Transcript wcs-sysii-wk6-fa2012

MORE GASTROINTESTINAL
I just thought we needed a better symptom picture
October 15, 2012 Dr. Megan Gonzales ND, EAMP SIOM Western Clinical Sciences Fall 2012
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intrinsic factor is an important glycoprotein released by
the gastric parietal cells that is required for B12
absorption later in the small intestine
GERD
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Gastroesophageal Reflux
Disease:
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backflow of gastric or
duodenal contents into the
esophagus past the lower
esophageal sphincter
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there are not always
symptoms - commonly
heartburn relieved by
antacids
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symptoms may be worsened by vigorous exercise, bending over and
lying down
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the pain can mimic angina pectoris
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there may be pain or difficulty swallowing after long term reflux.
Esophageal stricture, spasm or even esophageal bleeding.
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Sometimes it can waken the patient at night with coughing and
choking.
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There may be an associated hiatal hernia
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Pulmonary symptoms are associated with aspiration of gastric
contents. Chronic bronchitis, asthma, morning hoarseness and
nocturnal wheeze.
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The Lower Esophageal Sphincter functions in two ways - opening by relaxation
and opening based on differences in pressure gradients between the lower
esophagus and stomach. The esophageal muscles can be weakened by
mechanical disturbance or through sliding through the diaphragmatic hiatus (a
hiatal hernia). Tight clothing or other causes of increased pressure below the
diaphragm can lead to GERD (pregnancy, overweight).
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Factors that can increase pressure on the lower esophageal sphincter:
carbohydrates, low-dose ethanol, nonfat milk, protein.
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Factors that lead to a lower pressure and can increase incidence of GERD:
antiflatulents, chocolate, cigarette smoking, fat, high dose ethanol, lying on
either side of your body, orange juice, peppermint, sitting, tomatoes, whole milk.
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REALLY.
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it’s important to avoid acid producing foods: wine, tomato, chocolate,
orange juice, liquor, carbonated beverages, spicy food.
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Remember large meals cause increased pressure below the
esophageal sphincter
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a person who suffers from GERD should not lie down for 2 hours
post-meal
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Nicotine relaxes the lower esophageal sphincter and stimulates
stomach acid production. Smoking decreases gastric motility and can
injure the esophagus.
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The book states that stress is not a direct factor but I think if we were
to delve more specifically into psychoneuroimmunology there would
be quite a direct link to many diseases and stress.
Mallory-Weiss
Syndrome
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as we talked about earlier:
esophageal tearing related to
forceful and prolonged
vomitting.
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the upper esophageal sphincter
fails to relax during vomiting
often related to excessive
alcohol intake. More common
in men than women.
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complications - hypovolemia
and fatal shock
Hiatal Hernia
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a defect where the diaphragm allows the stomach to slip up
into the chest
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two types: a sliding hiatal hernia and paraesophageal hernia.
SLIDING - the stomach and gastroesophageal junction slip
up into the chest so the gastroesophageal junction is superior
to the diaphragm. PARAESOPHAGEAL - a part of the greater
curvature of the stomach rolls through the diaphragm
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often related to muscle weakening common with aging,
diaphragmatic malformations, obesity and smoking are
common risk factors. Incidence increases with age and
sliding is more common than paraesophageal malfunction.
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can lead to dysphagia, gastroesophageal reflux, Barrett’s
esophagus, esophageal adenocarcinoma
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often there are no symptoms, there may be a symptom of
fullness in the chest and pain resembling angina pectoris
(temporary pain, pressure, fullness, or squeezing in the
center of the chest or in the neck, shoulder, jaw, upper arm,
or upper back), if the sphincter is incompetent then symptoms
are those of GERD
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Diagnosis: based on endoscopy, barium study, pH studies,
esophageal motility studies
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treatment is focused on relieving symptoms
Gastritis
ACUTE: mucosal reddening, edema, hemorrhage, erosion
CHRONIC: common in elderly people and people with pernicious anemia.
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ACUTE: causes - chronic indigestion, drugs like aspirin, ingestion of poison,
endotoxins from infection bacteria. Can lead to stress ulcers, there is a rapid
onset of symptoms of epigastric discomfort and anorexia, nausea and vomiting
and hematemesis.
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CHRONIC: seen with peptic ulcers and gastrostomy where there is chronic
reflux of pancreatic enzymes, bile and bile acids into the stomach.
Environmental exposures can contribute to developing the disease - smoking,
pernicious anemia, alcohol, renal disease, diabetes mellitus
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either can lead to hemorrhage, shock, obstruction, perforation, peritonitis and
gastric ulcer
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Diagnosis is based on occult blood studies
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Treatment: focused on eliminating the cause of the disease H2 blockers,
antacids, neutralizing agents, replacement of blood with severe bleeding,
surgery, bland diet
Peptic Ulcer Disease
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Factors In Developing Peptic Ulcer Disease:
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INCREASED ACID PRODUCTION: increased parietal and chief
cells, increased sensitivity to food and other stimuli like caffeine,
excess vagal stimulation, decreased inhibition of gastric secretions
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IMPAIRED MUCOSAL BARRIER PROTECTION: inadequate
mucosal blood supply, impaired mucus production, bile or
pancreatic enzyme reflux from the duodenum, aspirin/NSAID or
alcohol consumption, colonization by H. pylori
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symptoms include - heartburn, indigestion, duodenal ulcers - well
localized midepigastric pain relieved by food. Pain usually returns
about 2 hours after ingestion of a meal or with eating oranges,
coffee, aspirin, or alcohol.
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Diagnosis is based on symptoms, upper endoscopy, barium
Proton Pump
Inhibitors
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inhibits gastric parietal cell
hydrogen-potassium ATPase
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PPIs work by entering a
parietal cell, becoming
activated in the lower pH
environment and then binding
to proton pumps inhibiting acid
secretion
H2 Blockers
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histamine 2 blockers are
named based on the type of
histamine receptor they affect
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they work by blocking
histamine 2 receptors on
parietal cells. These receptors,
when stimulated, increase
stomach acid secretion.
Zollinger-Ellison
Syndrome
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caused by tumors in the head
of the pancreas and/or upper
small intestine. Tumors
produce gastrin - “gastrinomas”
- cause an increase in stomach
acid production
Peptic Ulcer Disease
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Duodenal Ulcer
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relieved by eating
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symptoms return about 2 hours after a meal
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weight gain is a symptom
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Gastric Ulcer
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is not made better with food
Irritable Bowel Disease
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Ulcerative Colitis
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chronic inflammatory condition affecting the mucosa of the colon, begins lower - rectum and
sigmoid colon - and moves into the entire colon. Etiology is unknown though it is thought to
be related to an abnormal mucosal immune response related to food or bacteria. It occurs
in young women primarily. It is one of the diseases known to predominately affect those of
Ashkanazi Jewish descent.
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it can lead to nutritional deficiencies, perineal sepsis, anal fissures and fistulae, perirectal
abscess, toxic megacolon and coagulation deficit
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hallmark of the disease are recurrent bloody diarrhea attacks containing pus and mucus.
The patient can have upwards of 15 to 20 attacks of liquid bloody stools a day. It can lead to
hemorrhage, stricture and colonic perforation.
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People suffering from this disorder may also have joint inflammation, ankylosing spondylitis,
eye lesions, mouth ulcers, liver disease and pyoderma gangrenosum (necrotic tissue
generally in the lower extremities but can be present anywhere)
Ulcerative
Colitis
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diagnosis is made with at least a
sigmoidoscopy, if not colonoscopy
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showing increased mucosal
friability, decreased mucosal detail,
pinpoint hemorrhages, thick
inflammatory exudate. Bx helps
confirm
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Treatment is focused on controlling
inflammation. Antispasmotics and
antidiarrheals can cause extreme
dilation of the colon (toxic
megacolon) so are contraindicated
Crohn’s Disease
autoimmune inflammatory disease of the bowel
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Crohn’s Disease:
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also known as regional enteritis is an inflammation of any part of the GI tract usually the
proximal end of the colon but also the terminal illeum. The inflammation extends through
the entire intestinal wall. Granulomas are surrounded by normal tissue - multiple lesions
are called “skip lesions”
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autoimmune and genetic factors play a significant role in disease development. Lacteal
blockage in the intestinal wall leads to edema and inflammation, ulceration and stenosis.
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most prevalent in adults 20-40 again predominantly in Ashkanazi Jewish populations.
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Can lead to: anal fistula, perineal abscess, intestinal obstruction, nutritional deficiency
and peritonitis
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signs can be mild and nonspecific depending on lesion location. The acute symptoms
mimic appendicitis. Colicky right lower quadrant pain, cramping, tenderness, flatulence,
nausea, fever and diarrhea. Marked by weakness, fatigue, clubbing of the fingers,
weight loss and up to 4 episodes of diarrhea a day.
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Diagnosis
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barium enema showing segments of stricture and normal
bowel. Sigmoidoscopy or colonoscopy shows patchy
inflammation. Bx provides the definitive diagnosis
Treatment
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is focused on controlling the inflammatory process.
Steroids and immunomodulators are prescribed. Lifestyle
changes are necessary including adequate physical rest,
restricted diet, B12, elimination of dairy products. Surgery
can be used to correct perforation, fistulas and obstruction.
Irritable Bowel Syndrome
IBS
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is also called spastic colon or spastic colitis. Marked by chronic or periodic diarrhea
alternating with episodes of constipation and abdominal cramps.
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associated wit hpsychological stress but can result from physical factors like
hormonal changes and diverticular disease, lactose intolerance, laxative abuse and
foods like coffee and raw fruits and veggies.
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there is a higher incidence of people with IBS being diagnosed with colon cancer
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there is usually lower abdominal pain relieved by passing stool or gas, diarrhea that
occurs during the day alternating with constipation, dyspepsia and abdominal
distention may be present. More common in women than men.
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Diagnosis is made through a thorough history and rule-out of other disorders like
amebiasis, diverticulitis, colon cancer and lactose intolerance.
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Treatment focuses on relieving symptoms and counseling to help the patient
understand the relationship between stress and illness. Avoidance of food irritants
can be helpful but dietary restrictions otherwise do not seem to be beneficial.
Celiac Disease
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poor absorption and intolerance of the gluten protein present in wheat and
wheat products. The intestinal wall villi which are necessary for optimal
absorption of nutrients atrophy and there is a decreased amount and
activity of enzymes present on the epithelium.
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affects 1 out of every 133 people in the United States. Due to intramucosal
enzyme defect that causes an inability to digest gluten. The toxicity causes
increased cell turnover, increased epithelial lymphocytes and damage to
surface epithelium of the small intestine.
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Associated with DR3 and DQw2 two human leukocyte antigen halotypes,
often considered autoimmune in nature.
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associated with anemia, lactose intolerance, skin disorders like dermatitis
herpetaformis, type 1 diabetes, thyroid disease, down syndrome, infertility
and miscarriage, osteoporosis/osteopenia, autoimmune disorders
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can cause anemia due to malabsorption, syncope, heart failure and angina secondary to anemia, bleeding
disorders related to vitamin K deficiency, a higher incidence of intestinal lymphoma
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GI: steatorrhea, diarrhea, abdominal distention, stomach cramps, weakness, anorexia, malabsorption of all
macronutrients - protein, fat, carbohydrates, loss of fat soluble vitamins, calcium, minerals and electrolytes
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Hematologic: normochromic, hypochromic, macrocytic anemia due to poor absorption of folate, B12, iron.
Also, hypoprothrombinemia due to vitamin K malabsorption
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calcium and vitamin D malabsorption lead to osteomalacia, osteoporosis, tetany and bone pain
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peripheral neuropathy, seizures and paresthesias can result
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skin diseases like dry skin, eczema, psoriasis, acne rosacea can occur
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amenorrhea, hypometabolism, adrenocortical insufficiency in severe disease presentations
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mood changes and irritability
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Diagnosis:
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histologic changes present in small bowel on Bx
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Treatment:
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elimination of gluten for life, intestinal lining can return to normal after several months but may not
Meckel’s
Diverticulum
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a congenital anomaly where a blind
tube (like the appendix) opens near
the ileocecal valve. Occurs mostly in
males.
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Can be asymptomatic
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complicated forms cause abdominal
pain especially around the umbilicus,
dark red melena or hematochezia,
the lining is actually gastric mucosa
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it can cause peptic ulcers,
perforation, peritonitis and even
bowel obstruction
Inguinal Hernia
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when part of an intestine
protrudes through an opening in
the abdominal wall - here along
the anatomical inguinal canal.
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Either direct or indirect. A direct
inguinal hernia develops from a
weakness in the fascial floor of
the inguinal canal. An indirect
hernia the intestine leaves the
abdominal cavity and descends
through the inguinal ring following
the spermatic cord or round
ligament
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it can lead to incarceration or strangulation of the
bowel, intestinal obstruction and intestinal necrosis
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there is usually a lump over the area of herniation, the
lump normally disappears when the patient lies supine
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strangulation produces severe pain and can lead to
obstruction and necrosis
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physical exam reveals the swelling, palpation while
Valsalva is performed confirms
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Treatment: pushing by reducing, herniography
Intussusception
Volvulus
Inactive Colon
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lazy colon or colonic stasis, atonic constipation
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usually due to lack of one of three things - dietary bulk, fluid intake, exercise.
Common in bedridden people because of inactivity and relieved by fiber and
exercise. Can also be due to habitual disregard of need to defecate,
emotional conflict, chronic laxative use, dependence on enemas
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the primary symptom is chronic constipation
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history of dry, hard, infrequent stools. DRE reveals stool in the rectum and a
palpable colon. Barium enema, fecal occult blood
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treatment varies depending on presenting symptoms and underlying cause.
Increase fluids, add fiber. avoid fats, exercise, avoid over-use of laxatives
Pancreatitis
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acute and chronic forms can be due to edema, necrosis,
hemorrhage
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in men it is associated frequently with alcoholism, trauma, peptic
ulcers
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in women it is linked to biliary tract disease
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prognosis is good if related to biliary tract disease but poor when
related to alcoholism
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Acute pancreatitis increases in frequency as patient age
increases. It is most commonly associated with alcoholism and
biliary tract disease. It can be linked to as diverse causes as use
of glucocorticoids and viral infections or pregnancy.
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Complications include: DM (when islets of langerhans are involved), massive hemorrhage,
destruction of pancreas, shock, coma, adult respiratory distress syndrome, atelectasis,
pulmonary effusion, pneumonia, GI bleeding, pancreatic abscess
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the first and only symptom of mild pancreatitis is steady pain centered near the umbilicus
radiating to the back - between the 10th thoracic and lower lumbar vertebra, NOT alleviated
by vomiting.
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Severe attack - extreme pain, vomiting, abdominal rigidity, diminished bowel activity,
crackles in lung bases and left pleural effusion
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as it progresses - extreme malaise, restlessness, mottled skin, tachycardia, low grade
fever, diaphoresis
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diagnosis: PE, thorough patient history, assessment is difficult due to location of pancreas.
LABS - serum lipase elevated, fat necrosis causes decreased calcium, WBCs elevated,
high glucose levels
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treatment - maintain circulation and fluid levels, emergency treatment, analgesics,
antibiotics
Pilonidal
Disease
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a cyst forms in the intergluteal
cleft. It usually contains hair and
can become infected. Highest
incidence in men aged 18-30.
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congenitally acquired or due to
stretching of irritation of the
sacrococcygeal region (heavy
exercise, heat, perspiration and
constrictive clothing)
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asymptomatic until infected
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treatment: I and D, extraction of
protruding hairs, sitz baths,
Proctitis
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acute or chronic inflammation of the rectal mucosa. Can result in
discomfort, bleeding and possibly discharge and mucus or pus
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caused by STI, amebiasis, in children b-hemolytic strep can cause it,
autoimmune proctitis is associated with UC and Crohn’s, medications,
chemical agents
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Contributing factors: chronic constipation, habitual laxative use,
emotional upset, radiation, endocrine dysfunction, rectal injury, rectal
medication, bacterial infections, allergies - especially milk, food
poisoning
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symptoms: tenesmus, constipation, feeling of rectal
fullness, abdominal cramps, intense urge to defecate
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detailed patient history, sigmoidoscopy
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treatment focuses on alleviating the underlying cause
of the disorder
What do I need to know about
GI?
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it’ll be a good idea to know the general anatomy.
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What is necessary to absorb vitamin B12? Where is it produced? Where is B12 absorbed?
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how would you clinically differentially diagnose duodenal vs. gastric ulcer? What bacteria is commonly
the infective agent in Peptic ulcer disease?
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What are GERD red flags?
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What are the types of hiatal hernia? What is a dangerous possible side effect of paraesophageal hernia?
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What is the cause of Barrett’s esophagitis? What are the histologic changes? What can Barrett’s
esophagitis transform into?
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What causes esophageal varices? What is the danger present with esophageal varices?
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Be able to distinguish the difference between acute and chronic gastritis: histologically, causally,
symptomatically.
More to know...
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know what IBD is, know the two forms of IBD and how each is distinguished from the other including presentation,
labs and symptoms. Know methods of diagnosis eg. barium enema, barium swallow study, x-ray, biopsy...
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diverticulitis vs diverticulosis
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celiac disease presentation and histologic changes, the effects of the histologic changes on the patient system as a
whole
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Know IBS, causes and links between psychology and environment in relation to IBS. Symptomatic presentation.
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gallbladder and pancreas anatomy. Know the difference between acute and chronic pancreatitis presentation. The
two most common causes and the systemic effects of pancreatitis. Why can this be a medical emergency?
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signs and symptoms of stomach cancer and what are thought to be causes/links to cause?
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internal vs. external hemorrhoids
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causes of inactive colon - eg. over-use of laxatives
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symptoms of proctitis and contributing factors
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problems with pilonidal cysts