Chapter 5 : Diseases of the Gastrointestinal Tract: The Pharmacy Professional’s Role in Treatment Management 4 Contact Hours By: Katie Ingersoll, RPh, PharmD, and Staff Pharmacist for a national chain. Author Disclosure: Katie Ingersoll and Elite do not have any Questions regarding statements of credit and other customer actual or potential conflicts of interest in relation to this lesson. service issues should be directed to 1-888-666-9053. This lesson is $16.00. Universal Activity Number (UAN): 0761-9999-13-273-H01-P Activity Type: Knowledge-based Educational Review Systems is accredited by the Initial Release Date: July 31, 2013 Accreditation Council of Pharmacy Education Expiration Date: July 31, 2015 (ACPE) as a provider of continuing pharmaceutical Target Audience: Pharmacists in a community-based setting. education. This program is approved for 4 hours (0.4 CEUs) of continuing pharmacy education To Obtain Credit: A minimum test score of 70 percent is credit. Proof of participation will be posted to your NABP CPE needed to obtain a credit. Please submit your answers either by profile within 4 to 6 weeks to participants who have mail, fax, or online at Pharmacy.EliteCME.com. successfully completed the post-test. Participants must participate in the entire presentation and complete the course evaluation to receive continuing pharmacy education credit. Learning objectives ● Define gastroesophageal reflux disease (GERD). ● Discuss how ulcerative colitis is diagnosed. ● State the incidence and prevalence of GERD. ● Identify the actions of prescription drugs used to treat ● Explain the pathophysiology of GERD. ulcerative colitis. ● Identify risk factors for the development of GERD. ● Evaluate the side effects of prescription drugs used to treat ● List the signs and symptoms of GERD. ulcerative colitis. ● Explain how GERD is diagnosed. ● Discuss herbal preparations used in the treatment of ● Define peptic ulcer disease. ulcerative colitis. ● Describe the incidence and prevalence of peptic ulcer ● Define Crohn’s disease. disease. ● Discuss the incidence and prevalence of Crohn’s disease. ● Explain the pathophysiology of peptic ulcer disease. ● Explain the pathophysiology of Crohn’s disease. ● List the risk factors for the development of peptic ulcer ● Identify potential complications of Crohn’s disease. disease. ● Identify the signs and symptoms of Crohn’s disease. ● List the signs and symptoms of peptic ulcer disease. ● Explain how Crohn’s disease is diagnosed. ● Discuss how peptic ulcer disease is diagnosed. ● Explain the actions of prescription drugs used to treat ● Review over-the-counter drugs used to treat GERD and Crohn’s disease. peptic ulcer disease. ● Evaluate the side effects of prescription drugs used to treat ● Evaluate the side effects of over-the-counter drugs used to Crohn’s disease. treat GERD and peptic ulcer disease. ● Discuss herbal preparations used in the treatment of Crohn’s ● Differentiate among the prescription drugs used to treat disease. GERD and peptic ulcer disease. ● Define irritable bowel syndrome. ● Evaluate the side effects of prescription drugs used to treat ● Discuss the incidence and prevalence of irritable bowel GERD and peptic ulcer disease. syndrome. ● Discuss herbal preparations used in the treatment of GERD ● Describe the pathophysiology and cause of irritable bowel and peptic ulcer. syndrome. ● Define ulcerative colitis. ● Identify potential complications of irritable bowel ● State the incidence and prevalence of ulcerative colitis. syndrome. ● Discuss the pathophysiology of ulcerative colitis. ● List the signs and symptoms of irritable bowel syndrome. ● List the potential complications of ulcerative colitis. ● Explain how irritable bowel syndrome is diagnosed. ● Identify the signs and symptoms of ulcerative colitis. Pharmacy.EliteCME.com Page 82 ● Describe the actions of medications used to treat irritable ● Discuss herbal preparations used in the treatment of irritable bowel syndrome. bowel syndrome. ● Evaluate the side effects of medications used to treat irritable bowel syndrome. Introduction The gastrointestinal (GI) tract is the body system dedicated the jejunum (the portion of the small intestine that is located to digesting foods and absorbing nutrients. Several organs are between the duodenum), and the ileum (the lowest portion of involved in digestion including the esophagus, stomach, and the small intestine that connects to the large intestine). This is small and large intestines. Other organs aid in the digestion of where vitamins, minerals, and nutrients are absorbed, as well foods by adding digestive enzymes to the GI tract; these include as many medications. After absorption of nutrients is complete, the pancreas, gallbladder and liver.2 the remaining contents are moved to the large intestine for reabsorption of excess water before the contents are excreted When food is eaten, it is carried through the esophagus past through the rectum.26 the lower esophageal sphincter to the stomach for breakdown by acids. Once the food is broken down and liquefied in the There are many points in the digestive process where disease stomach, it travels through the pylorus (the area of the stomach can occur. An overview of the most common gastrointestinal that connects to the small intestine) to the small intestine. diseases and their treatments will be discussed in this course in The small intestine is comprised of the duodenum (the first order to broaden the knowledge of the pharmacy professional. portion of the small intestine that connects to the stomach), GASTROESOPHAGEAL REFLUX DISEASE (GERD) AND PEPTIC ULCER DISEASE Definition of GERD Mrs. Gray is a 70-year-old retired professor of adult education. acidic liquids, such as coffee, and certain medications, such as She is a pleasant, cheerful individual and knows the pharmacy calcium channel blockers, increase the risk of GERD. staff at her local drugstore quite well. After suffering a mild heart attack about a year ago, she visits the pharmacy to refill Gastroesophageal reflux disease (GERD) is commonly her prescription for verapamil, a calcium-channel blocker. referred to as “heartburn” and is characterized by the backflow 4,7,26 When Mrs. Gray arrives at the pharmacy today, however, of acidic gastric contents into the esophagus. When she is not her normally cheerful self. She tells the pharmacy acidic gastric contents irritate the esophagus regularly, the professional that she has been experiencing ”heartburn” for esophagus becomes irritated; effects can range from minimal the past few months. This is especially pronounced after she to significant inflammation of the mucosa of the esophagus. drinks her morning coffee. The pharmacy professional on duty Severe, recurrent acid reflux can lead to erosion of the epithelial encourages Mrs. Gray to see her physician for evaluation. layer of the esophagus. Complications can arise from constant He knows that what can be interpreted as “heartburn” may esophageal irritation, such as esophageal ulcers, esophageal actually be a symptom of another heart attack. He also knows strictures (narrowing of the esophagus), or Barrett’s esophagus that Mrs. Gray’s symptoms may indicate GERD, because (replacement of the lining of the esophagus with tissue that is similar to the lining of the intestine, a risk factor for esophageal cancer).4,7,23,27 Incidence and prevalence of GERD It is believed that 25 percent to 40 percent of Americans have Long-term, ongoing maintenance therapy with medication may symptoms of GERD at some point during their lifetimes, and 7 be necessary. 4,21 percent to 10 percent of Americans must deal with symptoms of GERD every day. However, these figures are only estimates, Disease alert! GERD is usually thought of as a problem that because many people with GERD self-medicate with over-the- affects only adults. However, research shows that the problem counter drugs and do not seek medical advice.7 is very common in infants and children. Signs of GERD in these age groups include frequent vomiting, coughing, and While GERD can occur in patients of any age, it is more respiratory problems. GERD in infants and children is usually commonly seen in patients over 40 years old. It also is more the result of an immature digestive system. Fortunately, commonly seen in Western countries.27 most infants and children “grow out” of GERD without complications.7 GERD is often a chronic problem. Patients may go through periods during which their symptoms are well controlled only to be followed by periods when their symptoms are severe. Page 83 Pharmacy.EliteCME.com Pathophysiology of GERD Under normal conditions the lower esophageal sphincter puts not remain closed. Why doesn’t it remain closed? The problem enough pressure around the lower end of the esophagus to can be caused by the LES not having enough pressure to remain close it and prevent reflux of gastric contents back up into closed or the pressure in the stomach pushing the stomach the esophagus. When food is swallowed, the sphincter (LES) contents back up into the esophagus. Stomach contents are very opens so that food can pass into the stomach and then closes acidic, and this causes the typical pain and heartburn of GERD to prevent backflow. But with GERD, the sphincter often does when these contents move back into the esophagus.4,19 Risk factors for GERD There are several risk factors for the development of GERD. ● Tomato products. These include various foods, certain medications, and some ● Whole milk. medical conditions. Factors