Common GI conditions

1. Diverticular Disease

2. Overview
A diverticulum is an abnormal sac or pouch
protruding from the wall of a hollow organ.
• Diverticula ; pouches
• Diverticulosis ; condition of having diverticula
Diverticulosis is a common condition of Western
society and seems to be an unfortunate product of
the western dietary practices (low fiber/high fat).
• Decreased consumption of unprocessed cereals along
with the increased consumption of sugar and meat
The formation of diverticula is also related to aging
• Rare in individuals younger than the age of 30 years, but
at least two thirds of Americans will have developed
colonic diverticula by the age of 80.

4. Pathogenesis
 Diverticula are actually herniations of
mucosa through the colon at sites of
penetration of the muscular wall by
arterioles
• On the mesenteric side of the
antimesenteric teniae
 Sigmoid colon
• The most common site (50%)
• The smallest luminal diameter.
• Low fiber diet
-> decreased colonic luminal content
-> high intraluminal pressures to propel the
feces forward
-> herniations of mucosa through the
anastomically weak points in the colonic wall

5. Diverticular bleeding
The most common cause of hematochezia in
patients over the age of 60
• 20% of patients with diverticulosis will have GI bleeding.
Risk factor ; HTN, Artherosclerosis, NSAID
Usually self limited, but rebleeding risk (25%)
Localization ; Colonoscopy, Angiography
Surgery
• Unstable hemodynamics, 6-unit bleed within 24 hr
• Without localization ; Total colectomy

6. Diverticulitis
Definition
• Inflammation of a diverticulum, is related to the
retention of particulate material within the
diverticular sac and the formation of a fecalith
• Actually an extraluminal pericolic infection caused
by the extravasation of feces through the
perforated diverticulum
Presentation
• LLQ pain : may radiate to the suprapubic, groin,
back
• Bowel habit change, Anorexia, Fever, Chill,
Urinary urgency

7. Diverticulitis
Physical Findings
• Dependent on the site of perforation, the amount
of contamination, and the presence or absence of
secondary infection of adjacent organs
• Tenderness, Muscle guarding
• Tender mass : phlegmon or abscess
• Abdominal distension : ileus or obstruction
• Tender fluctuant pelvic mass on rectal or vaginal
exam

8. Diverticulitis
Diagnostic Tests
• CT
 The preferred test to confirm the suspected diagnosis
 Location of infection, extent of inflammatory process,
presence and location of an abscess, secondary
complications
 sigmoid diverticula, thickened colonic wall >4 mm, inflammation
within the pericolic fat ± the collection of contrast material or
fluid
• MRI, US
• Water soluble contrast enema
 Distinguish acute diverticulitis from perforated cancer
 Risk of increasing the colonic pressure, extravasation
of feces through the perforated diverticulitis

9. Uncomplicated Diverticulitis
Disease not associated with free intraperitoneal
perforation, fistula formation, or obstruction
Nonoperative treatment
• Bowel rest + Antibiotics ; 75% response
• Ciprofloxacin and metronidazole ; aerobic gram-
negative rods and anaerobic bacteria
• The addition of ampicillin to this regimen for
nonresponders ; enterococci
• Single-agent therapy ; a third-generation penicillin such
as piperacillin
• The usual course of antibiotics is 7 to 10 days

10. Uncomplicated Diverticulitis
Investigative studies
• After the symptoms have subsided for at least 3 weeks
• To establish the presence of diverticula and to exclude
cancer, which can mimic diverticulitis
• Colonoscopy > Barium enema
Recurrent disease
• Second attack (<25%) -> Third attack (>50%)
• Elective resection
 After infection control ; usually 4 to 6 weeks after the episode
 Laparoscopic resection ; growing trend
 Immunocompromised patient : after single attack

11. Complicated Diverticulitis
Hinchey classification
• Stage I: Pericolic or
mesenteric abscess
• Stage II: Walled-off
pelvic abscess
• Stage III: Generalized
purulent peritonitis
• Stage IV: Generalized
fecal peritonitis

12. Complicated Diverticulitis
Abscess
 Usually confined to the
pelvis
 Significant pain, fever, and
leukocytosis
 More than 2cm ; should be
drained
• Percutaneous or transanal >
laparotomy
 Elective surgery ; after
6weeks following drainage
• Complete removal of the entire
abnormally thickened bowel

13. Complicated Diverticulitis
Fistula
Skin, bladder, vagina, or small bowel
Sigmoid-vesical fistula
• Pneumaturia, fecaluria,
and recurrent UTI (Urosepsis)
• CT ; may demonstrate
air in the bladder
• Barium enema, IVP, Cystoscopy
Treatment
• Initial treatment ; infection control and reduce the
associated inflammation
• Rarely a cause for emergency surgery
• Diagnostic steps such as coloscopy should be taken to
confirm the cause of the fistula before a definitive
operation is undertaken.

14. Generalized Peritonitis
 Mechanism
• Perforation without sealing by the body’s normal
defenses -> contaminated with feces
• Abscess burst into the unprotected peritoneal cavity
-> contaminated with enteric bacteria
 Immediate operative intervention
• Excise the segment of colon containing perforation and
construct a colostomy using noninflammed colon
• Peritoneal cavity irrigation, iv antibiotics
 Colostomy repair
• Usually after a period of at least 10 weeks

16. Introduction to the Disease
Gastroenteritis is a medical condition characterized
by inflammation of the gastrointestinal tract that
involves both the stomach and the small intestine
resulting in some combination of diarrhoea,
vomiting, and abdominal pain and cramping.
Gastroenteritis is referred to as gastro, stomach
bug, and stomach virus. It has also been called
stomach flu and gastric flu.
Most cases in children are caused by rotaviruses.
In adults, noroviruses and Campylobacter are more
common.
Less common causes include other bacteria (or
their toxins) and parasites.
Transmission may occur due to consumption of
improperly prepared foods or contaminated water
or via close contact with individuals who are
infectious.

17. Signs and Symptoms
Gastroenteritis typically involves both diarrhea and vomiting .
Abdominal cramping may also be present .
Signs and symptoms usually begin 12–72 hours after contracting the
infectious agent.
Some viral causes may also be associated with fever, fatigue,
headache, and muscle pain .
If the stool is bloody, the cause is less likely to be viral and more
likely to be bacterial .
Dehydration is a common complication of diarrhea and a child with a
significant degree of dehydration may have a prolonged capillary
refill, poor skin turgor, and abnormal breathing.
Repeat infections are typically seen in areas with poor sanitation,
and malnutrition, stunted growth, and long-term cognitive delays can
result .
Low grade fever (100 F)
Loss of appetite .
Loss of important electrolytes.
This may be signaled by little or no urine, extreme thirst, lack of
tears, and dry mouth.

18. Rotavirus is the
most common
cause of severe
diarrhoea
among infants
and young
children.
Noroviruses are the
most common cause of
viral gastroenteritis in
humans . The viruses
are transmitted by
fecally-contaminated
food or water; by
person-to-person
contact; and via
aerosolization of the
virus and subsequent
contamination of
surfaces
Campylobacter is a genus
of bacteria that are
Gram-negative, spiral, and
microaerophilic . The sites
of tissue injury include
the jejunum, the ileum,
and the colon.
Gastrointestinal
perforation is a rare
complication of ileal
infection.

19. Causes
1.Viral
Rotavirus, norovirus,
adenovirus, and astrovirus
are known to cause viral
gastroenteritis. Rotavirus
is the most common cause
of gastroenteritis in
children. Rotavirus is a
less common cause in
adults due to acquired
immunity.
Norovirus is the leading
cause of gastroenteritis
among adults. Norovirus is
the cause of about 10% of
cases in children.
2.Parasitic
E. histolytica, is pathogenic;
infection can can lead to
amoebic dysentery or amoebic
liver abscess.
Giardia lives inside the
intestines of infected humans
or other animals. The Giardia
parasite originates from
contaminated items and
surfaces that have been tainted
by the feces of an infected
animal.
Cryptosporidium is the organism
most commonly isolated in HIV-
positive patients presenting
with diarrhea and can cause
gastrointestinal illness with
diarrhea in humans.

20. Causes
Causes
3. Bacterial
• Campylobacter jejuni is the
primary cause of bacterial
gastroenteritis. Bacteria
are the cause in about 15%
of cases, with the most
common types being
Escherichia coli, Salmonella,
Shigella, and Campylobacter
species.
• Toxigenic Clostridium
difficile is an important
cause of diarrhea that
occurs more often in the
elderly.
• “Traveler's diarrhea" is
usually a type of bacterial
gastroenteritis.
4.Transmission
Transmission may occur via
consumption of
objects.
contaminated water, or
when people share personal
Bottle-feeding of babies
with improperly sanitized
bottles is a significant
cause on a global scale.
Transmission rates are also
related to poor hygiene, and
in those with pre-existing
poor nutritional status.
Some agents (such as
Shigella) only occur in
primates(a mammal of the
order Primates, which
contains prosimians and
simians) , others may occur
in a wide variety of animals

21. Campylobacter jejuni E. histolytica
Giardia
Cryptosporidium Escherichia coli Shigella
Clostridium
difficile

22. Diagnosis
Gastroenteritis is typically diagnosed clinically,
based on a person's signs and symptoms.
Stool cultures should be performed in those with
blood in the stool, those who might have been
exposed to food poisoning, and those who have
recently traveled to the developing world.
Diagnostic testing may also be done for
surveillance. As hypoglycemia occurs in
approximately 10% of infants and young children,
measuring serum glucose in this population is
recommended.
Electrolytes and kidney function should also be
checked when there is a concern about severe
dehydration.

23. Prevention Measures
Management
Gastroenteritis is usually
an acute and self-limiting
disease that does not
require medication. The
preferred treatment in
moderate dehydration is
oral rehydration therapy
(ORT).
Metoclopramide and
ondansetron, however,
may be helpful in some
children.
Butylscopolamine is useful
in treating abdominal pain
.
Rehydration
The primary treatment of
gastroenteritis in both
children and adults is
rehydration.
Drinks especially high in
those with mild to simple sugars, are not
recommended in children
under 5 years of age as
they may increase
diarrhea.
Plain water may be used if
more specific and
effective ORT
preparations are
unavailable .
A nasogastric tube can be
used in young children to

24. Antiemetics
• Antiemetic medications may be helpful for treating
vomiting in children.
• Ondansetron has some utility, with a single dose being
associated with less need for intravenous fluids,
fewer hospitalizations, and decreased vomiting.
• Metoclopramide might also be helpful..
• The intravenous preparation of ondansetron may be
given orally if clinical judgment warrants.
• Dimenhydrinate, while reducing vomiting, does not
appear to have a significant clinical benefit.

25. Dehydration

26. Clinical Signs
• Increased capillary refill time (>2 seconds)
• Dry mucus membranes, dry skin and lips
• Abnormal skin turgor
• Sunken eyes
• Abnormal respiratory patterns
• Absence of tears
• Dry, sticky mouth
• Decreased urine output, dark urine
• Confusion
• Vertigo
• Lethargy
• Hypotension
• Dark urine

27. Causes of Dehydration
• Vomiting
• Diarrhea
• Poor fluid intake
• Sun exposure
• Travel (diarrhea)
• Blood loss
• Burns
• Kidney disease
• Diabetes/hyperglycemia

28. Laboratory Evaluation
• BUN/Creatinine ratio (not useful in children – serum creatinine
level changes with age)
• Serum bicarbonate less than 17 mEq per L may improve sensitivity
of identifying children with moderate to severe hypovolemia
• Serum bicarb of less than 13 mEq associated with increased risk of
failure of outpatient rehydration efforts
• Serum osmolality greater than or equal to 295 mOsm/kg
• BUN/Cr ratio > 10:1
• Fractional excretion of sodium under 1%
• Urine osmolality > 450 mOsm/kg
• Elevated AST/ALT
• Hemoconcentration – elevated hematocrit

29. Treatment
• Rapid fluid replacement
• Oral if tolerated
• Identification of fluid loss
• Isotonic crystalloid fluid boluses targeted to individual circumstance
• Colloids do not improve outcomes
• Buffered crystalloids may cause hyponatremia
• Lactated ringers contains potassium – do not use in hyperkalemia or
renal failure
• Caution – in patients with severe dehydration and severe
hyponatremia – rapid volume repletion may cause a rapid rise in
sodium. This can cause central pontine myelinolysis.

30. Fluid Requirements
• Initial rehydration: 20mL/kg over 15 minutes
• May repeat bolus until circulation stable
• After fluid bolus until circulation stable – Administer 100 mL/kg of
fluid
• Initiate maintenance fluids
• Maintenance Fluid
• Less than 10 kg – 100 mL/kg
• 10-20 kg – 1000 + 50 mL/kg for each kg over 10 kg
• Greater than 20 kg – 1500 +20 mL/kg for each kg over 20 kg
• Hourly fluid rate – 4-2-1 rule in peds