胃肠病药物治疗 .ppt

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1、胃肠病药物治疗上海市消化疾病研究所吴叔明教授.分类（1）.n n抗溃疡&胃-食管反流:抗酸药,H2-antigonists,PPI；膜保护剂,铋剂,铝制剂 n nIBD:5-ASA&4-ASA,SASP,n n急性胰腺炎；胰酶替代剂n n肝炎：贺普汀n nGallstone:胃肠动力药物（分类（分类2 2）n n止泻药物:n n胆盐结合药物n n平滑肌松弛药物n n抗便秘药物 n n促动药物n n抗动力药物 抗幽门螺杆菌药物（分类（分类3 3）n n抗生素GI 相关药物（分类（分类4 4）n n导泻剂导泻剂n n镇静剂镇静剂n n硬化剂硬化剂 n n止血药物止血药物n n造影剂造影剂n n生长

2、抑素生长抑素n n抗血清素抗血清素n n免疫抑制剂免疫抑制剂:Cy.A,:Cy.A,FK506,CorticoteroidsFK506,CorticoteroidsH2-Receptor Antagonist(H2-RA)n n西米替丁n n雷尼替丁n n法莫替丁n n尼扎替丁n n罗沙替丁H2-RA A structural analogue of histamine with an aliphatic side chain attached to an imidazole ring.组胺 cAMP 激活 H，KATPase西米替丁的用药技巧西米替丁的用药技巧FF抑制基础胃酸分泌抑制基础胃酸

3、分泌 FF与与 H H2 2-receptor-receptor可逆结合可逆结合 FF快速静脉注射可致心动过缓快速静脉注射可致心动过缓FF抗酸药会抑制其口服吸收抗酸药会抑制其口服吸收FF应激出血使用后不能控制应激出血使用后不能控制 pHpH，要考虑败血症，要考虑败血症可能可能FF某些药物低调某些药物低调 cimetidinecimetidine作用作用.FF男性乳房发育停药男性乳房发育停药 3 months3 months后解决后解决 Ranitidine的技巧FF唯一用于治疗唯一用于治疗GERDGERD的的 H H2 2-antagonist(FDA)-antagonist(FDA)FF未发

4、现抗雄激素作用未发现抗雄激素作用FF单分子作用比单分子作用比 cimetidincimetidin强强 510 510 倍倍FFRanitidine iv Ranitidine iv 可使可使 sGPTsGPT升高升高FF慢性肝病者使用时生物活性无影响慢性肝病者使用时生物活性无影响.FF HP HP根除治疗时与抗生素合用根除治疗时与抗生素合用 Famotidine的技巧n n西米替丁的25倍 RanitidineRanitidine 的10倍n n PU治疗疗效与西米替丁、RanitidineRanitidine相同相同 n n对其他药物的血清浓度无影响n n未发现抗雄激素作用未发现抗雄激素作

5、用n n 5%的病人可发生头痛.n n不影响酒精吸收 质子泵抑制剂（PPI）n n奥美拉唑n n达克普隆n n畔妥拉唑n n波立特质子泵抑制剂(PPI)直接与胃酸分泌的最后一步 H+/K+adenosinetriphosphatase(ATPase)结合,强力抑制胃酸分泌。Omeprazole,Lansolazole,Pantolazole，Pariet质子泵抑制剂n n抑制基础胃酸和最大胃酸分泌n n由酸敏感包膜包裹n n 使血清胃泌素升高质子泵抑制剂使用指症n nZollinger-Ellison综合症n n反流性食管炎n n消化性溃疡铋 剂 铋盐具有止泻、保护胃粘膜和选择性抗菌作用 Tr

6、ipotassium dicitrato bismuthate/colloidal bismuth subcitrate(TDB/CBS),Bismuth subsalicylate and other preparations铋 盐n n溶液时可部分吸收溶液时可部分吸收n n pH6pH6时沉淀时沉淀n n和受损组织易结合和受损组织易结合n n抑制某些细菌生长抑制某些细菌生长n n胃肠蠕动下降胃肠蠕动下降n n促进胃肠蠕动促进胃肠蠕动n n与蛋白酶鏊合，降低与蛋白酶鏊合，降低蛋白酶活性蛋白酶活性n nAspirinAspirin样作用样作用*n n CBSCBS抑制抑制HPHP浓度浓度 25

7、mg/l90%)溃疡愈合迅速，症状消失快)病人依从性好)不产生耐药性)疗程短，治疗简便)价格便宜全国HP科研协作组推荐方案nPPI+两种抗生素：PPI标准剂量+Cla.0.25+Amo.1.0 bid.X1周PPI标准剂量+Cla.0.5+甲硝唑0.4 bid.X1周n铋剂+两种抗生素：铋剂标准剂量+四环素 0.5+甲硝唑0.4 bid.X 2周铋剂标准剂量+Amo.0.5+甲硝唑0.4 bid.X 2周铋剂标准剂量+Cla.0.25+甲硝唑0.4 bid.X 1周动力药物Metoclopramide 胃复安Dompenridone吗叮啉Cisapride西沙比利Erythromycin红霉素

8、Metoclopramide 最早的动力制剂，极大的增强了临床医师治疗胃肠动力改变的能力胃复安n n普鲁卡因酰胺的衍生物n n多巴胺-receptor阻滞剂 n n升高 LESP,促进食管和胃窦蠕动n n幽门括约肌松弛n n缩短近端小肠的通过时间 胃复安指征n n糖尿病胃轻瘫n n胃-食管反流n n化疗引起呕吐n n小肠X线检查胃复安禁忌症n n肠梗阻n n胃肠道穿孔n n癫简n n嗜铬细胞瘤（Pheochromocytoma）n n椎体外系症状胃复安用法n n防止化疗引起的呕吐,a 10 mg dose of 12 mg/kg/day is used,with 0.5 to 1.0 mg/k

9、g given every 3 to 4 hours subsequently while the patient is receiving chemotherapy.技 巧n n糖尿病人注意空腹血糖，调整胰岛素n n眩晕和CNS性忧郁可因同时服用其他多巴胺受体阻滞剂而加重n n肌肉震颤可用苯海拉明对抗吗叮啉特异性多巴胺受体阻滞剂，无胃复氨的CNS副作用吗叮啉药理学n n峰值:po(13%).&im后 1530 mins.纳肛后(90%)12hr.n n组织中浓度是血浆浓度的28 times n n血浆中90%与蛋白结合n n脑、乳汁、胎盘中浓度低吗叮啉 机理n n胃肠道多巴胺受体亲和力较高n

10、 n食管:LESP 升高到1520 mm Hg n n胃底和幽门松弛n n 胃窦和十二指畅收缩 有利固体和液体食物的排空 吗叮啉止 吐n nProviding antagonism of apomophine-induced emesis at the level of the chemoreceptor trigger zonen n增加胃排空 吗叮啉指 征n n减轻胃排空延迟和胃食管反流导致的下列症状:嗳气,腹胀,饱胀，烧灼感,恶心,呕吐吗叮啉副反应n nCNS:n n泌乳素升高:FM.男性乳房发育和阳痿亦有报导。n nCirculation system:西沙比利n nA benzami

11、de derivative n n无抗多巴胺作用n n第一个对结肠有促动力作用药物西沙比利Pharmacologyn n消化道吸收较好(95%).血浆峰值出现于 1.52 hr.n n首相代谢(liver metabolism)n n血浆中90%与蛋白结合n n脑和胎盘中浓度低。动物实验中可进入乳汁西沙比利机理n n通过通过(5-HT(5-HT4 4)receptor)receptor非直接胆碱能机制来促进非直接胆碱能机制来促进乙酰胆碱的释放乙酰胆碱的释放.n n食管:LESP 升高到1520 mm Hg n n胃底和幽门松弛n n 胃窦和十二指畅收缩 n n结肠结肠:促推进作用促推进作用n

12、n小肠小肠:增加小肠运动的幅度和频率增加小肠运动的幅度和频率西沙比利指征n nGERDGERDn n胃瘫痪胃瘫痪胃瘫痪胃瘫痪n nFDFDn n术后盲襻术后盲襻n n慢性便秘慢性便秘慢性便秘慢性便秘n n慢性假性肠梗阻慢性假性肠梗阻慢性假性肠梗阻慢性假性肠梗阻n n其他:IBS:IBS:胆汁反流性胃炎胆汁反流性胃炎 脊髓损伤后肠功能不脊髓损伤后肠功能不全全 DU DU 维持治疗维持治疗.红霉素n n机理 增加胃动素浓度，并直接作用于胃动素受体.红霉素n n胃瘫痪n n术后应用:IV促进术后胃排空延迟.n nothers:vagatomy,scleroderma,chemotherapy Rou

13、x en Y symdromGERD,anorexia nerosa and chronic idiopathic intestinal pseudo-obstructionErythromycinSide effectn n恶心、呕吐、腹痛和腹泻.n n静脉炎.*诀窍n n对 糖尿病者促动力作用尤佳.n n静脉使用较口服效佳.n n在其他药物无效时使用.返流性食管炎胃食管返流炎的内镜诊断（Allison)Allison)鳞状上皮炎症 柱状上皮炎症发红发红 粘膜表面炎症粘膜表面炎症孤立浅表炎症孤立浅表炎症 急性粘膜糜烂急性粘膜糜烂溃疡融合，无狭窄溃疡融合，无狭窄 亚急性局限性溃疡亚急性局限性溃

14、疡溃疡融合、狭窄、易扩张溃疡融合、狭窄、易扩张 慢性穿透性溃疡慢性穿透性溃疡溃疡融合、狭窄、不易扩张溃疡融合、狭窄、不易扩张溃疡融合、狭窄、纤维化波及纵隔溃疡融合、狭窄、纤维化波及纵隔返流性食管炎分型（9 9thth WGC)WGC)分型 征特 I 稀疏、垂直糜烂或溃疡 II 融合性溃疡 III 溃疡融合成环状 IV 疤痕、狭窄 食管功能检查n n1.食管压力测定n n2.酸返流试验n n3.酸清除试验n n4.酸灌注试验n n5.食管闪烁照相术n n6.24小时pH监测溃疡性结肠炎的药物治疗上海市消化疾病研究所吴叔明教授炎症性肠病(IBD)n病因不明 n疾病难于治疗而易于复发.Criteri

15、a for Severe Colitis1.Diarrhea:6 stools/per day or more with 1.Diarrhea:6 stools/per day or more with macroscopic bloodmacroscopic blood2.Fever:Mean evening temp.2.Fever:Mean evening temp.37.5C or a temp.of 37.5C or a temp.of 37.8C on at least 2 days out of 4.37.8C on at least 2 days out of 4.3.Eryt

16、hrocyte sedimentation rate elevation3.Erythrocyte sedimentation rate elevation 30304.Anemia:Hemoglobin level 4.Anemia:Hemoglobin level 90/min 90/min Truelove-Lancet 1974;1:1067Truelove-Lancet 1974;1:1067Sulfasalazine(SASP)n nSASP:5-aminosalicylic acid(5-ASA)和 sulfapyridine(SP)二部分 n n2030%SASP 在上 GI吸

17、收,经胆汁和尿液排泄n n肠道细菌将 SASP裂解为 SP和5-ASAn n脂溶吸收的 SP:side-effectn n脂溶吸收差的SASP留在结肠Adverse Effects of SulfasazineDose relatedDose relatedn nnauseanausean nvomitingvomitingn nanorexiaanorexian nfolate mal-ab.folate mal-ab.n nHeadacheHeadachen nalopecia alopecia Not dose relatedNot dose relatedn nskin rashski

18、n rashn nhemolytic anemiahemolytic anemian nagrannulocytosisagrannulocytosisn nfibrosing alveolitisfibrosing alveolitisn nhepatitishepatitisn nmale infertilitymale infertilityn ncolitiscolitis溃疡性结肠炎的药物治疗n各种剂型 n膜包被 控释型 偶合型nAsacol Pentasa Osalazine nClaversal Balsalazide n nSalofalk MesalazinenRowasa

19、Mechanisms of Steroid Action-IBDn nStabilizes lysosomal membranesn nReduces capillary permeabilityn nFunction as inhibitors of chemotaxis and phagocytosis n nImpairs cell-mediated immunity in experimental models Administration and Dosagen nOral Dosage Taperingn nIntravenous Bolus or continuous infus

20、ionn nTopical Position,Dosage,DurationCommonly Used Glucorticoidds Equivalent Mineralo-Equivalent Mineralo-Glucocorticoid Glucocorticoid corticoid Glucocorticoid Glucocorticoid corticoidDuraton of action Potency Dose(mg)ActionDuraton of action Potency Dose(mg)Action Short-actingShort-acting Cortisol

21、 1 20 yes Cortisol 1 20 yes Cortisone 0.8 25 yes Cortisone 0.8 25 yes Prednisone 4 5 y/no Prednisone 4 5 y/no Prednisolone 4 5 y/no Prednisolone 4 5 y/no Methylpredinisolone 5 4 y/no Methylpredinisolone 5 4 y/noIntermediate-actingIntermediate-acting Triamcinolone 5 4 no Triamcinolone 5 4 noLong-acti

22、ngLong-acting Betamethasone 25 0.60 no Betamethasone 25 0.60 no Dexamethasone 30 0.75 no Dexamethasone 30 0.75 no免疫抑制药物 药名药名 作作 用用 适应症适应症 不良反应不良反应 用量用量mg/kg.dmg/kg.d硫唑嘌呤硫唑嘌呤 干扰嘌呤的干扰嘌呤的 缓解期的缓解期的 胰腺炎、胰腺炎、BM 12BM 12 生物合成生物合成 维持维持 抑制，过敏抑制，过敏 6-MP 6-MP 肝内转化肝内转化 缓解期的缓解期的 胰腺炎、胰腺炎、BM 11.5BM 11.5 硫唑嘌呤硫唑嘌呤 维持

23、维持 抑制，过敏抑制，过敏 环胞素环胞素 细胞免役细胞免役 对皮质激素对皮质激素 肝毒性肝毒性 口服：口服：5 5 抑制剂抑制剂 疗效不好者疗效不好者 静滴静滴:4:4UC直肠炎的治疗n n推荐治疗：5ASA栓剂或类固醇灌肠的表面治疗。5-ASA有更高的缓解率，激素布地奈的为首选。23周有所缓解。n n缓解治疗：缓解后减至23次/周n n栓剂治疗不耐受者口服SASP或美沙拉嗪远段溃疡性结肠炎（30403040厘米处乙结肠）厘米处乙结肠）n n轻、中度的早期：5ASA栓剂或类固醇灌肠的表面治疗。夜间灌肠（美沙拉嗪4克/天34周后每3天1次。无效时考虑加用氢考晨间灌肠。n n口服治疗：每天SASP

24、 1+美沙拉嗪1.2+奥沙拉嗪0.5。无效时每天SASP 46+美沙拉嗪4.8+奥沙拉嗪3。n n重度：5ASA+强的松4060毫克左半结肠炎和全结肠炎n n治疗效应和剂量相关n n中度：46克SASP或美沙拉嗪4.8克n n重度和无效者：强的松4060毫克，710天后减量。重度和爆发性结肠炎n n主治方式：强的松30毫克/BID或甲强龙16毫克TIDn n直肠症状为主：加用5ASA和氢考灌肠n n类固醇IV1014天无效者：手术或环孢素A治疗。类固醇治疗无效的UCn n最大剂量口服和表面治疗的5-ASA以及类固醇治疗无效者。n n2/3的这类病人在使用免疫抑制剂后可获缓解。n n硫唑嘌呤或6

25、-巯基嘌呤50毫克/天渐增至硫唑嘌呤1.5毫克或6-巯基嘌呤1.5毫克/kg/天n n6个月无效，可改用MTX7.5毫克25毫克，812周见效。类固醇依赖的UCn n类固醇减量后复发病例n n可应用硫唑嘌呤或6-巯基嘌呤，缓解后撤除类固醇，仍应维持免疫抑制治疗。Crohns病的药物治疗口腔Crohns病的治疗1.含氢考的甲基纤维素、果胶、或明胶作表面治疗，2/3的病人有效。2.硫糖铝表面治疗。胃十二指肠Crohns病的治疗n n甲基纤维素粒剂包裹的缓释美沙拉嗪（Pentasa）部分在近端小肠释放，可用之。n nPentasa无效时，类固醇治疗。n n类固醇依赖或类固醇无效：可应用硫唑嘌呤或6-

26、巯基嘌呤活动性回肠炎、回结肠炎和结肠炎n nSASP作用有限n n5-ASA治疗：美沙拉嗪4克/天一般有效。从11.6克/天开始。无改善者加用环丙沙星0.5克，一天二次。n n5-ASA无反应或伴全身症状：强的松4060毫克/天Crohns病局灶性腹膜炎的治疗n nCrohns病局灶性腹膜炎指患者出现发热、腹痛腹膜刺激症状、白细胞增多。n n甲硝唑+第二代头孢菌素；青霉素+庆大霉素n n是否使用类固醇药物尚有争议Crohns病小肠梗阻的治疗n n胃肠减压+TPN+类固醇治疗n n无效者手术治疗Crohns病的维持缓解治疗n nCrohns病的维持缓解治疗：5-ASA、类固醇n n5-ASA的作

27、用不大n n类固醇作用不明n n止泻药支持治疗：上述治疗无反应且无全身症状，洛呱丁胺和消胆胺控制腹泻有效类固醇无效和依赖的Crohns病n n硫唑嘌呤或6-巯基嘌呤：50毫克/天，可每月增加25毫克，直至最大剂量。n n治疗36个月有效n n硫唑嘌呤或6-巯基嘌呤无效：MTX或环孢霉素n n抗肿瘤坏死因子-A嵌合抗体输注Crohns病瘘管的治疗n n复发率高，先试用药物。甲硝唑1020毫克/公斤/天n n可应用6-巯基嘌呤n n静注环孢霉素n n抗肿瘤坏死因子-A嵌合抗体输注Crohns病肛周病和瘘管的治疗n n甲硝唑1020毫克/公斤/天n n甲硝唑和局部切除无效：可应用6-巯基嘌呤n n抗

28、肿瘤坏死因子-A嵌合抗体输注Pearls and Pitfall-IBDIBD flare during pregnacy IBD flare may be detrimental to the outcome of pregnancy?Steroid should be used to enhance a favorable outcome:n nNo perinatal or fetal adverse effectsn nNo fetal&newborn HPA(Hypopituitary adrenal axis)(Hypopituitary adrenal axis)n nAppro

29、priate routes&dosage Mogadam-Gastroenter.1981;80:72 Mogadam-Gastroenter.1981;80:72Pearls and Pitfall-IBDn nPatient with either psychiatric disease Not affect the risk of onset and developn nHypoalbuminemia Reduce the dosage to low side-effect and toxicity(nonprotein-bound steroid)n nIBD flare during

30、 dosage tapering Dosage return to previous high leveln nNo inprovement in once daily usage Splitting regiment could be tried Pearls and Pitfall-IBDn nRetard growth in child Steroid therapy be avoided in kid 5555岁岁2 2）WBC16000WBC160003 3）血糖）血糖200mg%200mg%4 4）LDH350U/LLDH350U/L5 5）AST250U%AST250U%n n4

31、848小时时小时时6 6）HCTHCT下降下降10%10%以上以上7 7）BUNBUN升高升高5mg%5mg%血钙低于血钙低于8ng%8ng%PaO260mmHgPaO260mmHg碱缺失超过碱缺失超过4mmol4mmol液体积聚量液体积聚量6000ml6000ml急性胰腺炎的CT诊断CT对重症胰腺炎的早期识别和预后判断有使用价值，“脂肪岛”的出现与继发感染关系密切。CT分级n nA级：正常n nB级：局限或弥漫的胰腺增大，胰腺内少量液体积聚，轮廓不规则。非出血性腺体增强。n nC级：胰腺异常显象模糊，条纹样改变。n nD级：单个胰外液体积聚。n nE级：两个以上胰外液体积聚n nF级：大量气

32、体和液体积聚于胰腺和邻近部位，累及腹膜后间隙。急性胰腺炎n n有待证实或有限作用的药物：抗酸剂、抗胆碱能药物、H2-受体拮抗剂镇静剂、胰高糖素、降钙素、生长抑素、加压素、丙基硫氧嘧啶、抑肽酶、加贝脂、肝素、抗生素、激素、前列腺素慢性胰腺炎胰腺炎的分类1963年马赛分类：n n急性胰腺炎n n急性复发性胰腺炎 n n慢性复发性胰腺炎n n慢性胰腺炎慢性胰腺炎的分类1988年罗马分类1.慢性钙化性胰腺炎；2.慢性阻塞性胰腺炎3.慢性炎症性胰腺炎慢性胰腺炎的确诊标准（1a）腹部B超：胰腺组织内有胰石存在（1b）CT：胰腺内钙化，胰石存在（2）ERCP胰管不规则扩张、不均匀；主胰管部分或完全阻塞（3）

33、分泌试验 重碳酸盐胰酶分泌减少（4）组织学检查（5）导管上皮增生不典型增生、囊肿形成胰脂酶n n胰腺外分泌不足导致脂肪泻胰腺外分泌不足导致脂肪泻 n n慢性胰腺炎导致腹痛慢性胰腺炎导致腹痛Pancrelipase-Pharmacologyn n脂酶含量:the basis of product potency for relief of steatorrhean npH4不可逆性失活n nEnteric-coated tablet:the coat dissolved at pH 6.(Poor bioavailability)n nCoated microspheres in capsule

34、:affected by gastric empty of spheresSuggested Regimen for Pancreatic Enzyme Replacement1.Begin with a preparation providing a total of 1.Begin with a preparation providing a total of 20,000 to 40,000 lipase units per meal.20,000 to 40,000 lipase units per meal.2.Enteric-coated formulations work wel

35、l for control 2.Enteric-coated formulations work well for control or steatorrhea,but the nonenteric release protease or steatorrhea,but the nonenteric release protease better in the duodenum and are preferred for pain better in the duodenum and are preferred for pain control.control.3.The preparatio

36、n should be taken at the beginnning 3.The preparation should be taken at the beginnning of a meal or throughout the meal for mal-of a meal or throughout the meal for mal-absorption absorption 4.for pain control,a nighttime dose be given4.for pain control,a nighttime dose be givenSuggested Regimen fo

37、r Pancreatic Enzyme Replacement5.If nonenteric-coated enzymes are used and no 5.If nonenteric-coated enzymes are used and no clinical improvement occurs,add one 500 mg clinical improvement occurs,add one 500 mg tablet of SB before and after meals,and with any tablet of SB before and after meals,and

38、with any nighttime enzymes.nighttime enzymes.6.If there is still no improvement,consider:6.If there is still no improvement,consider:a.Adding a PPI or an H a.Adding a PPI or an H2 2-blcker-blcker b.Is the Dx correct?b.Is the Dx correct?c.Small-bowel bacteria overgrowth may be c.Small-bowel bacteria

39、overgrowth may be present present Pearls&Pitfall1.Tx.of stearorrhea is effective with high-lipase 1.Tx.of stearorrhea is effective with high-lipase microsphere preparations.microsphere preparations.2.Tx.for pain relief is best by traditional uncoated 2.Tx.for pain relief is best by traditional uncoa

40、ted preparation with high protease and attention to preparation with high protease and attention to good acid neutralization.good acid neutralization.3.Bioavailability of the uncoated is uncertain in 3.Bioavailability of the uncoated is uncertain in postgatrectomy due to rapid gastric emptypostgatre

41、ctomy due to rapid gastric empty4.Acid neutralization is important in cystic fibrosis.4.Acid neutralization is important in cystic fibrosis.Pearls&Pitfall5.A low-fat diet should be given for severe pancritic 5.A low-fat diet should be given for severe pancritic insufficiency,if steatorrea is not rev

42、ersed insufficiency,if steatorrea is not reversed completely by replacement completely by replacement 6.SB may make the coat dissolved prematurely6.SB may make the coat dissolved prematurely7.A high-fiber diet makes replacement less 7.A high-fiber diet makes replacement less effective.effective.8.Me

43、asuring Tx.response in 34 Wks later.8.Measuring Tx.response in 34 Wks later.Steatorrhea improve as malnutrition corrected.Steatorrhea improve as malnutrition corrected.Pearls&Pitfall9.The magnesium or calcium form soaps with free fatty acids worsening steatorrhea.10.Replacement regimen is a life-lon

44、g threrapy,No.of tablets,comliance and the cost should be considered.乳果糖LactuloseA synthetic disaccharide analogue of lactase acts as a laxative by stimulating colonic peristalsis.Lactulosen nThe most important measures in the management of hepatic encephalopathy are eliminating exogenous sources of

45、 ammonia by restricting dietary protein,controlling gastrointestinal bleeding ane reducing the number of ammonia-producing enteric bacteria.LactuloseMechnismn nIt is hydrolyzed into galactose and fructose by bacteria in colon.The monosaccharides breakdown to hydrogen,lactate,and short free acids.n n

46、Acids enhanced colonic acidification,stimulated motility,inhibited coliform growth and ammonia production and increased fecal ammonia secretion.Lactulosen nDosage&Administration1.3040 ml 3/d ,dosage may be adjusted so that patient produces two or three soft stool per day.2.Enema retention:300 ml lac

47、tulose with 700 ml water or NS is gaven per rectum and held at least 20 mins.LactulosenSide Effects Gaseousness,abdominal distention,flatulence,belching,and abdominal cramping.Pearls&Pitfalln nOther measurement s should be includedn nRetention enema may be used for patients at risk of aspiration fro

48、m CNS abnormality.n nThe addition of neomycin may benefit those who continues manifest CNS changes.n nHypokalemia&hypernatremia was noted in chronic use.n nCautious usage in DM.Antidiarrheal AgentsAntidiarrheal AgentsKaolin&Pectinn nNonspecific absorbentNonspecific absorbentn nOnly subjective benefi

49、t in diarrheaOnly subjective benefit in diarrhean nNot used in intestinal obstruction or kid 3yearsNot used in intestinal obstruction or kid 3yearsn nAbsorbing concomitant medicationAbsorbing concomitant medicationn nElectrolytes disorder sould be noticedElectrolytes disorder sould be noticedn nPect

50、in(to be dietary fiber)shows inprovement of Pectin(to be dietary fiber)shows inprovement of blood sugar in DMblood sugar in DMLoperamiden nA synthetic antidiarrheal narcotic analogue,agonist activity on gut-associated mu-opiate receptorn nAntisecretory and prolonging gut transitn nDecreasing water&e