Disorders of Upper & Lower GI Systems

GI tract

Mouth to anus

Pain. ingestion, motility, Bleeding

Upper and Lower system disorders

4 cardinal sings and symptoms

1. ___

2. Altered ___

3. Altered ___

4. ___

Esophagus

Disorders of the ___

Digestive Pathway

• food and liquids enter the mouth

  • Mastication and addition of salivary enzymes

• Voluntary transport of food and liquids

  • Positioned at back of throat for ___ entry

  • pushed into the ___

• Common Manifestations of ___ defects

  • Pain, alteration in ingestion, and/or bleeding

Dysphagia

Difficulty of swallowing

Causes

1. Neurological deficit

2. Muscular disorder

3. Mechanical obstruction

Results/presentation

1. Pain with swallowing

2. Inability to swallow larger pieces of solid material

3. Difficult swallowing liquids

Types:

Acquired

• newly developed difficulty or pain when swallowing food, liquids, or saliva, rather than a lifelong condition

Esophageal atresia (a medical condition in which a natural body opening, tube, or passage is abnormally closed, missing, or blocked)

• The swallowing tube does not connect to the stomach, often splitting into separate upper and lower sections

Webs and Rings

Esophageal ___ and ___

• thin membranes or folds that narrow the esophagus

Cause

• Gastroesophageal reflux, iron deficiency anemia, and autoimmune diseases

Treatment

• Dietary restrictions (soft food)

• Endoscopic dilation therapy

Esophageal Cancer

Primarily squamous cell carcinoma (most common distal esophagus)

Significant dysphagia in later stages

Poor prognosis due to late manifestation

Associated with chronic irritation due to:

1. chronic esophagitis

2. achalasia

   1. nerves in the esophagus degenerate, preventing the lower esophageal sphincter (the muscle valve connecting the esophagus to the stomach) from relaxing, while normal wave-like muscle contractions (peristalsis) are lost

3. Hital hernia

4. Alcohol abuse and smoking

Hital Hernia

Part of the stomach protrudes into the thoracic cavity

Etiology

• Multifactorial

• May involve genetic link

Pathogenesis

• Herniation of stomach through esophageal hiatus of the diaphragm (an oval-shaped opening in the muscular diaphragm that allows the esophagus to pass from the thoracic (chest) cavity into the abdominal cavity)

• Lower esophageal sphincter LES permits reflux of gastric contents

Manifestations

• may be asymptomatic

• Frequently involves symptoms of gastroesophgeal reflux

• Type IV paraesophgeal hernia may produce dyspnea, reduced exercise tolerance, syncope, may cause chronic esophagitis

• HEARTBURN

Signs

• Heartburn or pyrosis, frequent belching, increase discomfort when laying down, substernal (behind sternum) pain that may radiate to shoulder and jaw

Hernia

Condition where an organ or tissue protrudes through a weak spot in the muscle or connective tissue that surrounds it

Esophagitis

Etiology

• Eosinophilic ___ (EoE)= cause unknown; many associated factors

  • chronic, immune-mediated inflammatory condition where WBCs, eosinophils build up in the lining of the esophagus

  • allergens trigger

• Radiation ___= treatment of thoracic cancers; exacerbated by chemotherapeutic agents

  • inflammation of the esophagus caused by external beam radiation therapy

• Corrosive __ = ingestion of strong alkaline or acid substances

• Pill ___ = swallowed pill lodges transversely in esophageal lumen and causes inflammation

Pathogenesis

• Irritation to and inflammation of esophageal tissues lead to esophageal damage

Manifestations

• Vary based on etiology

Esophageal Diverticula

Etiology

• acquired condition

• most common cause: Impaired esophageal motility

• May be caused by traction on esophagus due to inflammatory disease of mediastinum (eg. tuberculosis)

Pathogenesis

• pressure increases→ esophageal lumen

• Esophageal mucosa protrudes through weakened esophageal wall and produces out pouching

Manifestation

• Most often asymptomatic

• Manifestions vary based on location of divercula

• May produce dysphagia and heartburn

pockets formed due to damage to the mucosa and then food is trapped in those pockets

Stomach

Disorders of the ___

Main categories

• Disorders of secretion

• Disorders of motility

Associated cardinal GI symptoms

• Pain

• altered ingestion

• altered motility

• GI tract bleeding

Pepsin enzyme is used to break down proteins, pepsin needs low pH which this organ has a very low pH

Also has chyme and has rugae (folds) to increase/decrease in size

Peptic Ulcer Disease

Etiology

• various causes

• most common: H. pylori infection and NSAID use

• Contributing factors: smoking, excessive alcohol use, drug use, emotional stress, and psychosocial components

Pathogenesis

• Increased gastric acid secretion or a weakened mucosal barrier leads to mucosal erosion or ulceration of GIT

Manifestations

• Common: epigastric pain and dyspepsia (upset stomach)

• Common Complications: bleeding, perforation (hole, tear, or puncture through tissue or organ), obstruction

Treatment

• Identify causative facot

• H. pylorI- triple or quadruple therapy

• NSAID- induced - H2 receptor antagonist (decrease stomach acid production by blocking histamine from binding to H2 receptors on parietal cells in the stomach) and cease NSAID

Acute Gastritis

Inflammation of stomach wall
Etiology

• Infection-induced - H. pylori

• Drug-induced - e.g NSAIDS, steroids, some chemotherapeutic drugs, alcohol, and iron supplements

• Ulcerohemorrhagic - physiologic stress and ischemic changes caused by shock, hypotension

Pathogenesis

• Acute imbalance between mucosal injury and repair mechs

• Development of mucosal hyperemia (increase in the volume of blood within the tissues or organs of the body, caused by the dilation of blood vessels) and erosive changes with histologic presence of inflammation

Manifestations

• Most often asymptomatic or report mild dyspepsia

• Potenital symptoms may include abdominal pain or upset, burning sensation in chest or upper abdomen, feeling of fullness, bloating, belching, and reflux

• More severe symptoms include nausea, vomiting, GI bleeding, fever, and weight loss

Chronic Gastritis

Inflammation of stomach wall

Etiology

• Infection induced - H.pylori

• Chemical and caustic agents (eg NSAIDs, excessive alcohol ingestion, radiation exposure

• Autoimmune disease (eg. Crohn disease, Wegener granulomatosis,

  • autoimmune disease that causes inflammation of the small and medium blood vessels (vasculitis), restricting blood flow and damaging major organs

• and sarcoidosis

  • an inflammatory disease characterized by the formation of tiny, abnormal clumps of inflamed immune cells called granulomas in one or more organs throughout the body

Pathogenesis

• Begins with superfical gastritis

• Progresses to atrophic (wasting away) gastritis

  • chronic inflammation damages and thins the stomach lining, normal stomach glands to shrink and get replaced by intestinal or fibrous tissue

• Advances to gastric atrophy

• gastric glandular structures are lost and/or metaplasia

• Gastric atrophy is precursor to gastric cancer

Manifestations

• Most often asymptomatic or report mild dyspepsia

• Potenital symptoms may include abdominal pain or upset, burning sensation in chest or upper abdomen, feeling of fullness, bloating, belching, and reflux

• More severe symptoms include nausea, vomiting, GI bleeding, fever, and weight loss

Gastric Outlet Obstruction

Etiology

• Includes gastric, duodenal, and/or extraluminal pathology (outside the lumen (the inside space or hollow cavity of a tubular structure, such as the intestine, blood vessel, or airway)

• Malignancies of digestive organs

• Surgical and interventional induced obstructions

• Metastatic cancer

• Pyloric stenosis

Pathogenesis

• mechanical obstruction in pyloric region

Manifestsions

• abdominal pain, distention or bloating

• vomiting, dehydration, and weight loss

• May include early satiety and nausea

Treatment

• Benign cases - nasogastric tube suction, meds to suppress gastric acid production, IV fluid and electrolyte replacement, nutritional supplementation, trial liquid diet, endoscopic balloon dilation or surgery

• Malignant cases - Based on underlying cause, may include stenting, chemotherapy, endoscopic balloon dilation, or surgery

• Advanced cancers - Palliative procedures may be preferred

Stomach Cancer

Etiology

• Risk factors include H.pyloric infection, cigarette smoking, high alcohol ingestion, excessive dietary salt, inadequate fruit and veggie consumption, and pernicious anemia

• High nitrate diet may also increase risk

Pathogenesis

• tumors or neoplasms in the stomach arise from gastric mucosa (adenocarcinoma- most common ~85%)

Manifestsions

• Clinical manifestations are known as false alarms features

• Most common: weight loss and abdominal pain

• May include dysphagia, nausea, early satiety, occult GI bleeding, and palpable abdominal mass

Treatment

• Depends on cancer staging

• upper endoscopy may be used for palliative (focus on reliving pain) procedures

• May require endoscopic resection, radiation, chemo, and/or surgical resection

Chyme

Disorders of the Small intestines, Large intestines, and Rectum

Absorption in the lower GI tract

• ___ enters small bowel via duodenum

  • the thick, semi-fluid mass of partly digested food, water, hydrochloric acid, and digestive enzymes that forms in the stomach

• Bowel is primary site of absorption

  • nutrients and vitamins

  • electrolytes

  • water

• Impaired motility may cause multiple alterations

  • malabsorption

  • malnutrition

  • dehydration

Inflammatory Bowel Disease IBD

Chronic inflammatory disorder involving the GIT

2 Major IBD disorders

• Ulcerative colitis UC

• Crohn disease CD

Manifestations of IBD (including UC and CD)

• Active: Fever, loss of appetite, weight loss, fatigue, and night sweats

• Remission: Symptoms may decrease and even disappear

Ulcerative Colitis UC

Chronic inflammatory condition

Limited to mucosal layers of colon

Characterized by relapsing and remitting episodes of inflammation

Develops as a continuous lesion

Etiology

• Not completely understood

• Appears to involve environmental factors, microbial imbalance in the gut, genetic susceptibility and inappropriate immune response

Pathogenesis

• Inflammation of muscoal and submucosal layers of colon

• Continuous lesion of inflammation may extend into the proximal colon or may affect the whole colon (pancolitis)

• Bowel changes include epithelial damage, inflammation, crypt abscesses, and loss of goblet cells (secrete mucus)

Manifestations

• Bloody and/or mucoid, diarrhea, dehydration, and anemia

• Crampy abdominal pain, pain with defecation, and tenesmus (painful, persistant need to empty bowels or urine even if empty)

• Involvement of the rectum may also lead to constipation

Crohn Disease CD

Chronic inflammatory condition

May involve any portion of the GI tract

Charactered by transmural inflammation of the bowel

Most commonly affects ileum and proximal colon

Lesions are not always continuous (skip lesions)

Etiology

• Not completely understood

• Appears to involve environmental factors, microbial imbalance in gut, genetic susceptibility and inappropriate immune response

Pathogenesis

• Inflammation and destruction of the bowel

Manifestations

• Nausea, vomiting, and diarrhea with or w/o blood

• Abdominal pain and pain with defecation due to anorectal fissures

• Complications include bowel strictures (abnormal narrowing of the small or large intestine that slows or blocks the passage of waste), obstructions, perforations (holes) in bowel and intra-abdominal abscesses (collection of infected fluid and pus surrounded by inflamed tissue or organs)

stratified squamous

The inner lining (mucosa) of the esophagus is made primarily of non-keratinized ____ epithelial cells

Appendicitis

Etiology

• Not fully understood

• Believed to be due to appendiceal obstruction

Pathogenesis

• obstruction is thought to lead to bacterial overgrowth and luminal distention

• Increased intraluminal pressure and/or excessive inflammation can inhibit blood flow causing vascular compromise to the affected tissue

• Appendix may become gangrenous (death of tissue due to low oxygen or bacterial infection) and can rupture

Manifestations

• Cramping abdominal pain, tenderness with palpation of right lower abdominal quadrant, nausea or vomiting, increased WBC count, and low grade fever

Treatment

• Gold standard- Laparoscopic surgery (tiny cuts)

Bowel Obstruction

Etiology

• Most often due to adhesions 75% of cases

  • bands of fibrous scar-like tissue that form between internal body surfaces, organs, or tissues, causing them to stick together

• Other causes hernia, adhesions neoplasm/tumor,

• gallstone ileus

  • small bowel obstruction caused when a large gallstone (usually larger than 2.5 cm) slips into the digestive tract through an abnormal connection (fistula) between the gallbladder and the intestine,

• intussusception,

  • serious medical condition where one segment of the intestine slides or folds inside an adjacent section,

• volvulus

  • medical condition where a loop of the intestine twists around itself and its supporting tissue (the mesentery), causing a blocked bowel and cutting off blood flow

Pathogenesis

• Intestinal tract blockage develops due to various etiologies

• Up to 80% are small bowel obstructions SBOs

• Obstruction may be partial or complete

• Complications include strangulation and bowel necrosis (may lead to bowel perforation, sepsis, and death)

Manifestations

• Abdominal pain, nausea, vomiting, abdominal distention, and inability to satisfactoryily pass gas or stool

• Hyperactive, high pitched bowel sounds often present

• Bowel sounds will be absent if ileus develops (temporary stoppage or slowing of the normal muscle contractions (peristalsis) in the intestines)

Treatment

• Medical management includes gastric decompression, IV fluids, and serial physcial and serum tests

• Surgery may be indicated if medical management fails

• If strangulation and bowel ischemai present- Emergent surgery needed

Pyloric Stenosis

Narrowing and obstructing pyloric sphincter

May be developmental abnormality

Signs appears after birth

1. Projectile vomiting after feeding

2. Firm mass that can be palpitated at pylorus

3. Infant failure to gain weight

Diverticular Disease

Etiology

• Associated factors include alterations in colonic wall resistance, alterations in colonic motility, low-fiber diets, NSAID use, advanced age, obesity, and lack of exercise

Manifestations

• sudden, constant abdominal pain in Left lower quad

• Abdominal distention and nausea

• Diarrhea, constipation, decreased appetite

• Fever, tachycardia, hypotension

Diverticula

Diverticulosis

Diverticulitis

Diverticula

Small outpouchings (herniations) of colonic mucoasa

Protrudes through muscle layers of the colon wall

small, bulging pouches or sacs that form in the inner lining of the digestive tract—most commonly in the colon (large intestine)—pushing outward through weak spots in the muscular wall

• Diverticulum: A single pouch

• Diverticula: Multiple pouches

Diverticulosis

Divercula without evidence of inflammation

Diverculitis

Inflamed diverticula

When one or more diverticula become infected or inflamed, leading to symptoms like severe lower-left abdominal pain, fever, and nausea.

hemorrhoids

Internal and external ___

• A swollen vein or group of veins in the region of the anus

Hemorrhoidal Disease

Etiology

• Straining during bowel movement

• Risk factors - conditions that increase intraabdominal pressure and/or impede venous return (eg pregnancy or portal hypertension)

Pathogenesis

• abnormal enlargement of the 3 vascular mucosal cushions (hemorrhoidal cushions) that assist with anal continence

Manifestations

• Hematochezia

  • passage of fresh, bright red or maroon blood through the anus, either mixed with or coating the stool

• itching, perianal discomfort and soiling

• Large hemorrhoids may produce sensation of incomplete evacuation

Cancer of colon and rectum

Adenomas (polyps) of colon

• precursors to most colorectal cancers CRCs

• benign tumors

• form in glandular structures in intestinal mucosal epithelium

Colon cancer

• malignant growth or tumor

• results from division of abnormal cells in the colon

• Occurs in ascending, transverse, or descedning colon

Rectal Cancer

• Malignant growth or tumor

• Located up to 15 cm from anal opening

Pathogenesis of CRC

• genetic abnormalities plus environmental factors

Conventional Adenomas and Sessile Serrated Polyps (flat, pre-cancerous growth located in the large intestine)

• Commonly developmental pathways

  • chromosomal instability pathway

  • Micro satellite instability pathway

Manifestations of early CRC

• typically asymptomatic

• Numerous potential manifestations

  • Hematochezia and symptoms of anemia

  • Change in bowel habits

  • Weight loss and fatigue

  • Generalized or localized abdominal pain

CRC Risk factors

__ and protective factors

Modifiable Risk Factors

• Obesity

• sedentary lifestyle

• smoking

• moderate to heavy alcohol ingestion

• Heavy consumption of red and processed meats

• Low consumption of fruits and veggies

Hereditary and Medical Risk Factors

• Family history of CRC and/or polyps

• Inflammatory bowel disease (US or CD)

• Type 2 DM

• Aging

Protective Factors

• diet rich in while grain giber

• Use of NSAIDs (eg, aspirin)

Potential Manifestations of advanced CRC

Physical assessment

• distended abdomen

• Palpable abdominal mass and lymph nodes

• Rectal cancer - palpable mass on digital exam

Right sided cancers (ascending colon)

• Usually silent

• May become painful

• May develop palpable mass in right lower quadrant

• Tumors stay to one side of colon wall

• Unlikely to develop intestinal obstruction

• Dark red blood in stool

Left sided tumors (descending colon)

• tumors grow circumferentially around colon

• stools may become long and pencil-like

• can lead to intestinal obstruction

• bright red blood in stool

Screening for CRC

• Early detection is essential

• Screening methods

  • Lower GI endoscopy, fecal tests for occult blood and DNA testing for mutant genes

• Screening recommendations

  • begin screening at age 50

    • those with predisposing genetic factors begin screening earlier than 50

TNM

Staging of CRC (national Cancer Institute classification)

• Used to determine treatment

• usually includes __ classification

  • Tumor, lymph nodes, and metastasis

  • Tumor: Describes the size of the primary tumor and how far it has grown into nearby tissues (ranked from T0-T4)

  • Nodes: Indicates whether the cancer has spread to nearby regional lymph nodes (ranked from N0-N3)

  • Metastasis: Shows whether the cancer has spread to distant parts of the body, such as the liver, lungs, or bones (M0 for no spread, M1 for distant spread).

• Endoscopy may be used for staging