perforation and hemorrhage

pt will complain of pain w/ ulcer

once ulcer perforates - no pain

stimulate secretion of mucus

stimulate secretion of HCO3

promote vasodilation (maintain submucosal blood flow)

suppress gastric acid secretion

often caused by Helicobacter pylori (gram - bacillus)

NSAID's - block action of PGA's (prostaglandins) & produce direct irritant effect

Pepsin - proteolytic enzyme present in gastric acid

Smoking - delays ulcer healing & increases the risk of recurrence

clarithromycin (Biaxin) - suppresses growth. AE: N, D

amoxicillin (Amoxil) - disrupts cell wall. AE: D

Bismuth subsalicylate (Pepto-Bismol) - disrupts cell wall. Stool discoloration may mask GI bleed

tetracycline - inhibits protein synthesis. ~1% of strains are resistant. AE: stains teeth

metronidazole (Flagyl) - disrupts DNA/protein synthesis. 40% of strains are resistant. AE: HA; N,V

tinidazole (Tindamaz)  - very similar to metronidazole

cimetidine (Tagamet)

suppresses secretion of gastric acid by blocking H2 receptors

histamine2-receptor antagonist(65% effective)

Use: gastric & duodenal ulcers; GERD; Zollinger-Ellison syndrome; aspiration pneumonitis; heartburn, acid indigestion, sour stomach

Effects: reduce volume of gastric acid; reduce acidity

AE: antiandrogenic effects(gynecomastea, ↓ libido (mainly seen in males)); CNS effects (confusion, hallucinations, excitement or depression)

DD: ↑ drug levels of: warfarin(Coumadin); phenytoin (Dilantin); theophylline (Theo-24); lidocaine (Xylocaine); antacids - ↓ cimetidine absorption

ranitidine (Zantac)

histamine2-receptor antagonist (65% effective)

similar to cimetidine(Tagamet), but more potent; fewer AEs; fewer DD interactions

omeprazole (Prilosec)

inhibits H+, K+ ATP'ase (enzyme that generates gastric acid)

proton pump inhibitor (90% effective)

Use: duodenal ulcers, gastric ulcers, GERD, erosive esophagitis, ulcer prophylaxis, Zollinger-Ellison syndrome

Effects: suppresses acid secretion (by 97% in 2 hr), persisting over 2 days

AE: HA; N, V, D, PNA(pneumonia), Fx, rebound acid production, hypomagnesemia

DD: decreases effectiveness of clopidrogerel (Plavix)

all similiar to omeprazole

esomeprazole (Nexium)

lansoprazole (Prevacid)

Dexlansoprazole (Dexilant)

rebeprazole (Aciphex)

pantoprazole (Protonix)

sucralfate (Carafate)

produces a gel that sticks to ulcer, forms protective barrier against acid & pepsin

"other anti-ulcer drugs"

Use: duodenal ulcers

Effects: protects ulcer from acid

AE: constipation

DD: antacids(interfere w/ sucralfate; take 30 mins apart); phenytoin (Dilantin), theophylline (Theo-24), digoxin (Lanoxin), warfarin (Coumadin) & fluoroquinolone antibiotics (sucralfate reduces the absorption of; take 2 hrs apart)

misoprostol (Cytotec)

replaces endogenous prostaglandins

"other anti-ulcer drugs"

Use: prevention of gastric ulcers caused by long-term NSAID therapy; induce labor

Effects: suppress gastric acid secretion; promote mucus & bicarbonate secretion; vasodilation

AE: D, abd. pain; pregnancy X-uterine contractions

alkaline compounds that neutralize stomach acid

Use: PUD (peptic ulcer disease) & GERD

AE: C, D

DD: ↓ absorption of other drugs, allow 1 hr between them

Combination packs - Helidac, Pylera, Prevpac: prepackages the multi drug treatment for ease of administration

avoid in pts w/ undiagnosed abdominal pain (r/t bowel stimulation) or D

long duration

usually in a preparation (Maalox; mixture of both) w/ magnesium hydroxide

constipation

long duration

AE: flatulence, acid rebound, constipation

short duration

AE: flatulence, Na exacerbate HTN & HF

laxative effect - production of soft, formed stool over one or more days

catharsis - prompt, fluid evacuation of the bowel

constipation - stool consistency vs frequency of bowel movement

polycarbophil (FibCon)

mimic dietary fiber (absorbs H2O, softening feces & ↑ mass; digested by colonic bacteria, ↑ mass)

"bulk-forming laxative"

Use: temporary tx of constipation, diverticulitis, irritable bowel syndrome; relief from diarrhea; reduce discomfort in pts w/ ileostomy or colostomy

Effects: promote ease of BM, softer stool; produces soft stool in 1-3 days

AE: esophageal obstruction (give w/ full glass of H2O); intestinal obstruction or impaction (if passage through intestine is stopped)

other bulk-forming drugs: psyllium (Metamucil)

docusate sodium (Colace)

docusate calcium (Surfak)

surfactant (lowers surface tension), allowing H2O to enter feces; inhibit H2O absorption in GI wall & stimulate secretion of H2O into intestine

"surfactant laxatives"

Use: constipation

Effects: production of soft stool in 1-3 days

AE: minimal

bisacodyl (Dulcolax)

stimulate intestinal motility, ↑ amt H2O in intestine

Use: constipation caused by opioids or slow intestinal transit

Effect: PO - semifluid stool in 6-12 hrs; PR - 15-60 min.

AE: minimal

avoid milk, antacids - give 1 hr after these

senna (Senokot)

similar to bisacodyl; may color urine (dark brown, or pink)

only stimulant to act on small intestine, acting quickly (2-6 hrs) to produce watery stool

laxative salts (Mg(OH2); MGSO4; magnesium citrate; NaPO4

"osmotic laxative"

Effects: osmosis draws H2O into intestine, causing feces to soften & swell. Swelling stretches intestinal wall, stimulating peristalsis.

Low doses produce soft or semifluid stool in 6-12 hrs.

Higher doses cause fluid evacuation of bowel in 2-6 hrs (diagnostic test & surgical prep)

AE: dehydration; in renal dysfunction pts - ↑ Mg leads to toxicity; ↑ Na leads to edema, HTN, heart failure

polyethylene glycol (Miralax)

similare to salts; nonabsorbable compound that retains H2O in the intestine

"osmotic laxative"

AE: N, abd. bloating, cramping, flatulence; D in high doses

lactulose

"misc. laxative"

produces osmosis by acid formation (lactic, formic, acetic); 1-3 days to work. Used to enhance intestinal excretion of NH3=ammonia (portal HTN, hepatic encephalopathy)

lubiprostone (Amitiza)

"misc. laxative"

chloride channel activator. promotes fluid secretion into small intestine & colon & ↑ motility. Semi soft stool in 24 hrs. Used for chronic idopathic constipation, IBS-C women >18

action by lubrication; enema for fecal impaction

glycerin suppository

misc. laxative

osmotic action for insipissated (thickened, hardened, impacted) feces

bowel cleansing products for colonoscopy or pre-op

• GoLytely, Colyte, NuLytely, MoviPrep

ondansetron (Zofran)

serotonin receptor antagonist in chemoreceptor trigger zone (CTZ)

"antiemetics serotonin antagonist

Use: N, V r/t chemotherapy-induced emesis and anesthesia, off label for other N, V

Effects: suppression of N, V

AE: HA; D; dizziness, prolongs QT interval - dysrhythmias

safe in pregnancy

most effective/most common

glucocorticoids: methylprednisolone (Solu-Medrol); dexamethasone (Decadron)

"antiemetics"

Effects: suppression of emesis from CA chemotherapy

AE: minimal

prochlorperazine (Compazine)

promethazine (Phenergan) - not for kids < 2

blocks dopamine receptors in CTZ

"antiemetics dopamine antagonist"

Use: emesis associated w/ surgery; CA chemotherapy; toxins

Effects: reduce N, V

AE: EPS, anticholinergic effects, hypotension, sedation

haloperidol (Haldol)

droperidol (Inapsine)

blocks dopamine receptors in CTZ

"antiemetics butyrophenones"

Use: post-op N, V; CA chemotherapy; radiation therapy; toxins

Effects: reduce N, V

AE: EPS, sedation, hypotension. doperidol - QT prolongation

dronabinol (Marinol)

"cannabinoid" - extract from marijuana

"other antiemetics"

Use: N, V from CA chemotherapy; appetite stimulation - AIDS pts

Effects: suppresses emesis

AE: ↑ HR, hypotension; drowsiness, psychoactive effects; abuse potential (Schedule III) - locked up and counted

diphenoxylate (Lomotil)

loperamid (Imodium)

↓ intestinal motility; allows ↑ time for H2O absorption

"antidiarrheal"

Effect: decrease diarrhea

AE: minimal

metoclopramide (Reglan)

suppresses emesis by blocking dopamine & serotonin receptors in trigger zone & increases upper GI motility

"prokinetic drug"

Use: suppression of N, V; GERD, gastroparesis (stomach paralysis)

Effects: reduce N, V; increase GI motility

AE: sedation, D; EPS - tardive dyskinesia