Gastrointestinal Tract and GERD

• Module 9 focuses on the digestive system
• Covers content from pages 36-38

Upper Gastrointestinal (UGI) Tract

Gastroesophageal Reflux Disease (GERD)

• Textbook reference pg 949
• A weak esophageal sphincter fails to completely close after food enters the stomach
• This allows stomach acid backflow into the esophagus
• Throat tissue cannot withstand stomach acid
• GERD can result over time from bearing down during bowel movements
• GERD can result from weightlifting while holding breath
• Heartburn results 30-60 minutes after meals due to chyme and gastric acid regurgitation, causing esophagitis which leads to tissue erosion
• Fibrosis (scar tissue) from the healing process does not stretch like esophageal tissue
• Over-the-counter antacids, like Tums or Rolaids, are temporary solutions
• Antacids do not prevent acid release
• Excessive antacid use can cause electrolyte imbalances due to high sodium, calcium, or magnesium content
• Pain worsens when lying down or bending over
• Patients may need to sleep in a recliner or with their head elevated
• GERD pain can mimic a heart attack requiring that patients are taught not to ignore or assume chest pain is heartburn
• Respiratory symptoms can develop if gastric reflux enters the larynx

GERD risk factors

• Obesity
• Pregnancy
• Smoking
• Hiatal hernia
• Fatty foods
• Alcohol
• Chocolate

GERD Treatment (Rx)

• Acid-suppressing medications like omeprazole
• Stop smoking and avoid secondhand smoke
• Limit caffeine intake
• Check for gluten intolerance
• Maintain a high-protein, low-fat diet
• Sleep with the head of the bed elevated
• Stay upright for 2-3 hours after eating
• A "cardiac cocktail", like Mylanta and viscous lidocaine, is administered to ER patients to rule out M.I.
• If pain subsides after the "cocktail", the problem is GI-related, not cardiac
• If pain is worse when lying down, indicative of GERD, not a cardiac issue
• Nissen Wrap/fundoplication surgery is an option for severe reflux, wrapping the stomach's top around the esophagus for a tighter sphincter
• Following surgery, the patient will be unable to vomit or belch air
• GERD can cause precancerous dysplasia (Barrett’s Esophagitis) and can develop into throat cancer
• Patients should be advised to never ignore heartburn, as it can lead to throat cancer

Hiatal Hernia

• Textbook reference pg 949
• Protrusion of the upper stomach through the diaphragm into the thorax causing congestion of blood flow and ischemia
• Pressure weakens the esophageal opening through the diaphragm called the "hiatus"
• Exact causes unknown
• Can be due to weakening of tissue that allows the diaphragm ring to widen
• Increases with age, pregnancy, obesity, habitual vomiting, weight training, and smoking/alcohol
• Very common, especially in people over 50 years old
• Hiatal hernias are commonly asymptomatic unless GERD is also present
• Hiatal hernia pain, similarly to GERD, can mimic a heart attack, where chest pain must be evaluated and tested for cardiac causes first and foremost
• Treatments include acid suppressing medications and potentially surgery if severe
• Endoscopic exam can observe and diagnose a hiatal hernia

Peptic Ulcer Disease (PUD)

• Textbook reference pg 954
• Erosion of the stomach lining
• Helicobacter pylori (H. pylori) is present in >90% in duodenal ulcers, and about 80% of stomach ulcers
• Stress ulcers are common in hospitalized patients (burn trauma, head injuries, critically ill patients)
• Multifactorial, though shock is a known precursor due to low blood perfusion to the stomach
• Proton-pump inhibitor drugs are used, such as I.V. pantoprazole [Protonix]
• Other risk factors include smoking, alcohol use, and NSAID use such as aspirin, ibuprofen, naproxen, etc
• Epigastric (substernal) or chest pain (dull, achy, or sharp) starts about two hours after eating, or in the middle of the night after the stomach has emptied
• Pain is often relieved by eating
• Ulcers can self-resolve or worsen to upper gastrointestinal bleeding or stomach/duodenal perforation
• Common finding in patients with unexplained low hematocrit/hemoglobin
• Main dangers include anemia, profuse bleeding, and stomach cancer

Tests for PUD and UGIB

• CBC
• Hematocrit & Hemoglobin
• H. pylori blood test
• Occult blood smear
• EGD (Esophagogastroduodenoscopy) visualizes and stops a GI bleed
• Biopsy of stomach tissue tests for H. Pylori, during the EGD procedure
• Treatment: Combination Drug Therapy with antibiotics to kill the H. pylori along with acid-suppressing medication
• Active UGIBs can often be cauterized during endoscopy

Types of Ulcers

• Includes duodenal, gastric, and stress

Duodenal Ulcers

• Age: 25-50 years old; any age, usually early adulthood
• Gender: Men > women 3 or 4:1
• Stress factors: N/A According to new research
• Hyperacidity: Increased
• Ulcerogenic drugs: Increased use of ETOH/tobacco
• Associated gastritis: Seldom
• Bacterial infection: Often H. pylori
• Pain: Pain relieved by eating, common nocturnal, remissions and exacerbations
• Hemorrhage: Common

Gastric Ulcers

• Age: 55-70 years old
• Gender: Men > women 3 or 4:1
• Stress factors: N/A According to new research
• Hyperacidity: Normal to low
• Ulcerogenic drugs: Moderate use of ETOH / tobacco
• Associated gastritis: Common
• Bacterial infection: May be present
• Pain: Pain relieved by eating, uncommon nocturnal, no remission and exacerbation
• Hemorrhage: Less common

Stress Ulcers

• Age: Persons with severe stress or trauma (hospitalized patients)*
• Gender: Both genders
• Stress factors: Increased
• Hyperacidity: Increased
• Ulcerogenic drugs: Increased use of ETOH, ASA, NSAID's
• Associated gastritis: Acute and common
• Bacterial infection: Not a factor
• Pain: Asymptomatic until hemorrhage or perforation
• Hemorrhage: Very common
• Stress ulcers are so common in hospitalized patients that they are given an acid-suppressing medication by IV prophylactically with pantoprazole/Protonix

Indications of a GI Bleed

• Type of blood informs of bleeding source

• UGIB (upper GI bleed) and LGIB (lower GI Bleeds) can be either slow/chronic with minimal symptoms or sudden and life-threatening

• Ulcer perforations will cause stomach acid to enter the peritoneal cavity, sudden agonizing pain and a RIGID ABDOMEN, sepsis, and shock

• Slow ulcer bleeds cause fatigue and anemia

• Occult GI Bleeding: Positive fecal occult blood test with no visible blood in feces

• Overt GI Bleeding can manifest as: - Hematemesis - Melena - Hematochezia

• “Bright red emesis” is a dangerous sign and indicates an emergency

• “Coffee-ground emesis” is due to partial digestion of blood in the stomach by stomach acids

• Melena causes black “sticky” stools that look like tar and smell awful caused by blood being partially digested in the small/large intestines which indicates a bleeding site in the stomach or intestines

• Hematochezia causes bright red blood from the rectum and is typically not a serious problem

Lower Gastrointestinal Tract

Irritable Bowel Syndrome (IBS)

• Textbook, pg. 958
• A "functional gastrointestinal (GI) disorder" with symptoms caused by changes in how the GI tract works
• IBS is a group of symptoms that occur together, not a disease, without damage like in Ulcerative Colitis and Crohn’s disease
• The disorder has physical and mental causes
• Defining characteristic: Pain relieved by defecation

IBS includes other potential contributing factors

• Genetics
• Brain-gut signal problems
• Hypersensitivity to bowel stretching
• Bacterial gastroenteritis
• Overgrowth of normal gut flora
• Altered levels of neurotransmitters

IBS can be related to mental health problems

• Panic disorder
• anxiety
• depression
• post-traumatic stress disorder
• Often found in people who have reported past physical or sexual abuse
• People who have been abused tend to express psychological stress through physical symptoms
• Diagnosed when a person has had abdominal pain or discomfort at least three times a month for the last 3 months without other disease or injury that could explain the pain
• Pain or discomfort affects stool frequency or consistency or be relieved by bowel movement
• Persistent or recurrent abdominal pain, altered bowel function without GI damage, varying complaints of flatulence, bloating, nausea, anorexia, constipation or diarrhea
• Can accompany anxiety or depression
• Treatment: Dietary management is being focused on “FODMAP” foods that seem to cause hyperstimulation of the intestines
• General diet recommendations are to eat smaller, more frequent meals, reduce fat content, avoid dairy/alcohol/caffeine, avoid gas-producing foods
• Other treatment: Stress management, medications (laxatives or antidiarrheal medications as needed; Antidepressants)

Inflammatory Bowel Diseases (IBD)

• Crohn's Disease and Ulcerative Colitis
• “umbrella term” that includes Crohn's Disease (CD) and Ulcerative Colitis (UC) since both diseases produce bowel inflammation

Crohn's Disease

• Textbook, pg 959
• Painful autoimmune disorder with inflammatory lesions anywhere in the G.I. tract that results in malabsorption of vitamins/minerals
• More often found in the ascending colon and terminal ileum
• Lesions involve all layers of the bowel wall and can cause fistulas (tunnels) to other organs or other parts of the body
• Fluid and electrolyte imbalances can result
• Skip lesions are characteristic, where some areas of the bowel are involved, but not all
• “Cobblestone” appearance of intestinal lining is also a characteristic
• Bowel wall becomes congested, thickened, leading to abscesses and fistulas
• Scar tissue interferes with movement of chyme through the intestine.
• Can lead to perforation or obstruction
• Can lead to:
  • Malabsorption (folic acid causing anemia, calcium/vitamin D causing bone weakness),
  • Fluid and electrolyte imbalance
  • Diarrhea and dehydration
  • Anal fissures

Ulcerative Colitis

• Autoimmune disease
• Textbook, pg 961
• Manifests as lesions only in the colon, causing chronic dehydration (decreased water reabsorption) and malnutrition
• Affects mucosal layer
• May lead to cavity formation with small hemorrhages and abscesses
• Causes wall of bowel thickens and ulcerations that are fibrotic in later stages
• Ulcerative Colitis may result in:
  • Intestinal obstruction
  • Dehydration, Fluid, and electrolyte imbalances
  • Malabsorption
  • Iron deficiency anemia
  • Chronic bloody diarrhea mixed with mucus
  • Weight loss
  • Abdominal cramping and pain
  • Nausea, vomiting, and the urge to defecate
  • hemorrhage
  • toxic megacolon
  • High risk for colorectal cancer is increased due to development of dysplasia, which requires frequent colonoscopy screening

Crohn Disease vs. Ulcerative Colitis

• Have similar S/S like abdominal pain, diarrhea, malabsorption of nutrients, dehydration (colon not absorbing water)
• Diagnosed with Colonoscopy and tissue biopsies
• Ulcerative Colitis affects the Large Intestine only to the mucosal layer, no "skip" lesions
• Crohn's Disease affects both the large and small bowel through "skip" lesions and affects the entire bowel wall thickness
• Anal/perianal fistulas are rare with Ulcerative Colitis but common with Crohn's, may require a colostomy
• Bloody stools are common in Ulcerative Colitis but uncommon with Crohn's
• Ulcerative Colitis is treated with Steroids & “-mab” drugs and possibly surgery
• Crohn's Disease can be treated with steroids and "-mab" drugs
• Surgery to remove portions of nonfunctioning colon is common for Crohn's

Colorectal Cancer

• PG. 973
• The second leading cause of cancer-related deaths in the United States and the third most common cancer in men and in women
• https://www.cdc.gov/cancer/colorectal/statistics/index.htm

Colorectal Cancer Risk Factors

• 1 in 20 people will be diagnosed with colon cancer and 1/3 die from this cancer.
  • Age: 50 years old or older
  • Gender: Greater in men than in women
  • Race: Black and Caucasian
  • Family History: 25% of colon cancer
  • History of Crohn disease or ulcerative colitis
  • Diet: Unhealthy fats, refined sugars and flour, low fiber, and low vitamins
  • Obesity, lack of exercise, smoking, alcohol consumption
• Rectal cancer is increasing rapidly in the 40 to 50-year age range

Pathophysiology of Colorectal Cancer

• Most colorectal cancers start as a polyp on the inner lining of the colon or rectum
• There are two main types of polyps:
  • Adenomatous polyps (adenomas) that sometimes change into cancer which is considered a pre-cancerous condition because of this tendency
  • Hyperplastic polyps and inflammatory polyps that are more common, and not pre-cancerous

Signs and Symptoms of Colorectal Cancer in Later Stages

• Changes in bowel movements including constipation or diarrhea
• Feeling unable to empty bowels completely or needing to urgently have a bowel movement
• Rectal bleeding or cramping
• Dark patches of blood in or on stool or long, thin, "pencil stools"
• Abdominal discomfort or bloating
• Unexplained fatigue, loss of appetite, and weight loss
• Pelvic pain
• These later stages may require a diagnosis using fecal occult blood test and colonoscopy

Hepatic Pathologies

Prehepatic Conditions

• Prevent blood from flowing to portal vein
• Thrombosis
• Cancer
• Enlarged Lymph nodes
• Compression

Intrahepatic Conditions

• Occur with the liver itself and cause obstruction of blood flow
• Alcoholic Cirrhosis

Post Hepatic Conditions

• Occur after liver lobules and through hepatic veins
• Right sided heart failure
• Thrombosis of hepatic veins

Mnemonic to Describe Liver Functions

• "People Drink So Much"

Liver Functions

• Produces Albumin that synthesize the oncotic/osmotic pressure in the blood veins, causing Ascites and Portal Hypertension
• Detoxes drugs and medications, causes buildup of bilirubin resulting in jaundice causes transport of bilirubin [blood breakdown byproduct], and cholesterol
• Biliary buildups cause jaundice or hyperlipidemia
• Coagulation Factors: Insufficient clotting factors causes bleeding problems
• Liver stores glycogen and metabolizes protein digested through small intestine so that ammonia byproduct gets metabolized to urea to be excreted by kidneys

Cirrhosis

• Textbook, pg 999
• Scarred liver tissue that does not function normally
• Most common cause is chronic alcohol use resulting in Alcoholic Hepatitis, where production of acetaldehyde from liver damage and ethly alcohol directly damages haptocytes
• Also can be caused by viral Hepatitis and hepatotoxic drugs ie: Acetaminophen
• Cirrhosis prevents proper blood flow through the portal hypertension, causing fluid backup and potential Ascites

Clinical Manifestations of Liver Failure

• Portal hypertension causes obstructive flow in liver, backing up fluids in Portal Veins, resulting in vein and organ engorgement
• As a result, esophageal/stomach varices, splenomegaly, ascites and hemorrhoids manifest
• Free Fluid in the abdomen in cases of ascites causes:
  • #1 Portal hypertension increasing capillary hydrostatic pressure, pushing fluid out of the guts of vessels and or,
  • Distension, displace diaphragm leading to dyspnea or peritonitis which can be treated through paracentesis
• Hepatitc encephalopathy results in brain changes due to increased levels of toxic ammonia, toxins cross the blood brain barrier and cause disturbances
• Jaundice causes sclera and skin to yellow, and potential anorexia, fatigue, and pruritis, dark urine
• Depleted circulating systems reduces renal function which trigggers angiotensin increases and can cause retention of waste fluids

Diagnostics

• Ascites: Paracentesis procedure that helps draw fluids and relieve intraabdominal pressure or pain
• Lab Test:
  • Liver Enzymes being high such as LFT or AST
  • Low levels of ammonia can cause encephalopathy
  • Abnormal levels of bilirubin and albumin may result in liver damages
  • Blood tests can be drawn to test coagulation

Viral Hepatitis

• Pg 991
• Chronic viral hepatitis slowly attacks the liver over many years without causing symptoms
• Signs and symptoms are vague and nonspecific so Hepatitis can go undetected until significant liver damage is present
• An estimated 4.4 million Americans are living with lifelong chronic hepatitis, but are not aware that they are infected
• Signs and symptoms include: fatigue, nausea, vomiting, anorexia, darkened urine, intense icterus/jaundice and related pruritis
• Can be chronic and may cause potential liver cancer
• Liver Damage is therefore more common when testing blood too late

Types of Viral Hepatitis

Hepatitis A

• Most common that comes from oral/fecal transmission through contaminated food
• Vaccine should be given three weeks to contamination, antibody immunoglobulin IgG given after to prevent contracting

Hepatitis B

• Caused by blood-body exposure such as mother-baby contact or shared needles
• Heptavax vaccine* (must complete series of 3); IgGimmunoglobulin and Interferon (Intron-A) can be given to unvaccinated patient

Hepatitis C

• No vaccine available treated most commonly by medicine such as Interferon
• 25 percent are cured from virus
• 75 continue which may be complicated and require the hepatitis C virus
• Note* vaccine should be given to prevent virus and short term IgG antibiotics can also be given to stregthen

Pancreatic Disease

• Pancreatitis
• pg 1008
• Pancreatic injuries where emzymes cause ruptures
• Most common cause alcohol abuse or formation of cists
• Can be stimulated by obstruction and the presence of alcohol where duct becomes damaged and gallstones further cause blockage
• Can cause pain or fever, mimic heartattack or have changed bowel functions

Key Notes

• Most common treatment is not eatting with NG tube and may involve antibiotics
• Bulky fatty stool and oil droplets are very common with this diagnosis

Cholecystitis and the Gallbladder

Cholecystitis

• pg 1006
• Associated with cholethiasis with stores of either bile or cholestoral
• May be inflamed depending on presence of a stone where GB becomes inflamed

Risk Factors

• Fair
• Fat
• Fertile
• Female
• HallMark pain with GB
• Forty
• Pain will occure with GB obstruction
• Family
• Pain caused by inflammation

Signs and Synptons

• Pain as caused by fats, triggering the GB and causing inflammation in the intestine
• Mimmics attacks that cause liver distention and light stools may occure

Treatment

• Change diet, avoid infection
• In severe circumstances may involve Cholecystectomy surgery