1. Reflux esophagitis

3. Reflux esophagitis
Also known as Acid reflux or GERD, is an inflammation of the esophagus.
Causes :
If The acid is regurgitated from stomach to lower esophagus because of
lowering of the sphincteric tone and
frequent relaxation of sphincter more than normal.

4. Main symptom heart burn, an acidic taste in the mouth, bad breath
hoarseness of voice and 
chest pain.

5. The diagnosis of GERD is depends on
1- Symptoms
*Reflux can be present without symptoms and the diagnosis needs both symptoms or complications
2- Esophagogastroduodenoscopy (EGD).

7. *Lines of management A- Non pharmacological Measures:
The patients should avoid the following:
- lying down after meals.
-Eating late at night
- Lifting of heavy wt,
-Bending
-Smoking

8. *more water is needed to dilute the acid and normalize the pH in stomach

9. B. Pharmacological measures (Drugs treatment).
It includes:
1- Antacids
2- H2-receptor antagonist
3- proton pump inhibitors .
4- Metoclopromide.
C- Surgery

11. sources of stimuli including 1. CTZ 2. The vestibular system
Anti-emetics
The medulla is a center for vomiting and it does not initiate but it coordinates vomiting
sources of stimuli including
1. CTZ
2. The vestibular system .

12. 3-Peripheral sources e. g. renal colic, GIT and heart. 4
3-Peripheral sources e.g. renal colic, GIT and heart. 4.Cortical centers:

13. Drugs stimulating GIT motility:
Those include
-D2-receptor antagonists
-5HT4 agonists
they have the following action:
1-Increase lower esophageal sphinecteric tone.
2-Increase rate of gastric emptying.
3-Increase peristalsis .

14. Metoclopramide: 1- Centrally by blocking D2-receptor in CTZ .
This drug acts
1- Centrally by blocking D2-receptor in CTZ .
2- Peripherally by enhancing the action of Ach in the gut
Kinetics: 1- It its metabolized by the liver,
2- t1/2 = 4 hrs.

15. Uses: 1.Nausea and vomiting associated with A- GIT disorders.
B- Chemotherapy and radiotherapy.
C- Migraine.
2. Empty the stomach before and after surgery .

17. Side Effects :
A- Extra-pyramidal
B. Gyencomastia (in males), galactorrhea (in female)
NOTE: The hormone prolactin stimulates lactation  Dopamine released by the hypothalamus stops the release of prolactin from the pituitary gland.

18. Dompridone: a peripherally selective dopamine D2 receptor antagonist
Centrally it blocks D2-receptor in CTZ
KINETICS:
1- t1/2 = 7hrs.
2-Poorly crosses BBB
S.E: It has little central side effects
galactorrhea and gyencomastia.

19. Cisapride: (5HT4 agonist effect and some 5HT3 antagonistic action).
It acts only peripherally by increase Ach.
Kinetics
1-lst pass metabolism
2- orally.

20. Drug interactions: Cardiac arrhythmia may occur when taken with
1- Macrolides antibiotics
2- Antifungal
Thus, this drug is no more used.

21. Renzapride It is a 5-HT4 agonist and 5-HT3 antagonist It considered as a gastroprokinetic drug and antiemetic.

22. 5HT3 RECEPTOR ANTAGONIST:
Ondanosetron.
Granisetron,
Tropisetron,
palosetron.
Ramasetron
Dolasetron

23. Note : They are selective 5HT3 receptor antagonists,
Palosteron has longer t ½, while the other have less t1/2
Ramosetron has higher affinity for the 5-HT3 receptor
Note :
Serotonin receptors of the 5-HT3 type are present:
Peripherally on vagal nerve terminals and
Centrally in CTZ

24. Mechanism of action:
Anti cancer (Cytotoxic drug) releases Serotonin from the enterochromaffin cells in small intestine
Thus blocking 5HT3 receptor will control vomiting by inhibiting serotonin binding to the 5-HT3 receptor.

25. Nabilone and Dronabinol:
Synthetic canabinoids, treat nausea and vomiting caused by chemotherapy.
Side Effects:
1. Sleep disturbance.
2. Dry mouth.
3.Decrease appetite.
4.hypotension.

26. Other anti-emetics
Dexamethasone Haloperidol Antihistamine Nk antagonist Drug producing amnesia

27. THANK YOU