Manifestations of Gastrointestinal Diseases   <ul><li>Celso M. Fidel MD,FPSGS,FPCS </li></ul><ul><li>Diplomate Philippine ...
What are These Manifestations? <ul><li>1. PAIN </li></ul><ul><li>2. FEVER </li></ul><ul><li>3. ANOREXIA </li></ul><ul><li>...
What are These Manifestations? <ul><li>10. ILEUS  </li></ul><ul><li>11. INTESTINAL OBSTRUCTION </li></ul><ul><li>a. Partia...
 
I  Pain <ul><li>Most common symptom of GIT disease </li></ul><ul><li>Three kinds have been described in gen. </li></ul><ul...
I  Pain   <ul><li>Two Types of Pain </li></ul><ul><li>1. Somatic Pain  2. Visceral Pain </li></ul><ul><li>Pathway:    A-d...
Pain   <ul><li>Un-referred Visceral Pain </li></ul><ul><li>ANS   innervations: </li></ul><ul><li>bilateral hence pain is m...
Pain   <ul><li>Un-referred Visceral Pain </li></ul><ul><li>   Midline location is the result of embryologic development o...
Pain   <ul><li>Un-referred Visceral Pain </li></ul><ul><li>   Periumbilical- Midgut: </li></ul><ul><li>Distal duodenum </...
Pain   <ul><li>   REFERRED PAIN </li></ul><ul><li>Result of afferent neurons that innervate two entirely separate anatomi...
Pain   <ul><li>   REFERRED PAIN </li></ul><ul><li>4 th   Cervical Nerve Route </li></ul><ul><li>1. Parietal peritoneum of...
Pain   <ul><li>   REFERRED PAIN </li></ul><ul><li>   Thoracic Afferents T6-T8 </li></ul><ul><li>Innervates : </li></ul><...
Pain <ul><li>   REFERRED PAIN </li></ul><ul><li>   10 th  Thoracic Nerve Route </li></ul><ul><li>Irritation to the kidne...
Acute Abdominal Pain <ul><li>Clinical Manifestations </li></ul><ul><li>Sudden Onset =more likely surgical </li></ul><ul><l...
Acute Abdominal Pain <ul><li>Clinical Manifestations   </li></ul><ul><li>Foregut  and  Midgut  inflammation  </li></ul><ul...
Acute Abdominal Pain  <ul><li>Physical Examination </li></ul><ul><li>Inspection </li></ul><ul><li>Scaphoid = Normal </li><...
Acute Abdominal Pain  <ul><li>Auscultation </li></ul><ul><li>Absent =No bowel sound in a minute </li></ul><ul><li>1. Ileus...
Acute Abdominal Pain   <ul><li>   Auscultation </li></ul><ul><li>Hypoactive </li></ul><ul><li>1. Hypokalemia  </li></ul><...
Acute Abdominal Pain   <ul><li>Auscultation </li></ul><ul><li>   Hyperactive </li></ul><ul><li>1. Early small bowel obstr...
Acute Abdominal Pain   <ul><li>Laboratory Evaluation </li></ul><ul><li>CBC </li></ul><ul><li>Urinalysis </li></ul><ul><li>...
Acute Abdominal Pain   <ul><li>   Radiologic Examination  </li></ul><ul><li>1. Pneumoperitoneum </li></ul><ul><li>2. Calc...
Acute Abdominal Pain <ul><li>Ultrasound </li></ul><ul><li>1. Suspected Pancreatic  </li></ul><ul><li>2. Hepatobiliary dise...
Acute Abdominal Pain <ul><li>   Ultrasound </li></ul><ul><li>(F.A.S.T.) detecting Hemoperitoneum </li></ul><ul><li>in Blu...
Acute Abdominal Pain <ul><li>   Surgical Decision Making </li></ul><ul><li>1. Usually made by History </li></ul><ul><li>2...
Acute Abdominal Pain <ul><li>Nature of Surgical Decision Making in </li></ul><ul><li>Acute Abdomen does not require  </li>...
Intermittent and Recurrent Abdominal Pain <ul><li>1. Various Hematologic disorders produce  </li></ul><ul><li>abdominal pa...
Chronic Abdominal Pain <ul><li>If persistent-- is a clear pathophysiologic </li></ul><ul><li>abnormality such as: </li></u...
Intractable Abdominal Pain <ul><li>1. Challenging and sometimes a frustrating </li></ul><ul><li>problem  </li></ul><ul><li...
II FEVER <ul><li>Not dangerous unless it is unusually high </li></ul><ul><li>Often a postoperative event often: </li></ul>...
II FEVER <ul><li>Indication of Illness such as: </li></ul><ul><li>1. Infection </li></ul><ul><li>2. Inflammation </li></ul...
II FEVER <ul><li>Pathophysiology </li></ul><ul><li>Inflammatory Response activates  Cytokines  </li></ul><ul><li>that are ...
II FEVER <ul><li>   Pathophysiology </li></ul><ul><li>Activated Macrophages also liberates  pyrogens </li></ul><ul><li>1....
II FEVER   <ul><li>Clinical Manifestation </li></ul><ul><li>Those of GIT origin=Infection in the  </li></ul><ul><li>Abdomi...
II FEVER   <ul><li>Clinical Manifestation </li></ul><ul><li>Intraabdominal Sepsis > polymicrobial </li></ul><ul><li>Fever ...
III Anorexia <ul><li>Complicates many diseases </li></ul><ul><li>Indicates a significant degree of  </li></ul><ul><li>infl...
III Anorexia <ul><li>Common cause is Carcinoma, usually  </li></ul><ul><li>with significant tumor burden </li></ul><ul><li...
III Anorexia   <ul><li>Pathophysiology </li></ul><ul><li>Complex and Multifaceted. In Animals </li></ul><ul><li>independen...
III Anorexia   <ul><li>Pathophysiology </li></ul><ul><li>Hypothalamus is feeding center of the brain  </li></ul><ul><li>La...
III Anorexia   <ul><li>Pathophysiology </li></ul><ul><li>Galanin located in several brain regions appear to selectively st...
III Anorexia   <ul><li>Pathophysiology </li></ul><ul><li>The discovery of obese gene protein( leptin) </li></ul><ul><li>pr...
III Anorexia   <ul><li>Pathophysiology </li></ul><ul><li>Elevated activity in Serotonin neurons  </li></ul><ul><li>also in...
III Anorexia   <ul><li>Pathophysiology </li></ul><ul><li>Carbohydrate intake appears to be under </li></ul><ul><li>Neurope...
III Anorexia   <ul><li>CANCER Anorexia </li></ul><ul><li>Results from tumor-induced aberrations </li></ul><ul><li>of neuro...
III Anorexia   <ul><li>CANCER Anorexia </li></ul><ul><li>Weight loss of  10-15 %  during 3 to 4  </li></ul><ul><li>months ...
IV HEARTBURN AND DYSPEPSIA <ul><li>Substernal burning associated w/ bitter taste </li></ul><ul><li>Normal individuals expe...
IV HEARTBURN AND DYSPEPSIA <ul><li>Esophagus is normally protected by: </li></ul><ul><li>1. Competent Lower esophageal sph...
IV HEARTBURN AND DYSPEPSIA <ul><li>Dyspepsia is a non specific term given </li></ul><ul><li>to a collection of symptoms in...
IV HEARTBURN AND DYSPEPSIA <ul><li>It is a postprandial complaint involving: </li></ul><ul><li>1. Substernal pressure </li...
IV HEARTBURN AND DYSPEPSIA   <ul><li>Work-up should include: </li></ul><ul><li>1. Cineflouroscopy </li></ul><ul><li>2. Con...
IV HEARTBURN AND DYSPEPSIA   <ul><li>Manometry if esophageal spasm is </li></ul><ul><li>suspected </li></ul><ul><li>Relati...
V  DYSPHAGIA  <ul><li>Disturbances in swallowing can be </li></ul><ul><li>categorized according to the etiologies: </li></...
VI NAUSEA AND VOMITING  <ul><li>1.  May be related or unrelated to diseases </li></ul><ul><li>of the gastrointestinal trac...
VI NAUSEA AND VOMITING   <ul><li>Rapidly changing directions of motion </li></ul><ul><li>stimulate receptors in the labyri...
VI NAUSEA AND VOMITING   <ul><li>Ischemia to the vomiting center in: </li></ul><ul><li>1. Increased intracranial pressure ...
VI NAUSEA AND VOMITING <ul><li>A variety of antibiotics directly affecting </li></ul><ul><li>the GIT may cause nausea & vo...
VI NAUSEA AND VOMITING <ul><li>Acute Nausea and Vomiting due to: </li></ul><ul><li>1. Inflammation or infectious agents </...
VII ABDOMINAL DISTENTION,ERUCTATION AND FLATULENCE <ul><li>Most of these patient’s are Aerophagics; </li></ul><ul><li>they...
VII ABDOMINAL DISTENTION,ERUCTATION AND FLATULENCE <ul><li>Chronic Eructation may be an indication </li></ul><ul><li>of ch...
 
VIII CONSTIPATION <ul><li>Most often Mechanical in origin </li></ul><ul><li>In trauma with retroperitoneal hematoma </li><...
VIII CONSTIPATION <ul><li>Can be a result of: </li></ul><ul><li>4. Neurogenic causes </li></ul><ul><li>a. Tabes Dorsalis  ...
IX DIARRHEA <ul><li>Pathophysiological Mechanisms </li></ul><ul><li>1. Luminal secretion of solute or water </li></ul><ul>...
X  ILEUS <ul><li>Three Types </li></ul><ul><li>1. Adynamic or inhibition ileus </li></ul><ul><li>a. Most Common </li></ul>...
X  ILEUS <ul><li>Adynamic ileus occurs after a variety of </li></ul><ul><li>abdominal operations </li></ul><ul><li>1. Gast...
X   ILEUS   <ul><li>If ileus is prolonged possible causes includes: </li></ul><ul><li>1. Metabolic </li></ul><ul><li>2. se...
XI INTESTINAL OBSTRUCTION <ul><li>Classification </li></ul><ul><li>1. Extra luminal( including adhesions and  </li></ul><u...
XI INTESTINAL OBSTRUCTION <ul><li>Partial Obstruction and Pseudo-obstruction </li></ul><ul><li>Chronic Nausea and Vomiting...
XI INTESTINAL OBSTRUCTION <ul><li>Partial Obstruction and Pseudo-obstruction </li></ul><ul><li>Chronic intestinal pseudo-o...
XI INTESTINAL OBSTRUCTION <ul><li>Partial Obstruction and Pseudo-obstruction </li></ul><ul><li>1. Pseudo-obstruction posto...
XI INTESTINAL OBSTRUCTION  <ul><li>Mechanical Obstruction </li></ul><ul><li>1. Physiologic derangement if intact blood sup...
XI INTESTINAL OBSTRUCTION <ul><li>Mechanical Obstruction </li></ul><ul><li>3. After 48 hours, rate of entry of water into ...
XI INTESTINAL OBSTRUCTION <ul><li>Close loop Obstruction </li></ul><ul><li>1. Both afferent & efferent limbs are obstructe...
XI INTESTINAL OBSTRUCTION   <ul><li>Colon Obstruction </li></ul><ul><li>1. Fluid and Electrolyte sequestration progresses ...
XI INTESTINAL OBSTRUCTION <ul><li>Clinical Manifestations </li></ul><ul><li>The distance of the obstruction from the  liga...
XI INTESTINAL OBSTRUCTION <ul><li>Clinical Manifestations </li></ul><ul><li>Cardinal Signs and Symptoms of Intestinal </li...
XII GASTROINTESTINAL BLEEDING <ul><li>1.  Has high morbidity & mortality particularly in </li></ul><ul><li>the elderly </l...
XII GASTROINTESTINAL BLEEDING <ul><li>4.Eighty( 80%) will stop spontaneously without </li></ul><ul><li>intervention </li><...
XII GASTROINTESTINAL BLEEDING <ul><li>Terminologies </li></ul><ul><li>1.  Hematemesis   is vomiting of blood ,  either  </...
XII GASTROINTESTINAL BLEEDING <ul><li>Terminologies </li></ul><ul><li>As little as  50-60m l of blood produce melena </li>...
XII GASTROINTESTINAL  BLEEDING <ul><li>Upper GI Bleeding  </li></ul><ul><li>Bleeding above the ligament of Treitz  </li></...
XII GASTROINTESTINAL  BLEEDING <ul><li>Upper GI Bleeding  </li></ul><ul><li>8. Stress Ulcer ( Documented Risk Factors) </l...
XII GASTROINTESTINAL BLEEDING <ul><li>Lower GI Bleeding  </li></ul><ul><li>Bleeding below the ligament of Treitz  </li></u...
XII GASTROINTESTINAL BLEEDING <ul><li>Lower GI Bleeding  </li></ul><ul><li>Work-up </li></ul><ul><li>1. Rectal Examination...
XIII JAUNDICE <ul><li>GIT related Causes : </li></ul><ul><li>1. Increased pigment production secondary to </li></ul><ul><l...
 
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  1. 1. Manifestations of Gastrointestinal Diseases <ul><li>Celso M. Fidel MD,FPSGS,FPCS </li></ul><ul><li>Diplomate Philippine Board of Surgery </li></ul>
  2. 2. What are These Manifestations? <ul><li>1. PAIN </li></ul><ul><li>2. FEVER </li></ul><ul><li>3. ANOREXIA </li></ul><ul><li>4. HEARTBURN and DYSPEPSIA </li></ul><ul><li>5. DYSPHAGIA </li></ul><ul><li>6. NAUSEA and VOMITING </li></ul><ul><li>7. ABDOMINAL DISTENTION, </li></ul><ul><li>ERUCTATION and FLATULENCE </li></ul><ul><li>8. CONSTIPATION </li></ul><ul><li>9. DIARRHEA </li></ul>
  3. 3. What are These Manifestations? <ul><li>10. ILEUS </li></ul><ul><li>11. INTESTINAL OBSTRUCTION </li></ul><ul><li>a. Partial Obstruction and Pseudo-obstruction </li></ul><ul><li>b. Mechanical Obstruction </li></ul><ul><li>c. Closed Loop Obstruction </li></ul><ul><li>d. Colon Obstruction </li></ul><ul><li>12. GASTROINTESTINAL BLEEDING </li></ul><ul><li>a. Upper GI Bleeding </li></ul><ul><li>b. Lower GI Bleeding </li></ul><ul><li>13. JAUNDICE </li></ul>
  4. 5. I Pain <ul><li>Most common symptom of GIT disease </li></ul><ul><li>Three kinds have been described in gen. </li></ul><ul><li>1. Superficial or Cutaneous pain </li></ul><ul><li>2. Deep pain from: </li></ul><ul><li>Muscles </li></ul><ul><li>Tendons </li></ul><ul><li>Joints </li></ul><ul><li>Fascia </li></ul><ul><li>3. Visceral pain </li></ul>
  5. 6. I Pain <ul><li>Two Types of Pain </li></ul><ul><li>1. Somatic Pain 2. Visceral Pain </li></ul><ul><li>Pathway:  A-delta fibers  Autonomic C-type fibers </li></ul><ul><li>Receptor:  Parietal, Muscle  Visceral </li></ul><ul><li>and Skin </li></ul><ul><li>Specific  Well localized  Poorly localized </li></ul><ul><li>Description  Sharp  Cramping, Gnawing </li></ul><ul><li>Stimulus:  Inflammation,  Distention, Traction </li></ul><ul><li>Pressure </li></ul>
  6. 7. Pain <ul><li>Un-referred Visceral Pain </li></ul><ul><li>ANS innervations: </li></ul><ul><li>bilateral hence pain is midline except: </li></ul><ul><li>Kidneys </li></ul><ul><li>Ureters </li></ul><ul><li>Cecum </li></ul><ul><li>Ascending colon </li></ul><ul><li>Descending colon </li></ul><ul><li>Sigmoid colon </li></ul>
  7. 8. Pain <ul><li>Un-referred Visceral Pain </li></ul><ul><li> Midline location is the result of embryologic development of Gut </li></ul><ul><li> Epigastric - Foregut: </li></ul><ul><li>Oropharynx </li></ul><ul><li>2 nd portion of duodenum </li></ul><ul><li>Liver </li></ul><ul><li>Spleen </li></ul><ul><li>Pancreas </li></ul>
  8. 9. Pain <ul><li>Un-referred Visceral Pain </li></ul><ul><li> Periumbilical- Midgut: </li></ul><ul><li>Distal duodenum </li></ul><ul><li>Jejunum </li></ul><ul><li>Ileum </li></ul><ul><li>Appendix </li></ul><ul><li>Ascending colon </li></ul><ul><li>Proximal transverse colon </li></ul><ul><li> Hypogastric- Remainder of Hindgut= Colon </li></ul><ul><li>down to c loaca </li></ul>
  9. 10. Pain <ul><li> REFERRED PAIN </li></ul><ul><li>Result of afferent neurons that innervate two entirely separate anatomically distinct structures that have a common embryologic </li></ul><ul><li>origin </li></ul>
  10. 11. Pain <ul><li> REFERRED PAIN </li></ul><ul><li>4 th Cervical Nerve Route </li></ul><ul><li>1. Parietal peritoneum of the </li></ul><ul><li>diaphragm </li></ul><ul><li>2. Area around the shoulder </li></ul><ul><li>3. Supraclavicular hollow </li></ul><ul><li>e.g. Kehr sign = Pain underneath the diaphragm felt at the tip of the shoulder </li></ul>
  11. 12. Pain <ul><li> REFERRED PAIN </li></ul><ul><li> Thoracic Afferents T6-T8 </li></ul><ul><li>Innervates : </li></ul><ul><li>1. Right sub-scapular area </li></ul><ul><li>2. Biliary tree </li></ul><ul><li>3. Liver </li></ul><ul><li>4. Peri-pancreatic area </li></ul>
  12. 13. Pain <ul><li> REFERRED PAIN </li></ul><ul><li> 10 th Thoracic Nerve Route </li></ul><ul><li>Irritation to the kidney or ureter </li></ul><ul><li>e.g. In male= Flank and genital </li></ul><ul><li>pain classically testicular pain </li></ul><ul><li>In females this is referred to the </li></ul><ul><li>labia </li></ul>
  13. 14. Acute Abdominal Pain <ul><li>Clinical Manifestations </li></ul><ul><li>Sudden Onset =more likely surgical </li></ul><ul><li>Gradual Onset= inflammatory process </li></ul><ul><li>or slower progressive obstruction </li></ul><ul><li>Nausea and Vomiting 6-12 hours after </li></ul><ul><li>onset of pain=Obstruction lower GIT </li></ul>
  14. 15. Acute Abdominal Pain <ul><li>Clinical Manifestations </li></ul><ul><li>Foregut and Midgut inflammation </li></ul><ul><li>often followed by: </li></ul><ul><li>Anorexia </li></ul><ul><li>Nausea </li></ul><ul><li>vomiting </li></ul><ul><li>Sensory afferents carried by Vagal fibers </li></ul>
  15. 16. Acute Abdominal Pain <ul><li>Physical Examination </li></ul><ul><li>Inspection </li></ul><ul><li>Scaphoid = Normal </li></ul><ul><li>Distention= Abnormal </li></ul><ul><li>Thin Individuals= bowel loops seen </li></ul>
  16. 17. Acute Abdominal Pain <ul><li>Auscultation </li></ul><ul><li>Absent =No bowel sound in a minute </li></ul><ul><li>1. Ileus </li></ul><ul><li>2. Hypokalemia </li></ul><ul><li>3. Peritonitis </li></ul><ul><li>4. Hypomagnesemia </li></ul><ul><li>5. Mesenteric thrombosis </li></ul><ul><li>6. Narcotic Overdose </li></ul>
  17. 18. Acute Abdominal Pain <ul><li> Auscultation </li></ul><ul><li>Hypoactive </li></ul><ul><li>1. Hypokalemia </li></ul><ul><li>2. Inflammation </li></ul><ul><li>3. Ischemic bowel disease </li></ul>
  18. 19. Acute Abdominal Pain <ul><li>Auscultation </li></ul><ul><li> Hyperactive </li></ul><ul><li>1. Early small bowel obstruction </li></ul><ul><li>2. Diverticulitis </li></ul><ul><li>Percussion </li></ul><ul><li>Palpation </li></ul>
  19. 20. Acute Abdominal Pain <ul><li>Laboratory Evaluation </li></ul><ul><li>CBC </li></ul><ul><li>Urinalysis </li></ul><ul><li>Blood Chemistry e.g. Amylase; Liver </li></ul><ul><li>function test </li></ul><ul><li>Pregnancy Test </li></ul><ul><li>ECG </li></ul>
  20. 21. Acute Abdominal Pain <ul><li> Radiologic Examination </li></ul><ul><li>1. Pneumoperitoneum </li></ul><ul><li>2. Calculi </li></ul><ul><li>3. Ileus </li></ul><ul><li>4. Air fluid level </li></ul><ul><li>5. Aerobilia </li></ul><ul><li>6. Fat lines </li></ul>
  21. 22. Acute Abdominal Pain <ul><li>Ultrasound </li></ul><ul><li>1. Suspected Pancreatic </li></ul><ul><li>2. Hepatobiliary disease </li></ul><ul><li>3. Phlegmon </li></ul><ul><li>4. Abscess </li></ul><ul><li>5. Pseudocyst </li></ul><ul><li>6. Gynecologic Problem that mimics GIT </li></ul><ul><li>disease </li></ul>
  22. 23. Acute Abdominal Pain <ul><li> Ultrasound </li></ul><ul><li>(F.A.S.T.) detecting Hemoperitoneum </li></ul><ul><li>in Blunt Trauma </li></ul><ul><li>1. Sensitivity of 93.4% </li></ul><ul><li>2. Specificity of 98.7% </li></ul><ul><li>3. Accuracy of 97.5% </li></ul>
  23. 24. Acute Abdominal Pain <ul><li> Surgical Decision Making </li></ul><ul><li>1. Usually made by History </li></ul><ul><li>2. Physical Examination is confirmatory </li></ul><ul><li>3. Laboratory tests are focused on the </li></ul><ul><li>suspected diagnosis </li></ul>
  24. 25. Acute Abdominal Pain <ul><li>Nature of Surgical Decision Making in </li></ul><ul><li>Acute Abdomen does not require </li></ul><ul><li>specific diagnosis, but </li></ul><ul><li>1. Plan of action </li></ul><ul><li>2. Indication for the operation </li></ul><ul><li>3. Timing and Approach </li></ul>
  25. 26. Intermittent and Recurrent Abdominal Pain <ul><li>1. Various Hematologic disorders produce </li></ul><ul><li>abdominal pain </li></ul><ul><li>2. Clinical Manifestations relate to the </li></ul><ul><li>occurrence of crisis; anemia; jaundice; </li></ul><ul><li>splenomegaly; and cholelithiasis </li></ul><ul><li>3. Due to disturbed gastrointestinal motility </li></ul><ul><li>or alternating areas of spasm and </li></ul><ul><li>dilatation </li></ul>
  26. 27. Chronic Abdominal Pain <ul><li>If persistent-- is a clear pathophysiologic </li></ul><ul><li>abnormality such as: </li></ul><ul><li>1. Chronic pancreatitis </li></ul><ul><li>2. Pancreatic Malignancy </li></ul><ul><li>3. Colonic Malignancy </li></ul><ul><li>May arise from the abdominal wall </li></ul><ul><li>1. Iatrogenic peripheral nerve injuries </li></ul><ul><li>2. Hernias </li></ul><ul><li>3. Myofascial Pain Syndrome </li></ul>
  27. 28. Intractable Abdominal Pain <ul><li>1. Challenging and sometimes a frustrating </li></ul><ul><li>problem </li></ul><ul><li>2. Opiate Analgesics, if given in sufficient </li></ul><ul><li>dosage, usually can control abdominal </li></ul><ul><li>pain, however risk of addiction is always </li></ul><ul><li>there undermining patient’s ability to </li></ul><ul><li>function effectively </li></ul><ul><li>3. In Properly selected patients, interruption </li></ul><ul><li>of pain pathway (Splanchnicectomy) is </li></ul><ul><li>suggested </li></ul>
  28. 29. II FEVER <ul><li>Not dangerous unless it is unusually high </li></ul><ul><li>Often a postoperative event often: </li></ul><ul><li>1. A Thermostat reset </li></ul><ul><li>2. Response to intraoperative body cooling </li></ul><ul><li>3. Result of Normal Cytokine Activation </li></ul>
  29. 30. II FEVER <ul><li>Indication of Illness such as: </li></ul><ul><li>1. Infection </li></ul><ul><li>2. Inflammation </li></ul><ul><li>3. Autoimmune Disease </li></ul><ul><li>4. Neoplasia </li></ul><ul><li> If persistent, indicative of infectious complication </li></ul>
  30. 31. II FEVER <ul><li>Pathophysiology </li></ul><ul><li>Inflammatory Response activates Cytokines </li></ul><ul><li>that are locally released in the brain or into </li></ul><ul><li>the bloodstream peripherally acting on the </li></ul><ul><li>hypothalamus in Endocrine fashion </li></ul>
  31. 32. II FEVER <ul><li> Pathophysiology </li></ul><ul><li>Activated Macrophages also liberates pyrogens </li></ul><ul><li>1. Interleukin </li></ul><ul><li>2. TNF </li></ul><ul><li>3. Interferon </li></ul><ul><li>Upward resetting of a thermoregulatory </li></ul><ul><li>Apparatus,triggering 2 physiologic mechanisms: </li></ul><ul><li>1. Vasoconstriction </li></ul><ul><li>2. Increase Heat production by shivering </li></ul>
  32. 33. II FEVER <ul><li>Clinical Manifestation </li></ul><ul><li>Those of GIT origin=Infection in the </li></ul><ul><li>Abdominal Cavity </li></ul><ul><li>Monomicrobial infections include: </li></ul><ul><li>1. Biliary Tract Infection </li></ul><ul><li>2. Spontaneous or Primary Peritonitis </li></ul>
  33. 34. II FEVER <ul><li>Clinical Manifestation </li></ul><ul><li>Intraabdominal Sepsis > polymicrobial </li></ul><ul><li>Fever of reactivated Crohn’s disease </li></ul><ul><li>Established Infection postop 10-20% </li></ul><ul><li>20% of unknown origin 2ndary to CA. </li></ul>
  34. 35. III Anorexia <ul><li>Complicates many diseases </li></ul><ul><li>Indicates a significant degree of </li></ul><ul><li>inflammation </li></ul><ul><li>Common in liver disease, through CNS </li></ul><ul><li>mechanism, probably mediated at least </li></ul><ul><li>in part by Ammonia & Neuropeptide Y. </li></ul>
  35. 36. III Anorexia <ul><li>Common cause is Carcinoma, usually </li></ul><ul><li>with significant tumor burden </li></ul><ul><li>Postoperatively associated with loss of </li></ul><ul><li>taste, especially in diarrhea whose zinc </li></ul><ul><li>stores are chronically low. Give 220 mgs </li></ul><ul><li>daily and taste returns in 10 days to 3 weeks. </li></ul>
  36. 37. III Anorexia <ul><li>Pathophysiology </li></ul><ul><li>Complex and Multifaceted. In Animals </li></ul><ul><li>independent variables alter food intake: </li></ul><ul><li>1. Changes in glucose utilization rate </li></ul><ul><li>2. Changes in rate of lipid metabolism </li></ul><ul><li>3. Alteration in brain & peripheral peptides. </li></ul><ul><li>4. Imbalance in plasma & brain amino profiles </li></ul><ul><li>5. Increase & decrease neurotransmitter activity </li></ul><ul><li>6. Alteration in Cytokine levels </li></ul>
  37. 38. III Anorexia <ul><li>Pathophysiology </li></ul><ul><li>Hypothalamus is feeding center of the brain </li></ul><ul><li>Lateral area lesions = anorexia </li></ul><ul><li>Ventro-medial region lesions causes </li></ul><ul><li>hyperphagia and obesity </li></ul><ul><li>Vagal afferents , important in communicating </li></ul><ul><li>peripheral nutrition related information from </li></ul><ul><li>the GIT or from Glucose sensitive cells in the </li></ul><ul><li>liver </li></ul>
  38. 39. III Anorexia <ul><li>Pathophysiology </li></ul><ul><li>Galanin located in several brain regions appear to selectively stimulate fat intake </li></ul><ul><li>According to Glucostatic hypothesis of feeding, </li></ul><ul><li>increased use of glucose signal satiety, and </li></ul><ul><li>decreased glucose metabolism is associated </li></ul><ul><li>with hunger </li></ul>
  39. 40. III Anorexia <ul><li>Pathophysiology </li></ul><ul><li>The discovery of obese gene protein( leptin) </li></ul><ul><li>provides a proposed mechanism for modula- </li></ul><ul><li>tion of food intake and body weight that is </li></ul><ul><li>directly related to adipose tissue mass. Level </li></ul><ul><li>of circulating leptin increase as the amount </li></ul><ul><li>of adipose tissue increases </li></ul>
  40. 41. III Anorexia <ul><li>Pathophysiology </li></ul><ul><li>Elevated activity in Serotonin neurons </li></ul><ul><li>also inhibit feeding; reducing serotonin </li></ul><ul><li>levels usually increases the amount of </li></ul><ul><li>feeding elicited by orexigenic agents </li></ul>
  41. 42. III Anorexia <ul><li>Pathophysiology </li></ul><ul><li>Carbohydrate intake appears to be under </li></ul><ul><li>Neuropeptide Y control </li></ul><ul><li>Adrenalectomy reduces feeding elicited </li></ul><ul><li>by intrahypothalamic Neuropeptide Y </li></ul><ul><li>or nor epinephrine </li></ul>
  42. 43. III Anorexia <ul><li>CANCER Anorexia </li></ul><ul><li>Results from tumor-induced aberrations </li></ul><ul><li>of neurochemical mechanisms that </li></ul><ul><li>normally control hunger and satiety </li></ul><ul><li>Weight loss & Cachexia have significant </li></ul><ul><li>negative prognostic implications </li></ul>
  43. 44. III Anorexia <ul><li>CANCER Anorexia </li></ul><ul><li>Weight loss of 10-15 % during 3 to 4 </li></ul><ul><li>months is one of two prime indicators </li></ul><ul><li>that a patient may be nutritionally or </li></ul><ul><li>immunologically impaired </li></ul>
  44. 45. IV HEARTBURN AND DYSPEPSIA <ul><li>Substernal burning associated w/ bitter taste </li></ul><ul><li>Normal individuals experience this when lying </li></ul><ul><li>down or bending over after overeating & </li></ul><ul><li>gastric capacity is exceeded </li></ul>
  45. 46. IV HEARTBURN AND DYSPEPSIA <ul><li>Esophagus is normally protected by: </li></ul><ul><li>1. Competent Lower esophageal sphincter </li></ul><ul><li>2. Rapid Esophageal clearing of reflux material </li></ul><ul><li>3. Neutralization of refluxed acid by bicarbonate </li></ul><ul><li>rich saliva </li></ul><ul><li>4. Intact mucosal diffusion barrier </li></ul><ul><li>Most common clinical abnormality of </li></ul><ul><li>esophageal motility is incompetence of LES </li></ul>
  46. 47. IV HEARTBURN AND DYSPEPSIA <ul><li>Dyspepsia is a non specific term given </li></ul><ul><li>to a collection of symptoms involving: </li></ul><ul><li>1. Esophagus </li></ul><ul><li>2. Stomach </li></ul><ul><li>3. Duodenum </li></ul><ul><li>4. Biliary Tree </li></ul><ul><li>5. Pancreas </li></ul>
  47. 48. IV HEARTBURN AND DYSPEPSIA <ul><li>It is a postprandial complaint involving: </li></ul><ul><li>1. Substernal pressure </li></ul><ul><li>2. Epigastric distress </li></ul><ul><li>3. Nausea </li></ul><ul><li>4. Bloating </li></ul><ul><li>Three (3%) of these patients have angina </li></ul>
  48. 49. IV HEARTBURN AND DYSPEPSIA <ul><li>Work-up should include: </li></ul><ul><li>1. Cineflouroscopy </li></ul><ul><li>2. Contrast Radiography </li></ul><ul><li>3. Upper GI series </li></ul><ul><li>4. Endoscopy and Biopsy </li></ul>
  49. 50. IV HEARTBURN AND DYSPEPSIA <ul><li>Manometry if esophageal spasm is </li></ul><ul><li>suspected </li></ul><ul><li>Relationship of symptoms to eating and </li></ul><ul><li>other activities may give clues to the </li></ul><ul><li>diagnosis </li></ul>
  50. 51. V DYSPHAGIA <ul><li>Disturbances in swallowing can be </li></ul><ul><li>categorized according to the etiologies: </li></ul><ul><li>1. Degenerative </li></ul><ul><li>2. Functional </li></ul><ul><li>3. Inflammatory </li></ul><ul><li>4. Mechanical </li></ul><ul><li>5. Autoimmune </li></ul><ul><li>6. Neoplastic </li></ul><ul><li>Odynophagia= Painful swallowing </li></ul>
  51. 52. VI NAUSEA AND VOMITING <ul><li>1. May be related or unrelated to diseases </li></ul><ul><li>of the gastrointestinal tract </li></ul><ul><li>2. Vomiting may result whenever any part </li></ul><ul><li>of the GIT excessively irritated, over- </li></ul><ul><li>distended, or excitable </li></ul><ul><li>3. Duodenal distention is a particularly </li></ul><ul><li>potent stimulus for vomiting </li></ul><ul><li>4. Vagal and Sympathetic afferents carry </li></ul><ul><li>impulses from the GIT to the bilateral </li></ul><ul><li>vomiting center in the medulla </li></ul>
  52. 53. VI NAUSEA AND VOMITING <ul><li>Rapidly changing directions of motion </li></ul><ul><li>stimulate receptors in the labyrinthine </li></ul><ul><li>apparatus, impulses are carried into the </li></ul><ul><li>vestibular nuclei into the cerebellum to </li></ul><ul><li>vomiting center </li></ul>
  53. 54. VI NAUSEA AND VOMITING <ul><li>Ischemia to the vomiting center in: </li></ul><ul><li>1. Increased intracranial pressure </li></ul><ul><li>2. Anemia </li></ul><ul><li>3. Vascular occlusion </li></ul><ul><li>4. Shock </li></ul><ul><li>5. Severe pain </li></ul>
  54. 55. VI NAUSEA AND VOMITING <ul><li>A variety of antibiotics directly affecting </li></ul><ul><li>the GIT may cause nausea & vomiting: </li></ul><ul><li>1. Erythromycin </li></ul><ul><li>2. Bactrim </li></ul><ul><li>3. Neomycin </li></ul>
  55. 56. VI NAUSEA AND VOMITING <ul><li>Acute Nausea and Vomiting due to: </li></ul><ul><li>1. Inflammation or infectious agents </li></ul><ul><li>affecting the GIT </li></ul><ul><li>2. Neoplastic disease </li></ul><ul><li>3. Mechanical obstruction at any level </li></ul>
  56. 57. VII ABDOMINAL DISTENTION,ERUCTATION AND FLATULENCE <ul><li>Most of these patient’s are Aerophagics; </li></ul><ul><li>they swallow too much Air when they </li></ul><ul><li>eat too quickly or talk too much when </li></ul><ul><li>they eat. Hyperactive bowel sounds is </li></ul><ul><li>the rule. </li></ul>
  57. 58. VII ABDOMINAL DISTENTION,ERUCTATION AND FLATULENCE <ul><li>Chronic Eructation may be an indication </li></ul><ul><li>of chronic pathology </li></ul><ul><li>Lactase deficiency can result in Eructation </li></ul><ul><li>and Flatulence </li></ul>
  58. 60. VIII CONSTIPATION <ul><li>Most often Mechanical in origin </li></ul><ul><li>In trauma with retroperitoneal hematoma </li></ul><ul><li>Can be a result of: </li></ul><ul><li>1. Psychologic factor </li></ul><ul><li>Improper training </li></ul><ul><li>2. Dietary constituents </li></ul><ul><li>3. Laxatives & drugs </li></ul>
  59. 61. VIII CONSTIPATION <ul><li>Can be a result of: </li></ul><ul><li>4. Neurogenic causes </li></ul><ul><li>a. Tabes Dorsalis </li></ul><ul><li>b. Multiple Sclerosis </li></ul><ul><li>c. Spinal Cord Tumor </li></ul><ul><li>5. Decreased skeleto-muscular power </li></ul>
  60. 62. IX DIARRHEA <ul><li>Pathophysiological Mechanisms </li></ul><ul><li>1. Luminal secretion of solute or water </li></ul><ul><li>2. Exudation or the loss of protein, blood and </li></ul><ul><li>mucus </li></ul><ul><li>3. Osmotic retention of water </li></ul><ul><li>4. Abnormal or disordered contact between </li></ul><ul><li>chyme and the absorptive surface of bowel </li></ul><ul><li>History is important in ascertaining whether </li></ul><ul><li>this is new, chronic, or recurrent problem </li></ul>
  61. 63. X ILEUS <ul><li>Three Types </li></ul><ul><li>1. Adynamic or inhibition ileus </li></ul><ul><li>a. Most Common </li></ul><ul><li>b. Inhibition of normal neuromuscular activity </li></ul><ul><li>2. Spastic Ileus with a tightly contracted bowel </li></ul><ul><li>without propulsive activity </li></ul><ul><li>3. Ischemic Ileus from either low flow( non- </li></ul><ul><li>occlusive ischemia) or vascular occlusion </li></ul><ul><li>Coordinated motility is impossible because </li></ul><ul><li>of dying musculature </li></ul>
  62. 64. X ILEUS <ul><li>Adynamic ileus occurs after a variety of </li></ul><ul><li>abdominal operations </li></ul><ul><li>1. Gastric ileus last approximately 2 days </li></ul><ul><li>2. Colonic ileus last for approximately 3-4 days </li></ul><ul><li>3. In the normal postoperative course, the small </li></ul><ul><li>bowel continues to function </li></ul>
  63. 65. X ILEUS <ul><li>If ileus is prolonged possible causes includes: </li></ul><ul><li>1. Metabolic </li></ul><ul><li>2. septic </li></ul><ul><li>3. Mechanical or inflammatory </li></ul>
  64. 66. XI INTESTINAL OBSTRUCTION <ul><li>Classification </li></ul><ul><li>1. Extra luminal( including adhesions and </li></ul><ul><li>Neoplastic Disease </li></ul><ul><li>2. Intra luminal( such as gallstone ileus & stricture </li></ul><ul><li>3. Intra mural( such as crohn’s disease </li></ul><ul><li>Small bowel obstruction secondary to adhesion </li></ul><ul><li>constitutes 60-80% </li></ul><ul><li>Hernia constitutes 15-20% </li></ul><ul><li>Colonic Obstruction due to CA is 60% </li></ul>
  65. 67. XI INTESTINAL OBSTRUCTION <ul><li>Partial Obstruction and Pseudo-obstruction </li></ul><ul><li>Chronic Nausea and Vomiting </li></ul><ul><li>When intestinal, bowel sounds reflect amphoric </li></ul><ul><li>fluid filled bowel loops </li></ul><ul><li>Succussion spasm when pylorus & duodenum </li></ul><ul><li>are obstructed </li></ul>
  66. 68. XI INTESTINAL OBSTRUCTION <ul><li>Partial Obstruction and Pseudo-obstruction </li></ul><ul><li>Chronic intestinal pseudo-obstruction involves </li></ul><ul><li>abnormalities in: </li></ul><ul><li>Intestinal muscle( myopathic) </li></ul><ul><li>Nervous system( myenteric) e.g. Chagas’ </li></ul><ul><li>disease and infiltrative diseases </li></ul>
  67. 69. XI INTESTINAL OBSTRUCTION <ul><li>Partial Obstruction and Pseudo-obstruction </li></ul><ul><li>1. Pseudo-obstruction postop is most dangerous </li></ul><ul><li>Vagotomized patients </li></ul><ul><li>Intestinal Operation </li></ul><ul><li>2. Early recognition of Pseudo-obstruction is </li></ul><ul><li>critical to proper therapy </li></ul><ul><li>a. Biopsy of intestine may or may not reveal </li></ul><ul><li>loss of myenteric plexi </li></ul><ul><li>b. Full thickness rectal biopsy( Hirschsprung’s </li></ul><ul><li>Disease) is suspected </li></ul>
  68. 70. XI INTESTINAL OBSTRUCTION <ul><li>Mechanical Obstruction </li></ul><ul><li>1. Physiologic derangement if intact blood supply </li></ul><ul><li>a. Accumulation of fluid and Gas above the </li></ul><ul><li>point of obstruction </li></ul><ul><li>b. Altered bowel motility leading to systemic </li></ul><ul><li>derangement </li></ul><ul><li>2. Gamble showed that mortality in simple type </li></ul><ul><li>was due to: </li></ul><ul><li>a. Loss of fluid and electrolytes by vomiting </li></ul><ul><li>b. Sequestration of fluid in obstructed bowel </li></ul>
  69. 71. XI INTESTINAL OBSTRUCTION <ul><li>Mechanical Obstruction </li></ul><ul><li>3. After 48 hours, rate of entry of water into the </li></ul><ul><li>intestinal lumen increases as a consequence </li></ul><ul><li>of blood to lumen flux </li></ul><ul><li>4. Prostaglandin release in response to bowel </li></ul><ul><li>distention, increases secretion to obstructed </li></ul><ul><li>loops </li></ul><ul><li>5.Interference with the mesenteric blood supply </li></ul><ul><li>is the most serious complication of intestinal </li></ul><ul><li>obstruction </li></ul>
  70. 72. XI INTESTINAL OBSTRUCTION <ul><li>Close loop Obstruction </li></ul><ul><li>1. Both afferent & efferent limbs are obstructed </li></ul><ul><li>2. Rapid progression of strangulation of blood </li></ul><ul><li>supply before manifestations of obstruction </li></ul><ul><li>becomes obvious </li></ul><ul><li>3. Abdominal distention does not occur </li></ul>  
  71. 73. XI INTESTINAL OBSTRUCTION <ul><li>Colon Obstruction </li></ul><ul><li>1. Fluid and Electrolyte sequestration progresses </li></ul><ul><li>more slowly </li></ul><ul><li>2. Progressive distention is the most dangerous </li></ul><ul><li>aspect of non-strangulated colon obstruction </li></ul>  
  72. 74. XI INTESTINAL OBSTRUCTION <ul><li>Clinical Manifestations </li></ul><ul><li>The distance of the obstruction from the ligament </li></ul><ul><li>of Treitz can be ascertained by: </li></ul><ul><li>1. How long before vomiting takes place after </li></ul><ul><li>the onset of pain </li></ul><ul><li>2. The nature of the vomitus </li></ul> 
  73. 75. XI INTESTINAL OBSTRUCTION <ul><li>Clinical Manifestations </li></ul><ul><li>Cardinal Signs and Symptoms of Intestinal </li></ul><ul><li>Obstruction: </li></ul><ul><li>1. Crampy Abdominal Pain </li></ul><ul><li>2. Nausea & Vomiting </li></ul><ul><li>3. Obstipation </li></ul><ul><li>4. Abdominal Distention </li></ul> 
  74. 76. XII GASTROINTESTINAL BLEEDING <ul><li>1. Has high morbidity & mortality particularly in </li></ul><ul><li>the elderly </li></ul><ul><li>2. Accurate diagnosis is critical before significant </li></ul><ul><li>amounts ( 4-6 units) of blood has been lost </li></ul><ul><li>3. Bleeding represents the initial symptoms of </li></ul><ul><li>gastrointestinal disease in more than 1/3 of </li></ul><ul><li>patients & in 70% there is no history of </li></ul><ul><li>bleeding episode </li></ul>
  75. 77. XII GASTROINTESTINAL BLEEDING <ul><li>4.Eighty( 80%) will stop spontaneously without </li></ul><ul><li>intervention </li></ul><ul><li>5. Flexible endoscopy and arteriography play an </li></ul><ul><li>interesting role in the diagnostic & therapeutic </li></ul><ul><li>management </li></ul>
  76. 78. XII GASTROINTESTINAL BLEEDING <ul><li>Terminologies </li></ul><ul><li>1. Hematemesis is vomiting of blood , either </li></ul><ul><li>digested in the stomach or fresh & unaltered </li></ul><ul><li>2 . Melena is the per anal passage of stools </li></ul><ul><li>with altered blood that are black and tarry </li></ul><ul><li>3. Hematochezia is the passage of liquid </li></ul><ul><li>blood or blood clots of varied brightness or </li></ul><ul><li>color, maroon to bright red </li></ul>
  77. 79. XII GASTROINTESTINAL BLEEDING <ul><li>Terminologies </li></ul><ul><li>As little as 50-60m l of blood produce melena </li></ul><ul><li>Melena can persist for 5-7 days after a 2-unit </li></ul><ul><li>(significant) bleed </li></ul><ul><li>Approximately 10 ml bleeding/ day (Guaiac +) </li></ul>
  78. 80. XII GASTROINTESTINAL BLEEDING <ul><li>Upper GI Bleeding </li></ul><ul><li>Bleeding above the ligament of Treitz </li></ul><ul><li>include: </li></ul><ul><li>1. Esophagitis </li></ul><ul><li>2. Esophageal Varices </li></ul><ul><li>3. Gastritis </li></ul><ul><li>4. Peptic Ulcer </li></ul><ul><li>5. Mallory Weiss </li></ul><ul><li>6. Gastric Carcinoma </li></ul><ul><li>7. Hemobilia </li></ul>
  79. 81. XII GASTROINTESTINAL BLEEDING <ul><li>Upper GI Bleeding </li></ul><ul><li>8. Stress Ulcer ( Documented Risk Factors) </li></ul><ul><li>a. Multiple System Trauma </li></ul><ul><li>b. Hypotension </li></ul><ul><li>c. Respiratory Failure </li></ul><ul><li>d. Sepsis </li></ul><ul><li>e. Jaundice </li></ul><ul><li>f . Burns </li></ul><ul><li>g. Renal Failure </li></ul><ul><li>h . Recent Surgery </li></ul>
  80. 82. XII GASTROINTESTINAL BLEEDING <ul><li>Lower GI Bleeding </li></ul><ul><li>Bleeding below the ligament of Treitz </li></ul><ul><li>includes: </li></ul><ul><li>1. Diverticulitis </li></ul><ul><li>2. Angiodysplasia </li></ul><ul><li>3. Ulcerative Colitis </li></ul><ul><li>4. Malignancy </li></ul>
  81. 83. XII GASTROINTESTINAL BLEEDING <ul><li>Lower GI Bleeding </li></ul><ul><li>Work-up </li></ul><ul><li>1. Rectal Examination </li></ul><ul><li>2. Proctosigmoidoscopy </li></ul><ul><li>3.Technetium 99 scan (Tag RBC) </li></ul><ul><li>4. Arteriography </li></ul><ul><li>5. Barium Enema </li></ul>
  82. 84. XIII JAUNDICE <ul><li>GIT related Causes : </li></ul><ul><li>1. Increased pigment production secondary to </li></ul><ul><li>tissue infarction </li></ul><ul><li>2. Inflammatory disease; e.g. spontaneous </li></ul><ul><li>peritonitis </li></ul><ul><li>3. Appendicitis, complicated by coliform organism </li></ul><ul><li>can give jaundice without pyelephlebiti </li></ul><ul><li>4. Ampullary Carcinoma or Carcinoma of the </li></ul><ul><li>duodenum </li></ul>
  83. 86. THANK YOU!!!
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