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F A L NA S U Y
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S ER A D I
C ADE
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 I C
PT R
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P LC
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Peptic Ulcer
 ANTACIDS
Mechanism of action
Neutralization of gastric acidity
Low doses promote gastric mucosal
defensive mechanisms
Common examples include
CaCO3
NaHCO3
Al(OH)3
Mg(OH)2
 SIDE EFFECTS AND ADVERSE
EFFECTS
Magnesium : diarrhea
Aluminum : constipation
Calcium : constipation

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 NURSING INTERVENTIONS
Monitor for side effects
Nausea, vomiting, abdominal pain, diarrhea
With calcium-containing products:
constipation, acid rebound
Monitor for therapeutic response
Notify heath care provider if symptoms are not
relieved.

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 H2 BLOCKERS
H2 blockers impede acid production in the
stomach by blocking the actions of
histamine, a substance produced by the body
that encourages acid secretion in the
stomach.
These drugs cannot cure ulcers, but in certain
cases they are useful in reducing inflamation
allowing the stomach to heal

8
 H2 BLCOKER

Four H2 blockers are currently available

as over the counter drugs in the
Indonesia :
Famotidine
Cimetidine
Ranitidine
Nizatidine
Anderson et al. Handbook of Clinical Drug Data 10th edition. 2002 .
New York :McGraw Hill Inc
Anderson et al. Handbook of Clinical Drug Data 10th edition. 2002 .
New York :McGraw Hill Inc
Anderson et al. Handbook of Clinical Drug Data 10th edition. 2002 .
New York :McGraw Hill Inc
 PROTON PUMP INHIBITORS (PPI)

Proton Pump Inhibitors reduce the

production of acid by blocking the enzyme
in the wall of the stomach that produces
acid.
Inhibitors do not neutralize excess acid but
inhibit the initial production of
hydrochloric acid
The reduction of acid prevents ulcers and
allows any ulcers that exist in the
esophagus, stomach and duodenum to heal.

14
 PROTON PUMP INHIBITORS
Proton Pump Inhibitors are generally available only
by prescription but low doses of some products are
now approved for over the counter use
Commonly prescribed Proton Pump inhibitors include
Rabeprazole
Lansoprazole
Omeprazole
Esomeprazole
Pantoprazole

15
 OTHER DRUGS
SUCRALFAT
Cytoprotective agent.
Used for stress ulcers, erosions, PUD.
Attracted to and binds to the base of ulcers and erosions, forming
a protective barrier over these areas.
Little absorption from the gut.

Use
Dosage Forms. Tab 1 g; Susp 100 mg/mL.
Patient Instructions. Take this drug with water on an empty
stomach 1 hr before each meal and at bedtime.
Misoprostol
Synthetic prostaglandin analogue.

Prostaglandins have Cytoprotective activity:

Protect gastric mucosa from injury by enhancing local
production of mucus or bicarbonate.
Promote local cell regeneration.
Help to maintain mucosal blood flow.

Used for preventation of NSAID-induced gastric ulcers.

Doses that are therapeutic enough to treat duodenal ulcers

often produce abdominal cramps and diarrhea.
 / A
E HE
R R
A
I R
D IA
D
otility & Secretion
 ETIOLOGY OF DIARRHEA
Rotavirus
Enterotoxigenic Escherichia coli
Shigella
Campylobacter jejuni
cryptosporidium
Vibrio cholera
salmonella (Non thyphoid )
Entropathogenic Escherchia coli
 PHATOGENIC MECANISM
PATHOGENIC PATHOGENIC
MECHANISMS MECHANISMS )
( VIRUSES) PROTOZOA)
Replicate within the Mucosal adhesion and
villous epithelium of cause shortening of the
small bowel villi

Patchy epithelial cell G,lambelia ,

destruction and cryptosporidum
villous shortening Mucosal invasion in the
The Loss of normally colon or ileum and
absorptive villous cells causing micro absess and
ulcer
Replacement
E, histolitica
immature ,
secretary ,crypt- like
cells
Loss of disaccharides ,
especially lactose
 PATHOGENIC MECHANISMS )BACTERIA)
Mucosal adhesion to avoid being swept away
Entrotoxicogenic E.coli ,vibrio .cholera
Toxins that cause secretion that reduce the
absorption of Na and increase the secretion of
chloride
Entrotixigenic E.coli , v.cholera
Mucosal invasion occurs in the colon and distal
ileum and destroying mucosal epithelial cells
and cause bloody diarrhea
Shigella ,C.jejuni ,entroinvasive E. coli and
salmonella
 PREVENTION OF DIARRHEA

Give only breast milk for first 4-6 month

Do not use feeding bottle
Prepare and store food safely
Use clean water for drinking
Wash hands when soiled
Dispose of faeces safely
 PRINCIPLES OF
MANAGEMENT
1. Prompt replacement of fluids &
electrolytes
2. Maintenance of nutrition
3. Use of anti-microbials only for those with
bloody diarrhea, suspected cholera or
serious non-intestinal infections &
avoidance of anti-diarrheal agent
4. Patients or caretakers should be taught
about feeding & hygiene practices that
reduce diarrhea morbidity. Emphasize
prevention & follow-up.

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 TREAT DIARRHEA
CHILD ADULT
REHYDRATIO REHYDRATIO
N N
ADSORBENT ADSORBENT
PROBIOTIC PROBIOTIC
ZINC ANTIBIOTIC !
!!
VITAMIN A
LOPERAMID
 COMPOSITION OF ORS
Ingredient Amount (g/liter)
Sodium chloride 3.5
Trisodium citrate or 2.9 or
Sodium bicarbonate 2.5
Potassium chloride 1.5
Glucose 20.0

Home-made ORS: Sugar or molasses (40 g) can be used as a substitute for glucose to
prepare home-made ORS. Common salt (5 g) will be added to it and dissolved in one
liter of clean water.
Rice-ORS: Rice powder (50 g) can replace the sugar or glucose. The amount of the
other salts will remain the same. These will be dissolved in one liter of clean water to
prepare rice-based ORS. Studies showed that rice-based ORS can reduce vomiting and
diarrhea more in some cases compared to the conventional ORS prepared with
 PREVENT OF TREAT DEHYDRATION
Choose the treatment plan that corresponds
with the patients degree of dehydration
No Signs of Dehydration follow Treatment Plan A
at home to prevent dehydration & malnutrition
Some Dehydration follow Treatment Plan B to
treat dehydration
Severe Dehydration follow Treatment Plan C to
treat dehydration urgently

31
 REHYDRATION
Treatment Plan A
Home ORS: Mix the in a 1 liter of water:
How much fluids to give after each loose stool:
Children < 2 yrs: 50 100 mL of fluid
Children 2 10 yrs: 100 200 mL
Older children & adults: as much fluid as they want
What foods to give
Milk
Breast milk as often & as long as child wants
Milk formula every 3 hrs, if possible by cup
Infants < 4 months: on mixed feeding should receive increased
breastfeeding. If possible, breastfeed exclusively

32
 REHYDRATION
Treatment Plan B
Patients with Some Dehydration should
receive oral rehydration therapy (ORT) with
ORS solution in a health facility following
treatment plan B
Adults can consume up to 750mL/hr while still
dehydrated
Children can consume up to 20mL/kg BW/hr

33
 REHYDRATION
Treatment Plan C
For patients with SEVERE dehydration
Patients should be brought to the hospital so
that IV fluids can be started immediately
Usual fluid given is Lactated Ringers solution
If not available, Normal Saline solution may be
used

34
 ADSORBENT
Coat the walls of the GI tract
Bind to the causative bacteria or toxin, which
is then eliminated through the stool
Examples:
BISMUTH SUBSALICYLATE
KAOLIN-PECTIN
ACTIVATED CHARCOAL
ATTAPULGITE
 PROBIOTIC
Intestinal flora modifiers
Bacterial cultures of Lactobacillus
organisms
work by:
Supplying missing bacteria to the GI tract
Suppressing the growth of diarrhea-causing
bacteria
Example: L. acidophilus
 ZINC
Zinc-supplemented children had:
24% lower probability of continuing diarrhoea
42% lower rate of treatment failure or death
Conclusion: zinc supplementation reduces
the duration and severity of persistent
diarrhoea
Provide children with 20 mg per day of zinc
supplementation for 10-14 days (10 mg per
day for infants under six months old)
 OPIATES
Decrease bowel motility and relieve rectal spasms
Decrease transit time through the bowel, allowing more time
for water and electrolytes to be absorbed
Examples:
LOPERAMIDE

Administration and Adult Dosage. PO for acute diarrhea or

travelers diarrhea, to a maximum of 16 mg/day (8 mg/day for
no more than 2 days with OTC product).
Dosage Forms. Cap 2 mg; Chew Tab 2 mg; Tab 2 mg; Liquid
0.2, 1 mg/mL; Chew Tab 2 mg plus simethicone
Adverse Reactions. Abdominal cramping, constipation,
distention, headache, rash.
 &
E A G
U S I N
A I T
N OM
V
 DEFINITIONS
Nausea
Unpleasant feeling that often precedes vomiting
Emesis (vomiting)
Forcible emptying of gastric, and occasionally,
intestinal contents
Antiemetic agents
Used to relieve nausea and vomiting
 VOMITING - ANTIEMETICS
The CTZ receives most of
the impulses from drugs,
toxins, and the vestibular
center. The neurotransmitter
dopamine stimulates the
CTZ, which stimulates the
vomiting center, when
triggered, motor neuron
responds contraction of
diaphragm, anterior
abdominal muscles, & the
stomach. the glottis closes,
the abdominal wall moves,
upward & vomiting occurs.
 ANTIEMETICS
Nonprescription antiemetics : used to prevent motion
sickness - minimal effect on severe vomiting from
anticancer agents, radiation, and toxins.
take 30 min before traveling
DIMENHYDRINATE, DIPHENHYDRAMINE
 ANTIEMETICS
METOCLOPRAMIDE, DOMPERIDONE
Blocks dopamine & serotonin receptors in the CTZ
Use : post-op emesis, chemo & radiation therapy
SE : sedation & diarrhea w/ high doses
 ANTIEMETICS
Serotonin Antagonists ONDANSETRON,
GRANISETRON
Action :
Suppress 5HT3 by blocking the serotonin receptors
in the CTZ & afferent vagal nerve terminals in
upper GI tract - Do not cause EPS symptoms
Use : chemo induce emesis - PO & IV
SE : headache, diarrhea, dizziness, fatigue
OVERVIEW OF PROKINETIC DRUGS

Masaoka T, et al: Update on Gastroparesis. Gut and Liver, Vol. 3,

No. 3, September 2009, pp. 166-173
 N
IO
AT
IP
S T
N
CO
 CONSTIPATION
Abnormally infrequent and difficult passage of feces
through the lower GI tract
Symptom, not a disease
Disorder of movement through the colon and/or
rectum
Can be caused by a variety of diseases
or drugs
 MECHANISM OF ACTION
Bulk forming
Emollient
Hyperosmotic
Saline
Stimulant

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 BULK FORMING
High fiber
Absorbs water to increase bulk
Distends bowel to initiate reflex bowel
activity
Examples:
PSYLLIUM
METHYLCELLULOSE
POLYCARBOPHIL

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 EMOLLIENT
Stool softeners and lubricants
Promote more water and fat in the stools
Lubricate the fecal material and intestinal
walls
Examples:
STOOL SOFTENERS: DOCUSATE SALTS
LUBRICANTS: MINERAL OIL

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 HYPEROSMOTIC
Increase fecal water content
Result: bowel distention, increased
peristalsis, and evacuation
Examples:
POLYETHYLENE GLYCOL
SORBITOL
GLYCERIN
LACTULOSE

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 SALINE
Increase osmotic pressure within the
intestinal tract, causing more water to enter
the intestines
Result: bowel distention, increased
peristalsis, and evacuation
Examples:
MAGNESIUM SULFATE
MAGNESIUM HYDROXIDE
MAGNESIUM CITRATE
SODIUM
d
PHOSPHATE (FLEET ENEMA)
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 STIMULANT
Increases peristalsis via intestinal
nerve stimulation
Examples:
CASTOR OIL
SENNA
CASCARA
BISACODYL

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 A K
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