1. CLINICAL PHARMACY inCLINICAL PHARMACY in
GASTROENTEROLOGYGASTROENTEROLOGY

2. Digestive diseasesDigestive diseases
All diseases that pertain to theAll diseases that pertain to the
gastrointestinal tractgastrointestinal tract are labelled asare labelled as
digestive diseasesdigestive diseases . This includes. This includes
diseases of thediseases of the esophagusesophagus,, stomachstomach, first,, first,
second and third part of thesecond and third part of the duodenumduodenum,,
jejunumjejunum,, ileumileum, the ileo-cecal complex,, the ileo-cecal complex,
large intestine (ascending, transverse andlarge intestine (ascending, transverse and
descending colon) sigmoid colon anddescending colon) sigmoid colon and
rectum.rectum.

3. GastritisGastritis
Gastritis means inflamation of the stomach. It means that white bloodGastritis means inflamation of the stomach. It means that white blood
cells move into the wall of the stomach as a response to some typecells move into the wall of the stomach as a response to some type
of injury. Gastritis does not mean that there is an ulcer or cancer. Itof injury. Gastritis does not mean that there is an ulcer or cancer. It
is simply inflammation–either acute or chronic. What are the causesis simply inflammation–either acute or chronic. What are the causes
of gastritis?of gastritis?
Helicobacter PyloriHelicobacter Pylori
 This is the name of a bacteria that has learned to live in the thickThis is the name of a bacteria that has learned to live in the thick
mucous lining of the stomach. Although it doesn't actually infect themucous lining of the stomach. Although it doesn't actually infect the
underlying tissue, it does result in acute and chronic inflammation. Itunderlying tissue, it does result in acute and chronic inflammation. It
probably occurs early in childhood and remains throughout lifeprobably occurs early in childhood and remains throughout life
unless antibiotics cure it. The infection can lead to ulcers and, inunless antibiotics cure it. The infection can lead to ulcers and, in
later life, even to stomach cancer in some people. Fortunately, therelater life, even to stomach cancer in some people. Fortunately, there
are now ways to make the diagnosis and treat this disorder.are now ways to make the diagnosis and treat this disorder.
Autoimmune Gastritis - Pernicious AnemiaAutoimmune Gastritis - Pernicious Anemia
 The stomach lining also may be attacked by the immuneThe stomach lining also may be attacked by the immune
system leading to loss of the stomach cells. This causessystem leading to loss of the stomach cells. This causes
acute and chronic inflammation which can result in aacute and chronic inflammation which can result in a
condition called pernicious anemia. The anemia occurscondition called pernicious anemia. The anemia occurs
because the body no longer can absorb vitamin B12 duebecause the body no longer can absorb vitamin B12 due
to a lack of a key stomach factor, destroyed by theto a lack of a key stomach factor, destroyed by the
chronic inflammation. Stomach cancer can even occurchronic inflammation. Stomach cancer can even occur
later in life.later in life.

4. GastritisGastritis
Aspirin & NSAID GastritisAspirin & NSAID Gastritis
 NSAID stands for non-steroidal anti-inflammatory drug.NSAID stands for non-steroidal anti-inflammatory drug.
These are arthritis and pain relievers and include theThese are arthritis and pain relievers and include the
over-the-counter drugs Advil, Naprosyn, Motrin andover-the-counter drugs Advil, Naprosyn, Motrin and
ibuprofen as well as many prescription arthritis medicinesibuprofen as well as many prescription arthritis medicines
such as Voltaren, Feldene, Lodine and Relafen. Alongsuch as Voltaren, Feldene, Lodine and Relafen. Along
with aspirin, they reduce a protective substance in thewith aspirin, they reduce a protective substance in the
stomach called prostaglandin. These drugs usually causestomach called prostaglandin. These drugs usually cause
no problems when taken for the short-term. However,no problems when taken for the short-term. However,
regular use can lead to a gastritis as well as a moreregular use can lead to a gastritis as well as a more
serious ulcer condition.serious ulcer condition.
AlcoholAlcohol
 Alcohol and certain other chemicals can causeAlcohol and certain other chemicals can cause
inflammation and injury to the stomach. This is strictlyinflammation and injury to the stomach. This is strictly
dose related in that a lot of alcohol is usually needed todose related in that a lot of alcohol is usually needed to
cause gastritis. Social or occasional alcohol use is notcause gastritis. Social or occasional alcohol use is not
damaging to the stomach although alcohol does stimulatedamaging to the stomach although alcohol does stimulate
the stomach to make acid.the stomach to make acid.

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6. Gastritis (cont’d)Gastritis (cont’d)
Hypertrophic GastritisHypertrophic Gastritis
 At times, the folds in the stomach willAt times, the folds in the stomach will
become enlarged and swollen along withbecome enlarged and swollen along with
the inflammation. There is not a great dealthe inflammation. There is not a great deal
known about why this occurs. A variationknown about why this occurs. A variation
of this type of gastritis is called Ménétrier'sof this type of gastritis is called Ménétrier's
disease where the gastric folds becomedisease where the gastric folds become
gigantic. With this condition, there is oftengigantic. With this condition, there is often
protein loss into the stomach from theseprotein loss into the stomach from these
weeping folds.weeping folds.

7. Gastritis (cont’d)Gastritis (cont’d)
SymptomsSymptoms
 The symptoms of gastritis depend on how acute it is andThe symptoms of gastritis depend on how acute it is and
how long it has been present. In the acute phase, therehow long it has been present. In the acute phase, there
may be pain or gnawing in the upper abdomen, nauseamay be pain or gnawing in the upper abdomen, nausea
and vomiting. In the chronic phase, the pain may be dulland vomiting. In the chronic phase, the pain may be dull
and there may be loss of appetite with a feeling ofand there may be loss of appetite with a feeling of
fullness after several bites of food. Very often, there arefullness after several bites of food. Very often, there are
no symptoms at all. If the pain is severe, there may beno symptoms at all. If the pain is severe, there may be
an ulcer as well as gastritis.an ulcer as well as gastritis.
TreatmentTreatment
 The treatment of gastritis will depend on its cause. ForThe treatment of gastritis will depend on its cause. For
most types of gastritis, reduction of stomach acid bymost types of gastritis, reduction of stomach acid by
medication is often helpful. Beyond that, a specificmedication is often helpful. Beyond that, a specific
diagnosis needs to be made. Antibiotics are used fordiagnosis needs to be made. Antibiotics are used for
infection. Elimination of aspirin, NSAIDs or alcohol isinfection. Elimination of aspirin, NSAIDs or alcohol is
indicated when one of these is the problem. For theindicated when one of these is the problem. For the
more unusual types of gastritis, other treatments may bemore unusual types of gastritis, other treatments may be
needed.needed.

9. Peptic ulcer disease (PUD) is a very common ailment,Peptic ulcer disease (PUD) is a very common ailment,
affecting one out of eight persons in the United States. Theaffecting one out of eight persons in the United States. The
causes of PUD have gradually become clear. With thiscauses of PUD have gradually become clear. With this
understanding have come new and better ways to treatunderstanding have come new and better ways to treat
ulcers and even cure themulcers and even cure them

10. PEPTIC ULCER DISEASEPEPTIC ULCER DISEASE
Helicobacter pylori (H. pylori)Helicobacter pylori (H. pylori)
 This funny-sounding name identifies the basic cause of most pepticThis funny-sounding name identifies the basic cause of most peptic
ulcers, excluding those caused by aspirin or arthritis drugs. Thisulcers, excluding those caused by aspirin or arthritis drugs. This
bacteria has a twisted spiral shape and infects the mucous layerbacteria has a twisted spiral shape and infects the mucous layer
lining of the stomach. This infection produces an inflammation in thelining of the stomach. This infection produces an inflammation in the
stomach wall called gastritis. The body even develops a proteinstomach wall called gastritis. The body even develops a protein
antibody in the blood against it. The bacteria is probably acquiredantibody in the blood against it. The bacteria is probably acquired
from contaminated food or from a drinking glass. It ims only after H.from contaminated food or from a drinking glass. It ims only after H.
pylori bacteria injure the protective mucous layer of the stomach,pylori bacteria injure the protective mucous layer of the stomach,
allowing damage by stomach acid, that an ulcer develops.allowing damage by stomach acid, that an ulcer develops.
Arthritis medications include ibuprofen (Advil), Feldene, Naprosyn,Arthritis medications include ibuprofen (Advil), Feldene, Naprosyn,
Voltaren, Indocin, Aleve, Lodine, and many others. As with aspirin,Voltaren, Indocin, Aleve, Lodine, and many others. As with aspirin,
they can damage the mucous layer of the stomach, after which thethey can damage the mucous layer of the stomach, after which the
stomach acid causes the final injury.stomach acid causes the final injury.
So, H. pylori and certain drugs are the two major factors that causeSo, H. pylori and certain drugs are the two major factors that cause
ulcers. In rare cases, a patient will produce very large amounts ofulcers. In rare cases, a patient will produce very large amounts of
acid and develop ulcers. This condition is called Zollinger -Ellisonacid and develop ulcers. This condition is called Zollinger -Ellison
syndrome. Finally, some people get ulcers for unknown reasons.syndrome. Finally, some people get ulcers for unknown reasons.

11. PEPTIC ULCER DISEASEPEPTIC ULCER DISEASE
SymptomsSymptoms
Ulcers cause gnawing, burning pain in the upper abdomen.Ulcers cause gnawing, burning pain in the upper abdomen.
These symptoms frequently occur several hoursThese symptoms frequently occur several hours
following a meal, after the food leaves the stomach butfollowing a meal, after the food leaves the stomach but
while acid production is still high. The burning sensationwhile acid production is still high. The burning sensation
can occur during the night and be so extreme as to wakecan occur during the night and be so extreme as to wake
the patient. Instead of pain, some patients experiencethe patient. Instead of pain, some patients experience
intense hunger or bloating. Antacids and milk usuallyintense hunger or bloating. Antacids and milk usually
give temporary relief. Other patients have no pain butgive temporary relief. Other patients have no pain but
have black stools, indicating that the ulcer is bleeding.have black stools, indicating that the ulcer is bleeding.
Bleeding is a very serious complication of ulcers.Bleeding is a very serious complication of ulcers.

12. PEPTIC ULCER DISEASEPEPTIC ULCER DISEASE
Therapy of PUD has undergone profound changes. There areTherapy of PUD has undergone profound changes. There are
now available very effective medications to supress and almostnow available very effective medications to supress and almost
eliminate the outpouring of stomach acid. These acid-suppresssingeliminate the outpouring of stomach acid. These acid-suppresssing
drugs have been dramatically effective in relieving symptoms anddrugs have been dramatically effective in relieving symptoms and
allowing ulcers to heal. If an ulcer has been caused by aspirin or anallowing ulcers to heal. If an ulcer has been caused by aspirin or an
arthritis drug, then no subsequent treatment is usually needed.arthritis drug, then no subsequent treatment is usually needed.
Avoiding these latter drugs, should prevent ulcer recurrence.Avoiding these latter drugs, should prevent ulcer recurrence.
The second major change in PUD treatment has been the discoveryThe second major change in PUD treatment has been the discovery
of the H. pylori infection. When this infection is treated withof the H. pylori infection. When this infection is treated with
antibiotics, the infection, and the ulcer, do not come back.antibiotics, the infection, and the ulcer, do not come back.
Increasingly, physicians are not just suppressing the ulcer with acid-Increasingly, physicians are not just suppressing the ulcer with acid-
reducing drugs, but they are also curing the underlying ulcerreducing drugs, but they are also curing the underlying ulcer
problem by getting rid of the bacterial infection. If this infection is notproblem by getting rid of the bacterial infection. If this infection is not
treated, the ulcers invariably recur.treated, the ulcers invariably recur.
There are a number of antibiotic programs available to treat H. pyloriThere are a number of antibiotic programs available to treat H. pylori
and cure ulcers. Working with the patient, the physician will selectand cure ulcers. Working with the patient, the physician will select
the best treatment program availablethe best treatment program available

13. Treatment of peptic ulcerTreatment of peptic ulcer
 Antimicrobial agents (tetracycline, bismuth subsalicylate, andAntimicrobial agents (tetracycline, bismuth subsalicylate, and
metronidazole) to eradicatemetronidazole) to eradicate H. pyloriH. pylori infectioninfection
 Misoprostol (a prostaglandin analog) to inhibit gastric acidMisoprostol (a prostaglandin analog) to inhibit gastric acid
secretion and increase carbonate and mucus production, tosecretion and increase carbonate and mucus production, to
protect the stomach liningprotect the stomach lining
 Antacids to neutralize acid gastric contents by elevating theAntacids to neutralize acid gastric contents by elevating the
gastric pH, thus protecting the mucosa and relieving paingastric pH, thus protecting the mucosa and relieving pain
 Avoidance of caffeine and alcohol to avoid stimulation of gastricAvoidance of caffeine and alcohol to avoid stimulation of gastric
acid secretionacid secretion
 Anticholinergic drugs to inhibit the effect of the vagal nerve onAnticholinergic drugs to inhibit the effect of the vagal nerve on
acid-secreting cellsacid-secreting cells
 H2 blockers to reduce acid secretionH2 blockers to reduce acid secretion
 Sucralfate, mucosal protectant to form an acid-impermeableSucralfate, mucosal protectant to form an acid-impermeable
membrane that adheres to the mucous membrane and alsomembrane that adheres to the mucous membrane and also
accelerates mucus productionaccelerates mucus production
 Dietary therapy with small infrequent meals and avoidance ofDietary therapy with small infrequent meals and avoidance of
eating before bedtime to neutralize gastric contentseating before bedtime to neutralize gastric contents
 Insertion of a nasogastric tube (in instances of gastrointestinalInsertion of a nasogastric tube (in instances of gastrointestinal
bleeding) for gastric decompression and rest, and also tobleeding) for gastric decompression and rest, and also to
permit iced saline lavage that may also contain norepinephrinepermit iced saline lavage that may also contain norepinephrine
 Gastroscopy to allow visualization of the bleeding site andGastroscopy to allow visualization of the bleeding site and
coagulation by laser or cautery to control bleedingcoagulation by laser or cautery to control bleeding
 Surgery to repair perforation or treat unresponsiveness toSurgery to repair perforation or treat unresponsiveness to
conservative treatment, and suspected malignancy.conservative treatment, and suspected malignancy.

14. Ranitidine (Ranitidin)
Forms of production: 0,15 g and 0,3 g tablets and ampoules with 2 ml of
2,5 % solution.

15. RECOMMENDATIONS OF
HELICOBACTER PYLORI ERADICATION
• omeprazole 20mg
• amoxicillin 1000mg
• clarithromycin 500mg, all twice daily for 7 days.
• An alternative regimen with a similar eradication
rate of around 90% is:
• omeprazole 20mg
• clarithromycin 250mg
• metronidazole 400mg, again all twice daily for 7
days.

17. A typical quadruple therapyA typical quadruple therapy
 a PPI twice a daya PPI twice a day
 bismuth 120 mg four times a daybismuth 120 mg four times a day
 metronidazole 400 mg three times a daymetronidazole 400 mg three times a day
 oxytetracyclineoxytetracycline 500 mg four times a day, all500 mg four times a day, all
for 7 days.for 7 days.

18. Ulcers associated with NSAIDsUlcers associated with NSAIDs
 omeprazole 20mg daily is preferable toomeprazole 20mg daily is preferable to ranitidineranitidine 150mg150mg
twice daily as the respective rates of healing are 80% andtwice daily as the respective rates of healing are 80% and
63%.63%.
 H2RAs are slow to heal the ulcers if the offending drug isH2RAs are slow to heal the ulcers if the offending drug is
not stopped and so, under these conditions, a PPI isnot stopped and so, under these conditions, a PPI is
preferred.preferred.
 H pylori eradication is no more effective than omeprazoleH pylori eradication is no more effective than omeprazole
alone to heal ulcers, but if the infection is present, thenalone to heal ulcers, but if the infection is present, then
eradication will reduce the rate of relapse.eradication will reduce the rate of relapse.
 H pylori is not associated with an increased risk of ulcerH pylori is not associated with an increased risk of ulcer
with NSAIDs in the elderly but there is an increased risk ofwith NSAIDs in the elderly but there is an increased risk of
bleeding.bleeding.

19. MotiliumMotilium
Form of production: 0,01 g tabletsForm of production: 0,01 g tablets

20. LAXATIVES AND CATHARTICSLAXATIVES AND CATHARTICS
ConstipationConstipation can be definedcan be defined
as infrequent or hard pelletas infrequent or hard pellet
stools, or difficulty instools, or difficulty in
evacuating stool. Passingevacuating stool. Passing
one or more soft, bulkyone or more soft, bulky
stools every day is astools every day is a
desirable goal. Whiledesirable goal. While
troublesome, constipation istroublesome, constipation is
not usually a seriousnot usually a serious
disorder. However, theredisorder. However, there
may be other underlyingmay be other underlying
problems causingproblems causing
constipation and, therefore,constipation and, therefore,
testing is oftentesting is often
recommended.recommended.

21. ConstipationConstipation
 Constipation is often caused by a lazy colon that does notConstipation is often caused by a lazy colon that does not
contract properly and fails to move the stool to the rectum.contract properly and fails to move the stool to the rectum.
The colon also can become spastic and remain contractedThe colon also can become spastic and remain contracted
for a prolonged time. In this case, stool cannot move along.for a prolonged time. In this case, stool cannot move along.
Too much water is absorbed and hard pellet-like stoolToo much water is absorbed and hard pellet-like stool
develops. Constipation also can result from a mechanicaldevelops. Constipation also can result from a mechanical
obstruction, such as tumors or advanced diverticulosis, aobstruction, such as tumors or advanced diverticulosis, a
disorder which can distort and narrow the lower-left colon.disorder which can distort and narrow the lower-left colon.
Other conditions that can produce a sluggish, poorlyOther conditions that can produce a sluggish, poorly
contracting bowel include: pregnancy, certain drugs, thyroidcontracting bowel include: pregnancy, certain drugs, thyroid
hormone deficiency, the chronic abuse of laxatives, travel,hormone deficiency, the chronic abuse of laxatives, travel,
and stress.and stress.

23. Indications for UseIndications for Use
 1. To relieve constipation in pregnant women, elderly clients1. To relieve constipation in pregnant women, elderly clients
whose abdominal and perineal muscles have become weak andwhose abdominal and perineal muscles have become weak and
atrophied, children with megacolon, and clients receivingatrophied, children with megacolon, and clients receiving
drugs that decrease intestinal motility (eg, opioid analgesics,drugs that decrease intestinal motility (eg, opioid analgesics,
drugs with anticholinergic effects)drugs with anticholinergic effects)
 2. To prevent straining at stool in clients with coronary artery2. To prevent straining at stool in clients with coronary artery
disease (eg, postmyocardial infarction), hypertension,disease (eg, postmyocardial infarction), hypertension,
cerebrovascular disease, and hemorrhoids and other rectalcerebrovascular disease, and hemorrhoids and other rectal
conditionsconditions
 3. To empty the bowel in preparation for bowel surgery or3. To empty the bowel in preparation for bowel surgery or
diagnostic procedures (eg, colonoscopy, barium enema)diagnostic procedures (eg, colonoscopy, barium enema)
 4. To accelerate elimination of potentially toxic substances4. To accelerate elimination of potentially toxic substances
from the GI tract (eg, orally ingested drugs or toxicfrom the GI tract (eg, orally ingested drugs or toxic
compounds)compounds)
 5. To prevent absorption of intestinal ammonia in clients with5. To prevent absorption of intestinal ammonia in clients with
hepatic encephalopathyhepatic encephalopathy
 6. To obtain a stool specimen for parasitologic examination6. To obtain a stool specimen for parasitologic examination
 7. To accelerate excretion of parasites after anthelmintic drugs7. To accelerate excretion of parasites after anthelmintic drugs
have been administeredhave been administered
 8. To reduce serum cholesterol levels (psyllium products)8. To reduce serum cholesterol levels (psyllium products)

24. LaxativesLaxatives
There are two main types of laxatives:There are two main types of laxatives:
stimulants (chemical)stimulants (chemical) andand saline (liquid or salt).saline (liquid or salt).
They occasionally help temporary constipationThey occasionally help temporary constipation
problems. However, chronic use of laxatives,problems. However, chronic use of laxatives,
especially stimulant laxatives is discouragedespecially stimulant laxatives is discouraged
because the bowel becomes dependent uponbecause the bowel becomes dependent upon
them. Bowel regularity should occur withoutthem. Bowel regularity should occur without
laxatives.laxatives. An occasional enema is preferrable overAn occasional enema is preferrable over
the chronic use of laxatives.the chronic use of laxatives.

25. Contraindications to UseContraindications to Use
Laxatives and cathartics should not be used inLaxatives and cathartics should not be used in
the presence of undiagnosed abdominal pain. Thethe presence of undiagnosed abdominal pain. The
danger is that the drugs may cause an inflameddanger is that the drugs may cause an inflamed
organ (eg, the appendix) to rupture and spill GIorgan (eg, the appendix) to rupture and spill GI
contents into the abdominal cavity with subsequentcontents into the abdominal cavity with subsequent
peritonitis, a life-threatening condition. Oral drugsperitonitis, a life-threatening condition. Oral drugs
also are contraindicated with intestinal obstructionalso are contraindicated with intestinal obstruction
and fecal impaction.and fecal impaction.

26. DietDiet
The following foods should be eaten daily inThe following foods should be eaten daily in
adequate amountsadequate amounts
Whole grain breads (whole wheat)Whole grain breads (whole wheat)
Bran cerealsBran cereals
 VegetablesVegetables -- Root (potatoes, carrots, turnips), leafy green (lettuce, celery,-- Root (potatoes, carrots, turnips), leafy green (lettuce, celery,
spinach), or cooked high residue (cabbage)spinach), or cooked high residue (cabbage)
 FruitFruit -- Cooked or stewed (prunes, applesauce) or fresh fruit (skin and pulp)-- Cooked or stewed (prunes, applesauce) or fresh fruit (skin and pulp)
 Bulking AgentsBulking Agents -- Fiber is the undigested part of plant food that passes into-- Fiber is the undigested part of plant food that passes into
the colon. Certain types of fiber can absorb and hold large amounts of water.the colon. Certain types of fiber can absorb and hold large amounts of water.
This, in turn, results in a larger, bulkier stool which is soft and easier to pass.This, in turn, results in a larger, bulkier stool which is soft and easier to pass.
Adequate fiber in food or from supplements is recommended daily. This type ofAdequate fiber in food or from supplements is recommended daily. This type of
water-retaining fiber generally is easily obtained each day by one of thewater-retaining fiber generally is easily obtained each day by one of the
following:following:
 Food branFood bran -- This is available as wheat, oat or rice bran. Processing of wheat-- This is available as wheat, oat or rice bran. Processing of wheat
and other grains removes this valuable fiberous part of the food so theseand other grains removes this valuable fiberous part of the food so these
processed products should be avoided.processed products should be avoided.
 Psyllium branPsyllium bran -- The psyllium plant is remarkable because its ground seeds-- The psyllium plant is remarkable because its ground seeds
can retain so much water. This product is available as Metamucil, Konsyl,can retain so much water. This product is available as Metamucil, Konsyl,
Effersyllium, Per Diem Fiber, or the less expensive generic preparation in drugEffersyllium, Per Diem Fiber, or the less expensive generic preparation in drug
and health food stores. Although labeled a laxative, it really is not a laxative.and health food stores. Although labeled a laxative, it really is not a laxative.
 MethylcelluloseMethylcellulose -- This is another fiber derived from wood which also retains-- This is another fiber derived from wood which also retains
water. It is available as Citrucel.water. It is available as Citrucel.

27. Antidiarrheals

28. Antidiarrheal drugs are indicated in the following
circumstances:
• 1. Severe or prolonged diarrhea (>2 to 3 days), to prevent
severe fluid and electrolyte loss
• 2. Relatively severe diarrhea in young children and older adults.
These groups are less able to adapt to fluid and electrolyte
losses.
• 3. In chronic inflammatory diseases of the bowel (ulcerative
colitis and Crohn’s disease), to allow a more nearly normal
lifestyle
• 4. In ileostomies or surgical excision of portions of the ileum,
to decrease fluidity and volume of stool
• 5. HIV/AIDS-associated diarrhea
• 6. When specific causes of diarrhea have been determined

29. Contraindications to UseContraindications to Use
Contraindications to the use of antidiarrheal drugsContraindications to the use of antidiarrheal drugs
include diarrhea caused by toxic materials,include diarrhea caused by toxic materials,
microorganisms that penetrate intestinal mucosa (eg,microorganisms that penetrate intestinal mucosa (eg,
pathogenicpathogenic E. coli, Salmonella, ShigellaE. coli, Salmonella, Shigella), or antibiotic-), or antibiotic-
associated colitis. In these circumstances, antidiarrhealassociated colitis. In these circumstances, antidiarrheal
agents that slow peristalsis may aggravate and prolongagents that slow peristalsis may aggravate and prolong
diarrhea. Opiates (morphine, codeine) usually arediarrhea. Opiates (morphine, codeine) usually are
contraindicated in chronic diarrhea because of possiblecontraindicated in chronic diarrhea because of possible
opiate dependence. Difenoxin, diphenoxylate, andopiate dependence. Difenoxin, diphenoxylate, and
loperamide are contraindicated in children younger thanloperamide are contraindicated in children younger than
2 years of age.2 years of age.