GREAT

1. PHS4108 PHARMACY OF GASTROINTESTINAL
SYSTEM, NUTRITION AND METABOLISM, 5CU
March 30th 2021

2. Course objectives
 To describe the pathophysiology and epidemiology of selected diseases of the gastrointestinal
system, nutrition and metabolism.
 To describe the investigative procedures in gastro intestinal, nutrition and metabolic disorders
 To discuss the goals of therapy, treatment modes and monitoring in the management of gastro
intestinal, nutrition and metabolic disorders
 To provide opportunities for students to learn clinical skills related to the treatment of patients
with disorders of the gastrointestinal system, nutrition, and metabolism in a practice laboratory
setting
 To provide opportunities for students to work with pharmacy interns and pharmacists in the
healthcare setting to practice the pharmaceutical care skills related to the treatment of patients
with disorders of the gastrointestinal system, nutrition, and metabolism

3. Expected outcomes
 Demonstrate knowledge of pathophysiology and epidemiology of gastrointestinal, nutrition and
metabolic diseases
 Integrate knowledge of pharmacology and therapeutics in management of patients with
gastrointestinal, nutrition and metabolic diseases
 Design and formulate a pharmaceutical care Plan for patients with gastrointestinal, nutrition and
metabolic diseases
 Demonstrate professionalism and ethical awareness during patient care
 Demonstrate the clinical skills necessary for the treatment of patients with disorders of the
gastrointestinal system, nutrition, and metabolism

4. Week 1 – GIT infections and
infestations
 To review GI physiology
 To discuss selected infections and infestations of the GI system; (definition, etiology, signs and
symptoms, precise pathogenesis, management)
 Bacterial infections; cholera, dysentery, typhoid/enteric fever
 Protozoal infections; Amoebiasis, Giardiasis, Cryptosporidiosis
 Helminthiasis; Nematodes, Trematodes and Cestodes
 To discuss patient assessment for infections of the GI system
 To outline and discuss antimicrobial agents used in treatment of infections and infestations of the GI
system (medicine, pharmacokinetics, pharmacodynamics, mechanism of action, dosage regimen,
monitoring parameters, clinically significant side/adverse effects, contraindications, clinical
pharmacokinetics aspects)
 To outline and explain indications and contraindications for enteral and parenteral nutrition in specific
disease states
 To outline and explain common nutritional deficiencies that can occur from GI losses due to infections
and infestations of the GI system
 To explain strategies for nutrition support of patients with GI infectious diseases

5. Week 2 – Disorders of GI System
 Discuss the etiology of selected disorders of the GI system;
 Gastro-esophageal reflux disease (GERD),
 Peptic Ulcer Disease (PUD),
 Liver disease
 Constipation,
 Inflammatory bowel disease
 To discuss patient assessment for disorders of the GI system
 To outline and discuss medicines used in treatment of disorders of the GI system (medicine,
pharmacokinetics, pharmacodynamics, mechanism of action, dosage regimen, monitoring parameters,
clinically significant side/adverse effects, contraindications, clinical pharmacokinetics aspects)
 To outline and explain indications and contraindications for enteral and parenteral nutrition in specific
disease states
 To outline and explain common nutritional deficiencies that can occur from GI losses due to disorders
of the GI system
 To explain strategies for nutrition support of patients with GI disorders diseases

6. Week 3 – Clinical Nutrition
Nutrient deficiencies and malnutrition
 Define nutrient deficiencies and characterise common nutritional disorders
 Identify signs and symptoms of potential nutrient deficiencies
 Discuss potential etiologies of nutrient deficiencies
 Discuss methods for measuring nutrient status
 Discuss principles of management of malnutrition in children
Overweight and obesity; children, young people, adults, pregnancy;
 Define overweight and obesity in children, young people, adults and in pregnancy
 Discuss the risks associated with overweight and obesity among the different population groups;
children, young people, adults and in pregnancy
 Discuss the principles of lifestyle weight management among children, young people, adults and in
pregnancy related weight gain


7. Week 3 – Clinical Nutrition
Assessment of Nutritional status of children, adults and in pregnancy
 Explain the assessment of nutrition status in different population groups; children, adults and pregnancy
 Discuss the critical nutrient requirements for pregnant and breastfeeding mothers and the rationale for
each nutrient.
 Describe Oral nutrition, Enteral nutrition and Parenteral nutrition, explain their respective indications and
precautions
 Outline and explain parameters used for nutritional, anthropometric and clinical monitoring of nutrition
support.
 Discuss how laboratory monitoring for nutritional support is done
 List the primary components of a nutrition assessment for a pediatric patient.
 Identify the different types of infant and pediatric formulas and their recommended uses.
 Define the nutrient needs of a pediatric patient receiving nutrition support.
 Calculate daily nutritional needs of a neonate or pediatric patient including: kcal, protein, fat carbohydrate,
electrolytes, minerals, trace elements, vitamins and NPC:N.
 Translate these needs into a regimen including these components for a typical patient.
 Identify and screen clinically for major as well as common drug-nutrient interactions, and outline strategies
for prevention and management.

8. Week 3 – Clinical Nutrition
Fluid and electrolytes balance
 Assess fluid and electrolyte needs of a patient
 Develop a therapeutic plan for fluid and electrolyte requirements
 Prevent and manage complications of fluid and electrolyte abnormalities

22. Gastrointestinal System Assessment
 Subjective
 Abdominal pain
 Nausea and Vomiting
 Change in bowel habit
 Objective
 Physical Assessment
 Inspection
 Auscultation
 Percussion
 Palpation
 Lab and diagnostic tests –
 Helicobacter pylori
 Pancreas – serum amylase and serum lipase
 Endoscopy
 Radiography with contrast dye
 Sonography
 Computed tomography

25. Hepatic System

26. Diarrhoea
 Abnormal passage of loose or liquid stools more than three times daily and/or a volume of stool
>200 g/day.
 Acute diarrhoea is usually defined as that lasting <4wks and chronic diarrhoea as that lasting >4wks.
 Increased frequency of bowel movement relative to normal for an individual patient.
 bowel movement relative to normal for an individual patient.
 Normal bowel habit - 2 bowel actions/week to 3 bowel actions/day.
 Mechanisms that result in diarrhoea are varied and include increased secretion or decreased
absorption of fluid and electrolytes by cells of the intestinal mucosa and exudation resulting from
inflammation of the intestinal mucosa.
 Diarrhoea is a non-specific symptom that is a manifestation of a wide range of GI disorders, including
inflammatory bowel disease, irritable bowel syndrome, GI malignancy, a variety of malabsorption
syndromes, and acute or subacute intestinal infections and infestations.
 Diarrhoea can be an unwanted effect of almost any drug, particularly those listed on E ‘Medications
commonly causing diarrhoea’,

27. Assessment of diarrhoea
 Determine the frequency and severity of symptoms
 quantity and
 character of the stools (e.g. watery, fatty, containing blood or mucus).
 Enquire about the presence of red flag symptoms:
 Blood in the stool
 Antibiotic treatment
 Persistent vomiting
 Weight loss
 Painless, watery, high-volume diarrhoea
 Nocturnal symptoms disturbing sleep—organic cause likely.
 Assess for complications of diarrhoea, such as dehydration.

28. Clinical features of dehydration
 Mild dehydration: commonly no specific symptoms, though
1. lassitude,
2. anorexia,
3. nausea,
4. light-headedness, or
5. postural hypotension can be experienced.
 Moderate dehydration: apathy, tiredness, dizziness, muscle cramps, dry tongue or sunken eyes,
reduced skin elasticity, postural hypotension, tachycardia, oliguria.
 Severe dehydration: profound apathy, weakness, confusion (leading to coma), shock, tachycardia,
marked peripheral vasoconstriction, systolic BP <90mmHg, oliguria, or anuria.

29. Medications commonly causing
diarrhoea
 Osmotic (drugs that create a hypertonic state in the intestine) Acarbose, magnesium salts
 Secretory (increase intestinal ion secretion or inhibit normal active ion absorption)
 Antineoplastics, digoxin, metformin, NSAIDs, misoprostol, and olsalazine
 Disturbed motility (leading to shortened transit time) - Erythromycin, levothyroxine
 Exudative (drugs that cause inflammation and ulceration) - Antineoplastics, NSAIDs, and
simvastatin
 Malabsorption or impaired digestion of fat or carbohydrates - Aminoglycosides, colestyramine,
metformin, orlistat, and tetracyclines
 Microscopic colitis (drugs causing a submucosal band of collagen in the intestine, resulting in a
watery diarrhoea) - Cytotoxic agents, budesonide, carbamazepine, ciclosporin, cobeneldopa,
ranitidine, and simvastatin
 All patients presenting with diarrhoea should be questioned about the relationship between
symptoms and changes in medications
 If an underlying cause of diarrhoea can be identified, management is directed at the cause rather
than the symptom of diarrhoea.

30. Treatment
 Usually supportive with attention to fluid intake and nutrition.
 The priority when treating acute diarrhoea is the prevention or reversal of fluid and
electrolyte depletion.
 Underlying cause may require specific treatment.
 Management of complications, especially dehydration.

31. Fluid electrolyte therapy
 Even in the presence of severe diarrhoea, water and salt continue to be absorbed by active
glucose-enhanced sodium absorption in the small intestine.
 Oral replacement solutions are effective if they contain balanced quantities of sodium, potassium,
glucose, and water. Glucose is necessary to promote electrolyte absorption.
 Proprietary soft drinks and fruit juices are inadequate treatment for individuals in whom
dehydration poses a significant risk—e.g. the elderly and patients with renal disease.
 In adults, an oral rehydration solution should be considered for patients with mild to moderate
dehydration (loss of <6% of body weight). Solutions should be made up freshly according to
manufacturers’ recommendations, refrigerated, and replaced every 24h.
 Several proprietary rehydration products are available and are made up according to brand
recommendations. The recommended ranges of concentrations for rehydration solutions for use
are as follows:
 sodium 50–60mmol/L
 potassium 20–35mmol/L
 glucose 80–120mmol/L.

32. Fluid electrolyte therapy
 For adults, encourage 2–3L of rehydration solution orally to be taken over 24h. This will provide
100–180mmol of sodium and 40–105mmol of potassium.
 Once rehydration is complete, further dehydration is prevented by encouraging the patient to
drink normal volumes of an appropriate fluid and by replacing continuing losses with an oral
rehydration product.

33. Drug therapy
 Antimotility drugs may be of symptomatic benefit in adults with mild or moderate acute diarrhoea.
 Short-term control of symptoms during periods of maximum social inconvenience (e.g. travel and
work).
 Contraindicated in patients with severe diarrhoea, and in patients with severe inflammatory bowel
disease or dilated or obstructed bowel.
 However, antimotility drugs are also sometimes useful for control of symptoms if treatment of the
underlying cause is ineffective or the cause is unknown.
 Antimotility drugs are never indicated for management of acute diarrhoea in infants and children
<12yrs.
 Options antimotility drugs:
 Loperamide 4mg orally initially, followed by 2mg orally after each unformed stool (maximum of
16mg/daily).
 Diphenoxylate 5mg + atropine 0.05mg orally three to four times daily initially (d dose as soon as
symptoms improve).
 Codeine phosphate 30–60mg orally up to four times daily.
 Colestyramine provides symptomatic relief of diarrhoea following ileal disease or resection.

34. Drug therapy
 Adsorbents, such as kaolin and activated charcoal, have not been shown to be of value in the
treatment of acute diarrhoea. They could interfere with absorption of other drugs and should not be
used.
 Antibacterials are rarely indicated in uncomplicated infective diarrhoea, except to treat properly
diagnosed enteric infections such as dysentery and antibacterial-associated colitis or for some bacterial
causes of gastroenteritis such as Campylobacter enteritis, shigellosis and salmonellosis.
 Diarrhoea can reduce the absorption of medicines. Drugs that may be affected clinically significantly
include
1. antiepileptics,
2. modified release formulations,
3. antidiabetic agents,
4. anticoagulants,
5. antimalarials,
6. antiretrovirals, and
7. oral contraceptives.

35. Constipation in adults

36. Acknowledgement