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02.06.12(b): A GI Smorgasbord - Common GI Problems part I


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02.06.12(b): A GI Smorgasbord - Common GI Problems part I

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