Pathophysiology Chapter 36

1. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
CHAPTER 36
GASTROINTESTINAL
DISORDERS

2. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
• Dysphagia
• Difficulty in swallowing
• Inability to initiate swallowing
• Sensation that swallowed solids/liquids “stick” in esophagus
• Pain with swallowing (odynophagia) may accompany

3. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)

4. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Dysphagia—Type I
• Problems in delivery of food/fluid into esophagus
• Causes
• R/T neuromuscular incoordination
• Normal sequence is altered or absent

5. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Dysphagia—Type I
• Symptoms
• May cough and expel the ingested food/fluids through mouth
or nose
• Aspirate when attempting to swallow
• Worse with liquids than solids

6. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Dysphagia—Type II
• Problems in transport of bolus down esophagus
• Causes
• Outpouchings of one or more layers (diverticula)
• Disorder of smooth muscle function (achalasia)
• Interference of peristaltic activity (neoplasms, strictures)

7. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Dysphagia—Type II
• Symptoms
• Sensation food is “stuck” behind sternum
• May have impaired passage of liquids

8. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Dysphagia—Type III
• Problems in bolus entry into stomach
• Causes
• Lower esophageal dysfunction or lesion obstruction
• Symptoms
• Tightness or pain in substernal area during swallowing process

9. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)

10. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Esophageal pain
• Heartburn (pyrosis)
• Cause
• Reflux of gastric contents into esophagus
• High acidic contents are an irritant to sensory afferent
nerve endings in mucosa
• Causes spasms of esophageal muscle

11. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Esophageal pain
• Heartburn (pyrosis)
• Symptoms
• Substernal burning sensation that may radiate to neck or throat

12. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Esophageal pain
• Chest pain (esophageal distention or obstruction)
• Symptoms
• Similar to angina pectoris (radiates to neck, shoulder, arm, and jaw)
• Brought on by swallowing

13. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Abdominal pain
• May be first sign of GI tract disorder
• Three types
• Visceral pain
• Cause
• Stretching or distending an abdominal organ
• Inflammation
• Symptoms
• Diffuse, poorly localized
• Gnawing, burning, or cramping

14. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Abdominal pain
• Three types
• Somatic pain
• Cause
• Injury to abdominal wall, parietal peritoneum, root of the
mesentery of the diaphragm
• Symptoms
• Sharp, intense pain
• Well localized to area of irritation

15. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Abdominal pain
• Three types
• Referred pain
• Felt at a location distant from source of pain
• In the same dermatome or neurosegment
• Symptoms
• Sharp and well localized
• May be felt in skin or deeper tissues

16. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT
DISORDERS (CONT.)
• Abdominal pain
• Acute
• Instantaneous onset
• Perforated ulcer or ruptured organ
• Chronic
• Diverticulitis
• Ulcerative colitis

17. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Vomiting
• Forceful expulsion of gastric contents through mouth
• Accompanied by nausea
• Characteristics of vomitus may suggest nature of disorder

18. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Vomiting
• Causes
• Coordinated sequence of abdominal muscle contraction with
reverse esophageal peristalsis
• Alterations in the integrity of GI tract wall (gastroenteritis)
• Alterations in motility (obstruction)

19. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Intestinal gas
• Results from altered motility or lack of digestive enzymes
• Belching
• Eructation of swallowed air

20. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Belching
• Causes
• Motility disorder
• Gastric outlet obstruction preventing passage of air
from stomach to small intestine

21. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Intestinal gas
• Belching
• Causes
• Swallowing of air
• Bacterial and digestive action on intestinal contents
• Diffusion from the blood
• Neutralization of acids by bicarbonate in upper GI tract

22. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Intestinal gas
• Abdominal distention
• Causes
• Failure to adequately digest nutrients such as lactose
• Excess gas resulting from defect in intestinal motility

23. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Intestinal gas
• Flatus
• Causes
• Increased amounts of gas produced by action of bacteria on gas-
producing nutritional substrates (legumes, vegetables)

24. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Bowel pattern alterations
• Constipation
• Small, infrequent, or difficult bowel movements
• Causes
• Dietary (low in fiber)
• Lack of exercise
• Pathologic conditions (ex: diverticulitis, obstruction)

25. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
CHEMICAL DIGESTION

26. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
• Bowel pattern alterations
• Diarrhea
• Increased frequency and fluidity of bowel movements caused
by decreased transit time in SI
• Acute
• Acute infection
• Emotional stress
• Leakage of stool around impacted feces

27. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Bowel pattern alterations
• Diarrhea
• Chronic
• Chronic GI tract infection
• Alterations in motility or integrity of GI tract
• Malabsorption
• Certain endocrine disorder
• Food allergy
• Ingestion of irritants
• Caffeine

28. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Pathophysiologic mechanisms
• Osmotic
• Increased amounts of poorly, absorbed solutes in the intestine
• Secretory
• Due to toxins that stimulate intestinal fluid secretion and impair
absorption

29. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
COMMON MANIFESTATIONS OF
GASTROINTESTINAL TRACT DISORDERS
(CONT.)
• Pathophysiologic mechanisms
• Exudative (mucus, blood, protein)
• Results from inflammatory processes
• Diarrhea related to motility disturbances
• Example: dumping syndrome

30. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
DISORDERS OF THE MOUTH
• Stomatitis
• Inflammation of oral mucosa
• Causes
• Pathogenic organisms
• Trauma
• Chemical irritants
• Chemotherapy, radiation
• Nutritional deficiencies

31. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
DISORDERS OF THE MOUTH (CONT.)
• Acute herpetic stomatitis
• “Cold sores”
• Signs and symptoms
• Fever
• Pharyngitis
• Prodromal tingling and itching
• Vesicles on erythematous base that rupture, leaving a painful
ulcer

32. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
DISORDERS OF THE MOUTH (CONT.)
• Acute herpetic stomatitis
• Treatment
• Use adequate oral hygiene
• Medications
• Antiviral meds (famciclovir, valacyclovir)

33. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ESOPHAGEAL DISORDERS
• Gastroesophageal reflux disease (GERD)
• Backflow of gastric contents into esophagus through LES
• Inflammation caused by reflux of highly acidic material
• Progression can lead to ulceration, fibrotic scarring,
strictures, Barrett esophagus

34. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ESOPHAGEAL DISORDERS (CONT.)
• Gastroesophageal reflux disease (GERD)
• Causes
• Any condition or agent that alters closure strength of
LES or increases abdominal pressure
• Fatty foods
• Caffeine
• Large amounts of alcohol
• Cigarette smoking
• Sleep position
• Pharmacologic agents
• Anatomic features (ex: hiatal hernia)

35. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ESOPHAGEAL DISORDERS (CONT.)
• Esophagitis
• Barrett esophagus
• Complication when columnar tissue replaces normal squamous
epithelium of the distal esophagus
• Carries a significant risk for esophageal cancer

36. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ESOPHAGEAL DISORDERS (CONT.)
• Hiatal hernia
• Defect in diaphragm when a portion of the stomach passes
through the diaphragmatic opening into the thorax
• Risk increases with age
• Women more than men

37. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ESOPHAGEAL DISORDERS (CONT.)
• Hiatal hernia
• Can be life threatening if large portion of stomach
becomes caught above diaphragm and becomes
incarcerated
• Signs and symptoms
• Similar to GERD
• Heartburn
• Chest pain
• Dysphagia

38. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ESOPHAGEAL DISORDERS (CONT.)
• Hiatal hernia
• Sliding hernia (most common)
• Portion of stomach and gastroesophageal junction slip up into
thorax above diaphragm
• Paraesophageal hernia (rolling)
• Part of greater curvature of stomach rolls through the
diaphragmatic defect
• Mixed

39. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ESOPHAGEAL DISORDERS (CONT.)

40. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ESOPHAGEAL DISORDERS (CONT.)
• Mallory-Weiss syndrome
• Bleeding caused by a tear in mucosa or submucosa of the
cardia or lower portion of esophagus
• Tear is usually longitudinal
• Primary cause is forceful or prolonged vomiting

41. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ESOPHAGEAL DISORDERS (CONT.)
• Mallory-Weiss syndrome
• Other factors or contributions
• Excessive ingestion of alcohol and salicylates
• Coughing
• Straining during bowel movements
• Trauma
• Hiatal hernia
• Esophagitis
• Gastritis

42. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ESOPHAGEAL DISORDERS (CONT.)
• Esophageal varices
• Complication of portal hypertension resulting from
alcoholic or posthepatitis cirrhosis
• Affects more than half of cirrhotic patients
• 30% have variceal hemorrhage within 2 years of diagnosis
• High mortality rate

43. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
INFLAMMATION OF THE
STOMACH AND INTESTINES
• Gastritis
• Acute
• Precipitated by ingestion of irritating substances
• Example: alcohol and aspirin
• Signs and symptoms
• Anorexia
• Nausea
• Vomiting
• Postprandial discomfort
• Hematemesis

44. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
INFLAMMATION OF THE
STOMACH AND INTESTINES
(CONT.)
• Gastritis
• Chronic
• Helicobacter pylori is nearly always a factor
• Complications
• Peptic ulcer disease
• Atrophic gastritis
• Gastric adenocarcinoma
• Mucosa-associated lymphoid tissue lymphoma

45. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
INFLAMMATION OF THE
STOMACH AND INTESTINES
(CONT.)
• Gastroenteritis
• Inflammation of stomach and small intestine
• Usually a result of another GI disorder
• Acute is caused by direct infection of tract by pathogenic
virus or bacterial toxin
• May be caused by imbalance in normal bacterial flora by
introduction of unusual bacteria (travel)

46. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
INFLAMMATION OF THE
STOMACH AND INTESTINES
(CONT.)
• Gastroenteritis
• Signs and symptoms
• Diarrhea
• Abdominal discomfort and pain
• Nausea
• Vomiting
• Fever
• Malaise
• Treatment
• Replace fluid and electrolytes

47. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
INFLAMMATION OF THE
STOMACH AND INTESTINES
(CONT.)
• Peptic ulcer disease
• Causes
• H. pylori
• Stress
• Smoking
• Alcohol
• Spicy foods
• Smoking
• Genetic

48. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
INFLAMMATION OF THE
STOMACH AND INTESTINES
(CONT.)

49. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
INFLAMMATION OF THE
STOMACH AND INTESTINES
(CONT.)
• Peptic ulcer disease
• Gastric
• Due to breakdown of protective mucous layer that prevents
diffusion of acids into gastric epithelia
• Barrier of epithelial layer and slightly alkaline layer of mucus
interrupted with chronic irritations

50. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
INFLAMMATION OF THE
STOMACH AND INTESTINES
(CONT.)

51. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
INFLAMMATION OF THE
STOMACH AND INTESTINES
(CONT.)
• Peptic ulcer disease
• Duodenal
• Inappropriate excess secretion of acid
• Increased basal activity of vagus nerve
• Stimulates pyloric antrum cells to release gastrin to act on gastric
parietal cells to release HCl
• Results in high level of HCl

52. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
INFLAMMATION OF THE
STOMACH AND INTESTINES
(CONT.)

53. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
INFLAMMATION OF THE
STOMACH AND INTESTINES
(CONT.)
• Peptic ulcer disease
• Treatment
• H. pylori: antibiotics
• H2 antagonists
• Proton pump inhibitors
• Sucralfate (forms protective coating over injured mucosa)
• Smoking cessation
• Avoidance of ASA and NSAIDs, caffeinated beverages, alcohol,
and irritating foods

54. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
INFLAMMATION OF THE
STOMACH AND INTESTINES
(CONT.)

55. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
INFLAMMATORY BOWEL DISEASE
• Ulcerative colitis
• Large ulcers form in mucosal layer of colon and rectum
• Associated with increased cancer risk after 8-10 years of
disease
• Hallmark symptoms are bloody diarrhea and lower
abdominal pain

56. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
INFLAMMATORY BOWEL
DISEASE (CONT.)
• Ulcerative colitis
• Treatment
• Corticosteroids
• Salicylate analogs
• Immunomodulating agents
• Azathioprine
• Mercaptopurine

57. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
INFLAMMATORY BOWEL
DISEASE (CONT.)

58. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
INFLAMMATORY BOWEL
DISEASE (CONT.)
• Crohn disease
• Affects proximal portion of the colon or terminal ileum
• Inflammation of all layers of the intestinal wall resulting from
blockage and inflammation of lymphatic vessels
• Suggestive findings are ulcerations, strictures, and fistulas

59. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
INFLAMMATORY BOWEL
DISEASE (CONT.)

60. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
INFLAMMATORY BOWEL
DISEASE (CONT.)
• Crohn disease
• Signs and symptoms
• Intermittent bouts of fever
• Diarrhea
• RLQ pain
• May have RLQ mass, tenderness
• Treatment
• Smoking cessation, drugs similar to ulcerative colitis

61. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ENTEROCOLITIS
• Antibiotic-associated colitis (AAC) (also called
Pseudomembranous enterocolitis)
• Acute inflammation and necrosis of small and large
intestine
• Caused by Clostridium difficile (exposure to antibiotics)
• Signs and symptoms
• Diarrhea (often bloody), abdominal pain, fever, colonic
perforation (rare)
• Treatment: stop current antibiotic (if possible), treat
ischemia, oral antibiotics such as metronidazole or
vancomycin

62. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ENTEROCOLITIS (CONT.)
• Necrotizing enterocolitis (NEC)
• Occurs in premature infants (<34 wk) and infants with low
birth weight (<5 lb)
• Characterized by diffuse or patchy intestinal necrosis with
sepsis
• Signs and symptoms
• Distended abdomen and stomach, intestinal perforation
• Treatment: surgical with antibiotics

63. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ENTEROCOLITIS (CONT.)
• Appendicitis
• Obstruction by fecalith, inflammation
• Signs and symptoms
• RLQ pain (“McBurney’s point”) (classic, but may be anywhere),
nausea, vomiting, fever, diarrhea, RLQ tenderness, systemic
signs of inflammation
• Treatment: immediate surgical removal

64. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ENTEROCOLITIS (CONT.)
• Diverticular disease (diverticulosis)
• Presence of diverticula in the colon
• Results in low intake of dietary fiber
• Signs and symptoms
• Diverticulosis—asymptomatic
• Diverticulitis—fever, acute lower abdominal pain
• Treatment: antibiotics and surgery for complicated
diverticulitis

65. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ENTEROCOLITIS (CONT.)

66. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ALTERATIONS IN MOTILITY
• Irritable bowel syndrome
• Chronic (>3 months) functional disorder
• Fluctuations in stool frequency and consistency (no
nocturnal diarrhea)
• Cause: unclear but slow wave activity of bowel in
increased.
• Often associated with anxiety or depression

67. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ALTERATIONS IN MOTILITY (CONT.)
• Irritable bowel syndrome
• Signs and symptoms
• Diarrhea or constipation or alteration of both, abdominal
cramping pain, mucus in stool, nausea, bloating
• Treatment
• Antidiarrheal agents, antispasmodic medications, increased
fiber in diet

68. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ALTERATIONS IN MOTILITY (CONT.)
• Intestinal obstruction
• Mechanical
• Adhesions, hernia, tumors, impacted feces, volvulus,
intussusception
• Functional
• Conditions that inhibit peristalsis such as narcotics, anesthesia,
surgery, peritonitis, hypokalemia, spinal cord injuries

69. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ALTERATIONS IN MOTILITY (CONT.)
• Intestinal obstruction
• Signs and symptoms
• Depend on site and duration: dehydration, vomiting, electrolyte
depletion, constipation, abdominal distention
• Treatment
• Surgical intervention or decompression with intestinal tube
• If left uncorrected may cause wall edema, ischemia, and
necrosis leading to bowel gangrene, sepsis, and shock

70. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ALTERATIONS IN MOTILITY (CONT.)
• Volvulus
• Twisting of bowel on itself causing intestinal obstruction and
blood vessel compression (ischemia)
• Results from anomaly of rotation, ingested foreign body, or
adhesion; cannot always be determined
• Common sites are cecum and sigmoid colon
• Sudden, tight, twisting of bowel impedes blood flow to
bowel

71. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ALTERATIONS IN MOTILITY (CONT.)
• Volvulus
• Impeded blood flow leads to gangrene, necrosis, and
perforation
• Life-threatening condition
• Signs and symptoms
• Depend on site and duration: dehydration, vomiting, electrolyte
depletion
• Treatment
• Varies according to severity and location: surgical intervention
or decompression

72. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ALTERATIONS IN MOTILITY (CONT.)

73. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ALTERATIONS IN MOTILITY (CONT.)
• Intussusception
• Telescoping/invagination of a portion of bowel into
adjacent (usually distal) bowel causing intestinal
obstruction
• Males more than females
• Signs and symptoms
• Increased bowel sounds, abdominal pain, varies
• Treatment: surgical treatment

74. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ALTERATIONS IN MOTILITY (CONT.)

75. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ALTERATIONS IN MOTILITY (CONT.)
• Hirschsprung disease
• Familial, congenital disorder of the large intestine in which
the autonomic ganglia are reduced or absent
• Occurs 1:5000 live births
• Most commonly found in infants and children
• Males more than females

76. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
ALTERATIONS IN MOTILITY (CONT.)
• Hirschsprung disease
• Signs and symptoms
• Profuse diarrhea, hypovolemic shock, intestinal perforation
• Treatment
• Colonic lavage, surgical intervention

77. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
MALABSORPTION DISORDERS
• Failure of GI tract to absorb or normally digest one
or more dietary constituents
• Causes
• Enzyme abnormalities
• Infection
• Radiation enteritis
• Signs and symptoms
• Diarrhea
• Passage of inappropriately processed intestinal contents
• Types (celiac diseases, tropical sprue)

78. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
MALABSORPTION DISORDERS
(CONT.)
• Celiac disease (celiac spruce)
• Familial intolerance of gluten-containing foods
• Leads to inflammation and atrophy of the intestinal villi
• Impaired nutrient absorption
• Reduced surface area
• Decreased brush border enzymes
• 2x increase for intestinal malignancy

79. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
MALABSORPTION DISORDERS
(CONT.)
• Celiac disease (celiac spruce)
• Diagnosis
• Intestinal biopsy
• Anti-tissue transglutaminase antibody (anti-ttg)
• Immunoglobulin A (IgA) endomysial antibody
• Treatment
• Gluten-free diet
• Supplemental Fe, folate, B12, fat-soluble vitamins (A, D, E, K)

80. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
MALABSORPTION DISORDERS
(CONT.)
• Tropical sprue
• Malabsorptive syndrome of unknown cause
• Prevalent in equatorial countries (living/visiting)
• Adults more than children
• Etiology
• Mucosa of small intestine atrophies resulting in malabsorption
along with B12 and folic acid deficiency

81. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
MALABSORPTION DISORDERS
(CONT.)
• Tropical sprue
• Signs and symptoms
• Severe diarrhea with blood-tinged stools, abdominal distention,
steatorrhea
• Treatment
• Predictability depends on area
• Antidiarrheals, prolonged antimicrobial therapy

82. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
MALABSORPTION DISORDERS
AFTER SURGICAL INTERVENTION
• Dumping syndrome
• Dumping of stomach contents into small intestine due to
impaired gastric emptying
• Common after gastrectomy
• Large volume of hyperosmolar food is dumped rapidly into
small intestine leading to increased bowel motility
• Rapid absorption of large amount of glucose leads to an
excessive rise in plasma insulin

83. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
MALABSORPTION DISORDERS AFTER
SURGICAL INTERVENTION (CONT.)

84. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
MALABSORPTION DISORDERS AFTER
SURGICAL INTERVENTION (CONT.)
• Dumping syndrome
• Signs and symptoms
• Diarrhea, abdominal pain,
• Rapid fall in blood glucose level 1-3 hr after meal (rebound
hypoglycemia)
• Treatment
• Eating small meals throughout day instead of large meals,
carbohydrate restriction, medications to reduce bowel motility

85. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
MALABSORPTION DISORDERS AFTER
SURGICAL INTERVENTION (CONT.)
• Short-bowel syndrome
• Severe diarrhea and significant malabsorption
• Develops after surgical removal of large portions of SI
• Rapid transit time and reduced surface area for absorption
• Diminished ability to absorb H2O, electrolytes, protein, fat,
carbohydrates, vitamins, and trace elements

86. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
MALABSORPTION DISORDERS AFTER
SURGICAL INTERVENTION (CONT.)
• Short-bowel syndrome
• Signs and symptoms
• Diarrhea and malabsorption
• Treatment
• Temporary or indefinite intravenous nutritional support

87. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
NEOPLASMS OF GI TRACT
• Esophageal cancer
• Accounts for 1%-2% of all cancers
• Men more than women
• Survival rate of <20% in men older than 60 years
• Risk factors
• Genetic, diet high in nitrosamine content, chronic severe reflux
(Barrett esophagus), environmental, smoking, alcohol

88. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
NEOPLASMS OF GI TRACT (CONT.)
• Esophageal cancer
• Prognosis: poor; spreads extensively to surrounding organs
• Very high degree of metastasis
• Treatment
• Stent placement, tumor ablation through heat probe and laser

89. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
NEOPLASMS OF GI TRACT (CONT.)
• Gastric carcinoma
• Prevalence in Japan 10x higher than U.S.
• Men > 30 years
• Stages (early and advanced)
• Determined by penetration into major muscle layer of stomach,
involvement of lymphatic system and surrounding organs
• Risk factors
• H. pylori infection, genetic, dietary habits, environmental
factors, smoking

90. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
NEOPLASMS OF GI TRACT (CONT.)

91. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
NEOPLASMS OF GI TRACT (CONT.)
• Small intestinal neoplasms
• Benign or malignant
• Unusual
• Account for <5% GI tumors
• > 50 years
• Causes partial or complete obstruction
• Depending on extent and type

92. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
NEOPLASMS OF GI TRACT (CONT.)
• Small intestinal neoplasms
• Signs and symptoms
• Depends on type and extent; partial or complete obstruction of
small bowel may occur
• Treatment
• Surgical removal of tumor and affected portion of SI

93. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
NEOPLASMS OF GI TRACT (CONT.)
• Colonic polyps
• Any protrusion into the lumen of the GI tract
• Benign or malignant
• Signs and symptoms
• Usually none; may cause occult or gross bleeding, abdominal
pain
• Treatment
• Varies according to size, type, and location

94. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
NEOPLASMS OF GI TRACT (CONT.)

95. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
NEOPLASMS OF GI TRACT (CONT.)
• Colon cancer
• Risk factors
• Increases after age 40
• High-fat, low-fiber diet
• Polyps, chronic irritation or inflammation

96. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
NEOPLASMS OF GI TRACT (CONT.)
• Colon cancer
• Warning signs
• Black, tarry, or pencil-shaped stool
• Change in bowel habits
• Urgent need to defecate on awakening in morning
• Alternating constipation and diarrhea
• Sensation of rectal fullness
• Dull ache may be felt in rectum/sacral region

97. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
NEOPLASMS OF GI TRACT (CONT.)
• Colon cancer
• Prognosis
• Early detection, better prognosis
• Depends on extent of tumor invasion, cell type, degree of
dysplasia, tumor genetics, presence or absence of metastasis
• TNM classification used for metastasis

98. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
NEOPLASMS OF GI TRACT (CONT.)

99. Elsevier items and derived items © 2010, 2005 by Saunders, an imprint of Elsevier Inc.
NEOPLASMS OF GI TRACT (CONT.)
• Colon cancer
• Treatment
• Surgical removal
• Chemotherapy, radiation, or both