Gastrointestinal system

Part I

Function of G I system
 The Primary Digestive Functions are 1. Break down food particles to absorbable forms 2. Absorb the small molecules into the bloodstream 3. Eliminate waste products & undigested food

Impaired Esophageal Motility (Achalasia)

 Achalasia: characterized by impaired peristalsis
of smooth muscle of esophagus and impaired relaxation of lower esophageal sphincter

 Manifestations:
1. 2. 3. 4. Dysphagia chest pain (pyrosis) Sensation of food stick in lower esophagus Food regurgitation

Gastroesophageal Reflux Disease (GERD)

Gastroesophageal reflux is the backward flow of gastric content into the esophagus

Gastroesophageal Reflux Disease (GERD)

2. Pathophysiology  a. Gastroesophageal reflux results from transient relaxation or incompetence of lower esophageal sphincter, or increased pressure within stomach  b. Factors contributing to Gastroesophageal reflux 1.Increased gastric volume (post meals) 2.Position pushing gastric contents close to Gastroesophageal juncture (such as bending or lying down) 3.Increased gastric pressure (obesity or tight clothing) 4.Hiatal hernia

Gastroesophageal Reflux Disease (GERD)

Manifestations
1. Heartburn after meals, while bending over, or recumbent 2. Dyspepsia or indigestion 3. Regurgitation of sour materials 4. Atypical chest pain 5. Sore throat with hoarseness

Hiatal Hernia
 Part of stomach protrudes through the esophageal hiatus of the diaphragm into thoracic cavity  Types 1. Sliding hiatal herni 2. Paraesophageal hiatal hernia: ( hernia can become strangulated; may develop gastritis with bleeding)

Gastritis
1. Definition: Inflammation of stomach lining from irritation of gastric mucosa. 2. Types:  A. Acute Gastritis: Disruption of mucosal barrier allowing hydrochloric acid and pepsin to have contact with gastric tissue: leads to irritation, inflammation, superficial erosions.  Gastric mucosa rapidly regenerates (self-limiting disorder)  B.Chronic Gastritis: Progressive disorder beginning with superficial inflammation and leads to atrophy of gastric tissues (prolong Gastritis)

Gastritis
Causes of acute gastritis
 a. Irritants include aspirin and other NSAIDS, corticosteroids, alcohol, caffeine
 b.Ingestion of corrosive substances: acid

 c.food contamination (microorganisms)

Manifestations
 Epigastric discomfort  abdominal pain, nausea, vomiting  Heart burn , &sour taste in mouth  If perforation occurs, signs of peritonitis

gastritis

Peptic Ulcer Disease (PUD)

Definition:  Break in mucous lining of GI tract comes into contact with gastric juice , referred to as gastric ,duodenal , or esophageal ulcer

Peptic Ulcer Disease (PUD)

2. Pathophysiology  a. Acute Ulcers or breaks in mucosa of GI tract occur with 1.H. pylori infection (spread by oral to oral, fecal-oral routes) damages gastric epithelial cells reducing effectiveness of gastric mucus 2.Use of NSAIDS: interrupts prostaglandin synthesis which maintains mucous barrier of gastric mucosa  b. Chronic with spontaneous remissions and exacerbations associated with trauma, infection, physical or psychological stress

Peptic Ulcer Disease (PUD)

Manifestations  Pain is classic symptom: burning, occurs when stomach is empty (pain: food: relief pattern)  Vomiting , nausea , constipation &diarrhea  presenting symptom may be complication: GI hemorrhage or perforation of stomach or duodenum

Peptic Ulcer Disease (PUD)

 Treatment
 1. 2. 3.   
Pharmacologic therapy H2 receptor antagonist Proton pump inhibitors Antacid Stress Reduction & Rest Smoking Cessation Dietary Modification

Acute Inflammatory Intestinal Disorders (Appendicitis)

Pathophysiology:  Obstruction of the appendix lumen by faecolith, enlarged lymph node, worms, tumour, brings about a raised intra-luminal pressure, which causes the wall of the appendix to become distended. invasion by bacteria found in the gut normally.  Clinical Manifestations  Rt Lower Quadrant pain, Fever, nausea , vomiting anorexia, tenderness, rebound tenderness.  Complications:  perforation peritonitis or abdominal abscess ,occurs after 24 hrs after onset of symptoms

Irritable Bowel Syndrome (IBS)

Definition  a. Functional GI tract disorder without identifiable cause characterized by abdominal pain and constipation, diarrhea, or both  b. Affects up to 20% of persons in Western civilization; more common in females

Irritable Bowel Syndrome (IBS)

Pathophysiology  a. Appears there is altered CNS regulation of motor and sensory functions of bowel 1.Increased bowel activity in response to food intake, hormones, stress 2.Increased sensations of chyme movement through gut 3.Hypersecretion of colonic mucus  b. Lower visceral pain threshold causing abdominal pain and bloating with normal levels of gas  c. Some linkage of depression and anxiety

Irritable Bowel Syndrome (IBS)

Manifestations  a. Abdominal pain relieved by defecation  b. Altered bowel habits, abdominal bloating, excess gas  c. Nausea, vomiting, anorexia, fatigue, headache, anxiety  d. Tenderness over sigmoid colon upon palpation

Peritonitis
Inflammation of peritoneum, lining that covers abdominal wall (parietal peritoneum) and organs of abdominal cavity (visceral peritoneum)

Peritonitis
Pathophysiology:  a. Peritonitis results from contamination of normal sterile peritoneal cavity with infections or chemical irritant.  b. Release of bile or gastric juices initially causes chemical peritonitis; infection occurs when bacteria enter the space.  c. Bacterial peritonitis usually caused by these bacteria (normal bowel flora): Escherichia coli, Klebsiella, Proteus, Pseudomonas.  d. Inflammatory process causes fluid shift into peritoneal space (third spacing); leading to hypovolemia, then septicemia.

Peritonitis
3. Manifestations  Presents with acute abdomen 1.Abrupt onset of diffuse, severe abdominal pain 2.Pain may localize near site of infection 3.Intensifies with movement  Entire abdomen is tender with board like rigidity  paralytic ileus  Systemically: fever, malaise, tachycardia.

Inflammatory Bowel Disease

Includes:  Ulcerative colitis  Crohns disease.

Ulcerative Colitis
Pathophysiology  1. Inflammatory process usually confined to rectum and sigmoid colon  2. Inflammation leads to mucosal hemorrhages and abscess formation, which leads to necrosis and sloughing of bowel mucosa  3. Mucosa becomes red, friable, and ulcerated; bleeding is common  4. Chronic inflammation leads to atrophy, narrowing, and shortening of colon Manifestations  Bloody Diarrhea with mucus

Ulcerative Colitis

Crohns Disease (regional enteritis)

Pathophysiology  1. Affect any portion of GI tract, but terminal ileum and ascending colon are more commonly involved  2. Inflammatory ulceration of mucosa and submuscosa develops into ulcers and fissures that involve entire bowel wall  3. Fibrotic changes occur leading to local obstruction, abscess formation and fistula formation  4. Fistulas develop between loops of bowel, bowel & bladder and bowel & skin.  5. Absorption problem (protein loss and anemia)

Crohns Disease

Intestinal Obstruction
Definition  a. May be partial or complete obstruction  b. Failure of intestinal contents to move through the bowel lumen; most common site is small intestine

Intestinal Obstruction
Pathophysiology a. Mechanical 1. Problems outside intestines: adhesions (bands of scar tissue), hernias 2. Problems within intestinal wall: tumors 3. Obstruction of intestinal lumen (partial or complete)  a. Intussusception: telescoping bowel  b. Volvulus: twisted bowel  c. Foreign bodies

Volvulus

Intussusception

Adhesions

Intestinal Obstruction
Functional 1. Failure of peristalsis to move intestinal contents: (paralytic ileus, ileus) due to neurologic or muscular impairment 2. Causes include  a. Post gastrointestinal surgery  b. Tissue anoxia or peritoneal irritation from hemorrhage, peritonitis, or perforation  c. Hypokalemia  d. Medications: narcotics, anticholinergic drugs, antidiarrheal medications  e. Renal colic, spinal cord injuries, uremia

Intestinal Obstruction
Manifestations Small Bowel Obstruction b.Colicky abdominal pain c. Vomiting  1. Proximal intestinal distention stimulates vomiting center  2. Distal obstruction vomiting may become feculent d.Bowel sounds  1. Mechanical obstruction: borborygmi may have visible peristaltic waves  2. Paralytic ileus, diminished or absent bowel sounds e. Signs of dehydration