DOCSLIB.ORG

Nonsteroidal Anti-Inflammatory Drug Toxicosis Petra A

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Nonsteroidal Anti-Inflammatory Drug Toxicosis Petra A Nonsteroidal Anti-Inflammatory Drug Toxicosis Petra A. Volmer, DVM, MS, DABVT, DABT BASIC INFORMATION (passage of a flexible fiberoptic viewing scope) of the stomach Description may reveal ulcers. Identification of the actual NSAID ingested Nonsteroidal anti-inflammatory drugs (NSAIDs) act against pain, may be possible through an outside laboratory; however, the anal- fever, and inflammation. A number of prescription and over- ysis is not usually available in time to be of much benefit. Other the-counter NSAIDs are available for human use. The following tests may be recommended to rule out other diseases and toxins NSAIDs are approved for use in dogs under the direction of a vet- that can cause similar signs. erinarian: carprofen (Rimadyl ), meloxicam ( Metacam ), deracoxib (Deramaxx ), tepoxalin (Zubrin ), etodolac (EtoGesic ), ketoprofen TREATMENT AND FOLLOW-UP (Anafen ). Only Metacam is approved for use in cats in the United Treatment Options States. Causes and Toxicity Your veterinarian may recommend induction of vomiting if the NSAIDs reduce prostaglandin synthesis by inhibiting the cyclo- ingestion was recent and the animal is not showing any clinical oxygenase enzymes known as COX-1 and COX-2. The COX-1 signs. Vomiting should be induced only under the direction of a enzyme regulates a number of important functions of the gut, plate- veterinarian. Activated charcoal may be administered to bind with lets, and kidneys. The COX-2 enzyme regulates inflammation, pain, the material in the gut and prevent its absorption into the body. and fever. Many of the NSAIDs currently available are selective for Hospitalization may be recommended in some cases for COX-2 and therefore produce less adverse effects on the stomach administration of intravenous fluids to rehydrate and improve kid- and kidneys. With ingestion of large doses, however, the COX-1 ney function and medications to protect the gut. Other therapy and enzyme is also affected. The end result is that the gut and the kid- supportive care may be indicated for stomach ulcers and bleeding neys can be damaged. Dogs and cats are very sensitive to the effects into the gut. In severe cases with unresponsive kidney damage, of NSAIDs, and seemingly small ingestions can pose problems. your veterinarian may recommend referral to a specialty facility for dialysis treatment, if it is available. Clinical Signs Follow-up Care Initially, animals may exhibit vomiting that sometimes contains blood. Diarrhea, abdominal pain, and lethargy may be noted. Laboratory tests are repeated periodically to monitor recovery of Sudden collapse and death may result from perforated stomach kidney function. Urine output may also be monitored, especially ulcers. Adverse effects on the kidneys can cause increased drink- while your pet is hospitalized. Monitoring may be required for ing and urinating and, eventually, a reduction in urine production several days until kidney function returns to normal. If chronic if kidney failure occurs. If urine production stops entirely, death kidney failure develops, then long-term monitoring is usually will result. needed. Keep all NSAIDs out of the reach of pets. Do not admin- ister NSAIDs to pets unless they are prescribed by a veterinarian. Diagnostic Tests Prognosis Diagnosis is based on evidence of ingestion and consistent clinical Prognosis is favorable for animals that receive prompt and aggres- signs. Laboratory tests may reveal abnormalities in kidney func- sive treatment. For large ingestions and for animals that develop tion tests. Examination of the urine may show blood as well as kidney damage, the prognosis is guarded (uncertain), and severe increased white blood cells and protein. Endoscopic examination cases may result in death. Copyright © 2011 by Saunders, an imprint of Elsevier Inc. All rights reserved..
Load more

Recommended publications
  • The Pathophysiology of Pain, Our Veterinary Patients, and You… What Can Or Should Be Done?
    The Pathophysiology of Pain, Our Veterinary Patients, And you… What Can or Should Be Done? Andrew Claude DVM, Dipl ACVAA Michigan State University College of Veterinary Medicine [email protected] Objectives • Definitions. • Process of Nociception. • What is pain? • AVMA/ACVAA regarding pain. • Patient – client considerations • Pain management in medicine • Clinical signs of pain in dogs/cats • Preemptive analgesia options • Pain scores in dogs and cats (if time) Definitions • Anesthesia = analgesia = analgesic? Clinician's Brief • General anesthesia: General vs. local and regional anesthesia • Analgesia: the inability to feel pain • Analgesic: any member or group of drugs used to achieve analgesia or relief from pain. • Analgesia →Nociception • Acute vs. Chronic pain, neuropathic pain Process of nociception • Transduction • Aβ, Aδ, c-Fibers, silent • Transmission • Dorsal horn, CNS • Primary Modulation • Segmental reflexes • Projection • Perception • Conscious Pain • Autonomic (SNS) • Memory • Emotions • Central/peripheral • Humans/animals What is pain? • Definition: “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” • Sensory component (nociception) • Affective component (experience) • Considered the 5th clinical sign • HR • RR • Temp • BP • Pain assessment What is pain? • Requires conscious perception of a noxious event • Do unconscious patients perceive pain? • Nociception: “the neurophysiological process whereby noxious mechanical, chemical, or thermal stimuli are transduced into electrical signals (action potentials) by high-threshold nociceptors.” These action potentials follow a series of pathways that ultimately end in the brain • The conscious result is “pain” AVMA • Pain in Animals • Animal pain is a clinically important condition that adversely affects an animal's quality of life. Drugs, techniques, or husbandry methods should be used to prevent, minimize, and relieve pain in animals experiencing or expected to experience pain.
    [Show full text]
  • Drug and Medication Classification Schedule
    KENTUCKY HORSE RACING COMMISSION UNIFORM DRUG, MEDICATION, AND SUBSTANCE CLASSIFICATION SCHEDULE KHRC 8-020-1 (11/2018) Class A drugs, medications, and substances are those (1) that have the highest potential to influence performance in the equine athlete, regardless of their approval by the United States Food and Drug Administration, or (2) that lack approval by the United States Food and Drug Administration but have pharmacologic effects similar to certain Class B drugs, medications, or substances that are approved by the United States Food and Drug Administration. Acecarbromal Bolasterone Cimaterol Divalproex Fluanisone Acetophenazine Boldione Citalopram Dixyrazine Fludiazepam Adinazolam Brimondine Cllibucaine Donepezil Flunitrazepam Alcuronium Bromazepam Clobazam Dopamine Fluopromazine Alfentanil Bromfenac Clocapramine Doxacurium Fluoresone Almotriptan Bromisovalum Clomethiazole Doxapram Fluoxetine Alphaprodine Bromocriptine Clomipramine Doxazosin Flupenthixol Alpidem Bromperidol Clonazepam Doxefazepam Flupirtine Alprazolam Brotizolam Clorazepate Doxepin Flurazepam Alprenolol Bufexamac Clormecaine Droperidol Fluspirilene Althesin Bupivacaine Clostebol Duloxetine Flutoprazepam Aminorex Buprenorphine Clothiapine Eletriptan Fluvoxamine Amisulpride Buspirone Clotiazepam Enalapril Formebolone Amitriptyline Bupropion Cloxazolam Enciprazine Fosinopril Amobarbital Butabartital Clozapine Endorphins Furzabol Amoxapine Butacaine Cobratoxin Enkephalins Galantamine Amperozide Butalbital Cocaine Ephedrine Gallamine Amphetamine Butanilicaine Codeine
    [Show full text]
  • Dog Owner Information About ® Chewable Tablets (Carprofen)
    Dog Owner Information about ® Chewable Tablets (carprofen) ® Caplets (carprofen, USP) Rimadyl® (pronounced “Rim-a-dill”) for Osteoarthritis and Post-Surgical Pain Generic name: carprofen (“car-pro-fen”) This summary contains important information about Rimadyl. You should read this What are the possible side effects that may occur in my dog during information before you start giving your dog Rimadyl and review it each time the Rimadyl therapy? prescription is refilled. This sheet is provided only as a summary and does not take Rimadyl, like other drugs, may cause some side effects. Serious but rare side effects the place of instructions from your veterinarian. Talk to your veterinarian if you do not have been reported in dogs taking NSAIDs, including Rimadyl. Serious side effects can understand any of this information or if you want to know more about Rimadyl. occur with or without warning and in rare situations result in death. What is Rimadyl? The most common NSAID-related side effects generally involve the stomach (such as Rimadyl is a nonsteroidal anti-inflammatory drug (NSAID) that is used to reduce pain bleeding ulcers), and liver or kidney problems. Look for the following side effects that and inflammation (soreness) due to osteoarthritis and pain following surgery in dogs. can indicate your dog may be having a problem with Rimadyl or may have another Rimadyl is a prescription drug for dogs. It is available as a caplet and chewable tablet medical problem: and is given to dogs by mouth. • Decrease or increase in appetite Osteoarthritis
    [Show full text]
  • Effects of Osteoarthritis and Chronic Pain Management for Companion Animals Rebecca A
    Southern Illinois University Carbondale OpenSIUC Research Papers Graduate School 2014 Effects of Osteoarthritis and Chronic Pain Management for Companion Animals Rebecca A. Cason Southern Illinois University Carbondale, [email protected] Follow this and additional works at: http://opensiuc.lib.siu.edu/gs_rp Recommended Citation Cason, Rebecca A., "Effects of Osteoarthritis and Chronic Pain Management for Companion Animals" (2014). Research Papers. Paper 521. http://opensiuc.lib.siu.edu/gs_rp/521 This Article is brought to you for free and open access by the Graduate School at OpenSIUC. It has been accepted for inclusion in Research Papers by an authorized administrator of OpenSIUC. For more information, please contact [email protected]. EFFECTS OF OSTEOARTHRITIS AND CHRONIC PAIN MANAGEMENT FOR COMPANION ANIMALS By Rebecca A. Cason B.S., Southern Illinois University Carbondale, 2012 A Research Paper Submitted in Partial Fulfillment of the Requirements for the Master of Science. Department of Animal Science, Food and Nutrition In the Graduate School Southern Illinois University Carbondale May 2014 RESEARCH PAPER APPROVAL EFFECTS OF OSTEOARTHRITIS AND CHRONIC PAIN MANAGEMENT FOR COMPANION ANIMALS By Rebecca A. Cason A Research Paper Submitted in Partial Fulfillment of the Requirements for the Degree of Masters in Science in the field of Animal Science Approved by: Rebecca Atkinson, Chair Amer AbuGhazaleh Nancy Henry Graduate School Southern Illinois University Carbondale March 18, 2014 TABLE OF CONTENTS Page LIST OF FIGURES.……………………………………………………………………………....ii
    [Show full text]
  • Cyclooxygenase Inhibitors, Aspirin and Ibuprofen, Inhibit MHC-Restricted Antigen Presentation in Dendritic Cells
    DOI 10.4110/in.2010.10.3.92 ORIGINAL ARTICLE pISSN 1598-2629 eISSN 2092-6685 Cyclooxygenase Inhibitors, Aspirin and Ibuprofen, Inhibit MHC-restricted Antigen Presentation in Dendritic Cells Hyun-Jin Kim1, Young-Hee Lee1, Sun-A Im1, Kyungjae Kim2 and Chong-Kil Lee1* 1College of Pharmacy, Chungbuk National University, Cheongju 361-763, Korea, 2College of Pharmacy, SahmYook University, Seoul 139-742, Korea Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) INTRODUCTION are widely used to relieve pain, reduce fever and inhibit inflammation. NSAIDs function mainly through inhibition of Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit cyclo- cyclooxygenase (COX). Growing evidence suggests that oxygenase (COX), the rate-limiting enzyme for the synthesis NSAIDs also have immunomodulatory effects on T and B of prostaglandins (1,2). Two COX isoforms have been identi- cells. Here we examined the effects of NSAIDs on the anti- fied in eukaryotic cells, COX-1 and COX-2. COX-1 is con- gen presenting function of dendritic cells (DCs). Methods: stitutively expressed in most cells, while COX-2 is inducibly DCs were cultured in the presence of aspirin or ibuprofen, expressed in a more limited array of cells at inflammatory and then allowed to phagocytose biodegradable micro- spheres containing ovalbumin (OVA). After washing and fix- sites (3,4). Thus, the ability of NSAIDs to inhibit COX-2 activ- ing, the efficacy of OVA peptide presentation by DCs was ity may explain their therapeutic effects as anti-inflammatory evaluated using OVA-specific CD8 and CD4 T cells. Results: drugs (2-5). Most of the NSAIDs that are currently in clinical Aspirin and ibuprofen at high concentrations inhibited both use inhibit both COX-1 and COX-2, although some inhibit one MHC class I and class II-restricted presentation of OVA in isosome to a greater extent than the other (6).
    [Show full text]
  • Non-Steroidal Anti-Inflammatory Drugs (Nsaids)
    Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) NSAIDs are pain medications. The first drug in this class of medication was aspirin. Aspirin in the Stop NSAID therapy and notify your form of willow bark was known by American Indians to be an effective pain medication but it was veterinarian if your not until 1973 that the mechanism of action was discovered. Since this time, more potent forms pet experiences: of aspirin have been developed that are safer for the stomach and kidneys. Examples of the newer • Decrease in appetite forms of aspirin in people include celebrex and ibuprofen. There have been NSAIDS specifically or vomiting designed for dogs that are safe and effective pain medications (see below). • Dark or NSAIDs are thought in people to have the best pain fighting characteristics relative to side effects bloody diarrhea and addiction potential. A BVNS doctor would prescribe an NSAID anytime a patient is thought to • Increased drinking be painful. We often use pain modulators as well which are not as effective but are safer. Examples or urination would include gabapentin, tramadol and amitriptyline. • Lethargy, yellowing of NSAIDs can cause stomach and intestinal problems, damage the kidneys and less commonly gums, skin, or whites of the liver and bone marrow. These problems are uncommon to rare, especially with the eyes (jaundice) appropriate monitoring. • Bleeding under the skin None of the following medications should be given together: NSAIDs Steroids Aspirin Cortisone Rimadyl/Carprofen Dexamethasone Etogesic/Etodolac Medrol/Methylprednisolone Deramaxx/Deracoxib Prednisone Metacam/Meloxicam Triamcinolone Previcox/Firocoxib Zubrin/Tepoxalin To learn more about neurologic diseases, treatments, medications and our practice, please visit www.bvns.net.
    [Show full text]
  • Carprovet® (Carprofen)
    ® Post-Approval Experience: Although not all adverse reactions are reported, the following adverse reactions are based on voluntary post-approval Carprovet (carprofen) adverse drug experience reporting. The categories of adverse reactions are listed in decreasing order of frequency by Flavored Tablets body system. Gastrointestinal: Vomiting, diarrhea, constipation, inappetence, melena, hematemesis, gastrointestinal ulceration, Non-steroidal anti-inammatory drug gastrointestinal bleeding, pancreatitis. For oral use in dogs only Hepatic: Inappetence, vomiting, jaundice, acute hepatic toxicity, hepatic enzyme elevation, abnormal liver function test(s), hyperbilirubinemia, bilirubinuria, hypoalbuminemia. Approximately one-fourth of hepatic reports were in CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian. Labrador Retrievers. DESCRIPTION: Carprovet (carprofen) is a non-steroidal anti-inammatory drug (NSAID) of the propionic acid class that Neurologic: Ataxia, paresis, paralysis, seizures, vestibular signs, disorientation. includes ibuprofen, naproxen, and ketoprofen. Carprofen is the nonproprietary designation for a substituted carbazole, Urinary: Hematuria, polyuria, polydipsia, urinary incontinence, urinary tract infection, azotemia, acute renal failure, 6-chloro-α-methyl-9H-carbazole-2-acetic acid. The empirical formula is C15H12ClNO2 and the molecular weight 273.72. tubular abnormalities including acute tubular necrosis, renal tubular acidosis, glucosuria. The chemical structure of carprofen
    [Show full text]
  • Ability of Tepoxalin. a Novel Anti-Inflammatory Agent
    EFFECT OF DIETARY FAT ON THE ORAL BIOAVAll..-ABILITY OF TEPOXALIN. A NOVEL ANTI-INFLAMMATORY AGENT By LYNNE MARIE HOMER Bachelor ofScience Oklahoma State University Stillwater. Oklahoma 1991 Doctor ofVeterinary Medicine Oklahoma State University Stillwater. Oklahoma 1995 Submitted to the Faculty ofthe Graduate College of the Oklahoma State University in partial fulfillment of the requirements for the Degree of MASTER OF SCIENCE December. 2000 EFFECT OF DIETARY FAT ON THE ORAL BIOAVAlLABILITY OF TEPOXALfN, A NOVEL ANTI-INFLAMMATORY AGENT Thesis Approved: -~-+-d \C. Jvo ~hesis Advisor fGk... }--VLvWLV---1\'__ ~~. 11 ACKNOWLEDGMENTS I would like to thank my major advisor, Dr. Cyril Clarke, for assisting me in my research and in the writing ofmy Master's thesis. III LIST OF TABLES T~k P~e 1. Assignment oftreatments to individual arumals 20 2. Doses administered to individual dogs 21 3. Plasma concentrations oftepoxalin after oral administration of 10 mglkg to fasted dogs and dogs fed a low fat meal.. 27 4. Plasma concentrations oftepoxalin after oral administration of 10 mg/kg to dogs fed a high fat meal and after intravenous administration 28 5. Plasma concentrations ofacid metabolite after oral administration of 10 mg/kg tepoxalin to fasted dogs and dogs fed a low fat meal. 29 6. Plasma concentrations ofacid metabolite after oral administration of 10 mg/kg tepoxalin to dogs fed a high fat meal and after intravenous administration oftepoxalin 30 7. Pharmacokinetic parameters describing disposition oftepoxalin after oral or intravenous administration (lO mg/kg) 31 8. Pharmacokinetic parameters describing disposition ofthe acid metabolite oftepoxalin after administration oftepoxalin (10 mg/kg) 32 v LIST OF FIGURES 1.
    [Show full text]
  • Nsaids in Cats
    ISFM and AAFP Consensus Guidelines Long-term use of NSAIDs in cats Clinical Practice A preprint from the Journal of Feline Medicine and Surgery Volume 12, July 2010 Journal of Feline Medicine and Surgery (2010) 12, 519 doi:10.1016/j.jfms.2010.05.003 EDITORIAL NSAIDs and cats – it’s been a long journey Although the first This issue of JFMS contains the first ever panel have covered much valuable ground: international consensus guidelines ✜ To set the scene they consider how use of NSAIDs on the long-term use of non-steroidal common chronic pain can be in cats, typically was probably anti-inflammatory drugs (NSAIDs) in cats. related to degenerative joint disease, This timely publication, which appears on idiopathic cystitis, trauma and cancer. by Hippocrates, pages 521–538 (doi:10.1016/j.jfms.2010.05.004), ✜ They then explain how and why NSAIDs is a collaborative enterprise by the International can have such positive and, potentially, it has taken until Society of Feline Medicine (ISFM) and negative actions. now for cats to American Association of Feline Practitioners ✜ They consider the best ways of enhancing (AAFP). It has been compiled by a panel of owner and cat compliance, make suggestions gain the benefit of world leaders in the understanding of pain about sensible dosing frequencies, timing of in cats and, without doubt, is essential reading medication and accuracy of dosing, and the long-term use for all small animal veterinary surgeons. emphasize the importance of always using of these drugs. It is interesting to reflect that although the ‘lowest effective dose’.
    [Show full text]
  • Previcox Client Information Sheet
    PreVIcox~ ~ ---6­ mrocoxlb) ~_,~ Information for Dog Owners about PREVICOX® (firocoxib) Chewable Tablets PREVICOX Chewable Tablets are used for the control of pain Tell your veterinarian about: and inflammation due to osteoarthritis or associated with • Any other medical problems or allergies that your dog has now, soft-tissue and orthopedic surgery in your dog. or has had in the past. This summary contains important information about PREVICOX.You • All medicines that you are giving or plan to give to your dog, should read this information before you start giving your dog PREVICOX including those you can get without a prescription and any tablets and review it each time your prescription is refilled. This dietary supplements. sheet is provided only as a summary and does not take the place of instructions from your veterinarian . Talk to your veterinarian if Tell your veterinarian if your dog: . you do not understand any of this information or you want to know • Is under 7 months of age. more about PREVICOX. • Is pregnant, nursing or if you plan to breed your dog. What is PREVICOX? How to give PREVICOX to your dog. PREVICOX is aveterinary prescription non-steroidal anti-inflammatory PREVICOX should be given according to your veterinarian's drug (NSAID) used to control pain and inflammation due to instructions. Do not change the way you give PREVICOX to your dog osteoarthritis,or associated with soft-tissue and orthopedic surgery without first speaking with your veterinarian. Your veterinarian will in dogs. tell you what amount of PREVICOX is right for your dog and for how Osteoarthritis is a painful condition caused by "wear and tear" of long it should be given .
    [Show full text]
  • TEPOXALIN Veterinary—Systemic†
    TEPOXALIN Veterinary—Systemic† A commonly used brand name for a veterinary-labeled product is Zubrin. Note: For a listing of dosage forms and brand names by country availability, see the Dosage Forms section(s). †Not commercially available in Canada. Category: Analgesic; anti-inflammatory (nonsteroidal); antipyretic. Indications Accepted Inflammation, musculoskeletal (treatment)1; or Pain, musculoskeletal (treatment)1—Dogs: Tepoxalin is indicated for the control of pain and inflammation associated with osteoarthritis in dogs.{R-1} 1Not included in Canadian product labeling or product not commercially available in Canada. Regulatory Considerations U.S.— Tepoxalin is labeled only for use by or on the order of a licensed veterinarian.{R-1} Chemistry Chemical name: 5-(4-chlorophenyl)-N-hydroxy-1-(4-methoxyphenyl)- N-methyl-1H-pyrazole-3-propanamide.{R-1; 5} {R-1} Molecular formula: C20H20ClN3O3. Molecular weight: 385.84.{R-1} Description: White, crystalline material with a melting range of 125 to 130 °C.{R-1} Solubility: Insoluble in water, soluble in alcohol and in most organic solvents.{R-1} Pharmacology/Pharmacokinetics Note: The pharmacokinetic data for tepoxalin show large intrasubject and intersubject variability.{R-1} An individual animal's metabolism and elimination of tepoxalin may vary significantly from the averages reported in this section. Mechanism of action/Effect: Anti-inflammatory—Tepoxalin is believed to act through the inhibition of cyclooxygenase activity and also the inhibition of lipoxygenase, making it a dual inhibitor of arachidonic acid metabolism.{R-1} An ex vivo whole blood eicosanoid production assay following oral administration to dogs demonstrated the inhibition of prostaglandin {R-6} F2alpha and leukotriene B4 by tepoxalin.
    [Show full text]
  • (COX)-2 in the Canine Proximal Gastrointestinal Tract. (Under the Direction of Drs
    ABSTRACT WOOTEN, JENNA GRAY. The Role of Cyclooxygenase (COX)-2 in the Canine Proximal Gastrointestinal Tract. (Under the direction of Drs. Anthony Blikslager and Duncan Lascelles.) In veterinary medicine, NSAIDs are the most commonly prescribed analgesic and anti-inflammatory medications; unfortunately, they are also commonly associated with ulceration and perforation in dogs. Recent studies have indicated that the role of COX-2 appears to be more complicated than originally thought and its inhibition may lead to corresponding benefits or risks. Therefore, we investigated NSAIDs with differing degrees of selectivity and examined the role of COX-2 in the pylorus and duodenum. Each dog received carprofen (4.4 mg/kg, q 24 h), deracoxib (2 mg/kg, q 24 h), aspirin (10 mg/kg, q 12 h), and placebo (1 dog treat, q 24 h) orally for 3 days (4-week interval between treatments). Prostanoid synthesis was greater in pyloric mucosa than it was in duodenal mucosa. Nonselective NSAIDs significantly decreased prostanoid concentrations in these mucosae, compared with the effects of deracoxib. Following the same model dogs received deracoxib (2mg/kg q24h PO), firocoxib (5mg/kg q24h PO), meloxicam (Day 1=0.2mg/kg q24h PO, Day 2-3=0.1mg/kg q24h PO), or placebo (1 dog treat, q 24 h). There were no significant effects of varying COX-2 selectivity on gastric and duodenal tissue prostanoid concentrations, and no significant relationship between the degree of selectivity and gross or histological appearance of the mucosa, suggesting that there are no differences among the preferential and selective COX-2 inhibitors with regard to adverse effects on the upper GI tract.
    [Show full text]