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

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Disorders of Nutrition

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    1. Gastrointestinal Disorders

    2. Disorders of Nutrition Alterations in: Ingesting Digesting Absorbing Eliminating

    3. Anorexia Pica Nausea & Nausea Esophageal Atresia Tracheoesopheal fistula Cleft lip/palate Anorexia Nervosa Pyloric Stenosis Projectile Vomiting Ingestion

    4. Maldigestion • Lactic Deficiency • Pancreatitis • Cystic Fibrosis

    5. Malabsorption • 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)

    6. Elimination • Diarrhea Osmotic Changes Secretory Changes Mucosal Damage Altered Motility • Crohn’s Disease • Ulcerative Colitis

    7. Basic Structure of the GI tract PSNS SNS longitudinal muscle Myenteric plexus Circular muscle Submucosal plexus Submucosa Lumen

    8. Enteric Nervous System Influenced by ANS PSNS SNS Pelvic nerves NE Ach ENTERIC NERVOUS SYSTEM Myenteric Submucosal Smooth muscle Secretory Cells Endocrine Cells Blood Vessels

    9. Gastric Motility LES fundus pylorus receptive relaxation Antrum approx 3 contractions per minute

    10. Control of Gastric Emptying PSNS SNS + - GASTRIC EMPTYING - - secretin - CCK Duodenal acid Duodenal fats Duodenal hypertonicity

    11. Small and Large Bowel Motility • 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

    12. Secretion in the Stomach • Parietal Cells • HCL • Intrinsic Factor • Chief Cells • Pepsinogen • Surface epithelia and mucous cells • HCO3- and mucus

    13. Control of Acid Secretion VagusMast CellsG cells Ach Histamine Gastrin muscarinic receptor H2 receptor gastrin receptor Gastric Parietal Cell Acid Secretion

    14. Secretion in the Small Intestine • Secretions from Pancreas • HCO3-, Proteases, Lipases, Amylases • Secretion from Gallbladder • Bile acids, pigment, phospholipid • Secretions from intestinal epithelia • Brush border enzymes

    15. Brush Border Enzymes Lactase: lactose glucose, galactose Sucrase: sucrose fructose, glucose Dextrinase: cleaves amylose branch points Glucoamylase: maltose glucoses Only Monosaccharides are Absorbed

    16. Digestion and Absorption of Proteins • Pepsin: 15% of peptide bonds broken • Pancreatic proteases • Trypsin • Chymotrypsin • Carboxypeptidases • Brush Border • Peptidases cleave into 1 to 4 aa chains

    17. Digestion and Absorption of Fat • 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

    18. Reabsorption of Bile • 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

    19. GI Disorders

    20. Dysphagia • 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

    21. Nasal regurgitation 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

    22. Dyspepsia • 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

    23. Diagnosis • 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

    24. PUD with H. pylori • 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%

    25. Acute Infectious Diarrhea 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

    26. Chronic Diarrhea: Stool Studies • 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

    27. Osmotic Diarrhea: Lactase Def. • 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

    28. Inflammatory Bowel Disease • 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

    29. Assess UC Disease Severity • Number of stools per day • Hematocrit • Sed rate • Albumin level

    30. Crohn Disease • 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

    31. Crohn Disease • 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

    32. Crohn’s Disease “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

    33. Motility Diarrhea: IBS • 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

    34. IBS • 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

    35. Occult GI Bleeding • 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

    36. Acute Abdominal Pain • 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)

    37. Assessment of the Pain • 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

    38. Localization of Abdominal Pain • 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

    39. Bowel Obstruction • 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

    40. Mechanical Obstruction * Adhesions * Tumors * Impaction * Strangulated Hernia * Volvulus “Twisting” * Intussusception (telescoping) Functional Obstruction * Bowel Manipulation (surgery) * Narcotic Anesthesia * Peritonitis Types of Bowel Obstruction

    41. “Itis” from TOP to BOTTOM “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

    42. “Itis” from TOP to BOTTOM “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

    43. “Itis” from TOP to BOTTOM “itis” Etiology Clinical Findings cholecystitis cholelithiasis - RUQ pain - steatorrhea hepatitis viral, acute ETOH - jaundice, big liver - high AST, ALT - flu-like symptoms

    44. Appendicitis • 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

    45. Diverticulitis • 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

    46. Liver, biliary, and pancreatic anatomy

    47. Acute Pancreatitis • Etiology: unknown • Associated with ETOH, biliary disease • Presentation: • Severe epigastric and back pain • Evaluation: • CBC, glucose, calcium, electrolytes, amylase, lipase (renal studies) • Severity index

    48. During first 48 hours 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

    49. Pancreatitis Severity Number of criteria Mortality Rate 0-2 3-4 5-6 7-8 1% 16% 40% 100%

    50. Cholecystitis • 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