GIT OTC

:BY
DR Mai Mosaad
Function of gastrointestinal tract
 Break down food into suitable energy sources to
allow normal physiological process
 Many conditions affect GIT

 Acute” self limiting” serious “refer”

Anatomy of GIT
 We have to know the anatomy of GIT To facilitate correct diagnosis

 Oral cavity “ teeth, cheeks and tongue “

 Stomach “ j shaped “
 Liver
 Gall bladder
 Pancreas
 Small intestine “ duodenum – jejunum – ileum “
 Large intestine “ceacum – colon – rectum “
MOUTH ULCERS
Oral cavity
 Mouth ulcers
 Taking history and physical examination
 Examine lesions “ size , shape, color ,swellings
and tooth decay “
 Pharmacist role is to exclude more serious
pathology , Ex : carcinoma &systemic causes
Types of mouth ulcers
 Minor aphthous ulcer
 Major aphthous ulcer
 Herptiform ulcers
 Carcinoma
 Herpes simplex
 Oral thrush
Clinical features of minor aphthous ulcers
Roundish , grey white in color and painful 

Smaller than 1 cm in diameter 

Take 7 to 14 days to heal 

No. of ulcers single up to 5 ulcers 

Location : cheeks , inside of the lips & tongue 

Small and irregular shape painful ulcers 

years may be herpes simplex 10 > 

Major aphthous ulceration
 Diameter is greater than 1 cm
 Deeper
 Take long time to heal 20 to 30 days
 Herpetiform ulcers
 Herpes like ulcers but its not a viral infection
 Less than 1 com diameter
 Small , filled with blisters
 Extreme painful and immunity related
 Take 15 days healing
 Trauma
 Tongue biting “ may be mechanical “
Herpes simplex
 Oral ulceration in children
 In gums, tongue and cheeks
 Small and discrete
 Systemic infection “fever and pharyngitis “
Oral thrush
 Painful, creamy white soft ulcers
 “candidasis
Medicine induced ulcers
 NSAIDS or beta blockers’ metoprolol –carvedilol
and propranolol for ex.
 “carvid – inderal- selenozoc “
Oral carcinoma
 Mouth “ tongue , lips ..”
 painless
 Over time it become painful , change color , crust
over and bleed
Hand , foot and mouth disease
 Mouth ulcers
 Blisters in hand and feet
 As a result of coxsacie virus
 Highly contagious
 Require good hygiene
Treatment
 We have to refer in painless , herpetiform , major
ulcers and hand , foot and mouth ulcers , also
ulcers then take longer than 14 days and children
under 10 years
Choline salicylate
 Anti inflammatory drug , decrease swelling and
pain reliever
 As “mundisal gel “ , “pansoral gel “
 For patients greater than 16 years old
 Dose : every 3 hours
 Safe , less side effects
Benzydamine
 Has analgesic effect
 Prevent recurency
 Ex : BBC spray “ contain benzocaine anaesthetic
“ dose : every 3 hours
tantum verde “ mouth wash “
Chlorohexidine
 Prevent gingivitis and for oral hygine
 Ex : pongeel and orovex “mouth wash”

DG care “oral gel “

Dose : apply for 2 minutes 2 to 3 times daily
Local anaesthetics
 Benzocaine “ short duration “
EX: BBC spray
: Dentocaine gel
 lidocaine EX : Dentinox gel
: Dento gel
“ Candidiasis “oral thrush
 Creamy white soft painful ulcers – fungal infection
 causes : immunocompromised patients

: Dentures
: MAU may transform into candidiais
: Diabetic patients “no control “
: inhaled corticosteroids and antibiotics “
amoxacillin and macroloids “
treatment
 Refer after 3 weeks to exclude sinister pathology
 Imidazoles > 4 months age
 E x : ketoconazole , clotrimazole and fluconazole
 “ Daktarin oral gel” “ miconaz oral gel “
Dose
2 times daily
 Leave at mouth as longer as possible
Gingivites
 Treatment : chlorohexidine “antibacterial “ it
reduce plaque formation and gingivitis
Ex : orovex “ mouth wash “
: hydrogen peroxide : over 6 years age
10 ml 4 times daily
: brush teeth twice
DYSPEPSIA
 Non ulcer dyspepsia
 Symptoms : flatulence , belching , feeling of
fullness , nausea , vomiting , heart burn ,
constipation and abdominal discomfort
Causes
 Eating fast
 Spice food
 Moving during eating
 Caffeine containing products
 Pain in certain point in abdomen
 Pain removed by eating or anti acids
 Dark stool

‘ may be ulcer not dyspepsia ‘

Continuous vomiting may be cancer
ULCERS
 Ulcers
 Gastric ulcer Duodenal ulcer
Causes
 Peptic
ulcer occur when the balance
between aggressive factor and mucosal
defensive mechanisms is disrupted
 Ulcers causes
 80 % up to 95 % cause is helico bactr pylori
bacteria and NSAIDS

 Cigarette smoking impairs ulcer healing , promote

ulcer recurrence and increase ulcer risk
 Relative Effect of some drugs
 Clopidogrel : impairs the healing of gastric ulcers
 Corticosteroids : it has no effect when taken alone
but relative risk is increased 2 folds (2 times ) with
NSAIDS ,( it impairs the healing of ulcer and may
cause ulcer )
.Cont
 Anticoagulant : relative risk of GI bleeding increase
20 folds ( 20 times ) when NSAIDS taken with
anticoagulants ex: warfarin “coumadin – marevan )
 SSRIs : risk of GI bleeding increase 6 folds ( 6 times
when SSRIs are taken with NSAIDS
 Ex : citalopram – esitalopram – fluoxetine
paroxetine ( anti depressant )
Others
 Alcohol
 Stress
 Chronic disease
 Renal failure and cirrhosis
 Worsen symptomes
Symptomes
 Epigastric pain May radiate to the back
 Burning or piercing
 Un comfortable feeling of emptiness of stomach refered
to as a painful hunger
 Weight loss ‘this may indicate carcinoma ‘
 Heart burn indicate GERD not PUD
 age from 30 to 50
Complications
 Hemorrhage
 Perforations
 Gastric outlet obstruction “rare “ : due to an
active ulcer with surrounding edema or because
the healing of ulcer has been followed by scaring
Diagnosis of H-pylori
 Gram –ve bacteria damage epithelial cells by its
enzymes and toxins
 Tests to determine :
 Blood test : IgG antibodies found in the blood sample
may indicate the presence of H-pylori but it may
present also in blood samples of patients who was
already cured
 So it is not sensitive
 Stool: more sensitive and specific
 c13 urea breath test : less sensitive
 Endoscope
Treatment of H-pylori
 Treatment for 14 days is better than 7 days
 Some people have H-pylori but with no symptoms
so no drug is required
 NSAIDS
 Non steroidal anti- inflammatory drugs
 Continue using of NSAIDs may cause ulcer
 Ex : ibuprofen , ketoprofen ,
Prostaglandin E
 Decrease HCL secretion in the stomach
 Increase secretion of mucus and bicarbonate
 In severe cases as in severe arthritis we can not
stop NSAIDS
 So we can decrease dose or use cox2 inhibitor
( selective )
 Ex : celecoxib
 Celecoxib has les effect on stomach but with
aspirin it has the same effect as NSAIDS
Duodenal ulcer
 Painthat awakes patient from sleeping
 Occurs after 2 to 3 hours after eating
Biliary disease
 Acute cholecystitis
 Cholelithiasis

 Acute and predominant pain after eating fatty meal

radiate to epigastric area and to the tip of the right
scapula
 Most common > 50 , women > men
A typical angina
 Symptoms like ulcer and radiate at the neck and
the shoulder
 Difficulty in breathing
 Increase by exercise
Treatment
 Advice the patient to decrease alcohol , spice ,
fatty diet , chocolate , caffeine and smoking as it
worsen symptoms
Antacids
 Na , K ‘ high soluble quick action ‘
 Mg , Al ‘ less soluble – long duration of action ‘
 Ca salts ‘ quick action –prolonged release ‘
 Ex : Gaviscon – maalox – fawar fruit
 Dose : every 3 hours , not used for more than 2 weeks take after
meals avoid taking with other drugs as it affect its absorption
 Glycodal tab : 1- 2 tab 3 times daily
Antacids
 Eff.containing NaHco3 is contraindicated in
heart disease patients , renal failure .pregnant
women due to high sodium content which might
increase the fluid over load
 Ex : fawar fruit
 Upper limit of sodium in healthy person is 2300
 Upper limit in patients <51 years is 1500 mg per
day including salt in food
 1 gram NaHCo3 contains 274 mg sodium / gram
 Fawar fruit contains 2.80 gram sodium
Alginates
 Firstline treatment for “GERD” gastro esophageal
reflux disease
 Combined with anti acids
 Neutralize stomach acidity
 Ex : Gaviscon “sodium alginate “
H2 antagonists
 Ranitidine , Famotidine , Cimetidine and Nizatidine
 Decrease stomach acidity
 It block histamine producing cell receptors in the
stomach so that it could not promote parital cells to
produce acids
 Dose : 1 tab 2 times daily
 Superior in effect than antacids
 Some patients may develop tolerance to h2
blockers after 30 days
H2 blockers + Antacids
 Fastonset of antacids with long duration of H2RA
 Dose : 1 – 2 tablets per day
 (famotidine + caco3 +MgoH2 ) “ antodine
chewing tablets
Proton pump inhibitors
 Omeprazole – pantoprazole – lansoprazole –
rabeprazole – esomeprazole
 PPIs > H2 antagonist > aliginate + antacids >
antacids
 Dose one tablet before break fast
 Drug of choice
 Proton pump inhibitors heals 85% of NSAIDs
induced gastric ulcer and 90 % of duodenal ulcers
in 8 weeks

 H2 blockers heals 70% of ulcer in 8 weeks

Omeprazole interactionswith drugs
 Diazepam “ anxiety “ : increase its side effects
 azole anti fungil “ miconazole – ketoconazole “ :
decrease its bioavailability
 Fluvoxamine “ dilating arteries “ : increase omeprazole
blood level
 Clopidogrel : decrease its blood level
 Pantoprazole : decrease milk secreation
Prophylactic therapy in high risk patients
 Over 65 years old
 Peptic ulcer history
 Therapy with corticosteroids and anticoagulants
Prophylaxis
 Misoprostol : is a prostaglandin analogue
 Dose : 600 to 800 mg / day
 PPIs : ( 20 mg / day )

protect against gastric and duodenal ulcers they are

both effective but misoprostol has more side effects
GERD
Gastro esophageal reflux disease
 GERD : heart burn that is frequent ( 2 or more
days a week ) and persistent ( 3 or more months )
GERD symptoms
 Burning sensation that usually arises from sub
sternal area ( lower chest ) and moves up towards
the neck or the throat
GERD
 Post prandial heart burn : usually occur with in
2 hours after eating or when bending over or lying
down
 Nocturnal heart burn : occurs during sleep and
often awaken the patient
 More than 60 million American suffer from heart
burn at least once a month and over 25 million
experience heart burn daily
Complications
 10-15 % of patients with GERD will develop
bariett’s esophagus (abdominal lining of
esophagus
 1- 10 % of those with barett’s esophagus will
develop carcinoma over 10- 20 years
? What prevent the acid reflux
 the lower esophageal sphincter serves as a
primary anti reflux barrier by preventing back
flow of stomach content
: The reflux is cleared from the esophagus by
 Peristaltic contractions
 Gravity
 Neutralization by the bicarbonate in the saliva
 The esophageal epithelium is not as tolerant as
that of the stomach to repetitive exposure of
gastric acid

 Thereflux acid may also damage the larynx ,

respiratory system (asthma )
Causes of GERD
 The most common mechanism for acid reflux is
the transient relaxation of the LES
 Other :

1. increase intra abdominal pressure

2. Delayed gastric emptying
3. Poor esophageal acid cleareance
? When to refer
 Dysphagia
 2 weeks of OTC PPIs or H2RAs with no resolution
 Children < 12 years
 Vomiting up blood or black stool
 Frequent heart burn > 3 months
 Weight loss
Life style and diet change
 Head of bed elevation : (10 : 20 cm )
 Avoidance of meals (2-3hs )before bed time
 Weight loss : there is definite relation ship
between GERD and obesity in symptoms and
complications
 Diet change : several food are believed to be
direct esophageal irritant but not with all patients
Ex : citrus juice, carbonated bevarages , coffee ,
fatty food and chocolate
Treatment
 Antacids
 H2RA
 (H2RA + Antacids)
 PPIS
 Prokinetics (not otc )
Selection of the drug is based on
 frequency ( 2 times per week –ppIs -if less we can use
H2RA or antacids )
 duration
 severity (mild –moderate –severe )
 drug drug interaction
 Costs
 Patient preferance
Prokinetics
 Metoclopramide “primperan “ use is limited as it
pass BBB and cause CNS side effects
 Domperidone “ motiulim “
 Cisapride‫لسوق‬PP‫تسحبمنا‬P‫“ ا‬cardiovascular risk “
 Mosapride “ Gasmovac “
Prokinetics
 Works by :
 Increase LESP
 Enhance esophageal peristalsis
 Enhance gastric emptying
 Not recommended as mono therapy
 Mosapride +omeprazole ( improve reflux symptoms and
gastric emptying )
Baclofen
 Muscle relaxer
 Anti spasmotic
 Has a use in GERD as it decrease the number of
transient LES relaxation
 Not used for long time
 Not approved by FDA
Pregnancy and GERD
 Are common due to mechanical pressure placed in
the stomach and the intestinal tract as the uterus
enlarges
 Therapy refer
 ( antacids – H2 blockers – PPIs )
DIARRHEA
 Diarrhea
 Diarrhea is 2 types : acute ‘ last for less than 7
days ‘ and chronic > 14 days
 may be due to bacterial or viral or parasitic
infection
 Chronic diarrhea may be because of “ IBS , colon
cancer or inflammatory disease ‘
 diarrhea
 Rota virus : Diarrhea” no blood and watery in
nature “ + cough + cold
 In infant diarrhea may be because of lactose
intolerance it also accompained with fever ,
vomiting and fail to gain weight
Types of diarrhea
 Viral infection : low fever and diarrhea
 bacterial infection :bloody diarrhea in case of
‘shigella – salmonella (gram -ve bacteria )
 Parasitic infection : blood + mucous and pre anal
itching
treatment
 Loperamide “ imodium 2 mg
 Decrease frequency of diarrhea for gasteroenteritis
and IBS
 Dose : 16 mg per day
 not for children under 12 years
 2 capsule immediately followed by 1 capsule after
each bout of diarrhea
Treatment
 Eating rice ,banana ,apple , tea and bread help in
preventing diarrhea
 Oral rehydration solution is important especially in
children
 Most important sign of dehydration is oligurea
 Others are : sunken eyes , delayed skin turgor and
dry mucous memberane
Treatment
 Bacterial infection : antibiotics “refer “
 Anti spasmotic : buscopan , viscerlagine , spasmofen amp
 Anti emetics : metoclopramide ‘ primperan ‘ 1 tab every 8 hours
 Domperidone : motilum
 Antinal ‘nifuroxazide ‘ : 1 tab 3 times daily
 Streptoquin : anti diarrhea and anti spasmotic
 Anti pyretic : paracetamol
CONSTIPATION
 Constipation
Causes :
 insufficient fluid of fiber in diet
 Reduce mobility of patient
 Drugs : antidepresents , calcium and iron
 Hyper thyrodism
 Hyper calciumia
 IBS
 Colorectal cancer
Treatment
 Bulk laxatives : they pass through the
gastrointestine tract indigested
 Increase faecal volume by adding directly to it and
softening of faeces
 It considered first line of treatment
 Plantago & ispagula ,ex : agiolax and biolax
sachet
Dose : one sachet with water before sleeping
 evaculax caps : “ poly carbophil “

dose : adult : 2 caps 1-3 times daily

: children : 1 caps 1-3 times daily
Stimulant laxatives
 Act mainly by stimulating the intestinal mucosa to
secret water and electrolytes
 May cause direct damage to intestine
 Not recommended in children and pregnancy
Types
 Diphenyl methane
1. Biscodyl ex :‘bisadyl ‘ – ‘abilaxine ‘
1 tab 2 times daily or one supp twice daily
2. Sodium picosulphate : ex ‘picolax’ for adults : 15 drop
by ½ cup of water before sleeping
children > 5 5 drops before sleeping children < 5
1-3 drops before sleeping safe at pregnancy
 Anthraquinons
 senna ‘sennalax ‘
 Not in pregnancy and lactation as it can pass to
baby through milk
 Dose : 2 tab before sleeping or 2 tab twice daily
Osmotic laxatives
 Lactulose “ organic “
 Dose for adults : 1-3 table spoonful 1-3 times daily
 Dose for children > 6 : 1 table spoonful 1-3 times daily
 Dose for children < 6 : 1 tea spoonful 1-3 times daily
 Not recommended in diabetic patients
 Safe at pregnancy
 Laxel sachets “ inorganic “
 Magnesium sulphate ,magnesium hydroxide and
sodium sulphate
 dose : one sachet 2 times daily
 sodium docusate
 Minalax tab
 dose : 1-2 tab before sleeping
PARASITIC INFECTIONS
Parasitic infection in adults
 Symptoms :
 diarrhea , constipation
 Bloody or mucous stool
 Abdominal cramps
 Perianal itching
 Anemia
Entameba histolytica
 Vegetative form
 Metronidazole ‘flagyl 500 ‘
 Dose :1 tab 3 times daily for a week
 Secnidazole ‘fladazol 500 ‘
 Dose :4 tab once after meal
 Cyst :
 Metronidazole :for one week then stop it for a
week then give it another week
 Secnidazole : 4 tab once for three days
 Metronidazole + diloxanide “furazol” “ 2 tab 3
times daily for10 days
Giardiasis
 Metronidazole : 1 tab 3 times daily
 Tinidazole ‘fasigyn ‘ : 4 tab once do not repeat
Entrobius (oxyuris )
Mebendazole ‘antiver ‘:
1 tab per week for 3 weeks
Flubendazole ‘fluvermal tab ‘
1 tab per week for 3 weeks
Albendazole ‘bendax –alzental 200’
1 tab per week for 3 weeks
Ascaris and anklystoma
 Mebendazole’antiver’ + flubendazole
‘fluvermal’
 1 tab 2 times per day for 3 days
 Albendazole
 2 tabs once and don’t repeat
 Verm-1 tab
 Broad spectrum
 For entrobius , ascaris and anklystoma
 Dose : one tab every 10 days
 Mebendazole 500 mg
HEMORRHOIDS
Hemorrhoides
 Symptoms :
 irritaion at anul fissure
 Pain
 Blood
treatment
 Hydrocortisone
 Lidocaine
 Laxatives
 Ex: H formula , faktu , sediproct
 Dose : twice daily
IBS
Irritable bowl syndrome
 Symptoms
 Affect any age but common at young females
 Distension ‫اخ‬P‫نتف‬P‫ا‬
 Abdominal pain relieved with defecation
 Symptoms appear with certain food and stress
 Alerted bowl habits diarrhea and constipation
treatment
 Eatsmall meals and divide it into several meals
 High fiber diet
 avoid caffeine and milk products
treatment
 Mebeverine
 Ex: librax – colona –duspataline –colospasmin
forte
 Dose : 1 tab 3 times daily before meal by ¼ hour
Treatment
 Coloverin A : chlorodiazepoxide
 For anxiety
 Coloverin D : dimethicone
 For flatulence
 Coloverin sr : sustained release
 Coloverin
Digestants
 Digestin
 Spasmo digestin
 Spasmo amrase
 1 tab 3 times daily before meal
Git regulators
 Gast-reg “trimibutane ‘
 Motilum

1 tab 3 times daily before meal

INTESTINAL GAS
Intestinal gas
 Causes :
 Food : fruits ( apples – pears ) – vegetables
( onions – broccoli ) – daily products ( milk –
cheese ) – food containing sorbitol ( suger in
fruits ) ) – carbonated soft drinks
treatment
 Drink before meal not with in
 Eat and drink slowly
 OTC digestive aids (digest carbohydrates
 Avoid smoking and drinking by using straw
 Use probiotics ( yogurt ) : benefit bacteria that aid
digestion and reduce excessive gas
OTC treatment
 Activatedcharcol
 Simethicone
Chronic excessive gas
 Incase of :
 lactuose intolerance
 IBS
 Colon cancer
 Upper gastrointestinal disorders
Flatulence
 Disflatyl ‘simethicone ‘
 1-2 tab 3 times daily
 Eucarbon
 1 tab 3 times daily
Abdominal pain
Thank you