Gastrointestinal                                                                                    ...
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Gastrointestinal Disorders . Disorders of Nutrition. Alterations in: Ingesting Digesting Absorbing Eliminating. Anorexia Pica

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Disorders of nutrition l.jpg
Disorders of Nutrition Disorders

Alterations in: Ingesting Digesting Absorbing Eliminating


Ingestion l.jpg

Anorexia Disorders

Pica

Nausea & Nausea

Esophageal Atresia

Tracheoesopheal fistula

Cleft lip/palate

Anorexia Nervosa

Pyloric Stenosis

Projectile Vomiting

Ingestion


Maldigestion l.jpg
Maldigestion Disorders

  • Lactic Deficiency

  • Pancreatitis

  • Cystic Fibrosis


Malabsorption l.jpg
Malabsorption Disorders

  • Intestinal Parasites

  • Gastrectomy Loss of Stomach as Reservoir for Food Dumping Syndrome Loss of Intrinsic Factor

  • Celiac Disease (Sprue)

  • Cholecystitis/Cholelithiasis

  • Regional Enteritis (Crohn’s Disease)


Elimination l.jpg
Elimination Disorders

  • Diarrhea Osmotic Changes Secretory Changes Mucosal Damage Altered Motility

  • Crohn’s Disease

  • Ulcerative Colitis


Basic structure of the gi tract l.jpg
Basic Structure of the GI tract Disorders

PSNS

SNS

longitudinal

muscle

Myenteric

plexus

Circular muscle

Submucosal

plexus

Submucosa

Lumen


Enteric nervous system influenced by ans l.jpg
Enteric Nervous System Disorders Influenced by ANS

PSNS

SNS

Pelvic

nerves

NE

Ach

ENTERIC NERVOUS SYSTEM

Myenteric Submucosal

Smooth

muscle

Secretory

Cells

Endocrine

Cells

Blood

Vessels


Gastric motility l.jpg
Gastric Motility Disorders

LES

fundus

pylorus

receptive

relaxation

Antrum

approx 3 contractions

per minute


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Control of Gastric Emptying Disorders

PSNS

SNS

+

-

GASTRIC EMPTYING

-

-

secretin

-

CCK

Duodenal

acid

Duodenal

fats

Duodenal

hypertonicity


Small and large bowel motility l.jpg
Small and Large Bowel Motility Disorders

  • Small Intestine

    • 2-4 hours to traverse

    • Segmental contractions to mix

    • Peristaltic waves to move forward

  • Large Intestine

    • Slow progression at 5-10 cm per hour

    • Segmental contractions produce haustra

    • 1-3 mass movements per day


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Secretion in the Stomach Disorders

  • Parietal Cells

    • HCL

    • Intrinsic Factor

  • Chief Cells

    • Pepsinogen

  • Surface epithelia and mucous cells

    • HCO3- and mucus


Control of acid secretion l.jpg
Control of Acid Secretion Disorders

VagusMast CellsG cells

Ach Histamine Gastrin

muscarinic

receptor

H2 receptor

gastrin

receptor

Gastric Parietal Cell

Acid Secretion


Secretion in the small intestine l.jpg
Secretion in the Small Intestine Disorders

  • Secretions from Pancreas

    • HCO3-, Proteases, Lipases, Amylases

  • Secretion from Gallbladder

    • Bile acids, pigment, phospholipid

  • Secretions from intestinal epithelia

    • Brush border enzymes


Brush border enzymes l.jpg
Brush Border Enzymes Disorders

Lactase: lactose glucose, galactose

Sucrase: sucrose fructose, glucose

Dextrinase: cleaves amylose branch points

Glucoamylase: maltose glucoses

Only Monosaccharides are Absorbed


Digestion and absorption of proteins l.jpg
Digestion and Disorders Absorption of Proteins

  • Pepsin: 15% of peptide bonds broken

  • Pancreatic proteases

    • Trypsin

    • Chymotrypsin

    • Carboxypeptidases

  • Brush Border

    • Peptidases cleave into 1 to 4 aa chains


Digestion and absorption of fat l.jpg
Digestion and Absorption of Fat Disorders

  • Bile salts are amphipathic molecules that break up large fat globs into droplet

  • Lipase are water soluble - only work at surface of droplet

    • Triglycerides --------> FFA and glycerol

  • Bile forms micelles with FFA to keep soluble.

  • FFA are lipid soluble so absorb directly


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Reabsorption of Bile Disorders

  • Bile is reabsorbed at terminal ileum

  • Passive diffusion and active transport

  • Transported to liver via portal blood

  • ALL reabsorbed bile is taken up on first pass by liver

  • Entire bile pool circulates 2 to 5 times per meal. 5-10% lost per day in stool


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GI Disorders Disorders


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Dysphagia Disorders

  • Neuromuscular: pharynx

  • Stricture or tumor: Progressive solid food dysphagia

  • Achalasia: esophageal motility disorder, loss of peristalsis in lower 2/3 plus impaired LES relaxation

  • Mallory-Weiss syndrome: mucosal tears at distal esophagus, bleeding, pain


Oropharyngeal vs esophageal l.jpg

Nasal regurgitation Disorders

Airway obstruction with eating

Coughing when swallowing

Immediate regurgitation

Hoarse voice

No airway distress

Late regurgitation

Chest pain @ meals

Frequent heartburn

Presence of collagen disease

Presence of Left supraclavicular node

Oropharyngeal vs Esophageal


Dyspepsia l.jpg
Dyspepsia Disorders

  • Present with heartburn, indigestion, epigastric distress

  • Up to 2/3 will have no identifiable cause

  • One-half will have relief from placebo

  • Symptom profile does not differentiate between GERD, PUD, and non-ulcer dyspepsia (functional)

  • Physical exam is rarely helpful


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Diagnosis Disorders

  • NSAID: suspect PUD and treat

  • Helicobacter pylori: urea breath test or biopsy during endoscopy

  • GERD: Trial of H2 therapy

  • Functional: may improve with agents that increase motility

  • Zollinger-Ellison syndrome: gastrin level


Pud with h pylori l.jpg
PUD with H. pylori Disorders

  • H. pylori is nearly always a factor in non-NSAID peptic ulcer disease

  • Conventional therapy with H2 blockers or H+ pump inhibitors has a 75-80% one-year recurrence rate

  • Treatment for H. pylori reduced recurrence rate to less than 5%


Acute infectious diarrhea l.jpg
Acute Infectious Diarrhea Disorders

High fever?

Bloody diarrhea?

NO

YES

Noninflammatory

Inflammatory

watery

large volume

periumbilical

pain

small volume

LLQ pain

+ fecal leukocytes

Shigella, Salmonella,

C. difficile, E. coli (bad)

Campylobacter, HIV-

associated

Viral: rotavirus, Norwalk

S. aureus food poisoning

Giardia

Rehydrate, symptomatic

Culture and treat


Chronic diarrhea stool studies l.jpg
Chronic Diarrhea: Stool Studies Disorders

  • Stool Osmolality: normal gap < 50

  • Laxative screen: Mg, PO4, SO4

  • Fecal leukocytes: Inflammatory disease

  • Ova and parasites: Giardia, cryptosporidium

  • Fecal Fat analysis: > 10 g/24 hrs indicates malabsorption

  • Fecal weight: > 1000 g is secretory


Osmotic diarrhea lactase def l.jpg
Osmotic Diarrhea: Lactase Def. Disorders

  • Incidence

    • 90% of Asian Americans

    • 95% of Native Americans

    • 50% of Mexican Americans

    • 60% of Jewish Americans

    • 25% of other Caucasians

  • DX: empiric trial of lactose-free diet for two weeks


Inflammatory bowel disease l.jpg
Inflammatory Bowel Disease Disorders

  • Ulcerative Colitis

    • Involves only the colon and rectum

    • Mucosal layer is affected

    • Hallmark is bloody diarrhea and lower abdominal cramps

    • Associated with increased cancer risk after 8-10 years of disease


Assess uc disease severity l.jpg
Assess UC Disease Severity Disorders

  • Number of stools per day

  • Hematocrit

  • Sed rate

  • Albumin level


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Crohn Disease Disorders

  • Intermittent bouts of fever, diarrhea, and RLQ pain

  • May have RLQ mass, tenderness

  • Can affect any portion of GI tract

    • 30% are small bowel only

    • 50% are small and large bowel

    • 15-20% are large bowel only


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Crohn Disease Disorders

  • Transmural process in the intestinal wall predisposes to fistula formation

  • If suspected, obtain upper GI series with small bowel follow through plus either colonoscopy or barium enema

  • Suggestive findings are ulcerations, strictures, and fistulas

  • RX: stop smoking, drugs similar to UC


Compare and contrast cd uc l.jpg

Crohn’s Disease Disorders “Skip” Lesions (granulomatous) Terminal ileum Diarrhea/Constipation Alternates – Less Bloody Malignant Potential(not totally determined)

Proned to Develop Abcesses & Fistula formation

Ulcerative ColitisContinuous ulcerationof mucosa of colonColon, rectum – distalWatery diarrhea – has mucus/pus – may be bloody – commonProned to develop colon carcinomarare abcess/fistula formation

Compare and Contrast – CD & UC


Motility diarrhea ibs l.jpg
Motility Diarrhea: IBS Disorders

  • Irritable bowel syndrome is a chronic (>3months) functional disorder with no identifiable pathology

  • Fluctuations in stool frequency and consistency (no nocturnal diarrhea)

  • Perceived abd distention, bloating, pain

  • Often associated with anxiety or depression


Slide34 l.jpg
IBS Disorders

  • It is not IBS if fever, bloody stools, nocturnal diarrhea, or weight loss are present

  • Consider checking CBC, sed rate, albumin, and stool for occult blood to rule out inflammatory disease, consider lactose-free trial.

  • RX: restrict caffeine, gas producing food, high fiber. Rx depression


Occult gi bleeding l.jpg
Occult GI Bleeding Disorders

  • Detected by FOBT: worry colorectal CA

  • Indicated for iron deficiency anemia in males or postmenopausal females

  • Unless S&S suggest Upper GI etiology (heartburn, dyspepsia PUD) start with colonoscopy (or barium enema)

  • If no source, follow with endoscopy


Acute abdominal pain l.jpg
Acute Abdominal Pain Disorders

  • Tension: spasm, associated with intense peristalsis (irritant, infection, obstruction)

  • Ischemia: intense constant pain (bowel strangulation, volvulus adhesion)

  • Inflammation: first localized to serosa covering inflamed part then extends to abdominal wall causing reflex muscle spasms (rigidity, involuntary guarding)


Assessment of the pain l.jpg
Assessment of the Pain Disorders

  • Is it nongastric? consider aortic aneurysm, ectopic pregnancy, PID, kidney

  • Is it an acute surgical abdomen?

    • Involuntary guarding, rigidity

    • Absent bowel sounds

    • Is there shock


Localization of abdominal pain l.jpg
Localization of Abdominal Pain Disorders

  • Stomach, duodenum: mid epigastric

  • Small bowel: periumbilical

  • Colon: low abdomen, midline

  • Rectum: sacrum and perineum

  • Gallbladder: mid epigastric radiates to RUQ or right scapula

  • Pancreas: mid epigastric radiate to back

  • Appendix: RLQ, but variable


Bowel obstruction l.jpg
Bowel Obstruction Disorders

  • Presentation

    • Pain, distention, vomiting, obstipation

  • Evaluation

    • Flat and upright abdominal film

  • Small bowel: less urgent

    • intestinal tube, decompression

  • Large bowel: urgent, danger of cecal perf

    • immediate surgical consult


Types of bowel obstruction l.jpg

Mechanical Obstruction Disorders * Adhesions * Tumors * Impaction * Strangulated Hernia * Volvulus “Twisting” * Intussusception (telescoping)

Functional Obstruction * Bowel Manipulation (surgery) * Narcotic Anesthesia * Peritonitis

Types of Bowel Obstruction


Itis from top to bottom l.jpg
“Itis” from TOP to BOTTOM Disorders

“itis” Etiology Clinical Findings

esophagitis reflux (GERD) - pain after meals

- “heartburn”

gastritis -PUD ASA, ETOH - epigastric pain

H. pylori

regional enteritis ? Etiology - diarrhea with

(Crohn) blood and mucus

ulcerative colitis ? Etiology - bloody diarrhea


Itis from top to bottom42 l.jpg
“Itis” from TOP to BOTTOM Disorders

“itis” Etiology Clinical Findings

diverticulitis low fiber diet low abdominal

pain, fever

appendicitis obstruction - RLQ pain, fever

“fecalith” - rebound pain

peritonitis perforation - severe pain, ileus

bowel ischemia - guarding, rigid

pancreatitis biliary disease - pain to back, shock

ETOH - high lipase, amylase


Itis from top to bottom43 l.jpg
“Itis” from TOP to BOTTOM Disorders

“itis” Etiology Clinical Findings

cholecystitis cholelithiasis - RUQ pain

- steatorrhea

hepatitis viral, acute ETOH - jaundice, big liver

- high AST, ALT

- flu-like symptoms


Appendicitis l.jpg
Appendicitis Disorders

  • Etiology:

    • Obstruction by fecalith, inflammation

  • Presentation:

    • RLQ pain (classic, but may be anywhere), N&V, fever, diarrhea, RLQ tenderness

  • Evaluation: CBC, abdominal ultrasound

  • RX: immediate surgical consult


Diverticulitis l.jpg
Diverticulitis Disorders

  • Etiology:

    • Microperforation with peridiverticular inflammation

  • Presentation:

    • Elderly with LLQ pain, severe constipation, nausea, fever

  • Evaluation:

    • CBC, abd film, CT if peritoneal signs

  • Rx: NPO, antibiotics, IV fluids



Acute pancreatitis l.jpg
Acute Pancreatitis Disorders

  • Etiology: unknown

    • Associated with ETOH, biliary disease

  • Presentation:

    • Severe epigastric and back pain

  • Evaluation:

    • CBC, glucose, calcium, electrolytes, amylase, lipase (renal studies)

    • Severity index


Severity scale pancreatitis l.jpg

During first 48 hours Disorders

HCT drop of >10%

BUN rise >5 mg/dl

PaO2 < 60

Calcium < 8 mg/dl

Fluid sequestration of > 6 liters

Severity Scale: Pancreatitis

Initially

  • Age over 55

  • WBC > 16,000

  • Blood glucose > 200

  • Base deficit > 4

  • Serum LDH >350

  • AST > 250


Pancreatitis severity l.jpg
Pancreatitis Severity Disorders

Number of criteria

Mortality Rate

0-2

3-4

5-6

7-8

1%

16%

40%

100%


Cholecystitis l.jpg
Cholecystitis Disorders

  • Etiology:

    • 95% associated with stone in cystic duct

  • Presentation:

    • Often obese female, fever, RUQ pain with scapular or epigastric pain, colicky, N&V

  • Evaluation:

    • CBC, RUQ ultrasound, HIDA scan

  • RX: Prompt cholecystectomy


Steatorrhea l.jpg
Steatorrhea Disorders

  • Pancreatic steatorrhea:

    • > 90% of exocrine function lost

  • Bile salt deficiency:

    • decreased ileal reabsorption (Crohn)

    • blocked secretion (cholestasis)

  • Bacterial overgrowth syndromes:

    • stasis of small bowel contents

  • Mucosal defects: Celiac disease (sprue)


Jaundice l.jpg
Jaundice Disorders

  • Jaundice occurs with bilirubin level > 3 mg/dl (normal 0.2-1.2)

  • Increased RBC breakdown

  • Impaired liver uptake of bilirubin

  • Impaired excretion of bilirubin


Functions of the liver l.jpg
Functions of the Liver Disorders

  • Nutrient metabolism (glucose, protein, fat, fat soluble vitamins)

  • Production of serum proteins and enzymes (albumin, clotting factors etc.)

  • Detoxification of hormones, drugs

  • Bile synthesis (conjugation of bilirubin)

  • Urea synthesis



Manifestations of liver dysfunction l.jpg
Manifestations of Liver Dysfunction Disorders

  • Impaired protein synthesis

    • bleeding (clotting factor deficiency)

    • edema (hypoproteinemia)

    • immune deficiency (substrate for antibody)

  • Accumulation of toxins and hormones

    • feminization (excess estrogens)

    • poor metabolism of drugs

    • spider nevi (estrogen)


Manifestations of liver dysfunction56 l.jpg
Manifestations of Liver Dysfunction Disorders

  • Inadequate bile synthesis

    • increased bilirubin level

    • jaundice

  • Inadequate urea synthesis

    • increased blood ammonia level (NH3)

    • hepatic encephalopathy

  • Release of marker enzymes into blood

    • AST (SGOT)

    • ALT (SGPT)


High direct bilirubin l.jpg
High Direct Bilirubin Disorders

  • Hepatocellular injury:

    • hepatitis

    • drugs

    • hemochromatosis

    • Alpha-1 antitrypsin deficiency

  • Cholestasis:

    • stones, tumors, strictures

    • cholangitis


Acute hepatitis l.jpg
Acute Hepatitis Disorders

  • Etiology: acute liver inflammation and cellular injury: viral, toxic

  • Presentation: jaundice, anorexia, fatigue, diffuse abd discomfort, dark urine

  • Evaluation: History of viral or toxin exposure, AST, ALT, Alk phos, bilirubin, serology for viral hepatitis


Viral hepatitis l.jpg
Viral Hepatitis Disorders

Type A B+(D)C E

Transmission oral-fecal blood and blood and oral-fecal

body fluids body fluids

Risk contaminated sexual, IV sexual, IV waterborne

food

Prognosis good more severe 85% chronic ?

5% carrier

B+D more

severe


Acute toxic hepatitis l.jpg
Acute Toxic Hepatitis Disorders

  • Etiology: exposure to hepatotoxin or its metabolite

  • Evaluation: No definitive tests:

    • history of exposure is important

    • negative viral serology screen

    • improvement after discontinuing drug

    • if alcohol is the toxin, AST > ALT, 2:1


Chronic alcoholic liver disease l.jpg
Chronic Alcoholic Liver Disease Disorders

  • Etiology: chronic, heavy ETOH exposure

    • Only 15-20% of alcoholics develop liver disease

    • Men > 4-6 drinks/day, Women > 3-4/day

  • Pathogenesis: unknown

  • Presentation:

    • fatty liver

    • hepatitis

    • cirrhosis


Cirrhosis of the liver l.jpg
Cirrhosis of the Liver Disorders

  • Fibrotic liver

    • loss of hepatocellular functions

    • obstruction to bloodflow from the gut

  • Etiology

    • Chronic alcohol use (most common)

    • Biliary (obstruction in bile drainage)

    • Postnecrotic (viral, toxic hepatitis)

    • Cardiac (right heart failure, liver congestion)


Liver cirrhosis l.jpg
Liver Cirrhosis Disorders

cell failure

From GI

tract

jaundice

bleeding

low albumin

-edema

immune deficient

estrogen excess

encephalopathy

Portal vein

To vena

cava

portal hypertension

ascites

esophageal varices

hemorrhoids

anorexia

Hepatic vein


Treatment monitoring l.jpg
Treatment & Monitoring Disorders

  • Abstinence from alcohol

  • Restore nutrition: (high protein diet unless hepatic encephalopathy)

  • Monitor PT, AST, ALT, albumin, bilirubin

  • Vitamin K

  • Abnormal PT despite vitamin K indicates a severely compromised liver


Treatment monitoring65 l.jpg
Treatment & Monitoring Disorders

  • Ascites:

    • caput medusae: flow outward from navel

    • sodium restriction

    • spironolactone

    • monitor for spontaneous bacterial peritonitis

    • If ascites is present, high likelihood of esophageal varices


Treatment monitoring66 l.jpg
Treatment & Monitoring Disorders

  • Hepatic Encephalopathy

    • Altered mental status due to accumulation of toxins, including ammonia (NH3)

    • Precipitated by GI bleed, drugs, increased shunting of blood around liver

    • Monitor NH3 level

    • lactulose

    • withhold protein


Liver cancer l.jpg
Liver Cancer Disorders

  • May and usually does have similar clinical manifestations to cirrhosis. Liver cancer is almost always metastatic. The survival rate s less than 5%.



The end l.jpg

The End….. Disorders

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