G.I.T.

CASES
1- Mr. Muhamad called you complaining from intense
abdominal pain affecting his epigastric area. The pain
associated with flatulence and heartburn. The onset of pain
rose up 3 hours after he arrived from a wedding party fulfilled
with varieties of delicious food.
He asks for your help.

➢What likely is the diagnosis?

➢How would deal with such case?

4
2- Mr. Kamel is 40 years old, he is presenting in your pharmacy
complaining from annoying heart burn that come through after almost
every meal in the last week . He also clarified that the heartburn
interrupted
®
his sleep at least 2 times in the past week.

➢What is your response if you know that

he his overweight, smoker & he is currently
taking COVERAM for his hypertension?

5
3- Mr. Ali is 45 years old diabetic patient, he called you
complaining from intense abdominal pain affecting his
epigastric area. The pain associated with flatulence and
heartburn. He can’t point the pain site. He also reports early
satiety, which is abnormal to him. These symptoms arises 3
months ago & progress badly.

➢What likely is the diagnosis?

➢How would deal with such case?
➢Is there any lab test you may request?

6
4- A patient called you complaining from intense pain in
the right mid region of his abdomen, the pain radiated to
the backside of his right shoulder, he clarified that the pain
increases when he eats a fatty meal.
✓ Persistent, steady severe pain.
✓ Pain can vary from sharp, in nature.
✓ Sudden onset and ↑after fatty meals
✓ Waking the patient in the early morning.
❖What likely is the diagnosis?
❖How would you deal with the case?
7
5- A customer calls you asking for
support regarding his brother
symptoms:
• Pain starts around the
umbilicus then migrates into
to the right lower quadrant
• Colicky or cramp-like pain
which become constant
• Movement ↑ pain (vomiting
may be present)
• What is the suggested
diagnosis?
• What will you recommend?

8
 CASE 6

◦ Manal is a woman aged about 50 years

◦ Sometimes she gets a burning sensation just above the breastbone and feels the burning in her throat,
often with a bitter taste, as if some food has been brought back up.
◦ The discomfort is worse when in bed at night and when bending over whilst gardening. She has been
having the problem for 1 or 2 weeks and has not yet tried to treat it.
◦ Manal is not taking any medicines from the doctor.
◦ To your experienced eye, this lady is overweight. You ask her if the symptoms are worse at any
particular time and she says they are worst shortly after going to bed at night.
 Case 7

◦ You have been asked to recommend a ‘strong’ mixture for heartburn for Ali Osman, a local man in his
late 50s who works in a nearby warehouse. Mr Ali tells you that he has been getting terrible heartburn
for which his doctor prescribed some medicines about 1 week ago.
◦ You remember dispensing a prescription for a Gaviscon SUSP.
◦ The bottle is now empty, and the problem is no better. When asked if he can point to where the pain is,
Ali gestures across his chest and clenches his fist when describing the pain, which he says feels heavy.
You ask whether the pain ever moves, and Ali tells you that sometimes it goes to his neck and jaw.
◦ When asked if the pain worsens when bending or lying down, Ali says it does not, but he tells you he
usually gets the pain when he is at work, especially on busy days.
 Case 8

Mr. Ali came to your pharmacy to dispense this ✓ Zithromax

prescription and want RENNIE tab for his heart burn ‫ ايام‬3 ‫ كبسولة يوميا‬2
✓ Lary pro
What is your comment about his choice (RENNIE)
‫قرص استحالب عند اللزوم‬
and what counselling tips will u advise him
✓ Brufen 600
‫ ساعة‬12 ‫قرص كل‬
How to Deal with Infective Diarrhea (gastroenteritis)?

❑Acute infective diarrhea is divided into 3 subtypes named bacterial, viral, & protozoal diarrhea.
❑To prescribe an effective treatment, we should make differential diagnosis for the case by asking patient about
stool volume, consistency, & odor & whether tenesmus is present.

Bacterial or protozoal
Viral diarrhea
diarrhea

1. Stool volume: large volume

2. Stool consistency: watery diarrhea 1. Stool volume: small volume
3. Stool odor: no offensive odor 2. Stool consistency: Mucoid &/or bloody.
4. Tenesmus: not present 3. Stool odor: offensive odor
4. Tenesmus: present

Primary Treatment Treatment

Oral rehydration solution (ORS) + HIDRASEC® Oral rehydration solution (ORS) + HIDRASEC®
or IMMODIUM® (only in severe cases) or IMMODIUM® (only in severe cases) +
Antibacerial or antiprotozoal drugs are not antibacterial e.g. ANTINAL® + antiprotozoal
effective in this case. e.g. NANAZOXID®
• Sample Prescriptions Would Contain:

Bacterial or protozoal
Viral diarrhea diarrhea

Primary Medications Primary Medications

▪ HIDRASEC® OR IMODIUM® ▪ NANAZOXID® + ANTINAL®
▪ (only in severe cases) ▪ HIDRASEC® OR IMODIUM® (only
in severe cases)
▪ Oral Rehydration Solution (ORS) ▪ Oral Rehydration Solution (ORS)
LOHYDRAN® OR HYDROSAFE® LOHYDRAN® OR HYDROSAFE®
VISCERALGIIN® ▪ VISCERALGIIN®
Cross Sales Cross Sales
▪ LACTEOL FORT® ▪ LACTEOL FORTE®
▪ SMECTA® OR KAPECT® ▪ SMECTA® OR KAPECT®
▪ SULFOZINC® syrup ▪ SULFOZINC® syrup
 Case 9
◦Hasnaa, 36 years describes acute onset diarrhea that started
about 36 hours ago. Since it started, she has had 3-4 loose
stools (watery) per day. She complains of mild-moderate
abdominal cramping and 1 episode of vomiting but has no
other relevant signs or symptoms. She remarks, “This
diarrhea is exhausting. I feel like it’s taken a lot out of me.”
She tells you, “I thought it would get better by itself, but it
hasn’t.”
 Case 10

◦The patient describes sudden onset of diarrhea with severe

abdominal cramps that awakened him from sleep at about 3 am
this morning. Since then, he has experienced 3 episodes of loose,
bulk offensive odor stool in the last 6 hours and notes that his
last stool looked as if it contained some blood. He also
complains of lightheadedness and becomes somewhat dizzy on
standing. He denies fever, but says that at times, he feels his heart
beating faster
Case 11

◦ A mother calls u asking about your advice for

her infant 16 months age suffering from
watery diarrhea
◦What will you recommend and mention
counselling tips
 Diarrhea In infants
Diarrhea is defined as an increased frequency of bowel evacuation, with the passage of abnormally soft or watery faeces

Diarrhea in pediatrics is mainly infectious (bacterial or viral).

Dehydration is the major risk associated with diarrhea in infants and children.

Most cases are self-limited, have to be referred to the physician if diarrhea in infants persist for more than 1 day.

Oral Rehydration Solution

Management
A- Protect against dehydration.
344521
if diarrhea (Rehydrozinc-Rehydran-Lohydran)
persist for 119017
B- Reconstituted by boiled and cooled water
more than (stable in the refrigerator for 24 h)
1 day in C- To be administered with quantities of: ORS are the
infants → < 1 yr. : 50 ml (1/4 glass) first choice
refer to the 1-5 yr. : 100 ml (1/2 glass)
physician 6-12 yr. : 200 ml (one glass)
adults : 400 ml (2 glasses)
310322
 Clays / Adsorbents Probiotics
• Adsorb toxins and reduce fecal
passage frequencies • E.g. lacteal fort sachets
319004
• Smecta : with doses of:
• For infants:
<1 year old: 1 sachet/day
1:2 years : 2 sachets/day 1 sachet / 12 h.
>2 years: 3 sachets/day 319017
A lab. Preparation of a loperamide
Zinc sulphate (Imodium) on Kapect with strength of

• Increases epithelial cells growth& Could be used but “not recommended”

Regeneration. “Prescribed only”
• Enhances GI immune-response.
310328
• Decreases endotoxins transfer to the
circulation. Infants < 6 months
10mg/day
• Inhibits Chloride, H2O secretion. 3202310
Infants > 6 months
20 mg/day/ 102012
Blenkinsopp, A., Paxton, P., & Blenkinsopp, J. (2014). Symptoms in the pharmacy: A guide to the management of common illnesses.
Products insert leaflets
 Cases 12
◦ Mostafa complains of constipation, which he has had for several weeks.
◦ His motions are hard and painful to pass.

◦ . He does not have any other symptoms, except a slight feeling of abdominal discomfort. You
ask him about his diet; he tells you that since he was made redundant from his job at a local
factory 3 months ago when it closed, he has tended to eat less than usual;

◦ A pregnant women in third trimester suffering from constipation?

◦ A mother asking ur advise for constipation of her infant 1 weeks old

13- Mr. Ali called you seeking help, his 2 years old child feels
unwell. He is suffering from nausea & recurrent vomiting; he
also have diarrhea. The stool is mucoid & has an offensive
odor.

➢What likely is the diagnosis?

➢In your thoughts, what is the
most proper prescription to control the case?
➢Is there any cross-sale you may offer?

20
14 Mr. Hosam 30 years old man, came to you complaining of a pain
affecting his lower abdominal region. He can’t locate the pain site
precisely, but it arises & may increase with defecation. His bowel
movements is always of high number , so he passes a large volume of stool
with urgency to defecate. He also has flatulence. He seems stressed due
to his overloaded work .

➢What likely is the diagnosis?

➢Give him a proper prescription.
➢Does this patient meet the criteria of referral?

21
• Anticholinerigc drugs → block M3 receptors → ↓ pain (Spasm only)
and diarrhea
Peppermint oil
• Have smooth muscle relaxant effect → ↓ IBS pain and cramping
 ➢ Direct smooth muscle relaxant and
✓ Clidinium bromide: antimuscarinic
local anesthetic action by:
❖ Trimebutine: Antimuscarinic + ✓ Chlordiazepoxide: sedative
➢ Antimuscarinic activity
moderate mu opioid agonist hypnotic, ↓ anxiety and stress and
➢ Blocking K+, Na+, and Ca2+
❖ Mechanism: Antimuscarinic + ↑ smooth muscle relxation
channels.
moderate mu opioid agonist ✓ Dosage: 1-2 capsules 3-4 times
➢ Dosage: 135 mg three times daily,
(spasmolytic effect) before meals
20 minutes before meals
❖ Dosage: one tablet 3 times daily ✓ Patient counseling: Gradual
➢ Pregnancy and lactation: avoid
❖ Pregnancy: not recommended withdrawal
➢ Side effects: has no systemic
✓ Pregnancy: D
anticholinergic side effect
• TCAs and SSRIs → analgesic effect (very effective for patients with severe or continuous
abdominal pain and bloating) and ↓ depression
TCAs
• Amitriptyline (Triptizole): 10–25 mg at bedtime
• TCAs should be avoided in patients with constipation.
• Side effects: Anticholinergic side effects + sedation
SNRIs
• Duloxetine (Cymbalta®) may improve pain and diarrhea in IBS patients.
SSRIs
• Fluoxetine, sertraline, citalopram, and paroxetine → prokinetic effect → improve constipation in
IBS-C.
• They can also be used in IBS-D if co-morbid depression or anxiety exists
• Side Effects: Insomnia, sexual dysfunction, and withdrawal
15- Ms. Shaimaa called you seeking help. Her newborn is 4 months old. The mom
reported that her baby is crying most of the day. He also have bowel movements more
than normal despite no change occurred in the feeding habits. She also reported that
her baby has erythema which onset is nearly accompanied the diarrheal episodes.
The baby feeding habits: the first 3 months was breastfeeding. The last month is
APTAMIL 1 milk formula.
➢ What likely is the diagnosis?
➢ Is there in the milk formula.
➢ If you answered the above Q. by “YES” → What are the
proper infant formula products that may help in such case?

27
16- Ms. Soaad is a 55 years old female patient came to your
branch complaining of a pain affecting her lower left
abdominal region. She had 3-4 bowel movements per week
but she have difficulties while defecating. She is diabetic &
taking SIFROL for her Parkinson disease?
❖What likely is the diagnosis?
❖In your thoughts, is it an acute or chronic condition?
❖Give her a proper prescription ?
❖Is there any cross-sale you may offer?

28
Case 17

◦ If CATAFLY® strength is 2 mg/ ml

and diclofenac pediatric dose is 2
mg/ kg/ day what is the dose / 8 hr for
a children weighted 20 kg?
Case 18
◦If CEFDIN ® strength is 125 mg/ 5 ml and cefdinir
paediatric dose for otitis media is 14 mg/ kg/
day divided / 12 hr what is the dose / 12 hr for a
children weighted 16 kg?
THANKS
Case 10
◦ 0 If CLARIKAN strength is 250 mg/ 5 ml and "Clarithromycin "pediatric dose for
Tonsillitis is 15 mg/ kg/ day divided / 12 hr what is the dose / 12 hr for a child weighted
12 kg?
 Case 11
◦ If CEPOREX® strength is 250 mg/ 5 ml and cephalexin pediatric dose
for TONSILITIS is 40 mg/ kg/ day divided / 12 hr what is the dose / 12 hr
for a children weighted 20 kg?
Case 12

◦ How many mLs do you need to reconstitute VANCOMYCIN ® 500 mg vial for the
preparation of fortified vancomycin 5% eye drop ?
Case 13
◦ How many vials of TAXOL® 100 mg/16.7 ml would you dispense to an ovarian cancer
patient (2 meter square BSA) if the required dose is 175 mg/ meter square?
Case 14
◦ How many vials of TAXOTERE® 80 mg/4 ml would you dispense to a prostate cancer
patient (1.5 meter square BSA) if the required dose is 75 mg/ meter square?
Case 15
◦ How many vials of CAMPTO ® 100 mg/ 5 ml would you dispense to an
COLORECTAL cancer patient (1.5 meter square BSA) if the required dose is 125 mg/
meter square?
 Cases 13
◦ Mostafa complains of constipation, which he has had for several weeks. He has been having a
bowel movement every few days; normally they are every day or every other day. His motions are
hard and painful to pass. He has not tried any medicines as he thought the problem would go of
its own accord. He has never had problems with constipation in the past. He has been taking
atenolol tablets 50 mg once a day, for over 1 year. He does not have any other symptoms, except a
slight feeling of abdominal discomfort. You ask him about his diet; he tells you that since he was
made redundant from his job at a local factory 3 months ago when it closed, he has tended to eat
less than usual; his dietary intake sounds as if it is low in fibre. He tells you that he has been
applying for jobs, with no success so far. He says he feels really down and is starting to think that
he may never get another job.