Gastrointestinal Disorders- Chapter 4

1. Gastrointestinal Disorders- Chapter 4 • The End of The DigestiveSystem

2. THE DIGESTIVE TRACT

3. THE DIGESTIVE TRACT • Basically a long tube for passage and processing of food • 28 feet long • Mouth • Pharynx • Esophagus • Stomach • Duodenum  Jejunum  Ileum (sm int) • Large intestine (colon)

4. THE DIGESTIVE TRACT • Mouth: teeth grind food, salivary glands lubricate and begin enzyme processing, tongue coordinates swallowing and allows taste • Pharynx: Aids swallowing, epiglottis prevents choking • Esophagus: Coordinated peristaltic contractions. lower sphincter competence important • Stomach: Villi (like velvet), mixes and stores food and secretes enzymes for digestion (pepsin and hydrochloric acid digest protein, amylase digests starch, intrinsic factor allows absorption of vitamin B12)

7. THE DIGESTIVE TRACT • Pyloric sphincter  Duodenum • Duodenum secretes alkaline mucus fluid + bile from gallbladder + enzymes from the pancreas • Pancreas secretes digestive enzymes into duodenum, also secretes insulin into blood stream  drives glucose into cells, and secretes glucagon into blood stream  stimulates liver to release glucose • Liver receives blood via portal circulation and purifies toxins (meds, alcohol), manufactures cholesterol, and produces bile. Bile absorbs and digests fats and fat-soluble vitamins, eliminates excess cholesterol by binding with it and passes thru GI tract. • Gallbladder stores bile. If cholesterol level is high  cholesterol rich bile in the gallbladder  stones.

9. THE DIGESTIVE TRACT • Small intestine: 20 feet long, vast surface area (2300 sq ft!) • Digests nutrients and absorb them into the portal circulation  liver for processing and detoxifying. • The lining secretes water, mucus, enzymes (amylase, pepsin, lipase, trypsin, bile, sucrase, lactase etc). Some of these enzymes are also responsible for the feeling of hunger and satiety, and peristalsis stimulation or suppression. • Rapid turnover of cells that line the small intestine. 50 million cells/minute (!) are sloughed off into the lumen and are part of our stool.

11. THE DIGESTIVE TRACT • Large Intestine: NOT a digestive organ • 4-5 feet long • Secretes mucus, absorbs water and electrolytes, solidifies feces • Cecum  Ascending colon  Transverse colon  Descending colon  Sigmoid  Rectum  Anus • Filled with bacteria that help absorb nutrients/vitamins. ½ the weight of dry stool is bacteria!

13. WHAT ARE SOME SYMPTOMS OF DIGESTIVE TRACT DISEASE? • Abdominal pain • Nausea • Vomiting • Diarrhea • Constipation • Dyspepsia • Gas • Belching

14. SYMPTOMS OF GI DISORDERS • Melena • Hematochezia • Hematemesis • Dysphagia • Bloating • Anorexia • Ascites • Fatigue

15. PHYSICAL EXAM • Inspect • Auscultate bowel tones • Percussion • Palpation

16. DIAGNOSTIC TESTS • Endoscopy • Upper endoscopy: mouth, pharynx, esophagus, stomach, duodenum • Lower endoscopy (colonoscopy): rectum, sigmoid, descending, transverse, ascending colon • Ability to not only view and diagnose conditions, but also take biopsies, cauterize, sew, grab stones or foreign bodies, remove polyps, dilate strictures…

17. Endoscope - Upper

18. Endoscope: Lower

19. DIAGNOSTIC TESTS • X-ray • Ultrasound • CT • MRI • Chemistry tests: blood, urine, feces, gastric contens

20. Imaging Studies

21. Organization of Chapter • Mouth and Esophagus (- tracheoesophageal fistula section) • Stomach, Intestine, pancreas • Anorectum

22. DISORDERS OF THE MOUTH • Canker sores (Apthous ulcers/stomatitis) • Oral herpes (HSV I) (Cold sores) • Thrush • Gingivitis • TMJ (temporomandibular joint syndrome) • Cancer of the tongue and mouth • Cigarettes, chew, snuff, alcohol, long term gingivitis

23. Disorders of the Esophagus • GERD • Tracheoesophageal fistula and esophageal atresia • Corrosive esophagitis and stricture • Mallory-Weiss Syndrome • Esophageal diverticula • Hiatal hernia

24. Apthous Stomatitis - Canker sore

25. Herpes - Cold sore (herpetic stomatitis)

26. Stomatitis • Inflammation of oral mucosa (cheeks, lips, palate) • Acute herpetic and apthous • Self-limiting, 10 -14 days • Severe or fatal in neonates • Viral and Unknown etiology • Tzanck smear

27. thrush - candidiasis Fungal Infx, candida usually Fissures in corners of mouth, Patches on tongue Trx with yogurt, topical anesthetic mouthwash to loosen secretions remove sugar, improve immunity

28. Periodontitis - gingivitis Vitamin deficiency, diabetics, OCPs, painless, swollen; gums detach from teeth trx with tooth cleaning and improved health status

29. Oral cancer

30. Glossitis-Big, red, painful tongue • Inflmx of the tongue • Strep • Vitamin B deficiency • some skin conditions • Trx by correcting the problem, avoidance of trigger foods

31. DISORDERS OF THE ESOPHAGUS • Dysphagia = trouble swallowing, sensation of food being “stuck” • Half the time it is psychological • Also due to: • Acid reflux  damage esophageal mucosa • Bacterial, viral, fungal infections • Tumors of the throat, thyroid, parathyroid • Chemical injury • Neuromuscular disease (Parkinson’s, MD, ALS) • Achalasia (lower 2/3 lacks normal innervation) • Congenital narrowing

32. DISORDERS OF THE ESOPHAGUS • Gastroesophageal Reflux Disease (GERD) = heartburn • 10% of adults in the US have daily GERD • Peristaltic abnormality, malfunction of the lower esophageal sphincter, widening of the esophageal-gastric junction (hiatal hernia) • Risks: obesity, alcohol, coffee, tobacco, caffeine, fats, chocolate, NSAIDs, pregnancy, hiatal hernia

33. GERD

34. GERD (continued) • Intensity of symptoms DOES NOT correlate with extent of disease • Sx’s: heartburn, pain, burping, acid in mouth • Complications: narrowing of the esophagus due to scarring, ulcers, Barrett’s esophagus (cell changes that make cancer 40x more likely; 10% of people with GERD sx’s have Barrett’s)

35. Barrett’s Esophagitis

36. GERD (continued) • Treatment: • No lying down for 3 hrs after eating • Elevate head of bed • Avoid citrus, tomato prdts, spicy foods, coffee, alcohol, NSAIDs • Antacids (Gaviscon, Tums, Rolaids, Maalox) • H2 receptor antagonists reduce acid production (Tagamet, Pepcid, Zantac) • Proton pump inhibitors reduce acid secretion (Nexium, Prevacid, Prilosec) • Surgery

37. **GERD RED FLAGS** • Wakes someone up from sleep • Occurs every day • Trouble swallowing • Persistent despite medical treatment • Changes in or loss of voice • Weight loss • Wheezing

38. ESOPHAGEAL VARICES • Varicose veins of the upper GI tract • Due to liver problems • Cirrhosis causes scarring of liver • Blood flow thru the liver is constricted due to scar tissue  portal hypertension  increased pressure in the veins of the lower esophagus and upper stomach  can rupture and bleed heavily and sometimes fatally

39. Esophageal Varices

40. ESOPHAGEAL VARICES • Causes upper GI bleed (hematemesis) • Diagnose by medical history (liver disease, alcoholism, hepatitis), symptoms, and upper endoscopy • Treat with cautery or ligature at the time of endoscopy, compression with balloon, surgery to redirect blood flow bypassing the liver

41. ESOPHAGEAL CANCER • History of heavy alcohol use, smoking, or chronic GERD • Usually 50-70 years old • Poor prognosis: 5 year survival is < 15% • Surgery to remove esophagus, but recurrence is common

42. Mallory-Weiss Syndrome • Mild to Massive bleeding after forceful and prolonged vomiting • Tear in cardia or Lower Esophagus • Mentioning because though rare, is fatal

43. Esophageal Diverticula • Hollow outpouchings in the esophageal wall • Mostly older men • Throat irritation--> dysphasia--> regurg after eating--> aspiration pneumonia • Sx/Sxs: hoarseness, asthma, pneumonitis in elderly, usually have bad breath, chronic cough

44. Hiatal Hernia • Defective diaphragm • Portion of stomach passes into opening to chest • sliding and paraesophageal hernia • Strangulation of herniated portion can happen

45. Hiatal Hernias • Visceral Manipulation

46. MOVING ALONG THE GI TRACT…WE REACH THESTOMACH • Gastritis = stomach inflammation • Most often caused by NSAIDs (ibuprofen) • The risk of having gastritis with regular NSAID use is close to 10% • 25,000 people out of every 100,000 hospitalized due to NSAID gastritis die of massive bleeding • Also caused by alcohol and stress (such as severe illness, particularly when treated with steroids, such as shock, respiratory failure, anaphylaxis)

47. GASTRITIS • Sx’s: loss of appetite, abdominal pain, bloating, upper GI bleed • Dx: endoscopy for those at risk and with sx’s • Tx: Proton pump inhibitors and sucralfate (liquid that adheres to damaged mucosa and protects it from acid by forming a barrier)

48. Gastroenteritis • Self-limiting • Nausea, vomiting, diarrhea • intestinal flu, traveler’s diarrhea, viral enteritis, food poisoning • 2nd to common cold in lost work and 5th in mortality of kids • life threatening in old people too • Bacteria, virus, toxins, drug reactions, food allerens • Supportive care, hydration, rest

49. GASTROENTERITIS • Caused by both virus and bacteria, but both usually resolve without specific treatment. Need to think twice if lasts > 10 days, bloody diarrhea. • Supportive care: HYDRATION, help with the nausea/vomiting. Diarrhea usually happens for a reason. Probiotics. • Signs of dehydration: dry mouth/tongue, no tears, dough-y feeling skin, fast heart rate, low blood pressure, lightheadedness esp with a position change

50. Peptic Ulcers • circumscribed lesions in the mucosa- LE, stomach, pylorus, duodenum, jejunum (80% are duodenal) • Gastric ulcers affect stomach, mostly elder men who use NSAIDs, tobacco and alcohol • H. pylori, NSAIDs and hypersecretory disorders like Zolinger Ellison Syndrome are etiological • Type A blood gets gastric ulcers and Type O get duodenal • Acid secretion exceeds buffering capacity