APPLIED ANATOMY OF DIGESTIVE SYSTEM
UNDER THE GUIDANCE OF
DR. SIPPY SIR
• Is a skin infection that occurs on the floor of the mouth,
underneath the tongue.
• Complications can be life threatening.
Causes:• Ludwig’s angina is a bacterial infection. It is usually caused by
the bacterium Streptococcus or Staphylococcus and often
follows a mouth injury or infection such as a tooth abscess.
• Poor dental hygiene, lacerations in the mouth or a recent
Symptoms:- Ludwig’s angina often follows a tooth infection or
other infection or injury in the mouth.
• pain in the floor of your mouth
• problems with speech
• neck pain
• swelling of the neck
• redness on the neck
• weakness, fatigue
• swollen tongue pushing against your palate
• fever, chills
Diagnosis:• Physical exam:-Head, neck and tongue will appear red and
• Imaging tests:-Contrast-enhanced magnetic resonance
imaging (MRI) or computed tomography (CT) images.
• Fluid cultures :-Fluid from the affected area may tested to
identify the bacterium.
Complications:• Blocked airway.
• Sepsis (a severe reaction to bacteria or other germs)
• Septic shock(infection that leads to dangerously low blood
Treatment:• Blocked airway
- Insert a breathing tube through your nose or mouth into
Prevention:• Practicing good oral hygiene.
• Having regular dental checkups.
• Seeking prompt treatment for tooth and mouth infections.
• Oral Mucositis (OM) refers to an inflammatory, erosive and
ulcerative process inside the mouth, which is usually caused
by radiation or chemotherapy.
Causes:• Side effect of cancer treatment.
Increased risk:• Smoking.
• Drinking alcohol.
• Eating spicy foods.
• Dry mouth–is another side effect of radiotherapy and
• Receiving a higher dose of chemotherapy.
Symptoms:-The symptoms of oral Mucositis usually begin five
to 10 days after starting chemotherapy or 14 days after
• Burnt sensation while eating very hot food.
• Develop white patches or ulcers on the lining of mouth, on
tongue and around lips.
• Red and inflamed oral mucosa.
• Ulcerations may cause severe pain.
Conditions look like Oral Mucositis:• Candidiasis (oral thrush);
• Herpes simplex virus (HSV); and
• Graft-versus-host disease (GVHD).
Diagnosis:• Examining your mouth.
• Diagnosis symptoms of pain.
• Checking ability to eat and drink properly.
Complications:• Severe pain and trouble eating .
• Dry mouth.
• Alterations in taste that can lead to Anorexia.
• Weight loss.
• Weakness due to poor nutrition.
• Severe inflammation and injury to the oral mucosa also
increases the chance of other infections in the mouth
• Cause a reduction in dose of treatment.
- Avoid tobacco, alcohol and hot & spicy foods.
- Drink plenty of fluids.
• Palifermin is given by injection which encourages the growth
of new cells on the lining of the mucous membrane.
• Adenoiditis is an inflammation of
• Adenoids are masses of lymph
tissue that help the body fight
• Adenoids are found in the
pharynx (throat) just behind the
nose and are the first line of
defense in your throat.
Causes:• Adenoiditis can be caused by a
bacterial infection, such
as Streptococcus, or by viruses
such as the Epstein-Barr virus.
Risk:Certain risk factors are:
• Recurring infections in the throat, neck, or head.
• Infections of the tonsils.
• Contact with airborne viruses, germs and bacteria.
• Difficult to breathe through nose.
• Sounding “nasal” when speaking.
• Sore or dry throat from breathing through the mouth.
• Snoring during the night or any time you sleep.
• Signs of infection, such as a runny nose that produces green
or discolored mucus.
Complications :- Complications may chronic or severe
inflammation that spread to other locations of the head
• Ear Infections
• Glue Ear
• Infections of the Chest
Diagnosis:• Physical examination
• Throat examinations
• Blood tests
Prevention:• Healthy foods.
• Plenty of fluids.
Haematemesis of oesophageal origin
Tumours of Oesophagus
Oesophageal Atresia and Tracheo-oesophageal Fistula
1 in 4425 live births.
Congenital esophageal atresia (EA) represents a failure of the esophagus to
develop as a continuous passage. Instead, it ends as a blind pouch.
Tracheoesophageal fistula (TEF) represents an abnormal opening between
the trachea and esophagus
Regurgitation of every feed
Attacks of cough
Death usually results from
The most immediate and effective treatment in the majority
of cases is a surgical repair to close the fistula/s and reconnect
the two ends of the esophagus to each other.
Duplication of Oesophagus
a neuromuscular dysfunction
Cardiac sphincter fails to relax during swallowing
Dialatation of the oesophagus
Signs and symptoms
Dysphagia (difficulty in swallowing),
Regurgitation of undigested food,
Chest pain behind the sternum,
Coughing when lying in a horizontal position.
Cardiospasm. It can be extremely painful in some sufferers.
Food and liquid, including saliva, are retained in the esophagus
and may be inhaled into the lungs (aspiration).
Forceful pneumatic dialatation using a 30-35mm diameter
endoscopically postioned balloon disrupts the oesophageal
sphincter and improves symptoms in 80% of patients
Endoscopically directed injection of botulinum toxin into
the lower oesophageal sphincter induces clinical
remission,but late relapse is common.
Hiatus hernia or hiatal hernia is the protrusion (or herniation)
of the upper part of the stomach into the thorax through a tear
or weakness in the diaphragm.
Sliding (Oesophago-Gastric) Hiatus Hernia- 90%
Rolling (Paraoesophageal) Hiatus Hernia- 5%
Mixed (Transitional) Hiatus Hernia- 5%
Failure of the muscle fibres of the diaphragm that forms the
margin of the oesophageal hiatus
Degenaration of muscle due to aging
Increased intra-abdominal pressure
Recurrent Oesophageal regugitation and spasm causing
inflammation and fibrosis
Increase in fatty tissue in obease people causing decreased
muscular elasticity of diaphragm
Signs and symptoms
Hiatal hernia has often been called the "great mimic"
because its symptoms can resemble many disorders.
Dull pains in the chest,shortness of breath
(caused by the hernia's effect on the diaphragm),
Heart palpitations (due to irritation of the vagus nerve),
Swallowed food "balling up" and causing discomfort in
lower esophagus until it passes on to stomach.
Heartburn (retrosternal burning sensation)
Regurgitation of gastric juice into the mouth
1.To minimise gastro-oesophageal reflux
Elevate bed head by 20cm
Avoid posture precipitating reflux,bending or stooping forwards,sitting in a
Avoid large meal
No food or drink for 3-4 hours before bedtime
Reduce weight if possible
Avoid all non dteridal anti-inflammatory drugs
Avoid food which provoke syptoms eg: pastries, coffee
2.Reduce gastric acidity and pepsin secretion
3.Increase tone of lower oesophageal sphincter
Metoclopramide 10 mg tds
Restoration of intra-abdominal segment of oesophagus into
abdomen and anchoring it,repairing the hiatus and enveloping
the lower oesophagus by gastric fundus.
( Nissen fundoplication)
(Upper end of the oesophagus or at the bifurcation of the trachea)
Pulsion (Zenker’s) Type
(in the region of hypopharynx)
(Occurs in the lower third of oesophagus from contraction of fibrous
tissue such as from pleural adhesions,scar tissue of healed
tuberculous lesions in the hilum,silicosis etc.
is a triangular area in the wall of the pharynx between the
thyropharyngeus part of the inferior constrictor of the pharynx
and the cricopharyngeus muscle, also of the inferior constrictor
muscle of the pharnyx
It represents a potentially weak spot where a
pharyngoesophageal diverticulum (Zenker's diverticulum) is
more likely to occur.
Oesophageal Webs and Rings
Esophageal webs are thin (2-3mm) membranes of normal
esophageal tissue consisting of mucosa and submucosa that
can partially protrude/obstruct the esophagus.
A Schatzki ring or Schatzki-Gary ring
is a narrowing of the lower part of the esophagus that can causedifficulty
swallowing (dysphagia). The narrowing is caused by a ring of mucosal tissue
(which lines the esophagus) or muscular tissue.
Heamatemesis Of Oesophageal Origin
Vomiting Of Blood
2.Mallory- Weiss Syndrome
3.Rupture Of The Oesophagus
4. Other Causes
Bursting of aortic aneurysm into
the lumen of oesophagus
Reflux of the gastric juice is the commonest cause of oesophagitis
Other Causes of oesophagitis
Intake of certain drugs
Ingestion of hot, irritating fluids
• Peptic ulcer disease refers to painful sores or ulcers in the lining
of the stomach or first part of the small intestine, called the
CAUSES OF PEPTIC ULCER
• ulcer is the end result of an imbalance between digestive fluids
in the stomach and duodenum. Ulcers can be caused by:
• Infection with a type of bacteria called Helicobacter pylori (H.
• Use of painkillers called no steroidal anti-inflammatory drugs
(NSAIDs), such as aspirin, naproxen (Aleve, Anaprox, Naprosyn,
and others), ibuprofen (Motrin, Advil, Midol, and others), and
many others available by prescription. Even safety-coated
aspirin and aspirin in powered form can frequently cause
• Excess acid production from gastrinomas, tumors of the acid
producing cells of the stomach that increases acid output
Symptoms of peptic ulcer
Vomiting blood (that can look like "coffee-grounds")
Severe pain in the mid to upper abdomen
TREATMENT AND DIAGNOSIS
The diagnosis of an ulcer is made by either a barium upper
gastrointestinal X-ray (Upper GI series) or an Upper GI
• The goal of ulcer treatment is to relieve pain, heal the ulcer,
and prevent complications. .
• The first step in treatment involves the reduction of risk
factors (NSAIDs and cigarettes).and second is medications:
• Proton-pump inhibitors (PPIs)
• A gastric ulcer is a sore in the lining of your stomach.
• Upsets in the balance of stomach acid and digestive juices can
lead to an ulcer. This can be caused by:
• Helicobacter pylori (H. pylori) infection
• Taking NSAIDs for a long time
and at higher doses
• Cigarette smoking
• Alcohol abuse
• Gnawing pain
• Weight loss
Talk to your doctor about the best treatment plan for you.
Treatment options may include one or more of the following:
• Lifestyle Changes
• Surgery and Endoscopy
• Gastritis occurs when the lining of the stomach becomes
inflamed or swollen.
• Gastritis can last for only a short time (acute gastritis), or
linger for months to years (chronic gastritis).
• Alcohol abuse
• Eating or drinking caustic or corrosive substances (such as
• Extreme stress
• Certain medications, such as aspirin
• Loss of appetite
• Nausea and vomiting
• Black stools
• H. pylori tests
• Stool test to check for small amounts of blood in the stools,
which may be a sign of bleeding in the stomach
• Antacids may be used to treat chronic gastritis caused by
infection with Helicobacter pylori bacteria.
• H2 antagonists: famotidine (Pepsid), cimetidine
Problems with the small intestine can include:
7.Irritable bowel syndrome
8.Ulcers, such as peptic ulcer
It causes inflammation of the digestive system. It is
one of a group of diseases called inflammatory bowel
disease. It most commonly starts between the ages of
13 and 30.
Crohn's can affect any area
from the mouth to the anus.
It often affects the ileum.
CausesThe exact cause of Crohn’s disease is unknown.
Most researchers think that it is caused by a
combination of factors.
2.The immune system
The five types of Crohn's disease1. Ileocolitis: Most common type of chron’s disease. Affects
the mouth and colon
2. Ileitis: affects the ileum
3. Gastroduodenal Crohn's disease: Affects the stomach and
4. Jejunoileitis: affects the jejunum
5. Crohn's colitis: Affects only the colon
1. Pain in the abdomen
3. Bleeding from the rectum
4. Weight loss
Diagnosis• Barium enema
• CT scan of the abdomen
• MRI of the abdomen
Complications of Crohn's disease1.Intestinal blockages
2.Ulcers in the intestine
3.Problems getting enough nutrients
4.Joint pain and skin problems
5.Growth problems (in children)
Treatment-There is no cure for Crohn's.
Treatment to control symptoms
3. Pain relievers
4. Iron supplements
5. Nutrition (special diet given via a feeding tube)
6. Vitamin B-12 shots
Surgery: Removes a damaged portion of your digestive
Limitations of surgery1. temporary benefits
2. Recurrence of chron’s
3. Post surgery medication’s required
Ulcerative colitis is a disease that causes inflammation and
sores, called ulcers, in the lining of the rectum and colon.
The main symptom of active disease is usually constant
diarrhea mixed with blood, of gradual onset. It is a form of
inflammatory bowel disease (IBD).
Ulcerative colitis is a form of colitis, a disease of the intestine,
specifically the large intestine or colon, that includes
characteristic ulcers, or open sores, in the colon
The most common symptoms of ulcerative colitis are
abdominal pain and bloody diarrhea. Patients also may
Loss of appetite
Loss of body fluids and nutrients
Growth failure (specifically in children)
• Many tests are used to diagnose ulcerative colitis. A physical
exam and medical history are usually the first step.
• Blood tests may be done to check for anemia, which could
indicate bleeding in the colon or rectum .
• In addition, a stool sample allows the doctor to detect
bleeding or infection in the colon or rectum caused by
bacteria, a virus, or parasites.
Drug Therapy:AMINO SALICYLATES
IMMUNO SUPRESSIVE DRUGS
OTHER SURGICAL ALTERNATIVES
BACTERIAL RE COLONIGATION
Site of maximum tenderness in appendicitis
• Hemorrhoids are swollen and inflamed veins in the anus and
Internal and External Hemorrhoids
• Internal hemorrhoids located inside the rectum;
• External hemorrhoids develop under the skin around the
• Too much pressure on the veins in the pelvic and rectal area
Factors that might cause increased pressure include:
• Diarrhea or constipation
• Sitting for long periods of time on the toilet
• Diet low in fiber or fluids
SIGNS AND SYMPTOMS
Extreme itching around the anus
Irritation and pain around the anus
Itchy lump located near your anus
Painful bowel movement
Blood on your tissue after having a bowel movement
• Digital rectal exam
• Rubber band ligation
• Surgery : Hemorrhoidectomy
Ointments: as zinc oxide or petroleum jelly
Ointment that contains 1% hydrocortisone
Acetaminophen can help with pain.
Aspirin and other nonsteroidal anti-inflammatory drugs such
as ibuprofen (Motrin) and naproxen (Aleve) can help with
pain and swelling.
• Blood clots within the swollen vein
• Iron-deficiency anemia (caused by blood loss)
• Avoid straining during a bowel movement.
• Increase your water intake. Drinking adequate water can
keep your stool from hardening.
Disorders of Tongue
• Glossodynia (burning mouth
syndrome)- spontaneous burning,
discomfort, pain, irritation, or
rawness of the tongue, has no
identifiable etiology most of the
• Etiology– Idiopathic, Infection,
– Xerostomia, Geographic tongue/
– Vesiculobullous disease,
– Referred pain from teeth or
– Drugs- Antibiotics, psychiatric
Treatment for burning mouth syndrome varies
greatly between cases based on the severity of the
symptoms, the underlying cause and the diagnosis
of the physician. In many cases the symptoms will
be associated with a psychological disorder such as
depression and the burning mouth and the
underlying cause will be treated together with antidepressants. In other cases patients can try altering
their medication, using different toothpastes,
checking their dentures and increasing their
consumption of vitamin B12.
Disorders of Tongue…
• Macroglossia- congenital or
acquired process, tongue is
disproportionately large relative to
the patient’s jaw size
• Difficulty with mastication and
speech and accidental tongue biting
• Differential- Down syndrome,
hypothyroidism, BeckwithWiedemann syndrome,
neurofibromatosis, infection by
mycobacteria, filamentous bacteria
or fungus, amyloidosis
Tongue Reduction Surgery
• Most common chronic blood-borne infection
accounts for 50% of all patients with chronic liver
disease in the US
• Flaviviridae family, genus Hepacivirus
• HCV RNA polymerase with poor fidelity inherently
unstable (+) genomic instability & antigenic
variability within one individual evade IFN-mediated
anti-viral response repeated bouts of hepatic
• Persistent infection and chronic hepatitis are
the hallmarks of HCV infection
2. blood transfusions
4. sexual transmission
Hepatitis C Therapy
• Interferon Alone < 15%
– 12 months Genotype 1
– 6 months Genotype 2 and 3
• Sustained response (Hep C PCR- 6 mos post
– 5-15% monotherapy
– 35-40% combo therapy
– 45-70% PEG combo therapy
• Must use birth control--teratogenic
What is cirrhosis?
• Cirrhosis is a condition
in which the liver slowly
malfunctions due to
chronic injury. Scar
tissue replaces healthy
liver tissue, partially
blocking the flow of
blood through the liver
What causes cirrhosis?
heavy alcohol consumption
chronic hepatitis C (the most common)
Autoimmune inflammation of the liver
What are the symptoms of cirrhosis?
Symptoms are hard to catch in the early stages of the disease.
However, as the disease progresses, a person may
experience the following symptoms:
• loss of appetite
• weight loss
• abdominal pain and bloating
• spiderlike blood vessels on the skin
Treatment and Prevention
•Stop drinking alcohol (or don’t start at all)
•Limit salt in the diet
•Eat a nutritious diet
•Get vaccinated for influenza, hepatitis A and B.
•Practice safe sex
Gallstones develop when
cholesterol and other
substances in the bile form
crystals that become hard
stones in the gallbladder. The
gallbladder is a small sac
located just under the liver.
Gallstones can form when too
much cholesterol is in the bile
or when the gallbladder does
not empty properly.
• Pain in the RUQ
– Most common and typical symptom
– May last for a few minutes to several hours
– Mostly felt after eating a heavy and high-fat meal
Pain under right shoulder when lifting up arms
Fever, nausea and vomiting
Jaundice (obstruction of the bile duct passage)
Acute pancreatitis (gallstone enters the duct
leading to pancreas and blocks it)
– Most sensitive and specific test
• Computerized tomography (CT)
– May show gallstones or
complications, such as infection and
rupture of GB or bile ducts
• Cholescintigraphy (HIDA scan)
– Used to diagnose abnormal
contraction of gallbladder or
obstruction of bile ducts
• Endoscopic retrograde
– Used to locate and remove stones
in bile ducts
• Blood tests
– Performed to look for signs of
infection, obstruction, pancreatitis,
– 5 - 40% of patients develop
distress and persistent pain in
– 20% of patients develop
• Two surgical options
– Open cholecystectomy
– Laparoscopic cholecystectomy
• Nonsurgical treatment:
– Only in special situations
• When a patient has a serious medical condition preventing
• Only for cholesterol stones
– Oral dissolution therapy
• Ursodeoxycholic acid - to dissolve cholesterol gallstones
• Months or years of treatment may be necessary before all
– Contact dissolution therapy
• Experimental procedure
• Involves injecting a drug directly into the gallbladder to
dissolve cholesterol stones
• DM is a group of metabolic diseases in which a person has
high blood sugar, either because the pancreas does not
produce enough insulin, or because cells do not respond to
the insulin that is produced.
• Types :
1. Type 1 DM results from the body's failure to produce insulin.
2. Type 2 DM results from insulin resistance, a condition in
which cells fail to use insulin properly, sometimes combined
with an absolute insulin deficiency.
3. Gestational diabetes