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Gastrointestinal Disease Normal Anatomy and  Physiology
Gastrointestinal Disease: Objectives 1.  To increase students’ working knowledge of gastrointestinal  anatomy, physiology ...
Gastrointestinal Tract: Pharynx Esophagus Liver Stomach Duodenum Small bowel Large bowel (colon) Rectum
GI:  Disorders Gastro Esophageal Reflux Disease (GERD)  Peptic Ulcer Disease (PUD) Inflammatory Bowel Disease (IBD) Pseudo...
Gastro Esophageal Reflux Disease (GERD) Gastro esophageal  junction
GI:  Disorders:  GERD Gastro Esophageal Reflux Disease (GERD) Problem:  reflux of acidic gastric contents into the esophag...
GI:  Disorders:  GERD Complications : ulceration stricture bleeding Fe deficiency anemia (2 0  to bleeding) aspiration Bar...
GI:  Disorders:  GERD Symptoms Typical:  heartburn (pain) Atypical:  cough, asthma, hoarseness, chest pain, aphthous ulcer...
GI:  Disorders:  GERD Diagnosis Symptoms Endoscopy Response to Proton Pump Inhibitor
GI:  Disorders:  GERD Treatment:  Lifestyle modification Diet, meal timing, HOB up 6 inches  Decrease:  fat, cola, chocola...
GI:  Disorders:  GERD Treatment:  Drugs Antacids :  Tums, Rolaids  H2 blockers :  raniditine, cimetidine, famotidine Proto...
GI:  Disorders:  GERD Dental Considerations: Be aware of worsening symptoms Risk of aspriation with positioning or sedatio...
Peptic Ulcer Disease (PUD) Stomach  Duodenum
GI:  Disorders (PUD) Peptic Ulcer Disease (PUD) - 3 mm or greater break in the mucosa - 80% duodenal / 20% gastric - 10% h...
GI:  Disorders (PUD) Peptic Ulcer Disease:  Etiology - Helicobacter pylori - found in 20% of adults > age 20 in NA 80% in ...
GI:  Disorders (PUD) Peptic Ulcer Disease:  Etiology - Helicobacter pylori (70-90%) - acid hypersecretion - cigarette smok...
GI:  Disorders (PUD) Peptic Ulcer Disease:  Pathophysiology - Helicobacter pylori produces urease which converts urea to N...
GI:  Disorders (PUD) Peptic Ulcer Disease:  Complications -  Hemorrhage … worse if anti-coagulated - Perforation … periton...
GI:  Disorders (PUD) Peptic Ulcer Disease:  S & S - Pain -  Relief by antacids, milk or food - Melena (blood in stool) due...
GI:  Disorders (PUD) Peptic Ulcer Disease:  Diagnosis - Signs and Symtoms -  Urea breath test  13 C (office) or  14 C (lab...
GI:  Disorders (PUD) Peptic Ulcer Disease:  Treatment Without  H. pylori: antisecretory drugs H2 antagonists:  cimetidine ...
GI:  Disorders (PUD) Peptic Ulcer Disease:  Treatment With  H. pylori: antibiotics and antisecretory drugs Antibiotics:  t...
GI:  Disorders (PUD) Peptic Ulcer Disease:  Treatment results With  triple or quadruple drug therapy:  92 to 99%  success ...
GI:  Disorders (PUD) Peptic Ulcer Disease:  Dental concerns - Be alert to signs and symptoms: refer - Role of cyclo-oxygen...
GI:  Disorders (PUD) Peptic Ulcer Disease:  Dental concerns -  Use NSAIDs with caution or with PPIs or misoprostol (Cytote...
Inflammatory Bowel  Disease (IBD) Crohn’s Disease: Distal ileum and proximal colon  Ulcerative Colitis: Distal colon and r...
<ul><li>GI:  Disorders </li></ul><ul><li>Inflammatory Bowel Disease (IBD) </li></ul><ul><li>Ulcerative Colitis  and  Crohn...
GI:  Disorders:  IBD Findings Ulcerative Colitis Crohn’s Disease - Limited to large intestine - Any portion of GI tract (r...
GI:  Disorders:  IBD Complications Ulcerative Colitis Crohn’s Disease - Anemia, malabsorbtion - Anemia, malabsorbtion - To...
<ul><li>GI:  Disorders:  IBD </li></ul><ul><li>Treatment </li></ul><ul><li>Supportive therapy:  rest, fluids, lytes,  </li...
GI:  Disorders:  IBD Treatment 3.  Immunosuppressives :  methotrexate, cyclosporin,  4.  Antibiotics:  Flagyl / Cipro 5.  ...
GI:  Disorders:  IBD Dental Concerns 1. Potential for  adrenocortical   suppression with steroids 2.  Methotrexate :  pneu...
GI:  Disorders:  IBD Dental Concerns 3.  Use acetaminophen / Avoid  NSAIDs 4. Use  Narcotics  with caution 5. Opportunisti...
PseudomembranousColitis Distal colon
GI:  Disorders Pseudomembranous colitis Broad spectrum antibiotics cause loss of enteric bacteria leading to an overgrowth...
GI:  Disorders Pseudomembranous colitis Clindamycin: 2 to 20% Ampicillin/amoxicillin: 5 to 9% Cephalosporins: < 2%
GI:  Disorders Pseudomembranous colitis Signs and symptoms: typically develop in 4 to 10 days  profuse, watery diarrhea bl...
GI:  Disorders Pseudomembranous colitis Diagnosis:  enterotoxin found in stool Treatment :  d/c offending antibiotic give ...
GI:  Disorders Pseudomembranous colitis Dental consideration: be cautious with the use of antibiotics
Irritable Bowel  Syndrome (IBS)
GI:  Disorders Irritable Bowel Syndrome (IBS) Most common GI problem:  functional Idiopathic … psycho-social issues Diarrh...
Questions????
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17. Gastroenterology

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Transcript of "17. Gastroenterology"

  1. 1. Gastrointestinal Disease Normal Anatomy and Physiology
  2. 2. Gastrointestinal Disease: Objectives 1. To increase students’ working knowledge of gastrointestinal anatomy, physiology and pathology 2. To incorporate this working knowledge into patient assessment and clinical decision making
  3. 3. Gastrointestinal Tract: Pharynx Esophagus Liver Stomach Duodenum Small bowel Large bowel (colon) Rectum
  4. 4. GI: Disorders Gastro Esophageal Reflux Disease (GERD) Peptic Ulcer Disease (PUD) Inflammatory Bowel Disease (IBD) Pseudomembranous colitis Irritable Bowel Syndrome (IBS)
  5. 5. Gastro Esophageal Reflux Disease (GERD) Gastro esophageal junction
  6. 6. GI: Disorders: GERD Gastro Esophageal Reflux Disease (GERD) Problem: reflux of acidic gastric contents into the esophagus Often related to hiatus hernia
  7. 7. GI: Disorders: GERD Complications : ulceration stricture bleeding Fe deficiency anemia (2 0 to bleeding) aspiration Barrett’s epithelium: increased risk of esophageal cancer
  8. 8. GI: Disorders: GERD Symptoms Typical: heartburn (pain) Atypical: cough, asthma, hoarseness, chest pain, aphthous ulcers, hiccups, dental erosions Warning (of stricture): dysphagia, early satiety, weight loss, bleeding
  9. 9. GI: Disorders: GERD Diagnosis Symptoms Endoscopy Response to Proton Pump Inhibitor
  10. 10. GI: Disorders: GERD Treatment: Lifestyle modification Diet, meal timing, HOB up 6 inches Decrease: fat, cola, chocolate, coffee, alcohol, smoking
  11. 11. GI: Disorders: GERD Treatment: Drugs Antacids : Tums, Rolaids H2 blockers : raniditine, cimetidine, famotidine Proton pump inhibitors : omeprazole, lansoprazole Prokinetic agents : bethanechol, metoclopramide, domperidone
  12. 12. GI: Disorders: GERD Dental Considerations: Be aware of worsening symptoms Risk of aspriation with positioning or sedation Dental changes due to oral acid reflux
  13. 13. Peptic Ulcer Disease (PUD) Stomach Duodenum
  14. 14. GI: Disorders (PUD) Peptic Ulcer Disease (PUD) - 3 mm or greater break in the mucosa - 80% duodenal / 20% gastric - 10% have multiple ulcers - prevalence 5 - 10% of population - 100 patients in a 2000 patient population
  15. 15. GI: Disorders (PUD) Peptic Ulcer Disease: Etiology - Helicobacter pylori - found in 20% of adults > age 20 in NA 80% in developing countries - approx 20% of infected individuals go on to having PUD
  16. 16. GI: Disorders (PUD) Peptic Ulcer Disease: Etiology - Helicobacter pylori (70-90%) - acid hypersecretion - cigarette smoking / alcohol - NSAID use (15-20%) - psychological and physical stress - age 30 - 50 - steroid use
  17. 17. GI: Disorders (PUD) Peptic Ulcer Disease: Pathophysiology - Helicobacter pylori produces urease which converts urea to NH 3 and CO 2 - this initiates an inflammatory cascade which causes mucosal breakdown often in association with co-factors
  18. 18. GI: Disorders (PUD) Peptic Ulcer Disease: Complications - Hemorrhage … worse if anti-coagulated - Perforation … peritonitis - Scarring … pyloric stenosis - Malignant transformation: carcinoma or lymphoma
  19. 19. GI: Disorders (PUD) Peptic Ulcer Disease: S & S - Pain - Relief by antacids, milk or food - Melena (blood in stool) due to bleeding - Worsening of symptoms may indicate complications such as perforation or pyloric outlet obstruction
  20. 20. GI: Disorders (PUD) Peptic Ulcer Disease: Diagnosis - Signs and Symtoms - Urea breath test 13 C (office) or 14 C (lab) for Dx and response to Tx - Double contrast barium radiograph - Fibreoptic endoscopy: visualization and biopsy
  21. 21. GI: Disorders (PUD) Peptic Ulcer Disease: Treatment Without H. pylori: antisecretory drugs H2 antagonists: cimetidine (Tagamet) ranitidine (Zantac) famotidine (Pepcid) Proton pump inhibitors: omeprazole (Prilosec) (PPIs) lansoproazole (Prevacid) esomeprazole (Nexium)
  22. 22. GI: Disorders (PUD) Peptic Ulcer Disease: Treatment With H. pylori: antibiotics and antisecretory drugs Antibiotics: tetracycline and metronidazole amoxicillin and clarithromycin Proton pump inhibitors: omeprazole (Prilosec) (PPIs) lansoproazole (Prevacid) esomeprazole (Nexium) Bismuth subsalicylate (Pepto-Bismol)
  23. 23. GI: Disorders (PUD) Peptic Ulcer Disease: Treatment results With triple or quadruple drug therapy: 92 to 99% success in eradicating H. pylori and curing ulcer Failure typically due to: - noncompliance with drug therapy - continued use of NSAIDs, alcohol, smoking - continued ingestion of spicy foods - continued stressful lifestyle
  24. 24. GI: Disorders (PUD) Peptic Ulcer Disease: Dental concerns - Be alert to signs and symptoms: refer - Role of cyclo-oxygenase-2 (COX-2) inhibitors?…details to follow - Use acetaminophen preparations
  25. 25. GI: Disorders (PUD) Peptic Ulcer Disease: Dental concerns - Use NSAIDs with caution or with PPIs or misoprostol (Cytotec) - Avoid NSAIDs if: patient over 75 history of bleeding concomitant steroid use
  26. 26. Inflammatory Bowel Disease (IBD) Crohn’s Disease: Distal ileum and proximal colon Ulcerative Colitis: Distal colon and rectum
  27. 27. <ul><li>GI: Disorders </li></ul><ul><li>Inflammatory Bowel Disease (IBD) </li></ul><ul><li>Ulcerative Colitis and Crohn’s Disease </li></ul><ul><li>Idiopathic (??? Genetic + environment) </li></ul><ul><li>Age of onset: 20 to 40 </li></ul><ul><li>5 patients in a 2000 patient practice </li></ul>
  28. 28. GI: Disorders: IBD Findings Ulcerative Colitis Crohn’s Disease - Limited to large intestine - Any portion of GI tract (rectum-colon) (lips to anus) - Limited to mucosa - Transmural - Continuous - Segmental - Episodic - Episodic - Diarrhea - Diarrhea - Bleeding, cramping - Pain LRQ, fever, wt loss
  29. 29. GI: Disorders: IBD Complications Ulcerative Colitis Crohn’s Disease - Anemia, malabsorbtion - Anemia, malabsorbtion - Toxic megacolon - Fistulae, stricture - Malignant transformation - Surgery more likely more likely
  30. 30. <ul><li>GI: Disorders: IBD </li></ul><ul><li>Treatment </li></ul><ul><li>Supportive therapy: rest, fluids, lytes, </li></ul><ul><li>nutritional supplementation </li></ul><ul><li>2. Antiinflammatories: sulphaslazine, </li></ul><ul><li>5-ASA, corticosteroids </li></ul>
  31. 31. GI: Disorders: IBD Treatment 3. Immunosuppressives : methotrexate, cyclosporin, 4. Antibiotics: Flagyl / Cipro 5. Surgery
  32. 32. GI: Disorders: IBD Dental Concerns 1. Potential for adrenocortical suppression with steroids 2. Methotrexate : pneumonia, marrow suppression, hepatic fibrosis Cyclosporin : renal damage
  33. 33. GI: Disorders: IBD Dental Concerns 3. Use acetaminophen / Avoid NSAIDs 4. Use Narcotics with caution 5. Opportunistic infections / lymphoma due to immuno-suppression 6. Crohn’s disease can manifest orally
  34. 34. PseudomembranousColitis Distal colon
  35. 35. GI: Disorders Pseudomembranous colitis Broad spectrum antibiotics cause loss of enteric bacteria leading to an overgrowth of Clostridium difficile which produce enterotoxins that induce potentially fatal colitis and diarrhea commensal in 2-3% of adults / 50% of elderly
  36. 36. GI: Disorders Pseudomembranous colitis Clindamycin: 2 to 20% Ampicillin/amoxicillin: 5 to 9% Cephalosporins: < 2%
  37. 37. GI: Disorders Pseudomembranous colitis Signs and symptoms: typically develop in 4 to 10 days profuse, watery diarrhea bloody diarrhea, fever, abdo pain death
  38. 38. GI: Disorders Pseudomembranous colitis Diagnosis: enterotoxin found in stool Treatment : d/c offending antibiotic give PO Flagyl or Vancomycin
  39. 39. GI: Disorders Pseudomembranous colitis Dental consideration: be cautious with the use of antibiotics
  40. 40. Irritable Bowel Syndrome (IBS)
  41. 41. GI: Disorders Irritable Bowel Syndrome (IBS) Most common GI problem: functional Idiopathic … psycho-social issues Diarrhea, constipation, bloating, abdo pain Difficult to control: dietary change, stress management, antidepressants
  42. 42. Questions????
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