GI & HPB by Dr.Ayman Shamsia

8/7/2019 GI & HPB by Dr.Ayman Shamsia.

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COMMON GASTROCOMMON GASTRO--

INTESTINAL &INTESTINAL &

HEPATOBILIARYHEPATOBILIARY

DISORDERSDISORDERS

ROLE OF THEROLE OF THE

PHARMACISTPHARMACIST



BYBY

Dr AYMAN M SHAMSEYADr AYMAN M SHAMSEYA

A. LECTURER OF INT MEDA. LECTURER OF INT MED

FACULTY OF MEDICINEFACULTY OF MEDICINE



Primary care«..WHO??Primary care«..WHO??

Across most of Europe & NorthAcross most of Europe & North

America, primary care is aAmerica, primary care is a

specific specialty that existsspecific specialty that existswithin a range of healthcarewithin a range of healthcare

systems & culturessystems & cultures

It is at the forefront of care of It is at the forefront of care of

most patientsmost patients




A primary care physician isA primary care physician isgenerally the first point of medicalgenerally the first point of medical

input when a person chooses toinput when a person chooses toconsultconsult

In primary care, GI problems tendIn primary care, GI problems tendto be undifferentiated &to be undifferentiated &management is largely symptommanagement is largely symptom--basedbased




An empiric approach in primaryAn empiric approach in primary

care is often more appropriatecare is often more appropriate

than the diagnostic modelthan the diagnostic modelgenerally used in secondarygenerally used in secondary

care, where investigation ratescare, where investigation rates

tend to be higher tend to be higher



Diseases of the gastrointestinalDiseases of the gastrointestinal

tract & liver together accounttract & liver together account

for aboutfor about 1010% of the total% of the total

burden of illness,burden of illness, 5050 millionmillionoffice visits, and nearlyoffice visits, and nearly 1010

million hospital admissionsmillion hospital admissions

annually in the USannually in the US



The cost of gastrointestinalThe cost of gastrointestinal

diseases depends on their diseases depends on their prevalence, direct costs (fees,prevalence, direct costs (fees,

hospital charges,hospital charges,

pharmaceutical costs), andpharmaceutical costs), and

indirect costs (time loss fromindirect costs (time loss from

work)work)



Anatomic considerationsAnatomic considerations



GI overviewGI overview

The major function of theThe major function of the

gastrointestinal tract is togastrointestinal tract is to

absorb water & nutrients whileabsorb water & nutrients whilefood moves physically fromfood moves physically from

mouth to colon where nonmouth to colon where non--

absorbable wastes are storedabsorbable wastes are stored

for periodic eliminationfor periodic elimination



Clinical approachClinical approach

The diagnosis of The diagnosis of

gastrointestinal diseasesgastrointestinal diseases

derives predominantly from thederives predominantly from thepatient¶s history and, to lesser patient¶s history and, to lesser

extent, from the physician¶sextent, from the physician¶s

examinationexamination



SYMPTOMATOLOGYSYMPTOMATOLOGY

The cardinal symptoms of The cardinal symptoms of

gastrointestinal diseases are:gastrointestinal diseases are:

Nausea & vomitingNausea & vomiting

Weight lossWeight loss

BleedingBleeding



CONSTIPATIONCONSTIPATION



CONSTIPATIONCONSTIPATION



DIARRHEADIARRHEA



Abdominal painAbdominal pain



BLOATINGBLOATING



NAUSEA & VOMITINGNAUSEA & VOMITING

Nausea is the unpleasantNausea is the unpleasant

feeling that one is about tofeeling that one is about to

vomitvomit

Vomiting (emesis) is theVomiting (emesis) is the

forceful ejection of contents of forceful ejection of contents of

the upper gut through thethe upper gut through the

mouthmouth




Causes of nausea & vomiting:Causes of nausea & vomiting:

1.1. Local gastrointestinal disease:Local gastrointestinal disease:

GatritisGatritis

Gastric ulcersGastric ulcers

Gastric neoplasmsGastric neoplasms

CholecystitisCholecystitis

pancreatitispancreatitis



NAUSEA & VOMITINGNAUSEA & VOMITING22. Systemic causes:. Systemic causes:

Elevated intraElevated intra--cranial pressure (benigncranial pressure (benignor neoplastic)or neoplastic)

Inner ear diseaseInner ear disease

Medications: (act locally on the stomach;Medications: (act locally on the stomach;NSAIDs, erythromycin, or cardiac antiNSAIDs, erythromycin, or cardiac anti--

arrhythmics or systemically likearrhythmics or systemically likechemotherapeutics and opiates)chemotherapeutics and opiates)

pregnancypregnancy




Antiemetic agents include:Antiemetic agents include:55--HTHT33 antagonists: ondansetron & othersantagonists: ondansetron & others

DD--22 antagonists: domperidone &antagonists: domperidone &metoclopramidemetoclopramide

HH--11 antagonists: diphenhydramine &antagonists: diphenhydramine &

cyclizinecyclizine




Historical information concerningHistorical information concerning

the duration, precipitation, & patternthe duration, precipitation, & pattern

of nausea & vomiting as well as theof nausea & vomiting as well as thenature of the vomitus are notnature of the vomitus are not

sufficient and one must also seeksufficient and one must also seek

signs of gastrointestinal diseasessigns of gastrointestinal diseases&/or CNS diseases&/or CNS diseases



Abdominal painAbdominal painPain is anPain is an

unpleasantunpleasant

sensation that issensation that is

perceived by theperceived by the

patient aspatient as

distressing; it isdistressing; it is

the most commonthe most commoncause for seekingcause for seeking

medical advicemedical advice



Abdominal painAbdominal painIn addition to the location of pain,In addition to the location of pain,

the character of pain (burning,the character of pain (burning,

steady, or colicky), its duration,steady, or colicky), its duration,time to reach peak, &its relievingtime to reach peak, &its relieving

and aggravating factors (such asand aggravating factors (such as

eating, passing stool or flatus)areeating, passing stool or flatus)arehelpful components of the medicalhelpful components of the medical

historyhistory



Abdominal painAbdominal painThe most common causes of The most common causes of

abdominal pain are:abdominal pain are: EsophagitisEsophagitis

Peptic ulcer Peptic ulcer

Gall bladder colicGall bladder colic

CholecystitisCholecystitis

PancreatitisPancreatitis Functional abdominal pain (IBS & nonFunctional abdominal pain (IBS & non--ulcer ulcer

dyspepsia)dyspepsia)



GI bleedingGI bleedingBleeding from the gastrointestinalBleeding from the gastrointestinal

tract may be gross & evident astract may be gross & evident as

hematemesis, melena, or hematemesis, melena, or hematochezia, or it may be occult;hematochezia, or it may be occult;

presenting as unexplained anemia &presenting as unexplained anemia &

requiring testing of the stool to berequiring testing of the stool to bedetecteddetected



GI bleedingGI bleeding It is always a serious symptomIt is always a serious symptom

that requires investigationsthat requires investigations

Endoscopy is the mostEndoscopy is the mosteffective way to diagnose theeffective way to diagnose the

cause of & to estimate thecause of & to estimate the

severity of bleedingseverity of bleeding











constipationconstipationConstipation is so common aConstipation is so common acomplaint that it is often notcomplaint that it is often notconsidered to be a symptom of aconsidered to be a symptom of adiseasedisease

It may result from endocrine,It may result from endocrine,metabolic, neurological, or anometabolic, neurological, or ano--

rectal causes, but more commonly itrectal causes, but more commonly itis idiopathicis idiopathic



constipationconstipationThe primary & usually empiricThe primary & usually empiric

treatment in the absence of antreatment in the absence of an

evacuation disorder is the trialevacuation disorder is the trialof high fiber diet or fiber of high fiber diet or fiber

medicationmedication





Functional GI disordersFunctional GI disorders

In clinical practice, mostIn clinical practice, mostpatients who present withpatients who present with

chronic or recurrentchronic or recurrentgastrointestinal symptoms dogastrointestinal symptoms donot have a structural or not have a structural or

biochemical explanationbiochemical explanationidentified by routine diagnosticidentified by routine diagnosticteststests




These patients are labeled asThese patients are labeled as

havinghaving functional functional

gastrointestinal disorder gastrointestinal disorder The wordThe word FUNCTIONALFUNCTIONAL does notdoes not

imply a psychiatric disturbanceimply a psychiatric disturbance

or absence of disease but rather or absence of disease but rather

a disorder of gut functiona disorder of gut function




Based on clinical &Based on clinical &

epidemiologic studies, the mostepidemiologic studies, the most

widely recognized functional GIwidely recognized functional GIdisorders are irritable boweldisorders are irritable bowel

syndrome (IBS), functional (nonsyndrome (IBS), functional (non--

ulcer) dyspepsia, and functionalulcer) dyspepsia, and functional(non(non--cardiac) chest paincardiac) chest pain



IBSIBSPreviously, ,most patients withPreviously, ,most patients withabdominal pain or dysfunctionabdominal pain or dysfunction

of bowel were labeled as havingof bowel were labeled as havingIBS, but now it is considered toIBS, but now it is considered tobe characterized by:be characterized by:

Chronic or recurrent abdominal painChronic or recurrent abdominal painErratic disturbance of defecationErratic disturbance of defecation

Bloating (very common)Bloating (very common)



IBSIBSSymptoms consistent with IBS are reportedSymptoms consistent with IBS are reported

by one in six in America, Europe,by one in six in America, Europe,

Australia, & Asia (women more than menAustralia, & Asia (women more than men

and similar in whites & blacks)and similar in whites & blacks)

Only about one third of persons with IBSOnly about one third of persons with IBS

consult a physician, but the condition still consult a physician, but the condition still

accounts for accounts for 1212% of primary care visits% of primary care visits





Functional dyspepsiaFunctional dyspepsia

Dyspepsia refers to persistentDyspepsia refers to persistent

or recurrent epigastric or or recurrent epigastric or

subjective upper abdominalsubjective upper abdominaldiscomfort that may bediscomfort that may be

characterized by early satiety,characterized by early satiety,

postprandial fullness, bloating,postprandial fullness, bloating,or nausea.or nausea.




PopulationPopulation--based studies frombased studies from

around the world indicate thataround the world indicate that

the prevalence of dyspepsia isthe prevalence of dyspepsia isaboutabout 2525%, only%, only 2525% of them% of them

(in the US) seek medical advice(in the US) seek medical advice




Treatment of unTreatment of un--investigated NUD:investigated NUD:

1.1. Dietary modificationsDietary modifications

2.2. AntacidsAntacids

3.3. Acid suppressing agentsAcid suppressing agents

4.4. ProkineticsProkinetics

5.5. CytoprotectionCytoprotection





GastroGastro--esophageal refluxesophageal reflux

diseasediseaseGERD is one of the most prevalentGERD is one of the most prevalent

diseases in the western worlddiseases in the western world

(based on the prevalence of (based on the prevalence of heartburn)heartburn)

Recurrent heartburn (which is theRecurrent heartburn (which is the

hallmark of GERD) enables ahallmark of GERD) enables adiagnosis of GERD to be made bydiagnosis of GERD to be made by

history alonehistory alone




diseasediseaseGERD, however, can induceGERD, however, can induce

damage to the orodamage to the oro--pharynx,pharynx,

larynx, & respiratory tract,larynx, & respiratory tract,leading consequently toleading consequently to

recurrent cough, asthma,recurrent cough, asthma,

earache, dental erosions, or earache, dental erosions, or globus sensationglobus sensation




diseasediseaseEmpiric treatment with antacidsEmpiric treatment with antacids

or acidor acid--suppressing agents,suppressing agents,

with positive response iswith positive response issometimes used to confirm thesometimes used to confirm the

diagnosis of GERDdiagnosis of GERD




diseasedisease1.1. Life style modificationsLife style modifications

2.2. Drug therapyDrug therapy







Peptic ulcer diseasePeptic ulcer disease

The most common causes of The most common causes of

peptic ulcer disease arepeptic ulcer disease are

infection with Helicobacter infection with Helicobacter Pylori and the use of nonPylori and the use of non--

steroidal antisteroidal anti--inflammatoryinflammatory

drugs (NSAIDs)drugs (NSAIDs)




Classically, an ulcer wasClassically, an ulcer was

considered likely when painconsidered likely when pain

was located in the epigastricwas located in the epigastricarea, was burning in quality,area, was burning in quality,

occurred on an empty stomachoccurred on an empty stomach

22 toto 44 hours after meals &/or athours after meals &/or atnight, was relieved by antacidsnight, was relieved by antacids

&/or meals&/or meals




This pattern of pain has beenThis pattern of pain has been

called acid dyspepsia becausecalled acid dyspepsia because

it occurs when acid isit occurs when acid isunbuffered by food and isunbuffered by food and is

relieved with neutralizing acidrelieved with neutralizing acid

or inhibiting acid secretionor inhibiting acid secretion







Diarrhea & dysenteryDiarrhea & dysentery

Normal stool frequency rangesNormal stool frequency ranges

from three times a week to threefrom three times a week to three

times a daytimes a dayA decrease in stool consistencyA decrease in stool consistency

(increased fluidity) and stools(increased fluidity) and stools

that cause urgency or abdominalthat cause urgency or abdominal

discomfort are likely to bediscomfort are likely to be

termed diarrheatermed diarrhea




The most common causes of The most common causes of

acute diarrhea (lasting less thanacute diarrhea (lasting less than

44 weeks) are infections (E coli,weeks) are infections (E coli,Vibrios, campylobacter, «) whileVibrios, campylobacter, «) while

chronic diarrhea (lastingchronic diarrhea (lasting 44 weeksweeks

or longer) categorizes threeor longer) categorizes threeimportant variants (osmotic,important variants (osmotic,

secretory, & inflammatory)secretory, & inflammatory)






The goal in evaluating a patientThe goal in evaluating a patient

with chronic diarrhea is towith chronic diarrhea is to

make a definitive diagnosis asmake a definitive diagnosis asquickly & inexpensively asquickly & inexpensively as

possiblepossible

In onlyIn only 2525% to% to 5050% of cases,% of cases,

expert history & physicalexpert history & physical

examination may be sufficientexamination may be sufficient






Dysentery refers to presence of Dysentery refers to presence of

blood, mucus, or both in stoolblood, mucus, or both in stool

The most important causes are:The most important causes are:

1.1.Infections (Amoeba, Giardia,Infections (Amoeba, Giardia,

Shigella, & S Mansoni)Shigella, & S Mansoni)2.2.IBDs (UC & CD)IBDs (UC & CD)

3.3.Radiation & ischemic colitisRadiation & ischemic colitis





HepatologyHepatologyThe scope of practice of liver The scope of practice of liver

diseases has expanded dramaticallydiseases has expanded dramatically

in the past decade, primarilyin the past decade, primarilybecause of the success of liver because of the success of liver

transplantation, the development of transplantation, the development of

effective treatment regimens for viraleffective treatment regimens for viralhepatitis and safer techniques for hepatitis and safer techniques for

diagnosing liver diseases anddiagnosing liver diseases and

treating obstructive jaundicetreating obstructive jaundice



HepatologyHepatologyThe current epidemic of hepatitis C,The current epidemic of hepatitis C,

which involves more thanwhich involves more than 44 millionmillion

people infected annually throughpeople infected annually throughcontaminated blood transfusion, andcontaminated blood transfusion, and

injectioninjection--type drug addiction willtype drug addiction will

lead to the development of cirrhosislead to the development of cirrhosisor hepatocellular carcinoma in aor hepatocellular carcinoma in a

significant percentagesignificant percentage



HepatologyHepatologyThe major function of the liver isThe major function of the liver is

to synthesize and metabolizeto synthesize and metabolize

proteins, carbohydrates, andproteins, carbohydrates, andfats, as well as to detoxifyfats, as well as to detoxify

normal metabolic wastes andnormal metabolic wastes and

ingested drugs and chemicalsingested drugs and chemicals



HepatologyHepatologyThe major sequelae of cirrhosisThe major sequelae of cirrhosis

include portal hypertension,include portal hypertension,

variceal hemorrhage, ascites,variceal hemorrhage, ascites,hepatohepato--renal and hepatorenal and hepato--

pulmonary syndromes, pluspulmonary syndromes, plus

hepatic encephalopathyhepatic encephalopathy



HepatologyHepatologyHemorrhage from gastroHemorrhage from gastro--

esophageal varices is often theesophageal varices is often the

initial complication of portalinitial complication of portalhypertensionhypertension

Bleeding from varices accountsBleeding from varices accounts

for one third of all deaths infor one third of all deaths in

patients with cirrhosispatients with cirrhosis



HepatologyHepatologyAscites, which is theAscites, which is the

accumulation of excess fluid inaccumulation of excess fluid in

the abdomen, is often among thethe abdomen, is often among thefirst signs of decompensation infirst signs of decompensation in

patients with chronic liver patients with chronic liver

diseasedisease



HepatologyHepatologyCirrhosis is the underlying causeCirrhosis is the underlying cause

of ascites in at leastof ascites in at least 8080% of % of

patients, but other causes (e.g.,patients, but other causes (e.g.,heart failure, constrictiveheart failure, constrictive

pericarditis, nephrotic syndrome,pericarditis, nephrotic syndrome,

tuberculous peritonitis,tuberculous peritonitis,peritoneal malignancy) must alsoperitoneal malignancy) must also

be consideredbe considered



HepatologyHepatologyApproximatelyApproximately 5050% of patients with% of patients with

cirrhosis develop ascites withincirrhosis develop ascites within 1010

years, and the development of years, and the development of ascites in the sitting of cirrhosis isascites in the sitting of cirrhosis is

an important landmark in the naturalan important landmark in the natural

history of chronic liver disease,history of chronic liver disease,because approximatelybecause approximately 5050% of % of

patients usually die withinpatients usually die within 44 years of years of

ascites developmentascites development



HepatologyHepatologyMost patients with cirrhoticMost patients with cirrhoticascites respond to dietaryascites respond to dietarysodium restriction (<sodium restriction (<20002000

mg/day) and a diureticmg/day) and a diureticTreatment with diuretics mayTreatment with diuretics mayresult in dehydration, severeresult in dehydration, severe

muscle cramping,muscle cramping,hyponatremia, and hepatichyponatremia, and hepaticencephalopathyencephalopathy







Thank YouThank You

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GI & HPB by Dr.Ayman Shamsia