Gastrointestinal Disorders - Hard

• Exam worth 25%

Dysphagia

• Defined as difficulty swallowing
• Can result from a developmental defect, such as a connection between the esophagus and trachea via a fistula
• Can be caused by neurological damage to cranial nerves
• Damage to cranial nerve V (trigeminal nerve) can cause difficulty chewing and forming a bolus
• Damage to cranial nerve X (vagus nerve) can cause issues with unconscious movements that allow food to go down smoothly
• Tumors from the outside can pressurize the GI tract, leading to obstruction
• Achalasia, or loss of muscle contraction in the lower esophagus, can cause food to get stuck
• Diverticulum, a pouch that forms within the inner layers of the GI tract, can trap food
• Fibrosis, where scar tissue contracts and constricts the airway causing Dysphagia

Hiatal Hernia

• Condition where part of the stomach protrudes into the upper GI tract

Sliding Hernia (95%)

• The sphincter slides upwards, and the stomach protrudes above the diaphragm
• Treated surgically by suturing it in place

Rolling Hernia (5%)

• The upper part of the stomach is above the small opening of the sphincter
• A small piece of the stomach may become necrotic and require surgical removal
• Pregnancy is a risk factor
• Manifestations include pyrosis (heartburn) and potential cancerous changes

Gastric Disorders

Gastritis

• Inflammation of the stomach lining caused by alcohol or medications
• Endoscopy reveals a red and inflamed lining

Peptic Ulcer

• Occurs in the stomach or duodenum
• Caused by H. pylori or overuse of NSAID drugs

Pyloric Stenosis

• Narrow opening between the stomach and duodenum
• Thickened pyloric sphincter can cause projectile vomiting in infants born before their due date
• Can also occur in adults with unresolved peptic ulcers that harden over time

Pathogenesis of H. Pylori

• Transmitted via stomach-to-oral contact, such as sharing food with someone infected

• Urease bacterium produces an enzyme that allows it to remain dormant

• Urea turns into NH3, creating an alkaline environment, neutralizing stomach acid

• Associated conditions include cancer/lymphoma of the stomach lining

• Diagnosed via fast, specific, and noninvasive tests such as urea breath or stool sample

• Medications include triple therapy (2 antibiotics and a proton pump inhibitor)

• Clarithromycin is used, but resistance to H. pylori is emerging

• Amoxicillin or metronidazole is given if penicillin allergy

• Pantoprazole(PPI) is given to reduces uric acid in the stomach

• Quadruple therapy with bismuth given if patient is immunocompromised

Dumping Syndrome

• Can occur after a gastric bypass to shrink the stomach for weight loss
• A part of the jejunum is bypassed, reducing nutrient absorption
• Accelerated gastric emptying causes food to leave the stomach too quickly
• Extreme diarrhea and rapid dehydration are common symptoms
• Rapid absorption pulls water and electrolytes out of cells, leading to dehydration
• Vitamin deficiencies can occur due to bypassing the jejunum
• Management includes avoiding sugar on an empty stomach and eating smaller, more frequent meals

Inflammatory Bowel Disease (IBS)

• A non-inflammatory condition affecting affects 15% of humans
• Manifestations include abnormal contractions of the large intestinal wall
• Changes in bowel habits
• Pain/discomfort in the left quadrant of the abdomen
• Males experience diarrhea, while females experience constipation
• Pain relieved after a bowel movement rules out rectal cancer

Predisposing Factors

• Stress interfering with the brain-gut axis (Vagus nerve controls peristaltic movement)
• Gut microbiome imbalances
• Broad-spectrum antibiotic use
• Food allergies
• 5-HT imbalance (serotonin)
• Splenic flexure syndrome: intestine kinks, trapping material

Intestinal Obstructions

• Inguinal hernia involves a twist
• More common in males due to heavy lifting
• Volvulus involves any twist leading to ischemia or necrosis due to lack of perforation
• When tissue dies, bacteria can cause sepsis
• The pathophysiology is an autoimmune response in white blood cells from the gut triggered by bacteria

Crohn's Disease

• Colposcopy reveals inflammation patches in the GI tract from mouth to anus
• Fissures (deep cracks/lesions) cause porridge-like stool
• Can result in malabsorption of nutrients in the small intestine, specifically the jejunum
• Fissures can cause a fistula combining the small & large intestine

Ulcerative Colitis

• Inflamed continuous lesions ulcerate innermost lining, causing bloody stool
• A lower GI bleed causes blood that is bright red
• Anemia results from iron loss
• Complications include toxic megacolon, requiring surgical removal
• Additional complications include rectovaginal and enterovesicle fistulas

Celiac Disease

• An autoimmune condition w/sensitivity to wheat, rye, barley (gluten = protein)
• The body creates antibodies after gluten is broken down into gliadin/binds w/tissue transglutaminase

Acute Appendicitis

• Inflamed appendix due to obstruction
• The appendix becomes reservoir of bacteria
• Is most often obstructed by fecaliths (hard fecal matter)
• Fecalith cuts the appendix, it can result in appendicitis
• Gastro patients can get appendicitis through an infection
• A neoplasm pinching the neck of the tumor
• Use of ozempic
• Manifestations include pain in the RLQ and belly button
• Firm upon palpation

Cholelithiasis

• More common in fair-skinned females/Indigenous
• Birth control(estrogen/progesterone): estrogen slows down the gallbladder, which leads to stone formation
• Biliary sludge often precedes cholelithiasis : calcium bilirubin ate, cholesterol micro crystals, and mucin.
• Usually a result of cholesterol delayed gallbladder emptying
• Larger calculi is worse
• Cholecystitis is an infection of the biliary system
• List the three types of cholelithiasis
• Which type is most common?
• Which type has a strong association with female hormones?
• Which type is associated with conditions that cause hemolysis?
• Define: biliary colic
• Locate the abdominal pain caused by cholelithiasis, and where it can radiate.

Treatment strategies

• Describe the goal of using an NG tube with intermittent suctioning.
• Describe lithotripsy
• Describe cholecystectomy

Cholestasis

• Gallstones in the gallbladder can get stuck in the cystic duct and cause obstruction
• Gallstones can also get stuck in the common bile duct
• Biles can get stuck in the duodenum, backing up into the liver
• Clay-colored stool can be observed due to blockage preventing excreatio

Acute Pancreatitis

• This medical conditions traps digestive enzymes, preventing proper nutrient absorption
• The digestive enzymes will start digesting the pancreas
• This results in inflammation then necrosis
• Precipitating factors:
  • Activation of pancreatic enzymes inside the pancreatic ducts (e.g., trypsin, peptidase, elastase, amylase, lipase)
  • Autodigestion of pancreatic tissue
  • Tissue necrosis
• The pancreas becomes irritated from some source (or by eating)
• Number one trigger for acute pancreatitis is gall stones
• The second trigger is alcohol use
• High triglycerides is a third trigger
• Mumps, medications are factors
• Too much fat or oil will irritate the pancreas
• Post ERCP can trigger

ERCP

• Can trigger pancreas to irritate
  • When it bends in the direction of the curving
    • To check for an obstruction/irritation or inflammation of the procedure Causing an inflammatory response releasing plasma leading to hypovolemic shock/neurogenic shock
• You cannot vasocontrict right away

Complications

• DIC (Disseminated Intravascular Coagulation) ARDS (acute respiratory distress syndrome) Septic shock Peritinitis
• Blood test lipase and amylase test are required

Endoscopic Retrograde Cholangiopancreatography

Chronic Pancreatitis

• Long term inflammation of pancreas will lead to fibrosis in tests

Etiology:

• Alcohol Use
• Smoking
• Gallstones

Manifestations For Chronic Pancreatitis:

• Abdonimal Pain with vomiting/nausea
• Weight Loss
• No appetite (Can't absorb)
• Steatorrhea (fatty stool)
• Secondary Diabetes

Cirrhosis Triggers:

• Hep B, C, or D infections will most likely bleed
• Auto Immune
• AlH (autoimmune herpetitis)
• PBC (primary biliary cholangis) automatic destruction of intrahepatic bile ducts
• PSC (primary sclerosis cholangitis)

Metabolic:

• NAFLD (non alcoholic fatty liver disease)
• resistance to blood flow through liver that's scarred/ non working
• Hepatocytes are no longer working due to poor blood circulation leading to liver cell cancer

Genetics

• HH (Heredity Hemochromatosis) Iron over load
• Wilson's disease (copper over load in liver)
• AlAT anti-tripsin deficiency genetics that give you liver damage

Cholangitis (PBC):

• Immune destruction of bile ducts.

Functions Of The Liver

• Functions Explanation
  • Digestion
  • Excretion
  • Nutrient storage, convert harmful chemicals, synthesis of new molecules, transform hormones.
  • Bile neutralizes acids so fats can digest & be emulsified.
  • Bile contains bile pigments
  • Store fat as glycogen - transforms nutrients into others
  • Liver removes ammonia circulation & turns into urea that pee’s out

Portal Circulation

• How blood affects the liver Step 1:
• Liver is scarred- blood can’t flow, high pressure to portal