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Transcript of 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
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BYBY
Dr AYMAN M SHAMSEYADr AYMAN M SHAMSEYA
A. LECTURER OF INT MEDA. LECTURER OF INT MED
FACULTY OF MEDICINEFACULTY OF MEDICINE
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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
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Primary care«..WHO??Primary care«..WHO??
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
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Primary care«..WHO??Primary care«..WHO??
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
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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
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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)
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Anatomic considerationsAnatomic considerations
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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
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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
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SYMPTOMATOLOGYSYMPTOMATOLOGY
The cardinal symptoms of The cardinal symptoms of
gastrointestinal diseases are:gastrointestinal diseases are:
Nausea & vomitingNausea & vomiting
Weight lossWeight loss
BleedingBleeding
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CONSTIPATIONCONSTIPATION
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CONSTIPATIONCONSTIPATION
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DIARRHEADIARRHEA
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Abdominal painAbdominal pain
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BLOATINGBLOATING
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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
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NAUSEA & VOMITINGNAUSEA & VOMITING
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
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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
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NAUSEA & VOMITINGNAUSEA & VOMITING
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
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NAUSEA & VOMITINGNAUSEA & VOMITING
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
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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
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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
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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)
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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
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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
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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
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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
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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
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Functional GI disordersFunctional GI disorders
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
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Functional GI disordersFunctional GI disorders
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
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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)
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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
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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.
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Functional dyspepsiaFunctional dyspepsia
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
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Functional dyspepsiaFunctional dyspepsia
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
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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
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GastroGastro--esophageal refluxesophageal reflux
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
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GastroGastro--esophageal refluxesophageal reflux
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
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GastroGastro--esophageal refluxesophageal reflux
diseasedisease1.1. Life style modificationsLife style modifications
2.2. Drug therapyDrug therapy
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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)
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Peptic ulcer diseasePeptic ulcer disease
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
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Peptic ulcer diseasePeptic ulcer disease
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
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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
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Diarrhea & dysenteryDiarrhea & dysentery
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)
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Diarrhea & dysenteryDiarrhea & dysentery
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
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Diarrhea & dysenteryDiarrhea & dysentery
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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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