those that have a systemic effect those that have a nonsytemic effect

 Sodium

Bicarbonate- one of the first antiulcer drugs; because of its many side effects, it is seldom used to treat peptic ulcer. Examples are, Bromo-Seltzer and Alka-Seltzer Calcium carbonate- most effective in neutralizing acids however a third to half of the drug can be systemically absorbed and can cause acid rebound

 Composed

of alkaline salts such as aluminum and magnesium. There is a small degree of systemic absorption with these drugs, mainly of aluminum Magnesium has greater neutralizing power than aluminum. A combination of magnesium and aluminum salts neutralizes gastric acid without causing severe diarrhea or constipation

 The

ideal dosing for antacids is 1 and 3 hrs after meals and at bedtime Antacids with magnesium salts are contraindicated to clients with impaired renal function. Prolonged use of aluminum hydroxides can cause hypophosphatemia

Aluminum carbonate A: PO: 10-30 ml or 2tab/cap q2h -to alleviate gastric hyperacidity related to gastritis, gastric and duodenal ulcers, esophageal reflux and hiatal hernia; increases gastric pH and inhibits pepsin activity. Duration of action is 2-3h when taken 1h after meals. Pregnancy category C