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Gastrointestinal DisordersChapter 4
The End of The
DigestiveSystem
THE DIGESTIVE TRACT
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)
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)
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.
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.
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!
WHAT ARE SOME SYMPTOMS OF
DIGESTIVE TRACT DISEASE?
Abdominal pain
Nausea
Vomiting
Diarrhea
Constipation
Dyspepsia
Gas
Belching
SYMPTOMS OF GI DISORDERS
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Melena
Hematochezia
Hematemesis
Dysphagia
Bloating
Anorexia
Ascites
Fatigue
PHYSICAL EXAM
Inspect
Auscultate bowel tones
Percussion
Palpation
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…
Endoscope - Upper
Endoscope: Lower
DIAGNOSTIC TESTS
X-ray
Ultrasound
CT
MRI
Chemistry tests: blood, urine, feces, gastric contens
Imaging Studies
Organization of Chapter
Mouth and Esophagus (- tracheoesophageal fistula
section)
Stomach, Intestine, pancreas
Anorectum
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
Disorders of the Esophagus
GERD
Tracheoesophageal fistula and esophageal atresia
Corrosive esophagitis and stricture
Mallory-Weiss Syndrome
Esophageal diverticula
Hiatal hernia
Apthous Stomatitis - Canker
sore
Herpes - Cold sore (herpetic
stomatitis)
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
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
Periodontitis - gingivitis
Vitamin deficiency, diabetics, OCPs,
painless, swollen; gums detach from teeth
trx with tooth cleaning and improved health status
Oral cancer
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
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
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
GERD
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)
Barrett’s Esophagitis
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
**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
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
Esophageal Varices
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
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
Mallory-Weiss Syndrome
Mild to Massive bleeding after forceful and prolonged
vomiting
Tear in cardia or Lower Esophagus
Mentioning because though rare, is fatal
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
Hiatal Hernia
Defective diaphragm
Portion of stomach passes into opening to chest
sliding and paraesophageal hernia
Strangulation of herniated portion can happen
Hiatal Hernias
Visceral Manipulation
MOVING ALONG THE GI TRACT…WE REACH THE
STOMACH
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)
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)
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
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
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
Ulcer Disease - Duodenal
Duodenal ulcers are relieved by eating
weight gain then ensues
a strange sensation of hot water bubbling in the back
of the throat
Attacks are 2 hrs after meals and with trigger foods
Bleeding can be fatal. Remember Jessie story
Dumping Syndrome
Associated with bolus of food stretching duodenum
and rapid gastric emptying
nausea, diaphoresis, weakness, flatulence, explosive
diarrhea, distention and palpitations about 30 minutes
after a meal
Avoid by having patient drink fluids between meal, lie
down after meals, don’t eat large meals and eat 6
small meals a day
INFLAMMATORY BOWEL DISEASE
(IBD)
Ulcerative colitis and Crohn’s Disease
Both are autoimmune, chronic lifelong illnesses
Ulcerative colitis affects only the large intestine
where it causes ulcerations and bleeding of the
mucosal lining.
Crohn’s affects the whole GI system from mouth to
anus and causes swelling, infection, narrowing of
the bowel with obstruction, and fibrosis of the
entire bowel wall.
IBD
Both UC and Crohn’s can cause abdominal pain,
cramping, bloody diarrhea, fecal urgency, weight
loss, anemia, fever, malaise/fatigue.
Crohn’s can cause fistulae (small tracts into the
surrounding tissue that contain pus and infection,
common at the anus  pain in the butt)
UC can cause other problems such as arthritis, eye
inflammation, and dermatitis. It also greatly
increases the risk of colon cancer. Folic acid
supplements can reduce this risk somewhat.
IBD
Dx: Sigmoidoscopy with biopsy of the mucosa to
diagnose UC. X-ray with barium can show
ulcerations, strictures, and fistulae associated with
Crohn’s. Endoscopy less helpful as it can’t look at the
small bowel.
IBD
Tx:
UC: high fiber diet, anti-diarrhea medications,
steroids (oral, rectal suppositories and rectal foam),
probiotics
Crohn’s: low lactose, low fiber, multivitamins,
mineral supplements, probiotics, steroids,
antibiotics, immunosuppressant drugs, surgery for
obstruction, abscess, fistulae
Celiac Disease
Gluten Enteropathy
Poor food absorption and intolerance to gluten
Intramucosal enzyme defect
Can cause anemia, heart problems, bleeding
disorders
Biopsy and Endomysial IgG and IgA
DIVERTICULOSIS
Common in Western countries due to low fiber diets.
Seen more in the elderly. (50% of people age 80 and
up)
The colon has to work too hard to move along small,
hard stools causing blow-outs in weakened, older
colonic tissue which has already lost its normal
elasticity due to age.
Most diverticulae are in the sigmoid colon.
DIVERTICULOSIS
Sx’s: Most people with diverticulae have no
symptoms (2/3).
Some have bleeding due to stretching and
breaking blood vessels in the bowel wall. (this is
the cause of HALF of all lower GI bleeds)
Diverticulitis is when infection begins inside the
out-pouching, and can cause perforation, abscess,
peritonitis with severe abdominal pain, fever, LLQ
tenderness (“reverse appendicitis”)
DIVERTICULOSIS
Dx: colonoscopy
Tx: Antibiotics for diverticulitis, high fiber diet to bulk
the stools, avoid small seeds (debatable point),
surgery if peritonitis or abscess, if recurrent
diverticulitis  remove the sigmoid colon
APPENDICITIS
Abd pain, fever,
anorexia, N/V
Pain starts diffusely or
peri-umbilical and then
localizes to RLQ
CT scan vs U/S
Surgery-laparoscopy
Complication: rupture
and peritonitis  sepsis
ABDOMINAL PAIN
LOCATION CAN HELP
ABDOMINAL PAIN
(DON’T FORGET NON-GI CAUSES)
RIGHT UPPER QUADRANT:
RIGHT LOWER QUADRANT:
LEFT UPPER QUADRANT:
LEFT LOWER QUADRANT:
ABDOMINAL PAIN
DIFFUSE:
PERI-UMBILICAL:
EPIGASTRIC:
WOMEN:
ELDERLY:
PAIN RADIATION PATTERNS
LOWER GI BLEED
Hemorrhoid
Fissure
Infection
Colon cancer/polyp
Diverticuli/diverticulitis
Ischemic gut
Inflammatory bowel disease
UPPER GI BLEED
Esophagitis
Gastritis
Esophageal cancer
Gastric cancer
Esophageal, stomach, or duodenal ulcer
Esophageal tear
Esophageal varices
Peritonitis
Acute Abdomen
Inflammation of the lining of the stomach
10% mortality
Other GI issues cause this
Intestinal Obstruction
Usually from adhesions and strangulated hernias
Simple, strangulated and closed-looped
Colicky pain, nausea, vomiting, constipation,
abdominal distention,
Intussusception
Telescoping bowel
Fatal if not treated
Most common in children
Volvulus
Twisted bowel
40-50% fatal
Can feel palpable mass with severe pain and vomiting
WHEN THE PANCREAS IS
UPSET...
Pancreatitis causes sudden, severe pain in the
epigastrium radiating to the back
Fever, altered consciousness, pain worse with
lying down and improved with sitting up or leaning
forward, nausea, vomiting, weak, anxious, sweaty
Who gets pancreatitis? People with gallstones,
alcoholics, trauma, viral infections including
mumps, reaction to medications, peptic ulcer
PANCREATITIS
Dx: Acute mid-epigastric tenderness, silent bowel
sounds. Amylase and lipase (on blood work) are
very high.
The pancreas can dissolve itself due to the release
of its own enzymes and can hemorrhage, and can
cause shock
Tx: nothing by mouth to quiet the GI system and
prevent stimulus to secrete enzymes, IV fluid and
food. Occasionally surgical removal of the
pancreas.
CHRONIC PANCREATITIS
Usually caused by alcoholism, but also CF
Chronic pain, malabsorption, nutritional deficiencies
STOMACH CANCER
The 2nd most common cancer worldwide (2nd to
skin cancer)
Less common in the US where spoiled food is less
common.
5 year survival is 10%
Strongly associated with H.pylori gastritis
STOMACH CANCER
Sx’s: severe epigastric pain, weight loss, weakness,
gastric obstruction with projectile vomiting after meals
Dx: endoscopy and biopsy
Tx: surgical removal of the stomach + chemotherapy.
Often when it is diagnosed it has spread
(metastasized) and surgery is palliative (to help
symptoms only, not to cure)
ANORECTUM
Hemorrhoids
Anorectal abscess and fistula- infections
Rectal Polyps
Pilonidal Abscess
Rectal Prolapse - not covering
Anal Fissure
Pruritis Ani
Proctitis
ANORECTUM
Hemorrhoids: engorged veins due to straining or
inflammation
Internal: nonpainful, can prolapse from the anus,
can cause blood streaking the stool, in the toilet
bowl, or seen when wiping
External: commonly seen in pregnancy, obesity,
constipation; blood clots can form inside them and
are VERY painful
HEMORRHOIDS
Dx: visual exam, anoscopy
Tx: Sitz baths, steroid creams, witchhazel, surgical
removal or banding
ANAL FISSURES
Splits of the anal mucosa which are inflamed.
Painful with bowel movements
Caused by straining and hard stools or due to
inflammation
Common in people with IBD and constipation
Tx: sitz baths, steroid ointment, high fiber diet or
supplements, BoTox
PRURITIS ANI
(ITCHY BUTT)
Can be quite intense
Very common
The itch you should not scratch
Allergy to soap or foods (chocolate, nuts, citrus, fruits,
berries, seafood, beer, coffee, vitamin C)
Too little or too much anal hygiene
Pinworms
Rectal Polyps
Masses of tissue that rise above mucosal membrane
and protrude into GI tract
asymptomatic
look for other conditions like familial polyposis
Proctitis
STD from anal intercourse is mostly the cause
Other factors are chronic constipation, laxative use,
emotional upset, endocrine issues, etc.
gonorrhea, herpes, chlamydia, anal-oral sex causes
amebiasis
symptoms are tenesmus, constipation, rectal fullness,
abd cramps on left side, intense sense of needing to
defecate and only small amount of fecal matter with
blood and mucous is produced.
Supportive treatment and antibiotics
Ulcerating proctitis with perirectal fistulas and abscess
Wow.
A PRETTIER END