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Gastrointestinal Disorders

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Gastrointestinal Disorders

Gastrointestinal Disorders

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    • 1. Disorders of the Gastrointestinal System Orlando Regional Medical Center 2008
    • 2.  
    • 3. Intestinal Obstructions
    • 4. Intestinal Obstruction
      • Blockage of intestinal tract that inhibits passage of fluid, gas, feces
      • Caused by
        • mechanical obstruction ( strangulated hernia, adhesion, cancer, volvulus, intussusception )
        • neurogenic obstruction ( paralytic ileus, uremia, electrolyte imbalance(low K), spinal cord lesion )
        • Vascular disease ( occlusion of superior mesentery vessels)
    • 5. Intestinal Obstructions
      • Paralytic Ileus or “silent bowel” is most often seen after abdominal surgery & anesthesia
          • bowel activity is < due to lack of neural stimuli (“functional”)
          • this can lead to “mechanical” obstruction due to accumulation of feces
      • Hernias: a loop of bowel protrudes through abdominal wall
          • inguinal canal, umbilicus, or incisional scar tissue
          • caused by heavy lifting, straining, or coughing
    • 6. Sigmoid Volvulus
      • Sigmoid Volvulus (twisting): usually seen in the older individual with a history of straining at stool
        • Symptoms: abdominal distention, nausea, vomiting, and crampy abdominal pain; check history of flatus and BMs
        • Abrupt onset is indicative of an acute obstruction
        • Sudden onset due to “torsion or hernia?”
      • A chronic history of constipation is related to a dx of diverticulitis or carcinoma
      • Obstipation (no flatus or BM) & loss of weight = carcinoma
    • 7. Sigmoid Volvulus
    • 8. Intussusception
      • only 5-15 % occurrence in adults
      • s/s colicky abd pain, nausea, vomit, diarrhea, constipation
      • diagnosed by barium enema, CT scan
      • treated via surgical resection
    • 9. Intussusception
    • 10. Small Bowel Obstruction
      • “ Never let the sun rise or set on a small bowel obstruction.”
      • (surgical saying)
    • 11. Small Bowel Obstruction
      • Causes of SBO:
      • Adhesions (post-surgical, post-inflammatory)
      • Incarcerated hernia
      • Malignancy : usually metastatic
      • Intussusception
      • Volvulus
      • Gallstone ileus
      • Parasites
      • Foreign body
    • 12. Small Bowel Obstruction
      • Causes of small bowel obstruction include:
      • Adhesions from previous abdominal surgery
      • Hernias containing bowel
      • Crohn's disease causing adhesions or inflammatory strictures
      • Neoplasms benign or malignant
      • Intussusception in children
      • Volvulus
      • Superior mesenteric artery syndrome a compression of the duodenum by the superior mesenteric artery and the abdominal aorta
      • Ischemic strictures
      • Foreign bodies (e.g. gallstones in gallstone ileus, swallowed objects)
      • Intestinal atresia
      • Parasites
    • 13. Small Bowel Obstruction
      • Signs & Symptoms of Small Bowel Obstruction:
      •   Abdominal pain
      •  Vomiting
      •    Elimination problems (Diarrhea)
      •    Bloating
    • 14. Small Bowel Obstruction
      • The essentials:
      • * Common, may or may not require surgery
      • * Emergent, if bowel is strangulated (to OR)
      • * KUB not necessarily diagnostic
      • -Shows dilated loops, air-fluid levels
      • * CT very sensitive and specific
      • -Better at transitional zone, cause of SBO
    • 15. Small Bowel Obstruction
    • 16. Large Bowel Obstruction
      • A large bowel obstruction is an emergency condition that requires early & prompt surgical intervention
      • Etiology:
          • infectious / inflammatory, neoplastic, or mechanical pathology (colorectal cancer)
      • Rotation or twisting of the cecum or sigmoid colon will cause abrupt onset of symptoms
      • Immediate abdominal distention
        • Decreases the ability to absorb Fluids & Electrolytes
    • 17. Large Bowel Obstruction
      • Causes of large bowel obstruction include:
      • Neoplasms
      • Hernias
      • Inflammatory bowel disease
      • Colonic volvulus (sigmoid, caecal, transverse colon)
      • Fecal impaction
      • Colon atresia
      • Benign strictures (Diverticular Disease)
    • 18. Large Bowel Obstruction
      • Signs & Symptoms of Large Bowel Obstruction:
      •   Abdominal pain
      •  Vomiting ( not common )
      •    Elimination problems (Constipation or Loose)
      •    Bloating
    • 19. Large Bowel Obstruction
    • 20. When to Operate?
      • Incarcerated or strangulated hernia
      • Peritonitis
      • Pneumoperitoneum
      • Suspected strangulation
      • Closed loop obstruction
      • Complete obstruction
      • Virgin abdomen
      • LARGE bowel obstruction
    • 21. Gastrointestinal Disorders
    • 22. Diarrhea
      • Causes of Diarrhea
        • Osmotic : the presence of nonabsorbable substances in the intestine causing water to be drawn into the lumen by osmosis
          • sorbitol-containing liquid medications; tube feedings
          • lactose intolerance
        • Secretory : excessive mucosal secretion of fluid & electrolytes
          • related to: gastroenteritis (E. Coli), rotavirus, laxative abuse, hyponatremia, fecal impaction
    • 23. Intestinal Ulcers
    • 24. Peptic Ulcer Disease
      • An inflammatory disorder causing deep erosion of stomach or duodenal mucosa by HCL & pepsin
      • At risk: infection with H. pylori; > NSAIDS; > secretion of HCL as seen in Zollinger-Ellison syndrome
      • Etiology: age, family hx
        • > mucolytic enzymes; may lead to pyloric obstruction, bowel perforation and ultimately peritonitis
      • Sx: hallmark sign = upper gastric pain
        • Emergency: hematemesis, melena, occult blood, shock
    • 25. Peptic Ulcer Disease
      • Treatment includes:
        • < ETOH intake
        • screen for H. pylori (C-urea breath test)
        • frequent small meals
        • avoid calcium based antacids d/t > gastrin release
        • H2 blockers (Tagamet & Zantac)
        • Insert NG tube for severe bleeding and gastric lavage
    • 26. Bowel Disorders
      • Ulcerative Colitis
        • A disease that causes inflammation and sores in the lining of the large intestine.
      • Crohn’s Disease
        • A disease that causes inflammation in the small intestine, but it may affect any part of the GI tract.
        • Smoking, diet, and/or immune response to bacteria
    • 27. Gastric Cancer
      • Adenocarcinoma is the primary malignant neoplasm
        • Etiology:chronic inflammation, dietary influences, genetic & environmental factors
          • 8th leading cause of mortality r/t cancer in US
          • Epidemiology: 55-60 year olds; 2 times greater incidence in men vs. women
          • Risk factors: H. pylori, < socioeconomic class, consumption of pickled foods, improper food storage, radiation exposure
    • 28. Colorectal Cancer
      • “ Patients with long-standing ulcerative colitis have been shown to be at increased risk of developing colorectal cancer” (Medscape, 1999)
      • Involves a primary malignant tumor of the rectum or colon
          • 2nd leading cause of cancer death in US
          • > incidence in 50 year olds
          • > fat and poor fiber diet; > ETOH consumption; cigarette smoking; obesity; sedentary life style
      • Exact etiology unknown…> incidence with polyps
    • 29. Colorectal Cancer
      • Symptoms:
        • fecal occult blood or ulcerative lesions manifest as anemia or rectal bleeding
          • distention, abdominal pain, vomiting, constipation
        • metastatic disease: weight loss, anorexia, possible palpable mass
      • Prevention: ASA may < risk; routine monitoring for guaic (+)
      • Treatment: colostomy repair; permanent colostomy for rectal tumors
    • 30. Gastrointestinal Bleeding
    • 31. Terms of GI Bleeding
      • Hematemesis – vomiting of blood (or coffee ground material) (indicates bleeding proximal to the Treitz)
      • Melena – passage of black tarry stools > 50ml (indicates degradation of blood in the bowel)
      • Hematochezia (rectal bleeding) – passage of red blood
      • Occult Bleeding – bleeding that is not apparent to the patient and results from small amounts of blood
      • Obscure Bleeding – occult or obvious but source not identified
    • 32. Localization of GI Bleeding
      • Hematemesis – always UGI source
      • Melana – indicates that blood has been in GIT for extended periods
        • Mostly UGI
        • Small bowel
        • Right colon (if bleeding relatively slow)
      • Hematochezia
        • Mostly colon
        • Massive UGI bleeding (not enough time for degradation)
    • 33. GI Bleeding
      • Upper: includes the esophagus, stomach, duodenum
          • peptic ulcer disease (PUD) or esophageal varices
      • Lower: includes the jejunum, ileum, colon, rectum
          • colorectal cancer, polyps, hemorrhoids, IBD
      • Manifestations:
          • hematemesis
          • bright red blood in the stool (“ hematochezia ”)
          • black,dark, tarry stools (“ melena ”)
          • “ occult ” bleeding (invisible blood in the stool)
      • Treatment: find the underlying cause; fluid volume replacement; endoscopy or colonoscopy; medical and /or surgical therapy
    • 34. Acute UGI Bleeding Mallory-Weiss Tear
      • Mucosal laceration at the GEJ
      • 10% of cases
      • Typically follows retching but mostly on 1st vomit (75%)
      • 90% stop bleeding spontaneously
      • Endoscopic Therapy sometimes required
    • 35. Acute UGI Bleeding Portal Hypertension
      • Sources of bleeding:
        • Esophageal varices
        • Gastric varices
        • Portal hypertensive gastropathy
      • Urgent gastroscopy:
        • Sclerotherpay
        • Band ligation
      • Somatostatin
      • Balloon tamponade (Sengstaken-Blackmore tube)
    • 36. Acute UGI Bleeding Duodenal & Gastric Ulcer
      • Most common etiology of UGI bleeding
      • Duodenum>stomach
      • Predisposing factors for bleeding:
        • NSAID’s
        • Underlying medical conditions: IHD; cerebrovascular disease
        • Ethanol, anticoagulant Therapy
        • Hospitalization
    • 37. Acute UGI Bleeding Duodenal & Gastric Ulcer
      • Predisposing factors for bleeding cont.:
        • Gastric acid
        • H. Pylori: Role in bleeding not certain but definitely, eradication prevents rebleeding
        • Aspirin & NSAID’s:
    • 38. Duodenal & Gastric Ulcer
    • 39. UGI Bleeding Gastric Erosions
      • NSAID’s
      • Stress:
        • Serious trauma
        • Extensive burns
        • Major surgery
        • Major illness (ICU)
        • Major neurological disease (CVA, tumor, trauma)
      • Alcohol abuse
    • 40. UGI Bleeding Malignancy
      • Malignant:
        • Esophageal cancer
        • Gastric cancer or lymphoma
        • Small intestinal lymphoma or cancer
      • Benign:
        • Leiomyoma
    • 41. UGI Malignancy
    • 42. Lower GI Bleeds
      • Four most common causes of LGI bleeds
      • vascular ectasias
      • colonic diverticuli
      • neoplasm
      • internal hemorrhoids
    • 43. LGI bleeds - Other Causes
      • solitary rectal ulcer syndrome (SRUS)
      • colonic varicies
      • mesenteric vascular insufficiency
      • ischemic colitis
      • Meckel’s diverticulum
      • small intestinal ulceration
      • intussusception
      • radiation-induced injury
      • diversion colitis
      • mesenteric venous thrombosis
      • small bowel diverticuli
      • Dieulafoy lesion
      • vasculitis
      • long-distance running
      • endometriosis
    • 44. Acute Lower GI Bleeding
      • Initial management – similar to acute upper GI bleeding
      • Presentation: wide range of presentation:
        • Mostly self-limiting bleeding that does not require hospitalization
        • Rarely massive with hemorrhagic shock
    • 45. Acute Lower GI Bleeding Diverticulosis of the Colon
      • Common cause (25%)
      • Acute, painless, bright red, maroon or melena (depending on site)
      • May compromise hemodynamics (elderly)
      • Diagnosis: per exclusion
      • Significant recurrence
      • Treatment: most subside spontaneously, some need angiographic embolization or surgery
    • 46. Acute Lower GI Bleeding Colonic AV Malformation
      • Aka : Vascular Ectasias, Angiodysplasias, AV malformations
      • They are :
        • degenerative lesions of previously normal blood vessels located in the cecum and ascending colon
      • They are not :
        • telangiectasias, congenital defect, hemangiomas
    • 47. Acute Lower GI Bleeding Vascular Ectasias
      • the right colon is subjected to numerous colonic distentions that cause intermittent obstruction of the submucousal veins outflow tract leading to their dilation
    • 48. Vascular Ectasias - Treatment
      • 90 % stop spontaneously
      • 80 % of the remainder stop after IV or intra-arterial vasopressin
      • transcatheter embolization
      • laser
      • endoscopic sclerosis
      • heater probe
      • electrocoagulate
      • surgery
    • 49. Acute Lower GI Bleeding Angiodysplasia
      • Presentation:
        • Acute (recurrent)
        • Chronic
        • Occult
      • Older pts (mainly>70)
      • High association with CRF
      • Most – right colon
    • 50. Acute Lower GI Bleeding Angiodysplasia
      • Diagnosis:
        • Colonoscopy
        • Angiography
      • Treatment:
        • Electrocoagulation
        • Injection
        • LASER
        • Surgery
    • 51. Angiodysplasia
    • 52. Acute Lower GI Bleeding Hemorrhoids
      • Most common cause
      • Presentation:
        • recurrent low-volume bright red blood on the paper or on stool
        • Straining aggravates bleeding
        • Rarely associated with anemia (acute or chronic)
      • Never relate bleeding to hemorrhoids before exclusion of other lesions
    • 53. Lower GI Bleeding Mesenteric Vascular Occlusion
      • Vascular insufficiency - occlusive vs. non
      • 75 % from mesenteric a. emboli
      • usu. elderly presenting as acute abd pain, concomitant heart disease, spontaneous GI bleed, pain out-of-proportion with the PE
      • mortality 50 - 90 %
      • diagnosed by arteriography
      • treated by emergent ex lap
    • 54. Acute Lower GI Bleeding Other Causes
      • Meckel’s diverticulum
      • Infectious colitis: Shigella; Salmonella; campylobacter
      • Radiation proctitis
      • Ischemic colitis
      • IBD – colitis (UC;CD)
    • 55. Acute Lower GI Bleeding
      • Evaluation of source:
      • History:
        • Age (tumors & diverticular disease more common in elderly pts; IBD more common in young)
        • HIV (CMV colitis)
        • NSAID’s
        • Family or personal Hx of polyps or CRC
        • Change in bowel habits
        • Pain (in IBD, ischemic colitis…); Anal pain
        • Previous abdominal irradiation
        • Previous surgery (particularly vascular)
        • ASCVD (ischemic colitis)
    • 56. Acute Lower GI Bleeding
      • Diagnostic procedures:
        • Colonoscopy
        • Tagged RBC Scintigraphy – low predictive value
        • Angiography + Embolization
        • Surgery (rare)
    • 57.
      • Effectiveness:
        • Localization of bleeding site: : 57-72%
        • Reduced operative mortality: : 9-14% vs.. 37-50%
      Angiography
    • 58. Transcatheter Embolization
      • • Initial control: 71 -100%
      • • Rebleed rate : 0-12%
      • • Ischemia: 0-21%
    • 59. Occult bleeding
      • Diagnosis:
        • Imaging of the colon:
          • Colonoscopy
          • DC barium enema
          • CTC
        • Gastroscopy
        • Small bowel follow-through
        • Video-capsule
    • 60. GI Bleeding
      • Do Not Underestimate GI Bleeding
        • Don’t assume anything
      • Do Not Ignore Bright Red Bleeding
        • Monitor VS
        • Don’t assume anything
      • Do Not Overreact to GI Bleeding
        • Monitor VS
      • Do Report GI Bleeding
        • Don’t assume anything
    • 61. References
      • Fundamentals of Diagnostic Radiology, 2nd edition (1999). Brant, William E. & Helms, Clyde A., eds. Williams and Wilkins, Baltimore MD.
      • Delabrousse, E., Destrumelle N., Brunelle S., Clair C., Mantion G., Kastler B. (2003) CT of small bowel obstruction in adults. Abdominal Imaging 28(2): 257-266.
      • www.uptodate.com: Clinical manifestations and diagnosis of small bowel obstruction; Treatment of small bowel obstruction; Abdominal wall and groin hernias.
      • Hansen, M. (1998). Pathophysiology: Foundations of disease and clinical intervention. Philadelphia: Saunders.
      • http://www.medscape.com
      • Givens BA, Simmons SJ: Gastroenterology in Clinical Nursing. 4th ed. St. Louis, Mo: C.V. Mosby Co, 1984. 
      • Ripamonti C, Bruera E: Palliative management of malignant bowel obstruction. Int J Gynecol Cancer 12 (2): 135-43, 2002 Mar-Apr.  [PUBMED Abstract]
      • Potluri V, Zhukovsky DS: Recent advances in malignant bowel obstruction: an interface of old and new. Curr Pain Headache Rep 7 (4): 270-8, 2003.  [PUBMED Abstract]
      • Baron TH: Expandable metal stents for the treatment of cancerous obstruction of the gastrointestinal tract. N Engl J Med 344 (22): 1681-7, 2001. PUBMED Abstract]
      • Mercadante S: Assessment and management of mechanical bowel obstruction. In: Portenoy RK, Bruera E, eds.: Topics in Palliative Care. Volume 1. New York, NY: Oxford University Press, 1997, pp. 113-30. 
    • 62. References
      • Givens BA, Simmons SJ: Gastroenterology in Clinical Nursing. 4th ed. St. Louis, Mo: C.V. Mosby Co, 1984. 
      • Ripamonti C, Bruera E: Palliative management of malignant bowel obstruction. Int J Gynecol Cancer 12 (2): 135-43, 2002 Mar-Apr.  [PUBMED Abstract]
      • Potluri V, Zhukovsky DS: Recent advances in malignant bowel obstruction: an interface of old and new. Curr Pain Headache Rep 7 (4): 270-8, 2003.  [PUBMED Abstract]
      • Baron TH: Expandable metal stents for the treatment of cancerous obstruction of the gastrointestinal tract. N Engl J Med 344 (22): 1681-7, 2001.  PUBMED Abstract] Mercadante S: Assessment and management of mechanical bowel obstruction. In: Portenoy RK, Bruera E, eds.: Topics in Palliative Care. Volume 1. New York, NY: Oxford University Press, 1997, pp. 113-30. 

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