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.