College of Pharmacy ‫ ضياء جبار‬: ‫د‬.‫م‬.

‫أ‬
Fourth Year. Clinical Pharmacy 2024-25
Gastrointestinal Conditions
1-Diarrhea
1-Diarrhea is an increased frequency of bowel evacuation with the passage of
abnormally soft or watery stools (1). Although the normal frequency of bowel
movements varies with each individual, more than three bowel movements per day are
considered abnormal (2).
2-Chronic and persistent diarrheal illnesses are often secondary to other chronic medical
conditions (or treatments) and need medical care (2). (Further reading 1)
Causes
1-Acute diarrhea (infective diarrhea, gastroenteritis):
The most common causes of acute diarrhea are bacterial and viral infection and food
toxins (3).
Viral: Rotavirus responsible for causing severe diarrhea in infants and children
and the most common cause of gastroenteritis among children worldwide (3).
Rotavirus tends to be a seasonal infection, with peaks of gastroenteritis occurring
between November and February. It is spread by the fecal-oral route (2).
Note: vaccine is available to protect against rotavirus (3). (Further reading 2)
Norovirus: This is another common cause of viral gastroenteritis in people of all
ages. The virus is readily spread through contaminated food or surfaces
contaminated with vomit. Treatment includes the usual advice on fluid
replacement (1). (Further reading 3)
Bacterial: These are the food-borne infections (previously known as food
poisoning). There are several different types of bacteria that can cause such
infections: Salmonella, Shigella, pathogenic Escherichia coli,…………... .
Antibiotics are generally unnecessary as most food-borne infections resolve
spontaneously (1). (Further reading 4)
Protozoan: Examples include Entamoeba histolytica (amoebic dysentery) and
Giardia lamblia (giardiasis). Diagnosis is made by sending stool samples to the
laboratory (1).
2-Chronic diarrhea:
There are several causes and chronic diarrhea requires medical investigation. Causes
include: Irritable-bowel syndrome (IBS), inflammatory bowel disease (Crohn’s
disease, ulcerative colitis), malabsorption syndromes (such as celiac disease)………
(4)
.
Patient assessment with diarrhea
A-Age
Infants (<1 years) and elderly patients are especially at risk of becoming dehydrated (1).

1
In newborn, water comprise up to 75% of total body weight. After 8-10 bowel
movements within 24 hours period, a 2-month-old infant could lose enough fluid to
cause circulatory collapse and renal failure (2).

B-Duration
Diarrhea of >1 day duration in children <1 year required referral (4).
(but in babies under 3 months: refer immediately)(4).
Diarrhea of >2 days duration in children <3 years and elderly patients required referral
(4).

Diarrhea of >3 days duration in older children and adults required referral (4).
Diarrhea of more than 24 hours in people with diabetes required referral (4).

C-Severity
Severe diarrhea (passing 6 or more unformed stool in 24 hours) required referral (2).

D-Periodicity
A history of recurrent diarrhea of no known cause ---------should be referred for further
investigations (5).

E-Associated symptoms
The presence of blood or mucus in the stools is an indication for referral for further
investigations (1).
Diarrhea with severe vomiting or with high fever required referral for further
investigations (1).
Diarrhea with severe abdominal pain required referral for further investigations (5).
F-Recent travel abroad
Diarrhea in patient who has recently travelled abroad requires referral since it may be
infective in origin (Traveler's diarrhea) (1).
G-Signs of dehydration (3)
Patient with signs or symptoms of debilitating dehydration required referral (table1).

Table1: Symptoms of dehydrations in children and adults (3)

children adults
Dry mouth, tongue and skin Increased thirst
Fewer or no tears when crying Decreased urination
Decreased urination (less than 4 wet diapers in 24 hours) Feeling weak or
Sunken eye, cheeks or abdomen lightheaded
sunken fontanel Dry mouth/ tongue
decreased skin turgor
irritability or listlessness

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H-Medication (1) Table 2: Some drugs that may cause
Medicines already tried: The pharmacist diarrhea (1).
should establish the identity of any medication Antacids: Magnesium salts
that has already been taken to treat the Antibiotics
symptoms in order to assess its Antihypertensives: methyldopa; beta-
appropriateness. blockers (rare)
Digoxin (toxic levels)
Other medicines being taken: Diuretics (furosemide)
Details of any other medication being taken Iron preparations
(both OTC and prescribed) are also needed, as Laxatives
the diarrhea may be drug induced (Table 2). Misoprostol
(Diarrhea occurs in around 10% of people Non-steroidal anti-inflammatory drugs
taking antibiotics. If severe, it may require the Selective serotonin reuptake inhibitors
course of antibiotics to be stopped)

Treatment timescale
One day in children, otherwise
2 days (1).

Management
A-Advices for patients
suffering from diarrhea (4)
1-Drink plenty of clear fluids,
such as water.
2-Avoid drinks high in sugar
as these can prolong diarrhea.
3-Avoid milk and milky drinks,
as a temporary lactose
intolerance occurs due to
damage done by infecting
organisms to the cells lining the intestine, making diarrhea worse.
4-Babies should continue to be fed as normal, whether by breast or bottle.

B-Oral rehydration therapy

1-The risk of dehydration from diarrhea is greatest in babies, and rehydration therapy
is considered to be the standard treatment for acute diarrhea in babies and young
children (1).
2-Oral rehydration sachets may be used with antidiarrheals in older children and
adults (1).
3-Rehydration may still be initiated even if referral to the doctor is advised (1).

A premixed solutions (2) or Sachets of powder for reconstitution are available; these
contain sodium as chloride and bicarbonate, glucose and potassium. The absorption of
sodium is facilitated in the presence of glucose (1).

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4-Table 3 provides the volumes required per watery stool (1).
5-Reconstitution of ORS: Only water should be used to make the solution and that
boiled and cooled water should be used for children < 1 year (1).
6-Stability of ORS after reconstitution: To avoid risk of possible exposure
to further infection, the solution should be discarded not later than 1hour after
reconstitution, or it may be kept for up to 24 hours if stored in a refrigerator. (9).
7- If the child is
vomiting, give 1 Table 3:Amount of rehydration solution to be offered to
teaspoon of ORS patients. (1).
every few minutes (2)
(or 10–20 ml every 5–
10 min) (1).

C-Antimotility
Drugs:
1-Loperamide, and
Co-phenotrope
(Diphenoxylate+Atrop
ine) [Atropine is included at a subtherapeutic dose to discourage abuse (unpleasant
antimuscarinic effects will be experienced if higher than recommended doses are
taken)] (4).
2-Loperamide is considered an OTC drug only for patient of > 12 years old (1).
Adult dose: Initially 2 tablets (4 mg) followed by 1 tablet (2 mg) after each loose stool
(max. 8 tablets / day) (6).
3-Co-phenotrope is considered an OTC drug only for patient of > 16 years old (1, 6).
B-Adult doses: 4 tablets initially followed by 2 tablets every 6 hours (6) .
D-Adsorbents: Like Pectokaolin® (pectin +kaolin)
Adsorbents such as kaolin are not recommended for acute diarrheas (6).

Extra-Notes:
A-Probiotics (dietary supplement): Probiotics are dietary supplements containing
bacteria (including several Lactobacillus species) that may promote health by
enhancing the normal microflora of the GI tract while resisting colonization by potential
pathogens (7). Probiotics have been shown to decrease the duration of infectious and
antibiotic-induced diarrhea (AAD) in adults and children (however; the use of
probiotics to treat and prevent AAD is controversial (8).

B-Use of zinc in children with diarrhea: Several large studies performed in

developing countries have shown that daily zinc supplementation in young children
with acute diarrhea reduces both the duration and severity of diarrhea (2, 3). The
WHO/UNICEF recommends that children with acute diarrhea also receive zinc (10 mg
of elemental zinc/day for infants younger than 6 months; 20 mg of elemental zinc/day
for older infants and children) for 10 to 14 days (2, 3).

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References
1-Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. Symptoms in the
pharmacy . A guide to the managements of common illness. 9th edition. 2023.
2-American pharmacists association. Handbook of Non-prescription drugs: An
Interactive Approach to Self-Care. 18th edition. 2016.
3-Canadian American pharmacists association (CPhA). CTMA: Compendium of
Therapeutics for Minor Ailments. 2014.
4-Nathan A. fasttrack. Managing Symptoms in the Pharmacy. Pharmaceutical Press.
2008.
5-Paul Rutter. Community Pharmacy. Symptoms, Diagnosis and Treatment. 5 th
edition. 2021.
6-BNF-80
7-Marie A. Chisholm-Burns .Pharmacotherapy Principles & Practice. 4 th edition.
2016.
8-Joseph T. DiPiro, Robert L. Pharmacotherapy: A Pathophysiologic Approach, 11th
edition. 2021..

2-Irritable Bowel Syndrome (IBS)

1-Irritable Bowel Syndrome is defined as: a
functional bowel disorder in which abdominal
pain is associated with abdominal distention
and a change in bowel habit (diarrhea and
constipation may occur; sometimes they Figure 1: The position of pain
alternate) (1, 2). (Further reading 5) associated with irritable bowel
syndrome (2).
2-The cause is unknown (1). Some possible causes include genetic mutations, abnormal
GI motility, enhanced gut pain sensation (visceral hypersensitivity), or psychological
changes. Most likely a combination of these factors leads to IBS (3).

Patient assessment with IBS

A-Age:
Because of the difficulties in the diagnosis of abdominal pain in children (1), it is best to
refer children less than 16 years (2).
IBS often develop in young adult life (1). If an older (above 45(2)) person presenting
with for the first time with no previous history of bowel problems, referral should
be made (1).

B-Symptoms:
IBS has three Key symptoms: abdominal pain, abdominal distention/bloating and
disturbance of bowel habit (1).

1-Abdominal pain: The pain can occur anywhere in the abdomen. It is often central
or left sided and can be severe (1) (pain normally located in the left lower quadrant)
(figure1) (2).
The site of pain can vary from person to person and even for an individual (1).
Sometimes the pain comes on after eating and can be relieved by defecation (1) or
the passage of wind (2).

2-Bloating: A sensation of bloating is commonly reported. Sometimes it is so

severe that clothes have to be loosened (1).

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 3-Bowel habit: Diarrhea and constipation may occur; sometimes they alternate. A
morning rush is common, where the patient feels an urgent desire to defecate
several times after getting up in the morning and following breakfast, after which
the bowel may settle .There, may be a feeling of incomplete emptying after a bowel
movement. The motion is often described as loose and semiformed rather than
watery. Sometimes it is like pellets or rabbit dropping, or pencil shaped. There may
be a mucus but never blood (1).

4-Other symptoms: Some patients may also complain of nausea, and other
unrelated symptoms such as: backache, feeling tiered, urinary urgency, and the need
to pass urine during the night.
Patient with unexplained weight loss, or with signs of bowel obstruction (like
vomiting) required referral for further investigation (1).
When to refer (1, 2)
C-Periodicity: -Children
IBS tend to be episodic. The patient -Older person with no previous history of IBS
might have a history of being well -Pregnant women
for a number of weeks or months in -Blood in stools
between bouts of symptoms (2). -Unexplained weight loss
-Caution in patients aged over 45 years with
D-Previous history: changed bowel habit
To know whether the patient has -Signs of bowel obstruction
consulted the Dr. about the -Unresponsive to appropriate treatment
symptoms and if so, what they were -Fever .
told. Any history of previous bowel
surgery would suggest a need for referral (1).

E-Aggravating factors:
Stress appears to play an important role and can precipitate and exacerbate symptoms.
Also some types of food may aggravate IBS (1).

F-Pregnant women: required referral for further investigation (1).

G-Medication (1):
To know:
1-What had been tried to treat the condition and whether it produced an improvement.
(Unresponsive to appropriate treatment required referral).
2-Other medicines (IBS is associated with depression and anxiety in many patients ).

Treatment timescale
Symptoms should start to improve within a week (1).

Management
A-Diet:

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Patient with IBS should follow the recommendation for a healthy diet (low fat, low
sugar, high fiber). In addition patient should avoid any food they know to exacerbate
their symptoms (1). Various foods such as beans, and fatty meals, and gas-producing
foods such as legumes, may aggravate symptoms in some patients. This has led many
patients to exclude these suspected aggravating foods from their diet although the
effectiveness of such practices remains controversial (3).

B-Antispasmodics:
Antispasmodics (table 4) (2) are the main stay of OTC treatment of IBS. They work
by a direct effect on the smooth muscle of the gut, causing relaxation and thus reducing
abdominal pain. The patient should see an improvement within a few days of starting
treatment (1).
1-Mebeverine: It is given in a dose of 135 mg (1 tablet) three times a day,
preferably 20 minutes before meals (1).

2-Hyoscine butylbromide: The recommended dose for adult is one tablet(10 mg)
three times a day , although this can be increased to two tablets four a day if
necessary (2).

3-Alverine citrate, 4-Pippermint oil capsules (Further reading 5)

Table 4: Practical prescribing: Summary of IBS medicines (2)

Name of Likely side Drug interactions of note Patients in which
medicine effects care is exercised
Hyoscine Constipation Tricyclic antidepressants, Glaucoma, myasthenia
and dry neuroleptics, antihistamines gravis and prostate
mouth and disopyramide enlargement
Mebeverine None None None
Peppermint Heartburn None None
oil
Alverine Rash None None

C-Laxatives and antidiarrheals:

1-In addition, Bulk-forming and stimulant laxatives can be used to treat constipation
predominant (IBS-C) (2). Insoluble fiber (e.g. bran) may exacerbate symptoms and its
use should be discouraged (4).

2-Use of OTC antidiarrheals such as loperamide is appropriate only on an occasional,

short-term basis (1).

D-Compound preparations:
Bulking agents are also available in combination with antispasmodics (1).
e.g. Fybogel® Mebeverine: effervescent Granules (in sachets), contain ispaghula husk
(Bulk-forming laxatives) and mebeverine hydrochloride (4).

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Dose: 1 sachet in water, morning and evening 30 minutes before food; an additional
sachet may also be taken before the midday meal if necessary (4).

E-Probiotics:
Probiotics such as lactobacillus and Bifidobacterium have also been promoted for IBS.
The studies showed that probiotics appear to be effective however the size of the effect
need to be established (2).

References:
1-Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. Symptoms in the pharmacy . A guide to
the managements of common illness. 9th edition. 2023.
2-Paul Rutter. Community Pharmacy. Symptoms, Diagnosis and Treatment. 5th edition. 2021.
3-Tracey JC, Carmela AW, Tomasz Z J. Irritable Bowel Syndrome Treatment Options. US Pharm.
2012;37(12):45-48.
4-BNF-80.

Further reading ‫لالطالع‬

1-Diarrhea may be acute (less than 14 days duration), persistent (14 days to 4 weeks
duration), or chronic in nature (more than 4 weeks).
2-Associated symptoms are those of a cold and perhaps a cough. The infection starts
abruptly and vomiting often precedes diarrhea. (1). Whilst in the majority the infection is
usually not too severe and is self-limiting, it should be remembered that rotavirus
infection can cause death. This is most likely in those infants already malnourished and
living in poor social circumstances who have not been breastfed (1).
3-After an incubation of up to 48 h, the illness begins suddenly with profuse vomiting,
diarrhea and flu-like symptoms. It usually settles in 2–3 days and treatment includes the
usual advice on fluid replacement. As with all cases of gastroenteritis, prevention of
spread is very important, and careful handwashing procedures and hygiene measures
are essential (1).
4-The typical symptoms include severe diarrhea and/or vomiting, with or without
abdominal pain. The most important treatment is adequate fluid replacement.
Antibiotics are used (by prescription only) for Shigella infections and the more severe
Salmonella. Ciprofloxacin (by prescription) may be used in such circumstances (1).
5-The two main classifications of IBS are IBS with constipation predominant (IBS-C)
and IBS with diarrhea predominant (IBS-D). Some patients may also have IBS with
alternating diarrhea and constipation (IBS-A) (3).
Adult prevalence rates in Western countries are reported to be between 10% and 20%,
with approximately twice as many women than men affected (2).

6-Alverine citrate: Alverine citrate is given in a dose of 60–120 mg (one or two

capsules) up to three times a day (1).

-Pippermint oil capsules: Capsules containing 0.2 mL of the oil are taken in a dose of
one or two capsules three times a day, 15–30 min before meals (1).

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 ‫خاص بالعملي‬

‫ماذا نسأل عن اإلسهال‬

‫‪-1‬من هو المريض وكم عمره ؟ (وان كانت امرأة في سن اإلنجاب نسأل إن كانت حامال أو مرضعا؟)‬
‫‪-2‬منذ متى تعاني من اإلسهال؟ وما هو عدد مرات الخروج في اليوم الواحد؟‬
‫‪-3‬هل تعاني من اإلسهال بصورة متكررة؟‬
‫‪ -4‬هل توجد هنالك أعراض أخرى مصاحبة اإلسهال (مثال ‪ :‬حمى عالية ‪ ,‬تقيؤ ‪ ,‬اآلم شديدة في البطن‪)......,‬؟‬
‫‪-5‬هل يحتوي اإلسهال على دم أو مخاط ؟‬
‫‪-6‬هل تناولت طعاما تعتقد إن له عالقة بحالة اإلسهال التي أصابتك ؟ وهل أصيب من أكل من نفس الطعام‬
‫باإلسهال أيضا؟‬
‫‪-7‬هل انك قادم من السفر حديثا؟‬
‫‪-8‬هل تعاني من أمراض أخرى ؟ ما هي؟ وما هي األدوية التي تستعملها لعالج هذه األمراض؟ منذ متى وأنت‬
‫تستعملها ؟‬
‫‪-9‬هل استعملت أدوية لعالج نوبة اإلسهال هذه ؟ ما هي ؟ منذ متى بدأت استعمالها ؟ وكيف تستعملها؟ وما هي‬
‫النتيجة ؟‬

‫ماذا نسأل عن القولون المتهيج‬

‫‪ -1‬من هو المريض وكم عمره ؟ (وان كانت امرأة في سن اإلنجاب نسأل إن كانت حامال أو مرضعا؟)‬
‫‪ -2‬ما هي األعراض التي تشكو منها؟ (بالتفصيل)‪.‬‬
‫‪ -2‬هل عانيت من هذه األعراض سابقا؟ أم إنها تظهر عندك ألول مرة ؟‬
‫‪ -3‬هل سبق وان راجعت الطبيب عن هذه األعراض ؟ وماذا قال لك ؟‬
‫‪ -4‬هل تتكرر هذه الحالة عندك بين فترة وأخرى؟‬
‫‪ -5‬هل لديك أعراض أخرى (فقدان في الوزن ؟ تقيؤ؟‪).....‬‬
‫‪ -6‬هل استعملت أدوية لعالج حالتك هذه ؟ ما هي ؟ منذ متى بدأت استعمالها ؟ وكيف تستعملها؟ وما هي‬
‫النتيجة؟‬
‫‪-7‬هل هناك أغذية او أسباب نفسية ترى أنها قد تسبب ظهور األعراض او زيادة حدتها؟‬
‫‪ -8‬هل تعاني من أمراض أخرى ؟ ما هي؟ وما هي األدوية التي تستعملها لعالج هذه األمراض؟‬

‫‪9‬‬