Prepared by I Gede Purnawinadi S Kep MKes Preview Very little of the food we eat is directly available to body cells Food must be broken down absorbed and chemically modified before it is in a useful form ID: 910403
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Slide1
Drugs for Gastrointestinal System Disorders
Prepared by I
Gede
Purnawinadi
, S.
Kep
.,
M.Kes
.
Slide2Preview
Very little of the food we eat is
directly available to body cells
. Food
must be broken down
,
absorbed
, and
chemically modified before it is in a useful form
. The digestive system performs these functions, and more.
Some disorders of the digestive system
are mechanical in nature, providing for the
transit of substances through the gastrointestinal tract
. Others are
metabolic
, involving the
secretion of digestive enzymes and fluids or the absorption
of essential nutrients.
Many
signs and symptoms
of digestive disorders are nonspecific and may be caused by any number of
different pathologies
.
This chapter examines the pharmacotherapy of two common disorders of the upper digestive system:
peptic ulcer disease (PUD) and
gastroesophageal
reflux disease (GERD).
Slide3Food
Nutrient
Non Nutrient
Assimilated
Eliminated
Digestive system
Slide4Normal Digestive Processes
The digestive system consists of two basic anatomic divisions:
the alimentary canal
and
the accessory organs. The alimentary canal, or gastrointestinal (GI) tract, is a long, continuous, hollow tube that extends from the mouth to the anus. The accessory organs of digestion include the salivary glands, liver, gallbladder, and pancreas. The digestive system is responsible for breaking down food, absorbing nutrients, and eliminating wastes.
Slide5Overview of GI tract
Slide6PROSES PENCERNAAN
:
Masuknya
makanan
mel. Sal. Cerna/GIT (Ingestion) Pergerakan
makanan mel. Sal. Cerna (Motility)
Sekresi getah pencernaan (Secretion)
Pencernaan makanan (Digestion)
Penyerapan hasil pencernaan, Air & berbagai
Elektrolit (Absorption) Sirkulasi darah
melalui Organ GIT membawa hasil
Absorpsi. Pengaturan: Sistem
Saraf & Sistem Hormonal Pembuangan
bahan
yg
tidak
dibutuhkan
tubuh
(
eliminasi
)
Slide7Overview of
GI Processes
Food
Secretion
Digestion
Absorption
Blood Vessels
Motility
Slide8The
inner lining of the alimentary canal
is the
mucosa layer
, which provides a surface area for the various acids, bases, mucus, and enzymes to break down food.Substances are propelled along the GI tract by peristalsis, which are rhythmic contractions of layers of smooth muscle. The speed at which substances move through the GI tract is critical to the absorption of nutrients and water and for the removal of wastes. If peristalsis is too fast, nutrients and drugs will
not have sufficient contact with the mucosa to be absorbed. In addition, the large intestine will not have enough time to absorb water, and diarrhea may result. Abnormally slow transit
may result in constipation or even obstructions in the small or large intestine.
To chemically break down ingested food, a large number of enzymes and other substances are required. Digestive enzymes are secreted by the salivary glands, stomach, small intestine, and pancreas. The liver makes bile
, which is stored in the gallbladder until needed for lipid digestion.
Slide9Slide10Slide11Food passes from the esophagus to the stomach by traveling through the
lower esophageal (cardiac) sphincter
. This ring of smooth muscle usually
prevents the stomach contents from moving backward
, a condition known as esophageal reflux. A second ring of smooth muscle, the pyloric sphincter, is located at the entrance to the small intestine. This sphincter regulates the flow of substances leaving the stomach. The stomach thoroughly mixes ingested food and secretes substances that promote the processes of chemical digestion. Gastric glands extending deep into the mucosa of the stomach contain several cell types critical to digestion
and important to the pharmacotherapy of digestive disorders.Chief cells secrete
pepsinogen, an inactive form of the enzyme pepsin that chemically breaks down proteins. Parietal cells secrete 1 to 3 L of hydrochloric acid each day. This strong acid helps break down food, activates pepsinogen, and kills microbes that may have been ingested
.
Slide12Stomach
lower esophageal (cardiac) sphincter
Slide13Slide14Control of Acid Secretion
May be considered as three separate phases.
1. Cephalic phase.
2. Gastric phase.
3. Intestinal phase.
Slide151. CEPHALIC PHASE
Sight, smell or
thought of food
Parasympathetic activation
of gastric motility & gastric juice secretion
Vagus nerve
Slide16Food arrival causes
muscular reflexes &
gastrin secretion by G cells.
2. GASTRIC PHASE
Gastrin
GO
FOOD
Gastrin stimulates secretion from both chief &
parietal cells.
Slide17Arrival of food in duodenum
triggers release of hormones
that inhibit gastric motility &
secretions.
3. INTESTINAL PHASE
Circulation
Secretin &
Cholecystokinin (CCK)
Slide18Slide19Pathogenesis of Peptic Ulcer Disease
An
ulcer is an erosion
of the
mucosa layer of the GI tract, usually associated with acute inflammation. Although ulcers may occur in any portion of the alimentary canal, the duodenum is the most common site. The term peptic ulcer refers to a lesion located in either the stomach (gastric) or small intestine (duodenal). Peptic ulcer disease is associated with the following risk factors: Close family history of PUD. Blood group O. Smoking tobacco (increases gastric acid secretion). Consumption of beverages and food that contain caffeine.
Drugs, particularly corticosteroids, nonsteroidal antiinflammatory drugs (NSAIDS), and platelet inhibitors such as aspirin and clopidogrel.
Excessive psychological stress. Infection with Helicobacter pylori
Slide20Slide21Slide22Pathogenesis of
Gastroesophageal
Reflux Disease
Gastroesophageal
reflux disease (GERD) is a common condition in which the acidic contents of the stomach move upward into the esophagus. This causes an intense burning (heartburn) sometimes accompanied by belching. In severe cases, untreated GERD can lead to complications such as esophagitis, or esophageal ulcers or strictures. Although most often thought a disease of people older than age 40, GERD also occurs in a significant percentage of infants. The cause of GERD is usually a weakening of the lower esophageal sphincter. The sphincter may no longer close tightly, allowing the contents of the stomach to move upward when the stomach contracts.
Slide23Slide24Slide25Pharmacotherapy of Peptic Ulcer Disease
Before initiating pharmacotherapy, patients are usually
advised to change lifestyle
factors contributing to the severity of PUD or GERD. For example, eliminating tobacco and alcohol use and reducing stress often allow healing of the ulcer and cause it to go into remission. Avoiding certain foods and beverages can lessen the severity of symptoms. For patients who are taking NSAIDs, the initial approach to PUD is to switch the patient to an alternative medication.For patients with PUD who are infected with H. pylori, elimination of the bacteria using anti-infective therapy is the primary goal of pharmacotherapy.
Slide26The goals of PUD pharmacotherapy are to
provide immediate relief from symptoms, promote healing of the ulcer, and prevent future recurrence of the disease.
The mechanisms of action of the primary drug classes for PUD are shown in Pharmacotherapy Illustrated 40.1:
Proton pump inhibitors, H2-receptor antagonists, Antacids, Antibiotics, Miscellaneous drugs
.
Slide27Histamine
has two types of receptors:
H1 and H2
. Activation of
H1 receptors produces the classic symptoms of inflammation and allergy, whereas the H2 receptors are responsible for increasing acid secretion in the stomach. The H2-receptor antagonists are effective at suppressing the volume and acidity of parietal cell secretions.
Slide28Proton pump inhibitors act by
blocking the enzyme
responsible
for secreting hydrochloric acid
in the stomach. They are drugs of choice for the short-term therapy of PUD and GERD.Proton pump inhibitors (PPIs) reduce acid secretion in the stomach by binding irreversibly to H+, K+-ATPase, the enzyme that acts as a pump to release acid (also called H+, or protons) onto the surface of the GI mucosa. PPIs reduce acid secretion to a greater extent than the H2-receptor antagonists and have a longer duration of action. PPIs heal more than 90% of duodenal ulcers within 4 weeks and about 90% of gastric ulcers in 6 to 8 weeks.
Slide29Prior to the
development of H2-receptor antagonists and PPIs
,
antacids
were the mainstays of peptic ulcer and GERD pharmacotherapy. Although antacids may provide temporary relief from heartburn or indigestion, they are no longer recommended as the primary drug class for PUD. This is because antacids do not promote healing of the ulcer, nor do they help to eradicate H. pylori.
Slide30Antibiotics for H. Pylori
The gram-negative bacterium H. pylori is associated with
80% of patients with duodenal ulcers
and
70% of those with gastric ulcers. It is also strongly associated with gastric cancer. To more rapidly and completely heal peptic ulcers, combination therapy with several antibiotics is used to eradicate this bacterium. Two or more antibiotics are given concurrently to increase the effectiveness of therapy and to lower the potential for bacterial resistance. The antibiotics are also combined with a PPI or an H2-receptor antagonist.
Slide31Miscellaneous Drugs for Peptic Ulcer Disease
Several additional drugs are beneficial in treating PUD.
Sucralfate
(Carafate)
consists of sucrose (a sugar) plus aluminum hydroxide (an antacid). The drug produces a thick, gel-like substance that coats the ulcer, protecting it against further erosion and promoting healing. It does not affect the secretion of gastric acid.Misoprostol (Cytotec) inhibits gastric acid secretion and stimulates the production of protective mucus. Its primary use is for the prevention of peptic ulcers in patients who are taking high doses of NSAIDS or corticosteroids
Slide32Slide33Slide34Drugs for Bowel Disorders and Other Gastrointestinal Conditions
The lower portion of the GI tract consists of the
small and large intestines.
The
first 10 inches of the small intestine, the duodenum, is the site where partially digested food from the stomach, known as chyme, mixes with bile from the gallbladder and digestive enzymes from the pancreas.The remainder of the small intestine consists of the jejunum and ileum. The jejunum is the site where most nutrient absorption occurs. The ileum empties its contents into the large intestine through the ileocecal valve.
Slide35The large intestine, or colon,
receives
chyme
from the ileum in a fluid state
. The major functions of the colon are to reabsorb water from the waste material and to excrete the remaining fecal material from the body.
Slide36Pathophysiology of Constipation
Constipation
is a
decrease in the frequency of bowel movements
. Stools may become dry, hard, and difficult to evacuate from the rectum without straining.As waste material travels through the large intestine, water is reabsorbed. Reabsorption of the proper amount of water results in stools of a normal, soft-formed consistency. If the waste material remains in the colon for an extended period, however, too much water will be reabsorbed, leading to small, hard stools. Constipation may cause abdominal distention and discomfort and flatulence. Constipation is not a disease but a symptom of an underlying disorder. The etiology of constipation may be related to lack of exercise; insufficient food intake, especially insoluble dietary fiber; diminished fluid intake; or a medication regimen that includes drugs that reduce intestinal motility.
Slide37Pharmacotherapy with Laxatives
Laxatives
promote the evacuation of the bowel
, or defecation, and are widely used to prevent and treat constipation.
Laxatives are drugs given to promote emptying of the large intestine by stimulating peristalsis, lubricating the fecal mass, or adding more bulk or water to the colon contents.
Slide38Slide39Pathophysiology of Diarrhea
When the large intestine
does not reabsorb enough water from the fecal mass, stools become watery
.
Diarrhea is an increase in the frequency and fluidity of bowel movements. Diarrhea is not a disease but a symptom of an underlying disorder.Indeed, diarrhea may be considered a type of body defense, rapidly and completely eliminating the body of toxins and pathogens. When prolonged or severe, especially in children, diarrhea can result in significant loss of body fluids, and pharmacotherapy is indicated. Prolonged diarrhea may lead to fluid, acid–base, or electrolyte disorders.
Slide40Pharmacotherapy with Antidiarrheals
Pharmacotherapy related to diarrhea
depends on the severity of the condition
and any identifiable etiologic factors. If the cause is an infectious disease, then an antibiotic or antiparasitic drug is indicated. If the cause is inflammatory in nature, anti-inflammatory drugs are warranted. When the diarrhea appears to be an adverse effect of pharmacotherapy, the health care provider may discontinue the offending medication, lower the dose, or substitute an alternative drug.
Slide41Slide42Pathophysiology of Nausea and Vomiting
Vomiting is a
defense mechanism
used by the body to rid itself of
toxic substances. Vomiting is a reflex primarily controlled by the vomiting center of the medulla of the brain, which receives sensory signals from the digestive tract, the inner ear, and the chemoreceptor trigger zone (CtZ) in the cerebral cortex. Interestingly, the CTZ is not protected by the blood–brain barrier, as is the vast majority of the brain; thus, these neurons can directly sense the presence of toxic substances in the blood. Once the vomiting reflex is triggered, wavelike contractions of the stomach quickly propel its contents upward and out of the body.
Slide43A large number of
antiemetics
are available
to treat nausea and vomiting
. Selection of a particular agent depends on the experience of the health care provider and the cause of the nausea and vomiting.
Slide44