Transcript The Abdominal Organs Lecture Notes Page

The Abdominal Organs
GI, Liver, Gallbladder, and Pancreas
AH 120
THE GI System
Congenital Defects
Cleft Lip & Cleft Palate
Incomplete fusion of embryonic facial segments
Cleft Lip & Cleft Palate (cont.)
• Etiology: heredity, dietary deficiencies during
pregnancy, maternal alcoholism, maternal
infection(s) during pregnancy, idiopathic
• S & S: cleft clip causes some feeding impairment.
Cleft palate causes significant feeding impairment,
ear infections, aspiration, and speech disturbances
• Treatment: Primary is surgical repair as soon as
infant is able to tolerate surgery.
Esophageal Atresia and TracheoEsophageal Fistula
Esophageal atresia = incomplete esophagus, often ending as a
blind pouch. T-E fistula = abnormal communication between
esophagus and trachea. These can occur together or separately.
Esophageal Atresia & T-E Fistula
(cont.)
Etiology: similar to cleft lip and palate
Manifestations:
• Esophageal atresia – frequent regurgitation of
feedings, failure to thrive
• T-E Fistula – airway obstruction when feeding,
aspiration pneumonia
Treatment: Surgical repair
• Isolate trachea prior to surgery with cuffed,
endotracheal tube. Esophageal atresia may need
gastrostomy feeding tube prior to surgery
Neoplasia in the Oral Cavity and
the Esophagus
Leukoplakia
• Hyperplastic cell growth
of hard-white squamous
tissue in the mucus
membrane of the oral
cavity
• Etiology: chronic irritation
• Smoke, chewing tobacco,
irritating liquids or food
• Leukoplakia is often a
precancerous sign!
Oral Cancer
• Malignant epidermoid or
lymphocytic tumors in the
cheek, lip, gum, or tongue
• Etiology: chronic
irritation, alcohol, dental
problems
• Manifestations: cosmetic
concerns, interference
with eating and speaking,
and, sometimes breathing
• Treatment: Surgical
resection with chemo and
radiation therapy
• Surgery can be very
mutilating!
Esophageal Cancer
• Usually squamous cell
carcinoma or
adenocarcinoma that
occurs in the lower portion
• Etiology: chronic irritation
• Tobacco, alcohol, poor
dental health
• Manifestations:pain,
dysphagia and indigestion,
feeling that something is
“stuck” after eating
• Treatment: surgical
resection of esophagus,
chemo and radiation
Inflammatory Diseases of the GI
Tract
Gastritis
• Inflammation of the gastric
mucosa that can be chronic or
acute
• Acute causes edema and some
superficial erosion
• Chronic may cause hypertrophy
or atrophy of mucosa
• Atrophy may lead to
pernicious anemia and/or
gastric cancer
• Etiology: infection from
contaminated food/water,
dietary “indiscretion”,
chemical irritation
• Excessive alcohol, coffee,
smoking, drugs
Gastritis (cont.)
Manifestations:
• Abdominal pain
• Intense N & V
• Possible hematemesis
• Fever (if acute)
• Chronic manifestations are much milder or absent
Treatment: Supportive care; may need antibiotics for
infectious causes
• Acute often resolves in 24-36 hours
Crohn’s Disease
Regional Enteritis
• A chronic inflammatory
disease that occurs in
patches, usually in the
terminal ileum and colon
• Characterized by periods of
remission and exacerbation
• Etiology: unknown but
may be due to
combination of dietary,
infectious, and
autoimmune factors
• Pathology- patchy
thickening of the intestinal
wall with possible
erosion/ulceration
Crohn’s Disease (cont.)
Manifestations
During exacerbation:
• Fever, abdominal
pain,diarrhea
Complications:
• Bowel obstruction
• Peritonitis (if
erosion/ulceration
occurs
• Fistulas
Crohn’s Disease
Treatment
• Anti-inflammatory drugs to prevent
exacerbation
• Diet – eliminate foods that trigger
exacerbation
• Surgery – repair of fistulas; resection of
sights of exacerbations
• May be simple end to end anastomosis,
ileostomy, or colostomy
Gastroenteritis
Gastroenterocolitis
• Acute inflammation throughout the stomach
and small and large intestine
• Etiology: infection, dietary indiscretion,
stress
• S & S; Abdominal pain and cramps,
borborygmi, N & V, diarrhea
• Treatment: Supportive; maintain
hydration;treat any infectious agents
Gastric/Duodenal Ulcers
• Circumscribed erosion of the mucus
membrane that usually occurs in the lesser
curvature of the stomach and in the
duodenum (just past the pyloric valve)
• Etiology: most are due to infection by a
bacteria, Helicobacter
• Stress, diet, smoking, alcohol, drugs, etc,
aggravate and encourage ulcer activity, but
probably do not cause them
Acute Ulcer
• Red, swollen areas
that may have blood in
the center of the lesion
Sub-acute Ulcer
• Erosion is through
mucosa and into
muscle layer
• Center of lesion
usually has pus in it
Chronic Ulcer
• Fibrous, scar tissue
is present with the
erosions
Ulcer: Signs & Symptoms
• Painful, gnawing
sensation in stomach
that is usually relieved
by intake of food
• Increased gastric
acidity
• Perforation may lead
to peritonitis and
hemorrhage (which
leads to shock)
Ulcer Treatment
• Antibiotics for Helicobacter
•
•
•
•
• Usually Amoxicillin tried first
Antacids
Dietary control
No smoking!
Surgery for perforations/ erosions that cause
bleeding
Ulcerative Colitis
• A chronic, diffuse
inflammatory and
ulcerative disease (with
periods of remission and
exacerbation) that
normally starts in the
rectosigmoid area and
spreads to envelop a large
portion of the entire bowel
• Note it is similar to
Crohn’s, but Crohn’s is
patchy inflammation, not
diffuse
• Leads to abscesses,
necrosis, and possible
ulceration with perforation
Ulcerative Colitis (cont.)
• Etiology – most likely
auto-immune
• Stress, poor, diet, and
infection may aggravate
condition and cause
exacerbations
• S & S – painful & bloody
diarrhea, weight loss,
anemia and shock from
internal blood loss,
peritonitis (if perforation
occurs)
• Patients with this disease
are at high risk for
developing colon cancer
Treatment
• Diet– minimal raw fruits
and vegetables, no
milk/milk products
• Steroids
• Surgery – may need to
resect chronically
inflamed areas
• May necessitate a
colostomy or an ileostomy
Diverticulosis
• Saccular herniation of
colon mucosa through the
muscular wall of the colon
• Result is an “outpouching”
of the intestinal wall. This
pouch acts as a pocket in
which digestive material
can become caught and
cause inflammation of the
“pouch”
• Inflamed diverticula is
called diverticulitis
Diverticulitis
Etiology – low roughage diet
allows digested material to
become trapped in pouches
Pathology – fluid is absorbed
and the material becomes a
concretion
• Concretion causes the
diverticula to become
inflamed which causes
bowel obstruction, possible
fistula formation, and if
perforation occurs,
peritonitis
Diverticulitis (cont.)
S & S: localized pain and tenderness, fever,
leukocytosis, alternating constipation and
diarrhea, possible hemorrhage, flatulence
Treatment:
• High roughage diet and adequate fluid
intake to prevent concretion formation
• Surgery to resect inflamed area
• May require ileostomy or colostomy
Neoplasia in the Stomach, Small
and Large Intestine
Carcinoma of the Stomach
• Etiology – unknown, but
chronic gastritis due to
helicobacter infection may
be a cause
• S & S – very vague but
may be similar to an ulcer
• Except gastric acidity is
usually normal or low and
food intake does not usually
ameliorate symptoms
• Often no specific symptoms
until the cancer has
metastasized
• Treatment: Surgical
resection with
chemotherapy
Polyposis
• A mass of pedunculated
tissue seen in the colon
• The bigger the polyp, the
more likely it is to be a
pre-cancerous mass
• Primary symptom is rectal
bleeding
• Treatment – removed
during
sigmoidoscopy/colonosco
py and tissue is biopsied
• Resection of colon tissue if
malignant cells are seen
Colo-Rectal Cancer
• Usually a slowgrowing
adenocarcinoma
• Second leading cancer
after lung
• Etiology
• Heredity
• High fat diet that is low
in fiber
• Polyposis
• Chronic ulcerative
colitis
Colo-Rectal Cancer (cont.)
S & S:
• Unexplained weight loss and fatigue
• Blood in stool (may be occult)
• Periods of constipation and diarrhea
Diagnosis: colonoscopy, sigmoidoscopy, and/or
barium enema
Treatment: Surgical resection with chemotherapy
• May end up with a colostomy
Hernia
Protrusion of an organ (or part of an
organ) through the wall of the cavity
normally containing it
Inguinal Hernia – intestine
protrudes through the abdominal
wall in the groin or in the
scrotum
Inguinal Hernias (cont.)
• Etiology: congenital
defect in fascia or damage
due to straining
• Pathology:
• Reducible – herniated tissue
can be pushed back into
place
• Incarcerated – herniated
tissue can not be pushed
back into place
• Strangulated – incarcerated
hernia has had its blood
supply cut off and the tissue
becomes necrotic
• S & S – minimal if
any pain; just
noticeable “bulge”
where there should
normally not be one
• Treatment: Surgical
repair
• Strangulated hernia is a
surgical emergency
Hiatal Hernia
• Herniation of the stomach
into the thorax at the
esophageal hiatus
• Etiology: congenital, age,
trauma
• S & S: intense indigestion
especially if patient goes
to bed after eating
• Treatment: frequent small,
meals; allow at least three
hours before going to bed
after a meal; sleep with
head elevated; drug
therapy
Umbilical Hernia
• Herniation of
umbilical stump in
young children
• Usually no
complications and
recedes on its own
• Very stressful to the
parents!
Omphalocele
• Herniation of
abdominal viscera due
to congenital defect in
abdominal wall
closure in utero
• Surgical emergency
Malabsorption Syndrome
Failure to digest and/or absorb food
Etiology
Impaired digestion:
• Pancreatic disease
• Liver disease
• Altered continuity of
the GI tract
• Injury
• surgery
Impaired absorption:
• Crohn’s disease
• Ulcerative colitis
• Celiac disease
• Gluten intolerance
• Causes atrophy of intestinal
mucosa
• Tropical Sprue
• Chronic inflammation and
atrophy possibly due to
parasite, food toxin, or
vitamin deficiency
Malabsorption Manifestations
•
•
•
•
•
•
Weight loss
Cutaneous bruising
Abdominal distension
Anemia
Calcium deficiency
Fat-soluble vitamins
deficiency
• Large, bulky, foul
smelling fecal material
Malabsorption Treatment
Depends on the specific cause:
• Celiac disease – gluten free diet
• Tropical Sprue – folic acid and tetracycline
• Treatment of underlying cause (pancreatic
disease, liver disease, etc)
• Replacement of lost vitamins and minerals
Liver Disease
Hepatitis
Acute or chronic inflammation of the
liver that causes poor liver function
due to necrosis and the buildup of
fatty cells in the liver
Hepatitis Etiology
• Biliary tract dysfunction, eg, biliary atresia
• Substance abuse
• Causes some necrosis and a lot of fatty
deposition
• Often leads to chronic inflammation which can
cause cirrhosis and/or liver cancer
• Viral infection
Viral Agents
• Type A (also known as infectious hepatitis)
• Freely shed in saliva and fecal matter
• Epidemics occur with contaminated food and
water
• Type B (also known as serum hepatitis)
• Found in blood and body fluids
• Spread through poor decontamination, sexual
intercourse, etc
Viral Agents (cont.)
• Type C (also known as non-A, non-B)
• Blood and body fluids
• Type D
• Found only in patients already infected with type B
• Type E
• Similar to A; poor hygiene and sanitation
• Type G
• Blood and body fluids
Hepatitis Manifestations
Flu like symptoms
• Anorexia
• Malaise
• N&V
• Sometimes B, C, D, E
and G will have no
symptoms
•
•
•
•
Large, palpable liver
Dark urine
Jaundice
Labs
• Decreased liver function
• Increased liver enzymes
• In severe cases of
hepatitis, the patient may
lapse into a coma
B, C, D E, or G may become chronic and or the patient may
become a “carrier” of the disease
Hepatitis Treatment
• Primarily supportive
• For known exposure to type A, gamma – globulin (up
to 14 days after exposure)
• Interferon for chronic B and C
• Many experimental therapies
• Prevention
• Proper hygiene and sanitation
• Vaccines for prevention of type A and B
• Chronic hepatitis can lead to cirrhosis and/or
liver cancer
Cirrhosis
End stage liver failure usually caused
by chronic inflammation
(Biliary tract problems, substance
abuse, chronic infection)
Cirrhosis Pathology
• Necrosis
• Fibrosis
• Nodular regeneration
• Often “fatty” nodules
• Fibrosis and nodular
regeneration often lead
to portal hypertension
• This leads to
esophageal varices and
splenomegaly
Cirrhosis Manifestations
(due to poor liver function AND
portal hypertension)
• Weakness, malaise,
anorexia and weight
loss
• Hemorrhage/shock
due to esophageal
varices
• In males, hair loss,
testicular atrophy, and
gynecomastia
Cirrhosis Manifestations (cont.)
• Ascites (due to
•
•
•
•
hypoproteinemia and portal
hypertension)
Jaundice
Spider angioma and “Caput
Medusae”
Multi-organ system failure. Eg,
renal failure, respiratory failure
Encephalopathy/hepatic coma
due to accumulation of
nitrogen-containing compounds
in blood
Hepatic Coma
Cirrhosis Treatment
• Surgical shunts to
control esophageal
varices and ascites
• Supportive care
• Liver transplant
Gallbladder Disease
Cholelithiasis
The presence of stones in the
gallbladder
Cholelithiasis (cont.)
• Stones are usually a
sediment from bile
containing cholesterol,
bilirubin, and calcium
Cholelithiasis Etiology
Cholelithiasis Diagnosis
• Abdominal X-ray
• Cholecystogram
• Ultrasound (usually
best)
Cholelithiasis (cont.)
Stones cause obstruction
of the biliary tract
which can lead to:
• Cholecystitis
• Hepatitis
• Pancreatitis
Cholelithiasis Treatment
• Chenodiol
• Helps dissolve stones so that they pass
• May take weeks or months to work
• Lithotripsy
• Ultrasound to break up stones
• Cholecystectomy
Cholecystitis
Inflammation of the gallbladder
usually caused by cholelithiasis
Cholecystitis (cont.)
• Gallbladder becomes
swollen and the wall
starts to ooze calcium
• This facilitates more
stone formation
• Cholelithiasis causes
cholecystitis and
cholecystitis causes
cholelithiasis!
Cholecystitis Manifestations
• RUQ pain
•
•
•
•
• Rebound tenderness
N&V
Fever
Bloating and belching
Peritonitis if the gallbladder perforates
Cholecystitis Treatment
• Pain meds and hydration
• Cholecystectomy if repeated episodes or
perforation occurs
• Treat cause of stone formation
Pancreatic Disease
Pancreatitis
Acute or chronic inflammation of the
pancreas resulting in pancreatic
necrosis and possible hemorrhage
Pancreatitis Etiology
• Biliary tract disease
• Usually from cholelithiasis and cholecystitis
• Alcoholism
Pancreatitis Pathology
• Etiologic agent causes an
increase in pressure in the
pancreatic ducts which
allows pancreatic enzymes
to be released into the
pancreatic epithelium
• Besides poor pancreatic
function, this can lead to
necrosis of the pancreas
and allow it to start
hemorrhaging and may
also result in perforation
• Peritonitis!
Pancreatitis Manifestations
•
•
•
•
Severe LUQ pain
N&V
Fever
Signs of shock if
hemorrhaging
• Signs of peritonitis if
perforation occurs
• Labs show high levels
of pancreatic enzymes
in the blood
• If chronic,
malabsorption and
possibly diabetes
Pancreatitis Treatment
• Pain management
• Opiates tried first but in some patients, this
intensifies the pain
• Anticholinergics to inhibit pancreatic enzyme
secretion
• NPO and IV hydration
• May need surgery for necrosis or
hemorrhaging
Diabetes Mellitus
“Diabetes”
A syndrome characterized by
abnormal insulin secretion and/or
utilization, hyperglycemia, and
systemic complications caused by the
abnormal insulin secretion/utilization
and hyperglycemia
Insulin
Allows glucose to enter cells for
metabolism and allows excess blood
glucose to enter the liver to be stored
as glycogen
Etiology
• Heredity
• Damage to the pancreas from either trauma
or disease
• Autoimmune reaction (possibly triggered by
viral infection
• Obesity
• Aging
Diabetes Types
• Type 1
• Also know as Insulin Dependent Diabetes Mellitus
(IDDM) or juvenile onset
• Pancreas makes minimal or no insulin
• Type 2
• Also known as Non-insulin Dependent Diabetes
Mellitus (NIDDM) or adult onset
• Pancreas doesn’t make quite enough insulin and/or cells
have developed a resistance or tolerance to insulin
Diabetes Pathology
Diabetes Manifestations
Type 1
Hyperglycemia
• Glycosuria
• Polyuria
• Polydipsia
• Polyphagia
• N&V
• Dehydration
• Infections & wounds that
don’t heal
• Warm, red, itchy skin
Ketosis (Ketoacidosis)
• Unexplained weight
loss
• Kussmaul respirations
• Pungent, “fruity”
smell to breath
• Metabolic acidosis
• Appears intoxicated
• Coma
Diabetes Manifestations
Type 2
More gradual onset
• Hyperglycemia and glycosuria
• Polydipsia, polyuria, and polyphagia
• Unexplained weight loss
• Tingling sensations or hot sensation in
lower leg and foot
• Infections and wounds that don’t heal
Diabetes Diagnosis
Besides manifestations:
• Elevated fasting blood sugar (FBS)
• May also utilize Glucose tolerance Test (GTT)
• Glycosylated hemoglobin greater than 6% (A1C)
• Best test to show long term blood glucose levels and
control
• UA to check for glycosuria, proteinuria, and
ketonuria
Diabetes Treatment
Type 1
• Diet – specific caloric intake for proteins,
carbohydrates, and fat
• Exercise regime
• Insulin injections
• Self-administered and requires frequent blood
sugar monitoring
• Implanted insulin pump
• Transplant (pancreatic cells or stem cells)
Diabetes Treatment
Type 2
• Diet – low fat diet and no more than 50%
carbohydrate
• Weight loss too!
• Exercise
• Helps lower blood sugar and to sensitize the body’s
cells to insulin
• Oral drugs
• Hypoglycemic drugs (sulfonylureas) such as Diabinase,
Tolinase
• Insulin sensitizing drugs (also slow the release of
glucose from the liver) - Glucophage
Diabetes Complications
• Occur more quickly and severely in Type 1
• Are due to swings in blood sugar levels and
increased lipid metabolization which
damages the basement membrane of the
blood vessels
Diabetes Complications (cont.)
• Atherosclerosis
• More prone to heart attack and stroke
• Hyperglycemia – gradual development of original
symptoms
• Usually patient eats too much or does not take
medications
• Hypoglycemia –comes on quickly!
• Patient is not eating enough or is taking too much
medication
• Personality change, headache, jittery/tremors, profuse
sweating, seizure
• This patient needs sugar!
Diabetes Complications (cont.)
Retinopathy
• Due to blood vessel
damage, diabetics are
prone to retinal artery
aneurysm,
hemorrhage, and
detachment.
• Partial or total vision
loss
• Also increased chance
of cataracts
Diabetic Complications (cont.)
Nephropathy
• Due to poor blood
flow and
hyperglycemia,
diabetics are prone to
repeated bouts of
pyelonephritis
• May become chronic
• This could progress to
chronic renal failure
Diabetic Complications (cont.)
Neuropathy
• Poor blood flow and
hyperglycemia tend to
cause nervous system
dysfunction
• Ankle and wrist drop
• Tingling, pain, and a
sensation of heat in the
lower leg and feet
• Strabismus and diplopia
Diabetic Complications (cont.)
Poor Wound Healing
• Because of poor blood
flow, hyperglycemia,
and poor nervous
system function,
diabetics are prone to
wounds on the lower
extremity that get
infected and don’t heal
• Gangrene infection is
the worst
With a good care and monitoring
plan, and a compliant patient,
the frequency and severity of these
complications can be diminished