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Department of clinical pharmacology with pharmaceutic care 1 Clinical pharmacy in gastroenterology.

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Presentation on theme: "Department of clinical pharmacology with pharmaceutic care 1 Clinical pharmacy in gastroenterology."— Presentation transcript:

1 Department of clinical pharmacology with pharmaceutic care 1 Clinical pharmacy in gastroenterology

2 Department of clinical pharmacology with pharmaceutic care 2 The structure of digestive or alimentary tract

3 Department of clinical pharmacology with pharmaceutic care 3 Digestion is the first stage of metabolism This system does secretory, motor, absorption, excretion and immune functions

4 Department of clinical pharmacology with pharmaceutic care 4 Secretory function Anatomico-physiological bases - formation and exudation of digestive juices into intestinal lumen Daily secretion: 1,5 l saliva, 2,5 l gastric juice, 1,0 l pancreas juice, 1,2 l bile, 2,5 l intestinal juice

5 Department of clinical pharmacology with pharmaceutic care 5 Motor function - food movement into intestinal pipe and its permanent mixing with digestive juices Absorbtion - absorption of some ingredients from undigested food and indigestible material Anatomico-physiological bases

6 Department of clinical pharmacology with pharmaceutic care 6 Excretion - moving off undigested food remainders and also some matters picked out in intestinal lumen Immune function In wall of large intestine there are accumulations of lymphoid tissue - “Peyer’s plaques”, where ripening of lymphocytes takes place Anatomico-physiological bases

7 Department of clinical pharmacology with pharmaceutic care 7 Anatomico-physiological bases Stomach Duodenum Small intestine Large intestine

8 Department of clinical pharmacology with pharmaceutic care 8 Basic stomach functions: physical and chemical processing of food, his depositing and evacuation;physical and chemical processing of food, his depositing and evacuation; participation in metabolism;participation in metabolism; participation in hemostasis (synthesis of gastromucoprotein by parietal cells etc.);participation in hemostasis (synthesis of gastromucoprotein by parietal cells etc.); participation in water-salt metabolism;participation in water-salt metabolism; Synthesis of prostaglandines and gastrointestinal hormonesSynthesis of prostaglandines and gastrointestinal hormones Anatomico-physiological bases

9 Department of clinical pharmacology with pharmaceutic care 9 Клиническая фармация в гастроэнтерологии Factors that play the great role of the development of inflammation diseases in the gastroduodenal area Protective factors mucus mucus Ionic gradient Ionic gradient bicarbonates bicarbonates prostaglandins prostaglandins Epithelial cells Epithelial cells Mucus membrane blood supply Mucus membrane blood supply Aggression factors Drugs and medicines (NSAIDs) hydrochloric acid Pepsin Helicobacter pylori

10 Department of clinical pharmacology with pharmaceutic care 10 Клиническая фармация в гастроэнтерологии Ways of examination: questioning The main complaints of GIT impairment: Pain (in epigastric area) Pain (in epigastric area) Appetite disorders Appetite disorders Dysgeusia Dysgeusia Eructation Eructation Heartburn Heartburn Nausea Nausea Vomitting Vomitting Constipation Constipation Diarrhea Diarrhea Meteorism Meteorism Fatigue Fatigue

11 Department of clinical pharmacology with pharmaceutic care 11 Клиническая фармация в гастроэнтерологии Laboratory and instrumental methods of examination Fiber-optic gastroduodenoscopy

12 Department of clinical pharmacology with pharmaceutic care 12 Клиническая фармация в гастроэнтерологии Laboratory and instrumental methods of examination Colonoscopy and biopsy

13 Department of clinical pharmacology with pharmaceutic care 13 Клиническая фармация в гастроэнтерологии Laboratory and instrumental methods of examination X-ray examination of GIT

14 Department of clinical pharmacology with pharmaceutic care 14 Клиническая фармация в гастроэнтерологии Laboratory and instrumental methods of examination Bacteriologic, histologic and fast urea test of Н. Pylori

15 Department of clinical pharmacology with pharmaceutic care 15 Клиническая фармация в гастроэнтерологии Laboratory and instrumental methods of examination Non-invasive test : Breath test with urea

16 Department of clinical pharmacology with pharmaceutic care 16 Клиническая фармация в гастроэнтерологии An algorithm approach to the diagnosis of GIT disorders

17 Department of clinical pharmacology with pharmaceutic care 17 Клиническая фармация в гастроэнтерологии Laboratory and instrumental methods of examination Hematology

18 Department of clinical pharmacology with pharmaceutic care 18 Клиническая фармация в гастроэнтерологии Laboratory and instrumental methods of examination Urinalysis and blood biochemistry tests

19 Department of clinical pharmacology with pharmaceutic care 19 Клиническая фармация в гастроэнтерологии Laboratory and instrumental methods of examination Faeces analysis

20 Main syndromes in gastroenterology: Gastric dyspepsia Intestinal dyspepsia Maldigestion and malabsorption Hypovitaminosis Gastrointestinal bleeding Asthenoneurotic syndrome Anemic syndromes Pain syndrome

21 Department of clinical pharmacology with pharmaceutic care 21 Syndromes in GIT disorders Hypovitaminosis: skin dryness, angular cheilosis, stomatitis, hair loss, trophic changes of nails

22 Department of clinical pharmacology with pharmaceutic care 22 Chronic gastritis - chronic inflammatory-dystrophyc process in stomach mucous, being attended with violation of cells regeneration processes and progressing atrophy of glandular epithelium Basic stomach diseases

23 Department of clinical pharmacology with pharmaceutic care 23 Chronic gastritis Chronic autoimmune gastritis (type A) Chronic gastritis (type B) Basic stomach diseases In accordance with dominant etiologic factor…

24 Department of clinical pharmacology with pharmaceutic care 24 Basic stomach diseases Chronic autoimmune gastritis (type A) - variant of chronic gastritis, conditioned by appearance of antibodies to parietal (acid- secretory) cells of stomach mucous

25 Department of clinical pharmacology with pharmaceutic care 25 Etiology At the beginning of this disease there is fundamental importance of combination of the exogenic and endogenic factors Pathogeny Along of antibodies making to parietal cells of mucous stomach takes place her damage. Hereinafter develops diffuse atrophy of stomach mucous, his secretory function lowers, up to significant secretory insufficiency. In part of cases there is a produce of auto- antibodies to gastromucoprotein (internal Castle’s factor) then which lead to the development of В 12 - deficiency anemia. Basic stomach diseases

26 Department of clinical pharmacology with pharmaceutic care 26 1.Pain syndrome: pain in epigastric area, temporary aching after food. Patients complaints about heaviness or sense of stomach enlargement, pressure in epigastric area and left subcostal area. 2.Syndrome of gastric dyspepsia: lowering of appetite, disagreeable taste in mouth, eructation, nausea with possible vomiting. 3.Syndrome of intestinal dyspepsia: rumbling sounds in abdomen, flatulency, leaning to diarrhea. Clinical manifestations/ syndromes Chronic autoimmune gastritis (type A)

27 Department of clinical pharmacology with pharmaceutic care 27 4.Maldigestion and malabsorption: dehydration due to diarrhea, hypovitaminosis, weight loss. 5.Neurotic (asthenoneurotic) syndrome: weakness, irritability, paresthesias, cold sensations in the extremities, neurogenic, cardiogenic, vascular symptoms (angina like pains, hypotension). Clinical manifestations/ syndromes Chronic autoimmune gastritis (type A)

28 Department of clinical pharmacology with pharmaceutic care 28 Diagnostic criteria of chronic gastritis type А Clinical manifestations Special methods of investigation Complaints - blunt pains in epigastrium, appetite loss, disagreeable taste in mouth, nausea, heaviness after food, belch rotten, diarrheas. Examination - coated tongue, symptoms hypovitaminosis (skin dryness, hair loss, stomatitis and etc.), flatulency. X-ray examination X-ray examination- tone and peristalsis is weak, forced stomach evacuation. Gastroscopy Gastroscopy faded mucous. Biopsy Biopsy - stomach mucous atrophy and inflammation signs Chronic autoimmune gastritis (type A)

29 Department of clinical pharmacology with pharmaceutic care 29 correction of gastric secretion violations (substitution therapy, forcing of gastric secretion). forcing of mucous regeneration process (anabolic hormones, biologic stimulants). correction of metabolic disturbances (aminoacids, vitamins, anabolic hormones). correction of motored violations (prokinetics). correction of intestinal digestion violations (polyenzymatic medications: festal, panzynormum). Principles of medicinal therapy Chronic autoimmune gastritis (type A)

30 Department of clinical pharmacology with pharmaceutic care 30 Chronic gastritis (type B) - variant of chronic gastritis, induced by bacterium Нelicobacter pylori. Basic stomach diseases

31 Department of clinical pharmacology with pharmaceutic care 31 Etiologic factors may be Exogenous Endogenous Basic stomach diseases

32 Department of clinical pharmacology with pharmaceutic care 32 Genetic predisposition: augmentation of parietal cells; surplus gastrin liberation; rise of pepsinogen level in blood; Violation in gastroduodenal movements; lack of pepsin inhibitors; violation of Ig A structure; blood group 0 (I); positive Rh-factor; Presence of antigenes HLA В5, В15, В35. Endogenous factors Basic stomach diseases

33 Department of clinical pharmacology with pharmaceutic care 33 violation of nutrition; harmful habits (smoking, alcohol, abuse of coffee); professional influences and mode of life; damaging action of medicinal preparations (anti- inflammatory drugs, corticosteroids, some antibiotics, iron preparations, potassium). To be infected by Helicobacter pylori Exogenous factors Basic stomach diseases

34 Department of clinical pharmacology with pharmaceutic care 34 Pain syndrome: “hungry” pain (nighttime pain) in epigastric area, which can stop after food intake; Neurotic syndrome: irritability, fatiguability, bad sleep; Syndrome of gastric dyspepsia: heartburn, nausea, sour belch; Syndrome of intestinal dyspepsia: constipations. Clinical manifestations Basic stomach diseases

35 Department of clinical pharmacology with pharmaceutic care 35 Diagnostic criterions of chronic gastritis type В Clinical manifestations Special methods of investigation Complaints - hungry epigastric pains, vomiting on pains height, heart- burn, belch sour, constipation. Examination - sickliness attached to epigastral palpation X-ray exam X-ray exam- raised tonus of stomach antral area, peristalsis is weakened, hypersecretion signs. Gastroscopy Gastroscopy - edema and hyperemia of mucous, folds hypertrophy mucous stomach. Biopsy Biopsy - signs of chronic inflamma- tion and hyperplasia mucous of stomach antral area. Basic stomach diseases

36 Department of clinical pharmacology with pharmaceutic care 36 Symptoms of Dyspepsia Nocturnal pain Localized epigastric burning Better with food HeartburnRetrosternal burning burning NauseaBloating Early satiety Worse with food Ulcer-like Dominant Dysmotility-like Dominant

37 Department of clinical pharmacology with pharmaceutic care 37 Williams 1988Stanghellini 1996Heikkinen 1996 (n=1386) (n=1057) (n=766) Major Causes of Dyspepsia % of Patients with Diagnosis Gastric Cancer Peptic Ulcer Esophagitis/Functional

38 Department of clinical pharmacology with pharmaceutic care 38

39 39 Helicobacter pylori A spiral shaped, Gram- negative, microaerophilic, and flagellated bacterium, living in the stomach and duodenum About 3 microns long with a diameter of about 0.5 micron Causing up to 80% of peptic ulcers, more than 90% of duodenal ulcers, and some types of gastritis Rediscovered in 1982 by the laureates and made connection with stomach ulcers and gastritis Helicobacter pylori (blue bars, curved, 2-4 microns) localized in the mucus on the mucous surface, at the intercellular lines. Photo: tangential section of the gastric mucous

40 Department of clinical pharmacology with pharmaceutic care 40 Epidemiology Approximately two-thirds of the world's population is infected with H. pylori. 70% - 90% in developing countries 25% - 50% in developed countries Over half the population is infected in early childhood in China. Most of those infected never have symptoms. The bacteria are most likely spread from person to person through fecal-oral or oral-oral routes. Possible environmental reservoirs include contaminated water sources. The source of H.pylori is unknown yet.

41 Department of clinical pharmacology with pharmaceutic care 41 H. pylori Epidemiology

42 Department of clinical pharmacology with pharmaceutic care 42 Pathogenicity H.pylori lives in the mucus lining to escape from the highly acidic gastric juice. (Its helical shape facilitates its penetration of the mucus layer.) It can fight the acid by excreting an enzyme called urease. The immune system responds to the infection by sending white cells, killer T cells, and other infection fighting agents. However, they cannot easily get through stomach lining to reach the infection. As the immune response grows, immune cells die and release destructive compounds on the stomach lining cells. Within a few days, gastritis and perhaps eventually a peptic ulcer results. Gastric epithelium Stomach acid

43 Department of clinical pharmacology with pharmaceutic care 43

44 44

45 45 Symptoms The most common ulcer symptom is burning pain in the epigastrium (the upper middle region of the abdomen). The pain typically occurs when the stomach is empty. Less common symptoms include nausea, vomiting, and loss of appetite. Bleeding can also occur. Recent studies have shown an association between long-term infection and the development of gastric cancer, which is the most common cancer in China.

46 Department of clinical pharmacology with pharmaceutic care 46 Testing for H. pylori C13 or C14 90% to 100% 96% to 100%++Limited - requires urease breathnuclear medicine test department Serology91% to 98%75% to 80%+Widely available commercial labs Capillary 85% to 90%75% to 80%+Office test, must purchased by doctor admin Endoscopic99%99%++++Requires biopsy specialist Invasive TestSensitivitySpecificity Cost Comments (Cutler A. Gastro 1995;109:136. Megraud F. Scand J Gastro 1996;215:57)

47 Department of clinical pharmacology with pharmaceutic care 47 Steady lowering of acid reaction (рН > 3 not less h/day): Proton pump ihibitors Н 2 -histaminoblockers Antacids Eradication of Helicobacter pylori: Antibiotics Bismuth Derivative nitromidazole Rise cytoprotection (peculiarly attached to gastric ulcers ): Sucralfate Colloid bismuth Synthetic analogues prostaglandins Reparants Use of medications with minimum side effects Optimum compliance (observance by treatment program) Fundamental rules of anti-ulcer therapy

48 Department of clinical pharmacology with pharmaceutic care 48 H. pylori Eradication (All given for one week) Treatments of choice PPI - ACBIDAmoxicillin 1 g bid Clarithromycin 500 mg bid PPI - MCBIDMetronidazole 500 mg bid Clarithromycin 250 mg bid RegimenPPIAntibiotics Alternate PPI - BMTBIDBismuth 2 tabs qid Metronidazole 250 mg qid Tetracycline 500 mg qid

49 Department of clinical pharmacology with pharmaceutic care 49  cure by one medication does not adapt  First line therapy:“triple therapy”: proton pump inhibitor (omeprazolum 20 mg twice/day or pantoprazolum 40 mg/ day) + antibiotics against Н. pylori (amoxicillin 1 g or metronidazol mg twice/day and clarithromycin (500 mg twice/day))  First/Second line therapy: “cure standard” - “quadrotherapy therapy”  proton pump inhibitor (omeprazolum 20 mg twice/day or pantoprazolum 40 mg/ day)  metronidazol (500 mg triplicate/day)  tetracycline (500 mg quadruplicate/day)  bismuth (120 mg quadruplicate/day) Course of treatment -10 days  Second line therapy:«tripletherapy» includes  proton pump inhibitor (omeprazolum 20 mg twice/day or pantoprazolum 40 mg/day) from first to tenth day  clarithromycin (500 mg twice/day)  levofloxacin (500 mg once/day) H. pylori Eradication

50 Department of clinical pharmacology with pharmaceutic care 50 Acid Suppression Therapy for Ulcer-like Functional Dyspepsia H 2 -receptor antagonist for 4 weeks H 2 -receptor antagonist for 4 weeks OR OR Proton pump inhibitor for 2 weeks Proton pump inhibitor for 2 weeks

51 Department of clinical pharmacology with pharmaceutic care 51 Receptor stimulation of acid secretion

52 Department of clinical pharmacology with pharmaceutic care 52 Fundamental rules antihelicobacter therapy In the same patient it is not allowed to repeat the previously used therapy which turned to be ineffective one If two types of treatment regimens are not effective, and there id no significant eradication, then it is necessary to determine the sensitivity of Н.рylori strain to the whole spectrum of used antibiotics Administration of back up “quadritherapy” regimen is desirable only after complete clarification of the failure of the different variants of “triple therapy” The presence of Н. рylori up to year after conducted therapy should be considered as an infection set-back, but and not einfection “Quadrotherapy” regimen must be used in case of infection set-back

53 Department of clinical pharmacology with pharmaceutic care 53 Management of Ulcer-like Functional Dyspepsia Ulcer-like Symptoms Dominant Education/lifestyle modification Test Hp ++-- Eradicate Hp SuccessSuccessFailureFailure Trial of acid suppression InvestigateInvestigate Trial of prokinetic ReassessReassess

54 Department of clinical pharmacology with pharmaceutic care 54 Lifestyle Modification for Patients with Functional Dyspepsia Small frequent meals Small frequent meals Stop smoking Stop smoking Reduce alcohol Reduce alcohol Reduce caffeine Reduce caffeine Avoid irritating foodstuffs Avoid irritating foodstuffs Maintain an ideal weight Maintain an ideal weight Review medications Review medications

55 Department of clinical pharmacology with pharmaceutic care 55 Risk Factors for Stomach Cancer Helicobacter pylori was the first bacterium to be officially recognized as a cancer-causing agent. Helicobacter pylori infectionNitrates nitrites Helicobacter pylori infection. Nitrates and nitrites are substances commonly found in cured meats, some drinking water, and certain vegetables, that can be converted by Helicobacter pylori, into compounds that have been found to cause stomach cancer in animals.

56 Department of clinical pharmacology with pharmaceutic care 56 Helicobacter pylori: associated pathology Gastritis B 100% Gastritis B 100% Ulceration 10% Ulceration 10% Gastric Ca <1% Gastric Ca <1% Lymphoma (MALT) <1% Lymphoma (MALT) <1% Gastritis B 100% Gastritis B 100% Ulceration 10% Ulceration 10% Gastric Ca <1% Gastric Ca <1% Lymphoma (MALT) <1% Lymphoma (MALT) <1%

57 Department of clinical pharmacology with pharmaceutic care 57 Gastro-oesophageal reflux disease chronic symptom of mucosal damage caused by stomach acid coming up from the stomach into the esophagus.mucosalstomachesophagus GERD is usually caused by changes in the barrier between the stomach and the esophagus, including abnormal relaxation of the lower esophageal sphincter, which normally holds the top of the stomach closed, impaired expulsion of gastric reflux from the esophagus, or a hiatal hernia.stomachlower esophageal sphincterhiatal hernia

58 Department of clinical pharmacology with pharmaceutic care 58 Gastro-oesophageal reflux disease EndoscopicEndoscopic image of peptic stricture, or narrowing of the esophagus near the junction with the stomach: This is a complication of chronic gastroesophageal reflux disease and can be a cause of dysphagia or difficulty swallowing.esophagusstomach Barrett’s oesophagus Alginate-containing antacid

59 Department of clinical pharmacology with pharmaceutic care 59 Undiagnosed dyspeptic patient If symptoms persist after 1 week of regular treatment then H2 antagonist Alginate-containing antacid If symptoms persist after 2 weeks of regular treatment the patient should be referred to the general practitioner Heart burn without “alarm symptoms”

60 Department of clinical pharmacology with pharmaceutic care 60 THE END


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