The document discusses various gastrointestinal disorders including intestinal obstructions, peptic ulcer disease, bowel disorders like ulcerative colitis and Crohn's disease, gastric cancer, colorectal cancer, and terms related to gastrointestinal bleeding. It provides details on causes, signs and symptoms, risk factors, treatments, and methods to localize sources of bleeding for different gastrointestinal conditions.

1. Disorders of the Gastrointestinal System Orlando Regional Medical Center 2008

3. Intestinal Obstructions

4. Intestinal Obstruction Blockage of intestinal tract that inhibits passage of fluid, gas, feces Caused by mechanical obstruction ( strangulated hernia, adhesion, cancer, volvulus, intussusception ) neurogenic obstruction ( paralytic ileus, uremia, electrolyte imbalance(low K), spinal cord lesion ) Vascular disease ( occlusion of superior mesentery vessels)

5. Intestinal Obstructions Paralytic Ileus or “silent bowel” is most often seen after abdominal surgery & anesthesia bowel activity is < due to lack of neural stimuli (“functional”) this can lead to “mechanical” obstruction due to accumulation of feces Hernias: a loop of bowel protrudes through abdominal wall inguinal canal, umbilicus, or incisional scar tissue caused by heavy lifting, straining, or coughing

6. Sigmoid Volvulus Sigmoid Volvulus (twisting): usually seen in the older individual with a history of straining at stool Symptoms: abdominal distention, nausea, vomiting, and crampy abdominal pain; check history of flatus and BMs Abrupt onset is indicative of an acute obstruction Sudden onset due to “torsion or hernia?” A chronic history of constipation is related to a dx of diverticulitis or carcinoma Obstipation (no flatus or BM) & loss of weight = carcinoma

7. Sigmoid Volvulus

8. Intussusception only 5-15 % occurrence in adults s/s colicky abd pain, nausea, vomit, diarrhea, constipation diagnosed by barium enema, CT scan treated via surgical resection

9. Intussusception

10. Small Bowel Obstruction “ Never let the sun rise or set on a small bowel obstruction.” (surgical saying)

11. Small Bowel Obstruction Causes of SBO: Adhesions (post-surgical, post-inflammatory) Incarcerated hernia Malignancy : usually metastatic Intussusception Volvulus Gallstone ileus Parasites Foreign body

12. Small Bowel Obstruction Causes of small bowel obstruction include: Adhesions from previous abdominal surgery Hernias containing bowel Crohn's disease causing adhesions or inflammatory strictures Neoplasms benign or malignant Intussusception in children Volvulus Superior mesenteric artery syndrome a compression of the duodenum by the superior mesenteric artery and the abdominal aorta Ischemic strictures Foreign bodies (e.g. gallstones in gallstone ileus, swallowed objects) Intestinal atresia Parasites

13. Small Bowel Obstruction Signs & Symptoms of Small Bowel Obstruction:   Abdominal pain  Vomiting  Elimination problems (Diarrhea)  Bloating

14. Small Bowel Obstruction The essentials: * Common, may or may not require surgery * Emergent, if bowel is strangulated (to OR) * KUB not necessarily diagnostic -Shows dilated loops, air-fluid levels * CT very sensitive and specific -Better at transitional zone, cause of SBO

15. Small Bowel Obstruction

16. Large Bowel Obstruction A large bowel obstruction is an emergency condition that requires early & prompt surgical intervention Etiology: infectious / inflammatory, neoplastic, or mechanical pathology (colorectal cancer) Rotation or twisting of the cecum or sigmoid colon will cause abrupt onset of symptoms Immediate abdominal distention Decreases the ability to absorb Fluids & Electrolytes

17. Large Bowel Obstruction Causes of large bowel obstruction include: Neoplasms Hernias Inflammatory bowel disease Colonic volvulus (sigmoid, caecal, transverse colon) Fecal impaction Colon atresia Benign strictures (Diverticular Disease)

18. Large Bowel Obstruction Signs & Symptoms of Large Bowel Obstruction:   Abdominal pain  Vomiting ( not common )  Elimination problems (Constipation or Loose)  Bloating

19. Large Bowel Obstruction

20. When to Operate? Incarcerated or strangulated hernia Peritonitis Pneumoperitoneum Suspected strangulation Closed loop obstruction Complete obstruction Virgin abdomen LARGE bowel obstruction

21. Gastrointestinal Disorders

22. Diarrhea Causes of Diarrhea Osmotic : the presence of nonabsorbable substances in the intestine causing water to be drawn into the lumen by osmosis sorbitol-containing liquid medications; tube feedings lactose intolerance Secretory : excessive mucosal secretion of fluid & electrolytes related to: gastroenteritis (E. Coli), rotavirus, laxative abuse, hyponatremia, fecal impaction

23. Intestinal Ulcers

24. Peptic Ulcer Disease An inflammatory disorder causing deep erosion of stomach or duodenal mucosa by HCL & pepsin At risk: infection with H. pylori; > NSAIDS; > secretion of HCL as seen in Zollinger-Ellison syndrome Etiology: age, family hx > mucolytic enzymes; may lead to pyloric obstruction, bowel perforation and ultimately peritonitis Sx: hallmark sign = upper gastric pain Emergency: hematemesis, melena, occult blood, shock

25. Peptic Ulcer Disease Treatment includes: < ETOH intake screen for H. pylori (C-urea breath test) frequent small meals avoid calcium based antacids d/t > gastrin release H2 blockers (Tagamet & Zantac) Insert NG tube for severe bleeding and gastric lavage

26. Bowel Disorders Ulcerative Colitis A disease that causes inflammation and sores in the lining of the large intestine. Crohn’s Disease A disease that causes inflammation in the small intestine, but it may affect any part of the GI tract. Smoking, diet, and/or immune response to bacteria

27. Gastric Cancer Adenocarcinoma is the primary malignant neoplasm Etiology:chronic inflammation, dietary influences, genetic & environmental factors 8th leading cause of mortality r/t cancer in US Epidemiology: 55-60 year olds; 2 times greater incidence in men vs. women Risk factors: H. pylori, < socioeconomic class, consumption of pickled foods, improper food storage, radiation exposure

28. Colorectal Cancer “ Patients with long-standing ulcerative colitis have been shown to be at increased risk of developing colorectal cancer” (Medscape, 1999) Involves a primary malignant tumor of the rectum or colon 2nd leading cause of cancer death in US > incidence in 50 year olds > fat and poor fiber diet; > ETOH consumption; cigarette smoking; obesity; sedentary life style Exact etiology unknown…> incidence with polyps

29. Colorectal Cancer Symptoms: fecal occult blood or ulcerative lesions manifest as anemia or rectal bleeding distention, abdominal pain, vomiting, constipation metastatic disease: weight loss, anorexia, possible palpable mass Prevention: ASA may < risk; routine monitoring for guaic (+) Treatment: colostomy repair; permanent colostomy for rectal tumors

30. Gastrointestinal Bleeding

31. Terms of GI Bleeding Hematemesis – vomiting of blood (or coffee ground material) (indicates bleeding proximal to the Treitz) Melena – passage of black tarry stools > 50ml (indicates degradation of blood in the bowel) Hematochezia (rectal bleeding) – passage of red blood Occult Bleeding – bleeding that is not apparent to the patient and results from small amounts of blood Obscure Bleeding – occult or obvious but source not identified

32. Localization of GI Bleeding Hematemesis – always UGI source Melana – indicates that blood has been in GIT for extended periods Mostly UGI Small bowel Right colon (if bleeding relatively slow) Hematochezia Mostly colon Massive UGI bleeding (not enough time for degradation)

33. GI Bleeding Upper: includes the esophagus, stomach, duodenum peptic ulcer disease (PUD) or esophageal varices Lower: includes the jejunum, ileum, colon, rectum colorectal cancer, polyps, hemorrhoids, IBD Manifestations: hematemesis bright red blood in the stool (“ hematochezia ”) black,dark, tarry stools (“ melena ”) “ occult ” bleeding (invisible blood in the stool) Treatment: find the underlying cause; fluid volume replacement; endoscopy or colonoscopy; medical and /or surgical therapy

34. Acute UGI Bleeding Mallory-Weiss Tear Mucosal laceration at the GEJ 10% of cases Typically follows retching but mostly on 1st vomit (75%) 90% stop bleeding spontaneously Endoscopic Therapy sometimes required

35. Acute UGI Bleeding Portal Hypertension Sources of bleeding: Esophageal varices Gastric varices Portal hypertensive gastropathy Urgent gastroscopy: Sclerotherpay Band ligation Somatostatin Balloon tamponade (Sengstaken-Blackmore tube)

36. Acute UGI Bleeding Duodenal & Gastric Ulcer Most common etiology of UGI bleeding Duodenum>stomach Predisposing factors for bleeding: NSAID’s Underlying medical conditions: IHD; cerebrovascular disease Ethanol, anticoagulant Therapy Hospitalization

37. Acute UGI Bleeding Duodenal & Gastric Ulcer Predisposing factors for bleeding cont.: Gastric acid H. Pylori: Role in bleeding not certain but definitely, eradication prevents rebleeding Aspirin & NSAID’s:

38. Duodenal & Gastric Ulcer

39. UGI Bleeding Gastric Erosions NSAID’s Stress: Serious trauma Extensive burns Major surgery Major illness (ICU) Major neurological disease (CVA, tumor, trauma) Alcohol abuse

40. UGI Bleeding Malignancy Malignant: Esophageal cancer Gastric cancer or lymphoma Small intestinal lymphoma or cancer Benign: Leiomyoma

41. UGI Malignancy

42. Lower GI Bleeds Four most common causes of LGI bleeds vascular ectasias colonic diverticuli neoplasm internal hemorrhoids

43. LGI bleeds - Other Causes solitary rectal ulcer syndrome (SRUS) colonic varicies mesenteric vascular insufficiency ischemic colitis Meckel’s diverticulum small intestinal ulceration intussusception radiation-induced injury diversion colitis mesenteric venous thrombosis small bowel diverticuli Dieulafoy lesion vasculitis long-distance running endometriosis

44. Acute Lower GI Bleeding Initial management – similar to acute upper GI bleeding Presentation: wide range of presentation: Mostly self-limiting bleeding that does not require hospitalization Rarely massive with hemorrhagic shock

45. Acute Lower GI Bleeding Diverticulosis of the Colon Common cause (25%) Acute, painless, bright red, maroon or melena (depending on site) May compromise hemodynamics (elderly) Diagnosis: per exclusion Significant recurrence Treatment: most subside spontaneously, some need angiographic embolization or surgery

46. Acute Lower GI Bleeding Colonic AV Malformation Aka : Vascular Ectasias, Angiodysplasias, AV malformations They are : degenerative lesions of previously normal blood vessels located in the cecum and ascending colon They are not : telangiectasias, congenital defect, hemangiomas

47. Acute Lower GI Bleeding Vascular Ectasias the right colon is subjected to numerous colonic distentions that cause intermittent obstruction of the submucousal veins outflow tract leading to their dilation

48. Vascular Ectasias - Treatment 90 % stop spontaneously 80 % of the remainder stop after IV or intra-arterial vasopressin transcatheter embolization laser endoscopic sclerosis heater probe electrocoagulate surgery

49. Acute Lower GI Bleeding Angiodysplasia Presentation: Acute (recurrent) Chronic Occult Older pts (mainly>70) High association with CRF Most – right colon

50. Acute Lower GI Bleeding Angiodysplasia Diagnosis: Colonoscopy Angiography Treatment: Electrocoagulation Injection LASER Surgery

51. Angiodysplasia

52. Acute Lower GI Bleeding Hemorrhoids Most common cause Presentation: recurrent low-volume bright red blood on the paper or on stool Straining aggravates bleeding Rarely associated with anemia (acute or chronic) Never relate bleeding to hemorrhoids before exclusion of other lesions

53. Lower GI Bleeding Mesenteric Vascular Occlusion Vascular insufficiency - occlusive vs. non 75 % from mesenteric a. emboli usu. elderly presenting as acute abd pain, concomitant heart disease, spontaneous GI bleed, pain out-of-proportion with the PE mortality 50 - 90 % diagnosed by arteriography treated by emergent ex lap

54. Acute Lower GI Bleeding Other Causes Meckel’s diverticulum Infectious colitis: Shigella; Salmonella; campylobacter Radiation proctitis Ischemic colitis IBD – colitis (UC;CD)

55. Acute Lower GI Bleeding Evaluation of source: History: Age (tumors & diverticular disease more common in elderly pts; IBD more common in young) HIV (CMV colitis) NSAID’s Family or personal Hx of polyps or CRC Change in bowel habits Pain (in IBD, ischemic colitis…); Anal pain Previous abdominal irradiation Previous surgery (particularly vascular) ASCVD (ischemic colitis)

56. Acute Lower GI Bleeding Diagnostic procedures: Colonoscopy Tagged RBC Scintigraphy – low predictive value Angiography + Embolization Surgery (rare)

57. Effectiveness: Localization of bleeding site: : 57-72% Reduced operative mortality: : 9-14% vs.. 37-50% Angiography

58. Transcatheter Embolization • Initial control: 71 -100% • Rebleed rate : 0-12% • Ischemia: 0-21%

59. Occult bleeding Diagnosis: Imaging of the colon: Colonoscopy DC barium enema CTC Gastroscopy Small bowel follow-through Video-capsule

60. GI Bleeding Do Not Underestimate GI Bleeding Don’t assume anything Do Not Ignore Bright Red Bleeding Monitor VS Don’t assume anything Do Not Overreact to GI Bleeding Monitor VS Do Report GI Bleeding Don’t assume anything

61. References Fundamentals of Diagnostic Radiology, 2nd edition (1999). Brant, William E. & Helms, Clyde A., eds. Williams and Wilkins, Baltimore MD. Delabrousse, E., Destrumelle N., Brunelle S., Clair C., Mantion G., Kastler B. (2003) CT of small bowel obstruction in adults. Abdominal Imaging 28(2): 257-266. www.uptodate.com: Clinical manifestations and diagnosis of small bowel obstruction; Treatment of small bowel obstruction; Abdominal wall and groin hernias. Hansen, M. (1998). Pathophysiology: Foundations of disease and clinical intervention. Philadelphia: Saunders. http://www.medscape.com Givens BA, Simmons SJ: Gastroenterology in Clinical Nursing. 4th ed. St. Louis, Mo: C.V. Mosby Co, 1984. Ripamonti C, Bruera E: Palliative management of malignant bowel obstruction. Int J Gynecol Cancer 12 (2): 135-43, 2002 Mar-Apr. [PUBMED Abstract] Potluri V, Zhukovsky DS: Recent advances in malignant bowel obstruction: an interface of old and new. Curr Pain Headache Rep 7 (4): 270-8, 2003. [PUBMED Abstract] Baron TH: Expandable metal stents for the treatment of cancerous obstruction of the gastrointestinal tract. N Engl J Med 344 (22): 1681-7, 2001. PUBMED Abstract] Mercadante S: Assessment and management of mechanical bowel obstruction. In: Portenoy RK, Bruera E, eds.: Topics in Palliative Care. Volume 1. New York, NY: Oxford University Press, 1997, pp. 113-30.

62. References Givens BA, Simmons SJ: Gastroenterology in Clinical Nursing. 4th ed. St. Louis, Mo: C.V. Mosby Co, 1984. Ripamonti C, Bruera E: Palliative management of malignant bowel obstruction. Int J Gynecol Cancer 12 (2): 135-43, 2002 Mar-Apr. [PUBMED Abstract] Potluri V, Zhukovsky DS: Recent advances in malignant bowel obstruction: an interface of old and new. Curr Pain Headache Rep 7 (4): 270-8, 2003. [PUBMED Abstract] Baron TH: Expandable metal stents for the treatment of cancerous obstruction of the gastrointestinal tract. N Engl J Med 344 (22): 1681-7, 2001. PUBMED Abstract] Mercadante S: Assessment and management of mechanical bowel obstruction. In: Portenoy RK, Bruera E, eds.: Topics in Palliative Care. Volume 1. New York, NY: Oxford University Press, 1997, pp. 113-30.