PHARMACY PRACTICE
II
MAHASEN A. RADWAN, PH.D.
PROFESSOR OF CLINICAL
PHARMACY
DEPARTMENT OF PHARMACEUTICS

• INTRODUCTION
• INTESTINAL GAS DISCOMFORT
• LACTOSE INTOLERANCE

VI. GAS DISCOMFORT
Bloating And Flatulence

DEFINITION
• Intestinal gas, or air in the digestive tract, is usually not noticed
until we burp or pass it rectally (flatulence).
• The entire digestive tract, from the stomach to the rectum,
contains intestinal gas as the natural consequence of swallowing
and digestion.
• Bloating and flatulence are two of the most common complain.
Bloating could be due to
• Excess intestinal gas
• Abdominal swelling from other serious disease (Colon Cancer)
• Excessive intestinal gas sometimes indicates a digestive disorder,
but everyone passes gas several times daily, and occasional
burping or belching is normal

DEFINITION ……
• Excess upper intestinal gas can result from
swallowing more than a usual amount of
air, overeating, smoking or chewing gum.
• Excess lower intestinal gas can be caused
by eating too much of certain foods, by the
inability to fully digest certain foods or by a
disruption in the bacteria normally found in
the colon.

SOURCES OF GAS
1. Swallowed air (oxygen , nitrogen)
2. Bicarbonate neutralization of stomach acids
(carbon dioxide)
3. Gas diffusion from blood to intestine
4. Bacterial fermentation produces hydrogen,
carbon dioxide & methane as by-products

ETIOLOGY
I. Medical Conditions
II. Medications
III. Sensitivity To Gas
Movement
IV. Food
V. Sweeteners

ETIOLOGY….
I. Medical Conditions
1. lactose intolerance & other food allergies/
intolerance lead to flatulence, usually coupled
with diarrhea & GI complaints
2. Irritable bowel syndrome (Abdominal distention
and excess flatus
3. Subacute intestinal obstruction, a medical
emergency

ETIOLOGY….
I. Medical Conditions…..
4. Giardiasis , Cholelithiasis & Peptic ulcer
5. Malabsorption syndrome allows
unabsorbed nutrients to pass through
intestine and bacterial fermentation
occurs with excess gas production

ETIOLOGY….
II. Medications
1. Bulk laxative containing fermentable
carbohydrates e.g. psyllium
2. R/ medications: Certain Abs (Cephalexin ,
Parenteral piperacillin) , NSAIDs , quinolones
(ciprofloxacin , norfloxacin) , nicotine gum ,
lactulose & cholestyramine

ETIOLOGY….
III. Sensitivity To Gas Movement
Normally average individual has ≤10-200
ml gas in stomach and colon at any time.
Patients may have normal amount of
stomach & colon gases but rectum is
abnormally sensitive to this amount
leading to retrograde movement of gas.

ETIOLOGY…. IV. Food
• Foods that cause gas in one person might not cause it
in another.
• Foods such as legumes contain indigestible
oligosaccharides raffinose, stachyose & verbascose
transfer to colon & bacterial fermentation occurs with
gas production as by-product .
• Common gas-producing foods and substances
include:
• Beans and lentils
• Vegetables such as cabbage, broccoli, cauliflower,
and brussels sprouts (cruciferous vegetables),
• Cereals and grain products like Bran, barley, wheat

ETIOLOGY…. IV.
Food…..
• Fructose, which is found in some fruits and used
as a sweetener in soft drinks and other products
• Sorbitol, a sugar substitute found in some sugar-
free candies, gums and artificial sweeteners
• Carbonated beverages, such as soda or beer
• Fatty foods also lead to flatulence as they
decrease GIT motility & give chance for bacterial
fermentation

ETIOLOGY…. V.
Sweeteners
Sweeteners such as fructose, sorbitol &
mannitol are poorly absorbed so they
can lead to flatulence & diarrhea.

Complications of bloating and
Intestinal GAS
•For most patients bloating presents only a minor
discomfort while flatulence is Socially
embarrassing, but nothing more.
• Fear of passing gas – withdraw from social
contact and give up lucrative careers.
•Increase risk of mechanical bowel obstruction,
gut necrosis or perforation
•An increase in the pressure of ambient air can
cause trapped gas to expand, known as “Trapped

Treatment of bloating and Intestinal
GAS
1. Non Pharmacological Therapy
•Lifestyle modification
1. Avoid chewing gums
2. Avoid smoking
3. Patient with lactose intolerance should avoid lactose
containing foods or take lactase enzyme with these
foods
4. Avoid carbonated beverages (soft drinks & beer)
5. Avoid rapid eating
6. Masticate food well
7. Remain upright several hours after meal

Treatment of bloating and Intestinal
GAS
2. Pharmacological OTC Therapy
1.Carminatives
2.Alpha-galactosidase
3.Simethicone
4.Activated Charcoal

Treatment of bloating and Intestinal
GAS
2. Pharmacological OTC Therapy ….
1.Carminatives
• Such as peppermint reduce flatulence
• Reduce pressure of lower esophageal
sphincter so allow patient to belch
• They can worsen the problem of
gastroesophageal reflux:
• Don’t prevent excessive gas
• Don’t easing the gas passage through GI

Treatment of bloating and Intestinal
GAS
2. Pharmacological OTC Therapy ….
2. Alpha-galactosidase
• Beano tablets or liquid contain alpha
galactosidase which degrades
oligosaccharides into digestible sugars
(sucrose and glucose)
• Tablets are taken after first bite of food
• It is affected by heat so hot food should be
cooled

Treatment of bloating and Intestinal GAS
2. Pharmacological OTC Therapy ….
3. Simethicone
• It is a defoaming agent
• It was used in endoscopic procedure to clear small bubbles
that obscured the visual field when bile mixed with infused
air.
• Hypothesis: It might alter the elasticity of interfaces of
mucus embedded bubbles in the GI tract, allowing the gas
bubbles to coalesce.
• Gas becomes more easily eliminated as belching or flatus
• The only antiflatulent!! recognized by the FDA as safe and
effective with no ADE (No absorption from GI)
• It is used at any age
• It relives symptoms of bloating pressure, fullness, or
stuffed feeling caused by gas by facilitating the passage of
gas through the GI tract, allowing the patient to more

Treatment of bloating and Intestinal GAS
2. Pharmacological OTC Therapy ….
4. Activated Charcoal
• It is used to reduce frequency of flatus events
and to improve symptoms of gaseousness.
• It is not approved by FDA.
• It can be found in combination with
simethicone (Also not FDA approved).

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Thank You

LACTOSE INTOLERANCE
(LI)
MAHASEN A. RADWAN, PH.D.
PROFESSOR OF CLINICAL
PHARMACY
DEPARTMENT OF
PHARMACEUTICS

LACTOSE INTOLERANCE (LI)
(Hypolactasia) / Lactose deficiency
What is lactose?
• Lactose is a unique carbohydrate found in the
milk of most mammals.
• The small intestine produces an enzyme
called lactase.
• Lactase breaks down (hydrolysis) lactose in
milk or dairy products into two simpler forms
(monosaccharides) of sugar: glucose and
galactose.
• The body absorbs these simpler sugars into

WHAT IS LACTOSE INTOLERANCE?
• It indicates low lactase activity in the brush
boarder membrane of the small intestine
(The outer most layer of the small
intestine epithelium, composed of many
microvilli) specially in the microvillus
membrane
• It is a condition in which people have
digestive symptoms (bloating, diarrhea,
and gas) after eating or drinking milk or
milk products.
• Lactase deficiency and lactose
malabsorption may lead to lactose
intolerance:

WHAT IS LACTOSE INTOLERANCE?
• Lactose malabsorption. Lactase deficiency
may cause lactose malabsorption.
• In lactose malabsorption, undigested lactose
passes to the colon.
• The colon, part of the large intestine, absorbs
water from stool and changes it from a liquid
to a solid form.
• In the colon, bacteria break down undigested
lactose and create fluid and gas.
• Not all people with lactase deficiency and
lactose malabsorption have digestive
symptoms.

How much lactose can a person with lactose
intolerance have?
•Most people with lactose intolerance can tolerate some amount of lactose
in their diet and do not need to avoid milk or milk products completely.
•Avoiding milk and dairy products altogether may cause people to take in
less calcium and vitamin D than they need.
•Individuals vary in the amount of lactose they can tolerate (inter-
individual variability.
•A variety of factors—including how much lactase the small intestine
produces
•Other people can easily eat yogurt and hard cheeses such as cheddar
and swiss, while they are not able to eat or drink other dairy products
without having digestive symptoms.
•Research suggests that adults and adolescents with lactose malabsorption
could eat or drink at least 12 grams of lactose in one sitting without
symptoms or with only minor symptoms (1 cup of milk).

TYPES OF LI
Four types of lactase deficiency may lead to lactose
intolerance:
Primary lactase deficiency (lactase non persistence), is
the most common type of lactase deficiency (70%).
• In people with this condition, lactase production
declines over time. This decline often begins at about
age 2; however, the decline may begin later.
• Children who have lactase deficiency may not
experience symptoms of lactose intolerance until late
adolescence or adulthood.
• Researchers have discovered that some people inherit

TYPES OF LI ….
Secondary lactase deficiency results from injury to the
small intestine (acute gastroenteritis) . It occurs
secondary to various environmental problems:
1. Infection: Such as acute gastroenteritis, rotavirus,
invasion of parasites as hookworm or giardia
(damage villus architectures)
2. Medical conditions: Celiac disease (gluten
sensitivity), sprue syndrome, malnutrition
3. Surgery: Resection of small intestine leads to short
bowl syndrome & insufficient contact between
lactose & intestine
4. Drugs & alcohol: Some medications also contain
lactose as diluents e.g. tetracycline, cimetidine,

TYPES OF LI ….
Developmental lactase deficiency may occur in
infants born prematurely. This condition usually
lasts for only a short time after they are born.
Congenital lactase deficiency (Congenital
Alactasia) is an extremely rare disorder in which the
small intestine produces little or no lactase enzyme
from birth. Genes inherited from parents cause this
disorder.

Manifestations of LI
1. Abdominal pain , cramp
2. Diarrhea , nausea
3. Stomach rumbling
4. bloating, dyspepsia
5. Watery or frothy stool
6. Involuntary leakage of stool in
severe cases

TESTS AND DIAGNOSIS
Hydrogen breathe test
• This test measures the amount of hydrogen in a person’s
breath.
• Normally, only a small amount of hydrogen is detectable in the
breath when a person eats or drinks and digests lactose.
• Undigested lactose produces high levels of hydrogen.
• The patient drinks a beverage that contains a known amount of
lactose.
• A health care provider asks the patient to breathe into a
balloon-type container that measures breath hydrogen level.
• In most cases, a health care provider performs this test at a
hospital, on an outpatient basis.
• Smoking and some foods and medications may affect the
accuracy of the results.

TESTS AND DIAGNOSIS …..
Lactose tolerance test
• It measures your body's reaction to a liquid that contains high
levels of lactose.
• Two hours after drinking the liquid, you'll undergo blood tests to
measure the amount of glucose in your bloodstream.
• If your glucose level doesn't rise, it means your body isn't
properly digesting and absorbing the lactose-filled drink.
Stool acidity test
• Used for infants and children who can't undergo other tests
• The fermenting of undigested lactose creates lactic acid and
other acids that can be detected in a stool sample.

Differentiating LI from other medical conditions:
A. lactose intolerance versus milk allergy
• Milk allergy is a true food allergy caused by an allergic reaction to the
protein in milk.
• "Milk allergy” usually shows up early in life.
• Lactose intolerance is more common, takes longer to develop, and
can occur at any time of life."
• Lactose intolerance can be genetic, or it can be caused by damage to
the small intestine due to a viral or bacterial infection
• Lactose intolerance increases with age and is quite common in the
elderly
• Lactose intolerance symptoms are between 30 min and 2 h after
ingesting milk or a dairy food.
• The same symptoms are seen in both but the most differentiating
symptoms is vomiting within first hour of ingestion in Cow’s milk

Differentiating LI from other medical conditions:
….
B. Irritable bowl Syndrome (IBS)
• They have duplicate symptoms
• Exclude LI before the diagnosis of IBS

Complications of LI:
• Patient will lose important nutrients found in
lactose containing food such as phosphorous,
magnesium, calcium, vitamin A and D which
leads to poor skeletal growth and osteoporosis
• Pharmacist may suggest supplemental
Calcium for LI patients who on restrict milk
and dairy products intake.

TREATMENT GUIDELINES
• There's currently no way to increase the body's production
of lactase, but we can usually avoid the discomfort of
lactose intolerance.
• Many people can manage the symptoms of lactose
intolerance by changing their diet.
• Some people may only need to limit the amount of lactose
they eat or drink.
• Others may need to avoid lactose altogether.
1. Determination of lactose tolerance level
2. Non pharmacological treatment
3. Pharmacological treatment

DETERMINATION OF LACTOSE TOLERANCE
LEVEL
1. Prevent patient from taking foods,
drinks and medications containing
lactose for 3 weeks
2. Gradually increase lactose
containing products until
symptoms occur
3. Drop back to the previous amount

NON PHARMACOLOGICAL TREATMENT
Counsel the patient to:
1. Eat several small meals rather than large meals
2. Eat other food with lactose containing food to dilute
lactose & facilitate hydrolysis
3. Taking yogurt (fermented milk product) with other dairy
products
4. Use special lactose reduced milk products
5. Neither cultured milk (buttermilk) nor unfermented milk
containing lactobacillus acidophilus improves LI.

PHARMACOLOGICAL TREATMENT
1. Lactase enzyme medications that can be in liquid,
tablet / capsule form can be added to milk or taken
after first bite of lactose containing products
2. Calcium supplement for patients who are completely
restricted from taking milk and dairy products

41
Thank You