Author(s): Rebecca W. Van Dyke, M.D., 2012License: Unless otherwise noted, this material is made available under the terms...
Attribution Key                   for more information see: http://open.umich.edu/wiki/AttributionPolicyUse + Share + Adap...
M2 GI Sequence     A GI Smorgasbord:  Common GI Problems – Part I              Rebecca W. Van Dyke, MDWinter 2012
Industry Relationship         Disclosures Industry Supported Research and       Outside Relationships• None
Topics•   Hiatal hernia•   Gas•   Constipation•   Diverticuli/Diverticulitis•   Hemorrhoids
Hiatal Hernia        James Heilman, M.D., Wikimedia CommonsA large hiatus hernia on X-ray marked by open arrows incontrast...
Hiatal hernia: extremely common                            Schematic diagram of different types of                        ...
Views of a Hiatal Hernia                      Esophagus                      Gastric                      mucosa in       ...
Radiologic evidence of    hiatal hernia
Consequences of Hiatal Hernia       • Benign       • Usually asymptomatic       • May predispose to         development of...
Gas
Gas Facts• Gas is a normal constituant of the GI tract• Bowel sounds are due to turbulent flow/  mixing of liquid and gas ...
Origin of Intestinal GasInput:                     H2S                                                          NO2  Air s...
Normally, gas does not accumulate in thebowel as it is rapidly passed through the GI                     tract.           ...
Thus, usuallythere is only amodest amountof gas in theGI tract (~200 ml)at any one time. This is a normal gas pattern
Some patientsdo have toomuch gas, dueto:                 Colon  obstruction  dysmotility    (ileus)This patient           ...
Excess gas in colon - much less in small bowel
Gas Symptoms• However, most people with “gas”  symptoms have normal amounts of gas in  the GI tract• Instead they have sen...
“GAS” symptoms: commoncomplaints of many patients     • Bloating     • Belching     • Enlarged abdomen     • Excess flatus
Many Causes of BloatingAbnormal viscerosomatic                               Mucosal immuneReflexes/abdomino-phrenic      ...
The typicalnormal gaspattern seenin most patientswith “excessgas” complaints
Most Common Cause of           Bloating• Sense of overdistension of stomach or  bowels  – Abnormal sensation with normal v...
Bloating Perception and Response        of Abdominal Wall                                                     Figure. Abdo...
By contrast: a patient with bowel   obstruction or dysmotility
Patient-initiated Treatment:          Eructation/BelchingPatients feel “full” or “bloated”Common response = belchEructatio...
Belching/Eructation FactsIn the supine position, patients cannot belchas liquid forms a water seal between gastric gasand ...
Belching Can Worsen Symptoms                                    31. Patients feel “full” or      2  “bloated”2. However, p...
Better Rx: Decrease Input• Air swallowing accounts for virtually all air      in the upper GI tract• Occurs during eating,...
Other Gas Symptoms• Enlarged abdomen: “my belly sticks out”  – Due to reflex relaxation of anterior abdominal    muscles• ...
Lower Gas Symptoms: Flatus• Normal process – 5-20 times per day• Increased by  – Changes in air/gas intake (air swallowing...
Foods Can Cause Flatus: Plants make many interesting compounds• Fruit juices, sodas  – fructose, sorbitol• Cruciferous veg...
Treatment of “Gas”: Poor Evidence•   Reassurance•   Reduce air swallowing and suppress belching•   Promotility agents (met...
Constipation• Definition  – <3 stools per week  – Hard stool, difficult to pass  – Straining, sensation of incomplete evac...
Constipation: Pathophysiology - I• Liquid material enters cecum from ileum• Colon’s job:  – Reabsorb electrolytes (Na, Cl,...
Constipation: Pathophysiology - II• Slow colon transit   – Motility decrease (diabetes, hypothyroidism)   – Drugs (narcoti...
Constipation: Pathophysiology - III• Insufficient bile acids or endogenous pro-  secretory or osmotically active compounds...
Enterohepatic Circulation of Bile Acids:         recycling is efficient   Bile acid   synthesis                           ...
Enterohepatic Circulation of Bile Acid                                   Cholestyramine: Bile acid                        ...
Constipation: Rx• Alter underlying factors if possible• Add fiber – start slow (1-2 T/day) and increase weekly    – High f...
Constipation: Myth Busting• Having 1 stool a day is not required for  health  – Normal range is 1 every 3 days up to 3/day...
Diverticuli of the Colon: A phenomenon  of aging and ? too little dietary fiber?
Opening of diverticulum as seen fromthe lumen of the colon.
Saccular Colonic DiverticuliVery large diverticuli in a woman with scleroderma. She had undergone a bariumswallow study on...
Diverticuli
Complications of Diverticuli• Stool/particulate matter accumulates in the  diverticulum• Mucosa inside diverticulum ulcera...
Diverticulitis: if a perforationoccurs, the contents can travel.                                    The usual             ...
Diverticular perforation - outcomes                               Abscesses canLocal, confined                erode into n...
DiverticulitisA 70-year-old, previously healthy man had had sudden, colicky lower abdominal pain and                      ...
DiverticulitisThickening of colon wall in region of inflammation  Compression of colon lumen by inflammation
Diverticuli can bleed
Diverticular bleeds are arterial – thus bleeding is oftenmassive. Since most diverticuli are in the distal colon,         ...
Myth Busting: Diverticulitis•   Clinical teaching states that patients with diverticuli should avoid nuts,    seeds, popco...
Hemorrhoids: they have been    around a long time.      Illuminated manuscript from 1190-1198
Anal Anatomy                                                        No                                                    ...
Pathophysiology: Hemorrhoidal              Disease• Vascular basis   – cushions of soft tissue with large vascular channel...
Appearance               WikipedianProlific, Wikimedia CommonsInternal: above the dentate line – not painful unless prolap...
Visual inspection makes the          diagnosis       Large external hemorrhoids                   or severely prolapsed in...
Prolapsed Internal Hemorrhoid
Internal hemorrhoids - view from         the endoscope                          Bleeding
Complications of Hemorrhoids• Pain/irritation/discomfort  – prolapsed internal hemorrhoids  – ulcerated or thrombosed exte...
Medical Management:       Little Evidence-Based Therapy• To prevent or reduce hemorrhoids:   – Soften stool, reduce strain...
Treatment of Hemorrhoids  1 – Sclerosis-internal  2 – Banding - internal  3 – Infrared photocoagulation - internal  4 – Su...
Rubber band ligation
Part II will be on Thursday, February 9 at 11:10 a.m.
Additional Source Information                              for more information see: http://open.umich.edu/wiki/CitationPo...
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02.06.12(b): A GI Smorgasbord - Common GI Problems part I

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  • Figure 1. A 70-year-old, previously healthy man had had sudden, colicky lower abdominal pain and increased urinary frequency for four days. He had marked suprapubic tenderness but no other abnormal physical findings. There was mild leukocytosis and a slight leftward shift; the results of urinalysis were unremarkable. A computed tomographic (CT) scan of the pelvis obtained on the first hospital day (Panel A and adjacent sketch) shows thickening of the sigmoid colon (thick arrows). The dark areas represent gas in the lumen, and the white areas represent contrast material. The small dark areas (thin arrows) represent gas in diverticula. A low-pressure barium enema (Panel B) performed on the same day revealed moderate narrowing of the distal sigmoid colon due to mucosal thickening and spasm (curved arrows), corresponding to the CT findings, and multiple diverticula in the proximal sigmoid colon (arrows). Within 48 hours of the initiation of therapy with metronidazole and clindamycin, the patient&apos;s pain, tenderness, and urinary frequency decreased. Three weeks later, when he was symptom-free, flexible sigmoidoscopy, carried out because of his concern about cancer, revealed wide-mouth diverticula with normal mucosa (Panel C). The patient remained well during 15 months of follow-up.
  • 02.06.12(b): A GI Smorgasbord - Common GI Problems part I

    1. 1. Author(s): Rebecca W. Van Dyke, M.D., 2012License: Unless otherwise noted, this material is made available under the termsof the Creative Commons Attribution – Share Alike 3.0 License:http://creativecommons.org/licenses/by-sa/3.0/We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use,share, and adapt it. The citation key on the following slide provides information about how you may share and adapt thismaterial.Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions,corrections, or clarification regarding the use of content.For more information about how to cite these materials visit http://open.umich.edu/education/about/terms-of-use.Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or areplacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to yourphysician if you have questions about your medical condition.Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
    2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicyUse + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation LicenseMake Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
    3. 3. M2 GI Sequence A GI Smorgasbord: Common GI Problems – Part I Rebecca W. Van Dyke, MDWinter 2012
    4. 4. Industry Relationship Disclosures Industry Supported Research and Outside Relationships• None
    5. 5. Topics• Hiatal hernia• Gas• Constipation• Diverticuli/Diverticulitis• Hemorrhoids
    6. 6. Hiatal Hernia James Heilman, M.D., Wikimedia CommonsA large hiatus hernia on X-ray marked by open arrows incontrast to the heart borders marked by closed arrows
    7. 7. Hiatal hernia: extremely common Schematic diagram of different types of hiatus hernia. Green is the esophagus, red is the stomach, purple is the diaphragm, blue is the HIS-angle. A is the normal anatomy, B is a pre-stage, C is a sliding hiatal hernia, and D is a paraesophageal type. Wikipedia
    8. 8. Views of a Hiatal Hernia Esophagus Gastric mucosa in hernia Diaphragm indentationView from esophagus View from stomachinto hernia back up into hiatal hernia
    9. 9. Radiologic evidence of hiatal hernia
    10. 10. Consequences of Hiatal Hernia • Benign • Usually asymptomatic • May predispose to development of acid reflux (and complications) • Rarely, gastric ulcers develop within hiatal hernia
    11. 11. Gas
    12. 12. Gas Facts• Gas is a normal constituant of the GI tract• Bowel sounds are due to turbulent flow/ mixing of liquid and gas in the tubular intestines• What goes in must come out• Everyone passes flatus many times per day but most people are not aware of most of these passages• Most people pass gas (infused into the GI tract) very rapidly
    13. 13. Origin of Intestinal GasInput: H2S NO2 Air swallowing trace gases O2 Acid neutralization + H2 CO2 Bacterial CO2 H+ + HCO fermentation, CH4 - = CO 3 CO2 2 H2 metabolism O2 CHO CH4Output: Eructation Diffusion (lungs) Flatus N2, O2, H2, CO2, CH4, trace gases
    14. 14. Normally, gas does not accumulate in thebowel as it is rapidly passed through the GI tract. 30 ml/min 12 ml/min 4 ml/min
    15. 15. Thus, usuallythere is only amodest amountof gas in theGI tract (~200 ml)at any one time. This is a normal gas pattern
    16. 16. Some patientsdo have toomuch gas, dueto: Colon obstruction dysmotility (ileus)This patient Smallhas excess gas bowelin bothcolon andsmall bowel, dueto profound ileusand continuedinput fromair swallowing.
    17. 17. Excess gas in colon - much less in small bowel
    18. 18. Gas Symptoms• However, most people with “gas” symptoms have normal amounts of gas in the GI tract• Instead they have sensations of increased gut distension and/or increased flatus• True increases in gas (and symptoms) ususally arises from: – Excess air swallowing – Excess bacterial fermentation of carbohydrate
    19. 19. “GAS” symptoms: commoncomplaints of many patients • Bloating • Belching • Enlarged abdomen • Excess flatus
    20. 20. Many Causes of BloatingAbnormal viscerosomatic Mucosal immuneReflexes/abdomino-phrenic activationdyscoordination Food sensitivity/Altered gut flora/ food intoleranceAbnormal colonicfermentation Gender/ sex hormonesExcessive gas/ Bloatingfocal or generalGI gas accumulation/ Abdominal distention CNS-ENSabnormal gas handling dysregulation/ psychological factorsVisceralhypersensitivity Altered motility Abnormal visceral Constipation/ reflexes hard stools
    21. 21. The typicalnormal gaspattern seenin most patientswith “excessgas” complaints
    22. 22. Most Common Cause of Bloating• Sense of overdistension of stomach or bowels – Abnormal sensation with normal volume of gas – ?Due to poor “compliance” of stomach/gut – Triggers eructation/belching – Abdominal muscles relax leading to increased abdominal girth
    23. 23. Bloating Perception and Response of Abdominal Wall Figure. Abdominal imaging in a patient with functional gut disorder. Note anterior abdominal wall protrusion and diaphragmatic descent during bloating compared with basal with only a small increase (by 22 mL) in gas content. Accarino et al. Gastroenterology 136:1544, 2009
    24. 24. By contrast: a patient with bowel obstruction or dysmotility
    25. 25. Patient-initiated Treatment: Eructation/BelchingPatients feel “full” or “bloated”Common response = belchEructation may release some gastric gas
    26. 26. Belching/Eructation FactsIn the supine position, patients cannot belchas liquid forms a water seal between gastric gasand esophagus.
    27. 27. Belching Can Worsen Symptoms 31. Patients feel “full” or 2 “bloated”2. However, prior to belch, patient swallows additional air3. The LES relaxes, releasing air4. Net volume of air in GI tract may increase.5. Bloating sensation may continue or even worsen.
    28. 28. Better Rx: Decrease Input• Air swallowing accounts for virtually all air in the upper GI tract• Occurs during eating, drinking, talking and dry swallows• Can be reduced by – Reduce belching/eructation – Using straw – Tilt glass/cup so fluid is above upper lip – Not chewing gum, sucking on candies• “Gas” from carbonated drinks plays a minor role in most people
    29. 29. Other Gas Symptoms• Enlarged abdomen: “my belly sticks out” – Due to reflex relaxation of anterior abdominal muscles• Rx: – reassure patient – loosen clothes
    30. 30. Lower Gas Symptoms: Flatus• Normal process – 5-20 times per day• Increased by – Changes in air/gas intake (air swallowing) – Intake of foods containing undigestible carbohydrates (remember lactose) – Carbohydrate malabsorption (disease) – Altered bacterial flora • Some individuals do pass excess and/or especially malodorous flatus, likely due to variations in colon bacterial flora• Noxious flatus involves sulfer-containing compounds (onions, meat, cabbage etc.)
    31. 31. Foods Can Cause Flatus: Plants make many interesting compounds• Fruit juices, sodas – fructose, sorbitol• Cruciferous vegatables (cabbage family) – sulfur-containing compounds (odoriferous gas)• Beer (sulfer compounds)• Legumes (dried beans) – melitose, stachyose, raffinose• Sugar-free gums/candies – sorbitol, mannitol• Milk – lactose
    32. 32. Treatment of “Gas”: Poor Evidence• Reassurance• Reduce air swallowing and suppress belching• Promotility agents (metoclopramide)• Agents that alter gas bubble surface tension (simethicone)• Identify and eliminate intake of poorly absorbed carbohydrates/other foods associated with gas• Alter bacterial flora (lactobacillus or yeast “probiotics”)• Bismuth subsalicylate (Pepto-Bismol) or zinc for H2S• Consider evaluation for malabsorptive disorders
    33. 33. Constipation• Definition – <3 stools per week – Hard stool, difficult to pass – Straining, sensation of incomplete evacuation• Prevalence (self-perceived): 10-20%• Occasional constipation is a part of normal life for most humans
    34. 34. Constipation: Pathophysiology - I• Liquid material enters cecum from ileum• Colon’s job: – Reabsorb electrolytes (Na, Cl, K) and water – Salvage nutrients, utilizing bacterial fermentation – Move material, in a timely manner, to rectum for appropriate defecation• Constipation or diarrhea usually reflect imbalances in these functions
    35. 35. Constipation: Pathophysiology - II• Slow colon transit – Motility decrease (diabetes, hypothyroidism) – Drugs (narcotics, Ca channel blockers, anticholinergics, Ca/Al antacids, cholestyramine) – Idiopathic• Increased bowel Na/H2O absorption (?)• Insufficient fiber - ?”natural laxative” – Unabsorbed complex carbohydrate – Increases stool bulk – Fermented to osmotically active compounds • adds water to stool – May stimulate colon motility
    36. 36. Constipation: Pathophysiology - III• Insufficient bile acids or endogenous pro- secretory or osmotically active compounds• Defecatory problems – Anal sphincter – Pelvic floor dysfunctions• Psychological factors/eating disorders
    37. 37. Enterohepatic Circulation of Bile Acids: recycling is efficient Bile acid synthesis Bile acids cycle between the liver and the small intestine.Liver Total bile acid pool is about 3 grams. About 90% of bile acids are reabsorbed in the terminal ileum. However about 5-10% of bile acids are lost daily into the colon. Effect? Liver synthesizes about Small bowel 5-10% of the total bile acid Colon pool each day.
    38. 38. Enterohepatic Circulation of Bile Acid Cholestyramine: Bile acid bile acid binding resin synthesis that removes bile acids from the enterohepatic circulationLiver Liver upregulates bile acid synthesis (using up what compound in the process?) If liver cannot keep up, what happens? Less free bile acid in the colon causes what? Small bowel Colon
    39. 39. Constipation: Rx• Alter underlying factors if possible• Add fiber – start slow (1-2 T/day) and increase weekly – High fiber foods – Purified fiber (metamucil, citracel, psyllium) – Side effect: flatus• Add osmotic agent – start slow (1-2 T/day), increase weekly – MOM, sorbitol, lactulose (lactose), polyethylene glycol (Miralax)• Consider promotility agent – (metoclopramide)• Consider stimulant laxatives (motor/?secretory effects) – Anthranoids (senna, Senokot, aloe, cascara etc.) – Polyphenolic compounds (bisacodyl/Dulcolax, phenophthalein, sodium picosulfate)• Monitor response to therapy with stool diary
    40. 40. Constipation: Myth Busting• Having 1 stool a day is not required for health – Normal range is 1 every 3 days up to 3/day – Thus, reassurance often works• More exercise rarely works (controlled trial was done)• Drinking more water/fluids rarely works – Water is absorbed and excreted by kidneys• Colace (dioctyl sodium sulfosuccinate), a detergent, has no effect on stool weight or frequency in controlled studies.
    41. 41. Diverticuli of the Colon: A phenomenon of aging and ? too little dietary fiber?
    42. 42. Opening of diverticulum as seen fromthe lumen of the colon.
    43. 43. Saccular Colonic DiverticuliVery large diverticuli in a woman with scleroderma. She had undergone a bariumswallow study one day before, leading to oral contrast accumulating in thecolonic diverticuli.
    44. 44. Diverticuli
    45. 45. Complications of Diverticuli• Stool/particulate matter accumulates in the diverticulum• Mucosa inside diverticulum ulcerates and erodes into the underlying artery – Diverticular bleed• Obstruction of diverticulum leads to infection, perforation and contained abscess outside the wall of the colon – Diverticulitis
    46. 46. Diverticulitis: if a perforationoccurs, the contents can travel. The usual route is into omentum
    47. 47. Diverticular perforation - outcomes Abscesses canLocal, confined erode into nearbyperforation and structureslocal infection(diverticulitis) Free rupture of diverticulumRupture of with release ofdiverticular free air and infectionabscess into peritoneum
    48. 48. DiverticulitisA 70-year-old, previously healthy man had had sudden, colicky lower abdominal pain and increased urinary frequency for four days Nanda, R. et al. N Engl J Med 1995;333:498
    49. 49. DiverticulitisThickening of colon wall in region of inflammation Compression of colon lumen by inflammation
    50. 50. Diverticuli can bleed
    51. 51. Diverticular bleeds are arterial – thus bleeding is oftenmassive. Since most diverticuli are in the distal colon, the blood passed is often bright red.
    52. 52. Myth Busting: Diverticulitis• Clinical teaching states that patients with diverticuli should avoid nuts, seeds, popcorn intake to reduce the chance that these might obstruct the mouth of diverticuli and cause diverticulits.• There is no evidence for this but it has become imbedded in medical/nursing lore.• This article (JAMA 300:907-914, 2008) is an 18 year study of 47,000 men and there actually was an inverse relationship between intake of these food items and development of diverticulitis or other complications.• Please do not tell your patients to avoid these foods for this reason.
    53. 53. Hemorrhoids: they have been around a long time. Illuminated manuscript from 1190-1198
    54. 54. Anal Anatomy No pain PainVascular cushions (“plexus”) provide for fine control ofcontinence, but can be injured, enlarge, stretch and “sag”.
    55. 55. Pathophysiology: Hemorrhoidal Disease• Vascular basis – cushions of soft tissue with large vascular channels• Injury/age/passage of hard stool damages or fragments these cushions or their supporting structures• Straining increases venous pressure and engorgement of these tissues• Once tissues prolapse, damage progressively worsens• Trauma causes epithelial damage leading to ulceration, bleeding, pain• Thrombosis of external hemorrhoids causes pain
    56. 56. Appearance WikipedianProlific, Wikimedia CommonsInternal: above the dentate line – not painful unless prolapsedExternal: below the dentate line – may be painful
    57. 57. Visual inspection makes the diagnosis Large external hemorrhoids or severely prolapsed internal hemorrhoids
    58. 58. Prolapsed Internal Hemorrhoid
    59. 59. Internal hemorrhoids - view from the endoscope Bleeding
    60. 60. Complications of Hemorrhoids• Pain/irritation/discomfort – prolapsed internal hemorrhoids – ulcerated or thrombosed external hemorrhoids• Bleeding – small amounts of bright red blood – rarely a major bleed• Leakage of liquid/stool – Prolapsing internal hemorrhoids impair tight closure of the anal sphincters
    61. 61. Medical Management: Little Evidence-Based Therapy• To prevent or reduce hemorrhoids: – Soften stool, reduce straining – fiber, osmotic agents• To treat pain/irritation: – Topical creams (OTC) – Anusol suppositories with hydrocortisone – 5-ASA suppositories – Sitz baths (soak in warm water) – Donut ring to sit on
    62. 62. Treatment of Hemorrhoids 1 – Sclerosis-internal 2 – Banding - internal 3 – Infrared photocoagulation - internal 4 – Surgery – internal and external
    63. 63. Rubber band ligation
    64. 64. Part II will be on Thursday, February 9 at 11:10 a.m.
    65. 65. Additional Source Information for more information see: http://open.umich.edu/wiki/CitationPolicySlide 6: James Heilman, M.D., Wikimedia Commons, http://upload.wikimedia.org/wikipedia/commons/3/3a/HiatusHernia10.JPG, CC:BY-SA,http://creativecommons.org/licenses/by-sa/3.0/deed.enSlide 56: WikipedianProlific, Wikimedia Commons, http://upload.wikimedia.org/wikipedia/commons/7/7b/Hemorrhoid.png, CC:BY-SA,http://creativecommons.org/licenses/by-sa/3.0/deed.en
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