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gastro intestinal Contemporary Report abdominal muscle

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					           Gastrointestinal Diseases       ESOPHAGEAL VARICES
                                           ESOPHAGEAL WEBS
                                           FISSURE - ANAL
                     1-25-05               FISTULA - ANAL
                                           GAS – BELCHING
                                           GAS – BLOATING
OVERVIEW OF GI DISEASE DVX                 GAS – FLATULENCE
ABETALIPOPROTEINEMIA                       GASTRITIS
ABSCESS- ANORECTAL                         GASTRINOMA
ABSCESS - INTRA-ABDOMINAL                  GERD - GASTRO-ESOPHAGEAL REFLUX DISEASE, AKA REFLUX
ACHALASIA                                  ESOPHAGITIS
ANGIODYSPLASIA                             GERD – H. PYLORI TESTING
APPENDICITIS (ACUTE)                       GI NEOPLASM – ANUS
BACTERIAL OVERGROWTH                       GI NEOPLASM - APPENDIX
BARRETT'S ESOPHAGUS                        GI NEOPLASM – CARCINOID
BASAL CELL CARCINOMA                       GI NEOPLASM – COLORECTAL
BLEEDING - GI                              GI NEOPLASM - COLORECTAL SUBTYPES
BOERHAAVE'S SYNDROME                       GI NEOPLASM – ESOPHAGEAL ADENOCARCINOMA
BOWEL HISTOLOGY                            GI NEOPLASM – ESOPHAGEAL SQUAMOUS CELL CANCER
CARCINOID SYNDROME                         GI NEOPLASM – GASTRIC ADENOCARCINOMA
CARCINOID TUMOR                            GI NEOPLASM – GIST
CELIAC DISEASE (CELIAC SPRUE)              GI NEOPLASM – LYMPHOMA
COLLAGENOUS COLITIS                        GI NEOPLASM – OVERVIEW
COLON - OVERVIEW                           GI NEOPLASM – SMALL INTESTINE
COLON - SURGERY                            GLOSSARY
CONGENITAL ABNORMALITIES                   HEARTBURN
DIARRHEA - ACUTE                           HEMOCHROMATOSIS
DIARRHEA – ANTIBIOTIC ASSOCIATED           HEMORRHOIDS
DIARRHEA - CHRONIC                         HERNIAS – OVERVIEW
DIARRHEA - DVX                             HERNIA – REPAIRS
DIFFUSE ESOPHAGEAL SPASM                   HIATAL HERNIA
DIVERTICULOSIS                             HIRSCHSPRUNG'S DISEASE
DIVERTICULITIS                             ILEUS
DYSPEPSIA                                  ILEUS – GALLSTONE
DYSPEPSIA – ROME II CRITERIA               ILEUS – POST-SURGICAL
ESOPHAGEAL DISEASE OVERVIEW                IMAGING STUDIES
ESOPHAGEAL DX - CAUSTIC INGESTION          INFECTION – INTRA-ABDOMINAL
ESOPHAGEAL DX - DYSPHAGIA                  IBD - INFLAMMATORY BOWEL DISEASE
ESOPHAGEAL DX - ODYNOPHAGIA                IBD - CROHN'S DISEASE
ESOPHAGEAL DIVERTICULA                     IBD - ULCERATIVE COLITIS
ESOPHAGEAL NEOPLASMS                       INTESTINAL LYMPHANGIECTASIA
ESOPHAGEAL OBSTRUCTIONS                    IRRITABLE BOWEL SYNDROME
                                           ISCHEMIA (ACUTE MESENTERIC ISCHEMIA)
                                       1
ISCHEMIC BOWEL DISEASE                                   ULCERS - DUODENAL
ISCHEMIA (CHRONIC MESENTERIC ISCHEMIA)                   ULCERS - GASTRIC
ISCHEMIC COLITIS                                         VITAMIN AND NUTRIENT DEFICIENCIES
KAPOSI'S SARCOMA                                         VOLVULUS
KWASHIORKOR                                              WHIPPLE
LACTOSE INTOLERANCE
LAXATIVES
LEUKEMIA
LICHENS PLANUS                                           Overview of GI Disease DVX
                                                         DISEASES
MALABSORPTION                                            Think of GI diseases in terms of anatomy:
MALLORY-WEISS SYNDROME                                   - Oral
MARASMUS                                                 – Esophageal
                                                         – Gastric
MECKEL'S DIVERTICULUM                                    – Hepatic
MEGACOLON (TOXIC MEGACOLON)                              - Biliary Tract
                                                         - Pancreatic
MELANOSIS COLI (CATHARTIC COLON)                         – Upper GI
MEN-1 (MULTIPLE ENDOCRINE NEOPLASIA SYNDROME), AKA       – Lower GI
WERMER’S SYNDROME                                        see each topic for a DVX in that category, and see "Liver, GB, and Pancreas" file for those diseases.

MENETRIER'S DISEASE                                      ABDOMINAL PAIN DVX
                                                         Always think of four possibilities:
MUCOCELE OF THE APPENDIX                                 - GI
MUCOSAL PROLAPSE                                         - GU
                                                         - Gyn
NECROTIZING ENTEROCOLITIS                                - Vascular
NUTRITIONAL ASSESSMENT
OBSTRUCTION - LARGE BOWEL
OGILVIE'S SYNDROME                                       Abetalipoproteinemia
ORAL PATHOLOGY                                           PATHOLOGY
                                                         Malabsorption syndrome
PEPTIC ULCER DISEASE                                     Deficiency in synthesis of liproprotein B, thus low levels in blood. (abetalipoproteinemia)
PEPTIC ULCER VS. CARCINOMA                               Circulating acanthocytes are diagnostic – (RBC with spiny projections - punk rock RBCs)
PERIODONTAL DISEASE
PERITONITIS - FOCAL
PERITONITIS - GENERALIZED                                Abscess- Anorectal
                                                         PATHOLOGY
PLUMMER-VINSON SYNDROME                                  Intersphincteric - between internal and external anal sphincters.
PNEUMATOSIS CYSTOIDES INTESTINALIS                       Perianal - between sphincters, but surrounding anus.
POLYPS                                                   Ischiorectal - outside external sphincter
                                                         Supralevator- superior to levator ani.
PSEUDOMEMBRANOUS COLITIS
                                                         HX
PYLORIC STENOSIS                                         Perianal pain, swelling, purulent drainage.
SALIVARY GLAND PATHOLOGY                                 RX
SCLERODERMA                                              Drainage of the abscess.
SIDEROSIS
SPONTANEOUS BACTERIAL PERITONITIS
                                                         Abscess - Intra-Abdominal
SQUAMOUS CELL CARCINOMA
                                                         PATHOLOGY
STEATORRHEA                                              Loculated collection of bacteria, PMNs, M0, and necrotic debris which is "walled off" in a collagen capsule by
STERCORAL ULCERS                                         the body. This helps prevent the spread of infection, but is bad because it prevents the immune system from
                                                         being able to reach, attack, and clear the invading bacteria.
TOXINS
                                                     2
Three patterns for intra-abdominal abscess development:                                                                  HX
- Immediately following generalized peritonitis.                                                                         Periumbilical pain, gradually worsening, N/V, febrile, pain shifts to RLQ as appendix contacts peritoneum
- Biphasic - acute peritonitis, then abscess formation days, months, or years later.                                     Anorexia is almost always present (negative Hamburger's sign).
- Insidious - not obvious initial insult, but slow formation of abscess.
                                                                                                                         PE
LOCATION                                                                                                                 Psoas sign - pain on extension of right hip.
Abdominal abscesses usually form in one of two areas:                                                                    Obturator sign - positive if patient has passive rotation of flexed right thigh while lying supine.
- Subphrenic area, due to the negative (relative to ATM) pressure created with each exhalation.                          Rovsing's sign - pressure on LLQ causes pain on RLQ.
- Pelvis, due to gravitational forces.
                                                                                                                         LAB
HX/PE                                                                                                                    Moderate leukocytosis
Fever, often Fever of unknown origin.
                                                                                                                         RX
Abdominal pain and tenderness.
                                                                                                                         Surgery - laparotomy, better to do needless surgery than to let appendix rupture (we accept 20% of surgeries for
Abscess may be palpable depending on size.
                                                                                                                         non-appendicitis).
LABs
Leukocytosis
CXR - unexplained pleural effusion or elevated diaphragm
Abdominal Xray - ileus or gas outside the intestinal tract.                                                              Bacterial Overgrowth
PATHOGENS                                                                                                                PATHOLOGY
see "Infections - Intra-abdominal"                                                                                       Overgrowth of colon with bacteria leading to steatorrhea, mucosal injury, B12 deficiency, defective amino
                                                                                                                               acid absorption, macrocytic anemia (hypoalbuminemia in blood + lack of B12)
RX                                                                                                                       Normal - we have < 10^4 bacteria/ml, mostly gram+
Antibiotics to cover for aerobes and anaerobes, surgery or percutaneous drainage.
                                                                                                                         Bacterial overgrowth - we have >10^5 bacteria/ml, mostly gram-
Aerobe Antibiotic usually 3rd gen cephalosporin and/or aminoglycoside
                                                                                                                         Conditions favoring growth - intestinal stasis (strictures, diverticula, scleroderma, dysmotility), fistulas,
Anaerobe Antibiotic usually Metronidazole, cefoxitin, or clindamycin.
                                                                                                                               hypochlorhydria
                                                                                                                         HX
                                                                                                                         diarrhea, weight loss
Achalasia                                                                                                                nutrient deficiencies
SUMMARY                                                                                                                  LAB
Constriction of LES                                                                                                      D-xylose test - patient eats D-xylose, requires no digestion, should be absorbed across duodenum and jejunum.
PATHOLOGY                                                                                                                      Ingest and measure serum level 1 hour later, or urine level 5 hours later. Low = mucosal problem
Loss of ganglionic inhibitory neurons on Auerbach's myenteric plexus (cholinergic) at LES. Unknown etiology.             Bile Acid Breath Test - C-14 labeled glycocholate ingested and converted to CO2 and measured in breath
Results in dilation of esophagus superior to sphincter, muscular hypertrophy, and loss of myenteric ganglion cells       RX
in wall.                                                                                                                 Antibiotics - metronidazole, amoxicillin, or tetracycline
DVX
Manometry
LAB                                                                                                                      Barrett's Esophagus
Barium swallow                                                                                                           PATHOLOGY
EGD (esophagoduodenoscopy)
                                                                                                                         Metaplasia of esophagus to columnar epithelium and mucus secreting goblet cells (from normal
RX                                                                                                                             squamous epithelium). Can be focal and patchy or continuous throughout entire lower esophagus.
Balloon dilation                                                                                                         Risk for adenocarcinoma development (10% prevalence in Barrett's esophagus).
Botulism toxin injection (producing total blockage of ACh release from preganglionic nerve terminals)                    RX
Myotomy (what Keith had for pyloric stenosis)
                                                                                                                         Surveillance w/ EGD (esophagoduodenoscopy)


Angiodysplasia                                                                                                           Basal Cell Carcinoma
PATHOLOGY                                                                                                                SUMMARY
Dilated, tortuous, submucosal vessels from chronic, intermittent obstruction of submucosal veins leading to
      dilation, tortuosity, and bleeding                                                                                 PATHOLOGY
                                                                                                                         Neoplasm arises from stratum basale, presents as hyperchromatic epithelial cells invading below an ulcerated
                                                                                                                              epidermal surface. 85% of cases on head and neck, rare in oral cavity.

Appendicitis (Acute)
PATHOLOGY                                                                                                                Bleeding - GI
Inflammation of the wall of the appendix, resulting in transmural necrosis and perforation.
60% of cases are due to lypmhoid hyperplasia (viral or bacterial infection)                                              PAINFUL, UPPER GI
35% of cases are due to fecolith obstruction of appendiceal opening into cecum.

                                                                                                                     3
Melena - black, tarry stool, generally indicates bleed is in right sided colon or higher.                               1/3 metastasize
Hematochezia - if fast flow.                                                                                            1/3 present with 2nd malignancy
Sources: PUD, esophagitis, tumors                                                                                       1/3 are multiple (MEN - Multiple Endocrine Neoplasia)
PAINFUL, LOWER GI                                                                                                       RX
Colitis, ischemia, anal fissure                                                                                         Octreotide.
PAINLESS, UPPER GI
PUD, esophageal varices, AVM
PAINLESS, LOWER GI                                                                                                      Celiac Disease (Celiac Sprue)
Diverticulosis, AVMs                                                                                                    PATHOLOGY
                                                                                                                        Gluten (storage protein of wheat) is toxic to small intestine, leads to mucosal injury
                                                                                                                        Can present in childhood as failure to thrive, or in adulthood
Boerhaave's Syndrome                                                                                                    HX
PATHOLOGY                                                                                                               Diarrhea/steatorrhea, abdominal pain, bloating, N/V, recurrent apthous ulcers of mouth, amenorrhea,
Perforation of distal esophagus. Common in middle aged men, associated with ROH and violent emesis after                      dermatitis herptiformis
      heavy meal.                                                                                                       Refractory anemia (lack of Iron, B12, folate)
                                                                                                                        Bruising (lack of Vitamin K)
                                                                                                                        Myopathy (low electrolytes)
                                                                                                                        Osteoporosis (low Calcium)
Bowel Histology                                                                                                         Edema (low protein)
HISTOLOGY
- Epithelium, endocrine cells, receptor cells
- Lamina propria                                                                                                        Collagenous Colitis
- Muscularis mucosa
- Submucosal (Meissner’s plexus)                                                                                        PATHOLOGY
- Circular muscle                                                                                                       elderly women w/ watery diarrhea, patchy bands of collagen deposited below epthelial suface,
- Auerbach’s myenteric plexus                                                                                           and increase in lymphocytes and eosinophils
- Longitudinal muscle
- Serosa
VILLI                                                                                                                   Colon - Overview
Formed by invaginations of the epithelium and extensions of lamina propria.                                             SPHINCTERS
                                                                                                                        Internal sphincter - autonomic, continuous w/ circular muscle of colon.
                                                                                                                        External sphincter - 3 parts - subcutaneous, superficial, deep (continuous w/ levator ani). External sphincter is
Carcinoid Syndrome                                                                                                      partly under voluntary neural control.

PATHOLOGY                                                                                                               FLATUS
Occurs when carcinoid tumor from small bowel or elsewhere metastasizes to liver.                                        Normal person passes 800-900mL of flatus/day, mostly Nitrogen from swallowed air.
Tumor secretes 5-HT and other vasoactive hormones, causing cutaneous flushing, diarrhea, wheezing, heart                Smell of flatus (bad smell) is due to methane, indole, and skatole.
disease.                                                                                                                Flora
If tumor was still in the small intestine the liver would clear these peptides, so the carcinoid syndrome usually       Mostly anaerobes such as Bacteroides fragilis.
only occurs after metastasis of the tumor to the liver.                                                                 As many as 30% of people who are "cleaned out" prior to surgery still get post-op infections.



Carcinoid Tumor                                                                                                         Colon - Surgery
PATHOLOGY                                                                                                               APR
Causes carcinoid syndrome after metastasis to the liver. Tumor is of enterochromaffin cell origin, usually in           Abdominoperineal Resection – used for tumor in distal colon. The distal sigmoid colon, rectum, and anus are all
appendix (50%) or small bowel. Tumor secretes serotonin and other hormones, causing diarrhea, cutaneous                 removed, and a proximal sigmoid colostomy is created.
flushing, asthmatic wheezing, and carcinoid heart disease.                                                              HARTMANN’S PROCEDURE
We test for 5-HIAA (serotonin metabolite) in urine.                                                                     Partial colectomy, with the distal remaining end oversewn and the proxmial remaining end brought out through
APUDoma – Amine Precursor Uptake and Decarboxylation type of tumor.                                                     peritoneum to skin and sewn to create a colostomy.
METASTASIS                                                                                                              LAR
Tumor <1cm, 2% metastasis.                                                                                              Low Anterior Resection – used for tumors in proximal or middle sigmoid colon. The proximal and middle
Tumor >2cm, 90% metastasis.                                                                                             sigmoid colon is removed, and a colo-proctostomy is performed (very proximal sigmoid colon to rectum).
RULE OF 1/3rds:

                                                                                                                        Congenital Abnormalities
                                                                                                                    4
ESOPHAGUS                                                                                                              Defect in mucosal absorption leading to malabsorption
Agnensis - doesn't form                                                                                                Sources: Celiac sprue, Whipple, Crohns, lymphoma, amyloid, Chronic infections - giardia, MAI,
Stenosis - closing, constriction. Usually due to GERD scarring, esophagitis                                            cryptosporidium
Atresia - absence of a normally patent lumen                                                                           DX - Improvement with fasting, steatorrhea (greasy, foul smelling stool), weight loss, osmotic gap in fecal water
TEF - Tracheo-Esophageal Fistula. Most commonly blind upper esophagus, and connection                                  SECRETORY DIARRHEA
       between lower esophagus and trachea. Upper esophagus fills with mucus and leads to aspiration soon              Abnormal fluid and electrolyte transport not related to ingestion of food. Watery diarrhea not related to ingestion
after birth.                                                                                                           of food.
STOMACH                                                                                                                Causes: Hormone producing tumors - carcinoid, VIP-oma, gastrinoma, Crohns, Infection - cholera
                                                                                                                       CHRONIC WATERY DIARRHEA
                                                                                                                       Causes:
Diarrhea - Acute                                                                                                       - Infection - Giardia, Opportunistic (cryptosporidium, MAI, CMV)
                                                                                                                       - Lactose intolerance
PATHOLOGY                                                                                                              - Bacterial overgrowth
Daily stool weight > 200g, or increased frequency of loose stools for less than 2 weeks.                               - IBD
Infectious is the most common:                                                                                         - Neoplasm, villous adenoma
       Water - giardia, vibrio, cryptosporidium                                                                        - Rare - Diabetes causes neuropathy leading to unopposed parasympathetic cholinergic stimulation
       Poultry - Salmonella, shigella, campylobacter                                                                   DX - Stool for O&P, giardia, R/O tumors (serum gastrin, serum VIP, serum glucagon, 24hr urine for 5-HIAA)
       Beef - E. coli 0157:H7
       Eggs - salmonella
       Mayonnaise - staphylococcal, clostridial
Foreign travel - E. coli, salmonella, shigella, campylobacter, cryptosporidium, amoeba                                 Diarrhea - DVX
DVX                                                                                                                    OVERVIEW
Stool for PMNs (inflammation in colon) - fecal leukocyte test tells us inflammatory vs. non-inflammatory.              (1) Always start with fecal leukocyte test - to determine if diarrhea is inflammatory or non-inflammatory.
Stool C&S (Culture and Sensitivity).
Stool for ova and parasites (giardia)
Stool for C. difficile
                                                                                                                       Diffuse Esophageal Spasm
RX
                                                                                                                       PATHOLOGY
Fluid replacement (IV or oral PRN)
                                                                                                                       Simultaneous onset of pressure contractions along with normal peristalsis. DX w/manometry.
Antibiotics:
- Erythromycin - campylobacter jejuni
- Metronidazole - C. difficile, Giardia
- Metronidazole + iodoquinol - Entamoeba histolytica                                                                   Diverticulosis
- Ciprofloxacin or Norfloxacin - salmonella, shigella, yersinia, vibrios, E. Coli
                                                                                                                       DIVERTICULA
                                                                                                                       Herniation of mucosa and submucosa through muscular layers of colon.
                                                                                                                       1. True (congenital) diverticula – full wall thickness outpouching of a portion of colon.
Diarrhea – Antibiotic Associated                                                                                       2. False (acquired) diverticula – mucosal herniation through muscular wall, usually occuring where branches of
                                                                                                                       marginal artery penetrate wall of colon.
YOGURT REDUCES INCIDENCE
Source: Digestive Disease Science 2003: 48 (2077-?)                                                                    EPIDEMIOLOGY
202 hospitalized patients randomized to vanilla flavored yogurt w/ active cultures of:                                 Linked to diets low in undigestible fiber (Western diet).
- Lactobacillus acidophilus                                                                                            80% of people are asymptomatic. Can produce spontaneous bleeding, leading to anemia.
- Lactobacillus bulgaricus                                                                                             95% of diverticuli are in colon, mostly on left side (sigmoid).
- Streptococcus thermophilus                                                                                           HX
Average age = 70, patients ate 8oz bid for 8 days.                                                                     LLQ pain, often recurrent.
Yogurt eaters – 12% reported diarrhea, average # of total diarrhea days = 23                                           Changes in BM – either diarrhea, constipation, or both.
Non-yogurt eaters – 24% reported diarrhea, average # of total diarrhea days = 60
                                                                                                                       PE
                                                                                                                       Afebrile
                                                                                                                       Normal WBC
Diarrhea - Chronic                                                                                                     RX
SUMMARY                                                                                                                Increase fresh fruits and veggies in diet w/ whole grain cereals, bran, and fiber supplements.
> 4 weeks. Inflammatory, secretory, osmotic
INFLAMMATORY DIARRHEA
Mucosal and submucosal inflammation, perhaps impaired intestinal absorption.                                           Diverticulitis
Blood and WBC in stool, abdominal pain, fever.
Causes - IBD, radiation colitis, eosinophilic gastroenteritis, infections (CMV, Yersinia, Entamoeba histolitica,       PATHOLOGY
      C. Difficile)
OSMOTIC DIARRHEA
                                                                                                                   5
Inflammation at base of diverticulum, likely due to fecal material (fecalith). Produces necrosis of bowel wall
leading to microperforation and macroperforation. 70% of diverticulosis is right sided colonic. (Fecoliths can't
                                                                                                                       Esophageal Disease Overview
fight gravity).                                                                                                        COMMON SYMPTOMS
COMPLICATIONS                                                                                                          1. Dysphagia
                                                                                                                       2. Odynophagia
1. Hemorrhage – 70% of lower GI bleeds (hematochezia) are diverticular. 25% of these are “massive”
                                                                                                                       3. Heartburn
(>4Units/day). Note, carcinomas present w/ similar symptoms, and bleed more frequently, but usually not as
severe as diverticuli.                                                                                                 DISEASES
2. Cicatricial bowel obstruction                                                                                       1. GERD
3. Fistula formation:                                                                                                  2. Obstructive Esophageal Conditions
- Colovesical – most common                                                                                            3. Esophageal Motor disorders
– Colovaginal                                                                                                          4. Diverticula
- Colocutaneous                                                                                                        5. Infections
HX                                                                                                                     6. Traumatic or physical injuries
                                                                                                                       7. Drug induced injuries
Recurrent LLQ abdominal pain, aka LLQ appendicitis.
                                                                                                                       8. Carcinoma
Changes in bowel habits (both diarrhea and constipation may occur, constipation more frequent).
                                                                                                                       9. Toxins/caustic ingestions
PE
Tenderness in LLQ.
Fever
LAB
                                                                                                                       Esophageal Dx - Caustic Ingestion
Leukocytosis                                                                                                           WORKUP
CT scan - look for thickening, stranding                                                                               IV, NPO, no NG tube, CXR.
                                                                                                                       Early endoscopy.
RX
                                                                                                                       NO induced emesis.
1. Medically stabilize:
- NPO                                                                                                                  PATHOLOGY
– Rehydration w/ IV fluids                                                                                             Grade I - superficial mucosa loss
- Antibiotic treatment usually can alleviate, Ciprofloxacin (or AG) + metronidazole.                                   Grade II - shallow mucosal ulcerations.
2. 20% of people will require surgery. After 2 bouts of medical treatment, patients should have elective               Grade III - Deep ulcers/perforations.
colectomy and Hartmann’s procedure.                                                                                    RX
                                                                                                                       I - Advance diet slowly, Barium swallow in 4-6 weeks.
                                                                                                                       II - NPO 1 week, IV Abx, Barium swallow in 4-6 weeks.
Dyspepsia                                                                                                              III - NPO, IV antibiotics, steroids?, monitor for pneumomediastinum, F/U endoscopy, monitor for
                                                                                                                       stricture/carcinoma.
SUMMARY
Impaired gastric function resulting in upper abdominal discomfort.
CHRONIC                                                                                                                Esophageal Dx - Dysphagia
Defined as greater than 3 months, w/ varying frequency.
                                                                                                                       GLOBUS
ULCER-LIKE
                                                                                                                       Functional, not organic disorder. Sensation of lump, fullness, or tickle in throat. Does not interfere with
Epigastric pain, burning, knawing, maybe helped with meals
                                                                                                                       swallowing although it may feel like it does.
DYSMOTILITY-LIKE                                                                                                       OROPHARYNGEAL
Abdominal discomfort - bloating, fullness
                                                                                                                       Trouble transferring foods from mouth/pharynx into esophagus. Nasal regurgitation, coughing, dysarthria, and
REFLUX-LIKE                                                                                                            nasal speech are associated.
Epigastric discomfort - heartburn (higher and more substernal than ulcer-like)                                         Causes include:
RX                                                                                                                     - Neuromuscular disorder of pharynx or proximal esophagus (post-CVA)
Treating H. pylori is controversial (AFP 7/2004).                                                                      – Proximal muscle weakness of pharynx or esophagus (polymyositis)
                                                                                                                       – Other NM disorder (MG, Myotonia dystrophica, Parkinsons)
                                                                                                                       DX w/ barium swallow.
                                                                                                                       RX w/diet, head position, removal of underlying cause.
Dyspepsia – Rome II Criteria                                                                                           ESOPHAGEAL
ROME II                                                                                                                (1) Problem with solids only = Structural disorder. Causes include:
The following criteria are met for at least 12 weeks (not necessarily consecutive) in the past year:                   - Ring (muscle hypertrophy)
(1) Persistent or recurrent pain or discomfort centered in upper abdomen                                               - Web (epithelium)
(2) No evidence of organic disease – including a negative upper endoscopy                                              – Benign stricture (GERD sequela)
(3) No relief of dyspepsia w/ defecation, or associated w/ change in stool frequency or form.                          – Dysphagia lusoria – an anomalous blood vessel crosses behind the esophagus
                                                                                                                       (2) Problem with Solids and liquids = Motility disorder. Causes include:
                                                                                                                       - Scleroderma
                                                                                                                       – Achalasia

                                                                                                                   6
– Symptomatic diffuse esophageal spasm.                                                                               Surgical resection if possible.
Diganose w/ manometry.                                                                                                Radiation adjunctive therapy if low grade.



Esophageal Dx - Odynophagia                                                                                           Esophageal Obstructions
OVERVIEW                                                                                                              PATHOLOGY
Pain on swallowing.                                                                                                   – Strictures
DVX                                                                                                                   – Webs
- Motor disease (Achalasia, DES)                                                                                      – Rings
- Mucosal disruption                                                                                                  STRICTURES
- Pharyngitis                                                                                                         Usually benign sequela of prolonged GERD.
LAB                                                                                                                   Heartburn may actually lessen as solid food dysphagia worsens with progression of stricture.
Try Barium swallow or endoscopy to elicit cause.                                                                      Rx is balloon dilation catheter.
                                                                                                                      WEBS
                                                                                                                      Web refers to growth of epithelium, similar to a spider’s web.
                                                                                                                      Causes include:
Esophageal Diverticula                                                                                                - Congenital – usually in upper 1/3rd due to failed embryonic cannalization.
PATHOLOGY                                                                                                             – Fe-deficiency anemia (Plummer-Vinson syndrome)
pulsion – “false” – mucosa and submucosa only push through muscularis externa – most common                           Rx with an esophageal bougie to fracture the webs.
traction – “true” – mucosa, submucosa, and muscularis propria push through serosa                                     RINGS – SCHATZKI’S RINGS
Zencker's                                                                                                             Hypertrophied smooth muscle ring 1.5cm superior to GE (gastroesophageal) junction, aka squamocolumnar
Upper esophageal, 70%, causes regurgitation, cough, halitosis                                                         junction.
Pulsion (false)                                                                                                       Associated with hiatal hernia. Esophageal bougienage can be effective.
Rx w/ excision of diverticula and myotomy of cricopharyngeal muscle (to eliminate formation of further Zenker's
diverticula).
Mid-esophageal (traction diverticula)                                                                                 Esophageal Varices
20%, caused by scarring, motility
Traction (true)                                                                                                       PATHOLOGY
                                                                                                                      Dilated veins of lower esophagus caused by portal hypertension forcing blood through collateral channels
Epiphrenic                                                                                                            (bypassing
Lower esophageal, 10%, caused by motility disorders                                                                          the liver). Lower esophageal veins drain to portal vein, while superior 1/3 drain to SVC, and middle 1/3
Pulsion (false)                                                                                                       drain to
                                                                                                                             azygous system. Thus, we only see varices in lower esophagus (1/3).
                                                                                                                      Hemorrhage is typically massive and results in death if not RX fast. Risk of re-bleeding is high without RX.
Esophageal Neoplasms
OVERVIEW
85% SCC, 10% Adeno                                                                                                    Esophageal Webs
ESOPHAGEAL ADENOCARCINOMA                                                                                             PATHOLOGY
Barrett's syndrome is big risk factor.                                                                                Thin, transverse membranes of squamous epithelium. Usually in superior esophagus in women over 40. Often
Tylosis - ADD characterized by hyperkeratosis of palms and soles. 95% of people w/ tylosis will eventually            with
develop esophageal adenocarcinoma.                                                                                           iron deficiency and Atrophic glossitis (Plummer-Vinson syndrome).
ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Risk factors are ROH, tobacco, black, hot tea, achalasia, Plummer-Vinson syndrome.
Other risks include low intake of vitamin C and E and high intake of nitrosamines.                                    Fissure - Anal
HX                                                                                                                    PATHOLOGY
Dysphagia                                                                                                             Painful linear tear in lining of anal canal.
Odynophagia
                                                                                                                      RX
Hoarseness
                                                                                                                      Sitz baths.
Anorexia and wt. loss
                                                                                                                      Lateral sphincterotomy if not healing.
Fistula formation to trachea - aspiration pneumonia.
75% have positive lymph nodes at time of diagnosis.
LABS
Barium swallow - shows "apple core" lesion (ragged shelf)                                                             Fistula - Anal
Lugol's Iodine can be used to visualize tumor in the mucosa (normal mucosa is green/black, tumor is invisible).       PATHOLOGY
RX
                                                                                                                  7
Intersphincteric - comes from perianal abscess
Transsphincteric - comes from ischiorectal abscess
Suprashpincteric - comes from supralevator abscess                                                          Gastrinoma
Extrasphincteric - connects to rectum.
                                                                                                            see Zollinger Ellison syndrome
RX
Fistulotomy - unroofing the tract and allowing it to heal spontaneously by secondary intention.
Goodsall's rule - predicts trajectory of abscess.
                                                                                                            GERD - Gastro-Esophageal Reflux Disease, aka Reflux Esophagitis
                                                                                                            PATHOLOGY
Gas – Belching                                                                                              Incompetence of LES leading to frequent or prolonged reflux of gastric contents. This causes irritation of
                                                                                                            esophageal lining due to acidity (low pH) of reflux.
ETIOLOGY                                                                                                    Inflammatory reaction ensues, with influx of PMNs and eosinophils, leading to ulceration and fibrosis.
- Eating or drinking too fast, not chewing food adequately
                                                                                                            Very common - 40% of adult Americans have it once/month.
- Poorly fitting dentures
                                                                                                            Complications - asthma, chronic cough, laryngitis
- Carbonated beverages
- Chewing gum or sucking on hard candies                                                                    LAB
- Excessive swallowing due to nervous tension or postnasal drip                                             EGD if warning signs (anemia, hematemesis, weight loss, dysphagia, guaiac stool positive for occult blood)
- Forced to relieve abdominal discomfort                                                                    HX
RX                                                                                                          Heartburn
- Simethicone                                                                                               Severity of symptoms do not correlate well with pathology.
- Avoidance of triggers – carbonation, gum, hard candies                                                    PE
                                                                                                            Pain increases w/ leaning forward
                                                                                                            RX
Gas – Bloating                                                                                              Lifestyle modification - Elevate HOB, avoid ROH, smoking, fatty foods, bedtime snacks, large meals, lying down
                                                                                                            after meals, NSAIDs
ETIOLOGY
                                                                                                            H2 blockers - ranitidine, famotidine, cimetidine
- IBS
                                                                                                            Proton pump inhibitors - omeprazole
- Intestinal sensitivity
                                                                                                            Prokinetic agents - metoclopramide, cisapride (increase LES pressure)
- Weak abdominal muscles – this is usually better in AM, worse in PM, and is relieved by lying down.
RX
(1) Avoid certain foods:
- Broccoli                                                                                                  GERD – H. Pylori Testing
- Baked beans                                                                                               ENDOSCOPY
- Cabbage                                                                                                   Three techniques can be used:
- Carbonated drinks                                                                                         (1) Biopsy urease test – antral biopsy, tissue placed in agar w/ urea and pH reagent. Urease cleaves urea to
- Cauliflower                                                                                               liberate ammonia, producing alkaline pH and color change. Commercial kits – “Clotest” (Campylobacter Like
- Chewing gum                                                                                               Organism), “Pyloritek”, “Hp-fast”. Results at 1 hour, but final results at 24 hours. 90-95% sensitive, 95-100%
- Hard candy                                                                                                specific. False negatives in – GI bleeds, recent PPI or H2 blocker use, recent Abx, recent Bismuth use. Patients
(2) Abdominal muscle weakness – do sit ups or other abdominal exercise, or wear binder                      should be off antacids for 3-4 weeks prior to testing.
                                                                                                            (2) Histology – sensitivity also decreased w/ PPI. Generally around 90% sensitive, but density of H. pylori may
                                                                                                            very in sites throughout mucosa.
Gas – Flatulence                                                                                            (3) Bacterial culture – This is used if treatment fails. H. pylori can be extremely resistant to Metronidazole (80-
                                                                                                            90% in tropical countries), and 10% resistance to Macrolides.
ETIOLOGY
                                                                                                            UREA BREATH TEST
Created by release of gasses from coliform bacteria which break down products of digestion.
                                                                                                            UBT – labeled carbon isotope is given by mouth, H. pylori liberates tagged CO2 which is detected in breath
- 10-18 passes of flatulence/day is normal
                                                                                                            samples. Meretek test (13C) – non-radioactive. Tri-Med (14C) – not used in women or children (radio-active).
- primary gasses are odorless and harmless
                                                                                                            Sensitivity of 90%, specificity of 95-100%. 13C test is expensive $250, 14C is cheap $50.
- noticeable smells are trace gasses related to food intake
FOODS CAUSING FLATULENCE                                                                                    SEROLOGY
                                                                                                            ELISA to detect IgG or IgA antibodies – high sensitivity 95%, but low specificity 80%, and one test doesn’t tell
(1) Milk, dairy, and certain lactose containing medicines – especially in lactase deficient people
                                                                                                            acute infection. Cheaper test - $50. Test is less specific with age over 50. Acute and convalescent (3-6mo.)
(2) Vegetables – baked beans, cauliflower, broccoli, and cabbage
                                                                                                            titres can be checked, and drop in titre by >50% confirms cure.
(3) Starches – wheat, oats, corn, potatoes. Rice is generally benign and does not produce flatulence.
                                                                                                            13C BICARBONATE ASSAY
                                                                                                            Patients eat 13C labeled Bicarbonate meal, and serum is measured pre and post-prandially for 13C bicarbonate.
                                                                                                            In patients w/ H. pylori this increases dramatically.
Gastritis
                                                                                                            STOOL ANTIGEN
PATHOLOGY                                                                                                   ELIZA of stool – high false positive result even after eradication.
see PUD - peptic Ulcer Disease
                                                                                                            URINARY ASSAY
                                                                                                        8
ELIZA of urine.                                                                                                       LEFT-SIDED HX
SALIVARY ASSAY                                                                                                        Think obstruction of bowel, hematochezia.
not as sensitive as histology or serum testing.                                                                       RIGHT SIDED HX
                                                                                                                      Think fatigue, occult blood, and Fe2+ deficiency anemia, and palpable mass, and Virchow’s node.
                                                                                                                      PE
GI Neoplasm – Anus                                                                                                    Blumer’s shelf – intraperitoneal masses (metastasis).
PATHOLOGY                                                                                                             LABS
Large morphological spectrum, but squamous primary tumors do arise in anus.                                           CRP is higher in people who are diagnosed w/ colorectal cancer, suggesting that inflammation may play a role.
Linked to HPV                                                                                                         METASTASIS
                                                                                                                      Spread is hematogenous, lymphatic, and local invasion.
                                                                                                                      Liver most common
GI Neoplasm - Appendix                                                                                                Lung 2nd most common

PATHOLOGY                                                                                                             PROGNOSIS
                                                                                                                      By TNM staging:
Most common tumor is carcinoid tumor.
                                                                                                                      TNM0 (Duke’s A)– 75% (5yr survival rate)
50% of GI carcinoid tumors are found in the appendix.
                                                                                                                      TNM1 (Duke’s A)– 70%
Adenocarcinoma is another tumor that occurs in the appendix - cure rate of 55% at 5 years.
                                                                                                                      TNM2 (Duke’s B)– 58%
RX                                                                                                                    TNM3 (Duke’s C)– 30%
If tumor is <2cm, appendectomy.                                                                                       Dukes-Turnbull Staging: (Lawrence)
If >2cm or extends through serosa, right hemicolectomy is indicated.                                                  A = Confined to mucosa – 99%, 85-90%
                                                                                                                      B1 = Negative nodes, extension into but not through muscularis propria - 70-75%
                                                                                                                      B2 = Negative nodes, extension through muscularis propria, into serosa – 60-65%
GI Neoplasm – Carcinoid                                                                                               C1 = same as B1 w/ positive nodes – 30-35%
                                                                                                                      C2 = same as B2 w/ positive nodes – 25%
PATHOLOGY                                                                                                             D = Distant metastasis – <5%
Well-differentiated neuroendocrine tumor of GI tract.
                                                                                                                      RX
Very aggressive (22%) if small intestine tumor.
                                                                                                                      (1) A or B1 - surgery
Morphology – little pleomorphism and mitosis are rare
                                                                                                                      (2) B2 or higher:
Tumor morphology can be nested (like birds nest), trabecular (anastomosing cords), tubular, or solid (diffuse
                                                                                                                      - Surgery, and
sheets of cells).
                                                                                                                      – Chemo => 5FU + Levamisole for 1y, or 5FU + Leucovorin for 6mo, and
Stain well with silver stain.
                                                                                                                      – Radiation – 50-60cGy.
APUDoma – Amine Precursor Uptake and Decarboxylation – thus carcinoids produce hormones.
                                                                                                                      (3) Metastatic - 5FU, Leucovorin, Irinotecan
LAB                                                                                                                   *With any treatment, monitor CEA (CarcinoEmbryonic Antigen) – if it trends upwards we have a recurrence.
5-HIAA level elvated (byproduct of amine hormones)


                                                                                                                      GI Neoplasm - Colorectal Subtypes
GI Neoplasm – Colorectal                                                                                              ADENOMA
EPIDEMIOLOGY                                                                                                          Dysplastic epithelium which has not invaded underlying stroma (mucularis externa).
 th                                 nd                                                                   st
4 most common cancer in USA, 2 most common cancer killer in USA (higher than breast, prostate), 1 (most               Sporadic occurrence, usually takes 10 years to develop into carcinoma (if it is going to become carcinoma).
common) GI cancer                                                                                                     Size - <1cm = benign, >3cm = 30% chance of becoming carcinoma
Males = females                                                                                                       Prevalence – 30% of adults over 40 have at least 1 adenoma
Median age of diagnosis = 71                                                                                          Screening and removal of polyps reduces instance of colorectal cancer. Flex sig will detect up to 50% of polyps
Western diet is large risk factor – fat, heterocyclic amines, high pH stool, more anaerobes in stool, more bile       – if we find them, do colonoscopy to remove or evaluate further (biopsy). Segmental resection of colon should
Immigrants obtain same risk as adopted country                                                                        be done if villous adenoma is large, ulcerated, or indurated.
GENETICS                                                                                                              3 types:
Genes:                                                                                                                1. Tubular – tube-like glands, usually pedunculated, very common (10% of adults have them). 7% chance of
- APC (tumor suppressor gene) – mutated in 100%                                                                       turning malignant. Only 20% are left sided and can be seen w/ flex sig.
- P53 (tumor suppressor gene) – mutated in > 50%                                                                      2. Tubulovillous – usually pedunculated, 20% chance of turning malignant.
- k-ras (proto-oncogene) – mutated in almost 50%                                                                      3. Villous – frond-like villi, usually sessile, fairly common in elderly. 33% chance of turning malignant. 80%
                                                                                                                      are left sided and can be seen w/ flex sig.
HX
GI bleeds – detected by patient noticed, or occult fecal blood, possible anemia                                       COLITIS-ASSOCIATED DYSPLASIA
Bowel obstruction (exophytic, fungating neoplasm)                                                                     patients w/ chronic IBD have increased risk of epithelial dysplasia.
Abdominal distention, generalized crampy abdominal pain                                                               High grade dysplasia is indicative for colectomy – since carcinoma in IBD is often flat and difficult to detect on
Thin stools – “pencil like”                                                                                           colonoscopy or radiology
Weight loss, localized abdominal pain are BAD                                                                         FAMILIAL ADENOMATOUS POLYPOSIS (FAP) and
Septicemia – due to perforated ulcerating carcinoma                                                                   ADENOMATOUS POLYPOSIS COLI (APC)
                                                                                                                  9
Autosomal dominant (50% chance of inheritance)                                                                    differentiated
Hundreds of adenomas form at young age (early 20s)                                                                Verrucous carcinoma – papillary masses
100% chance that some will become carcinomas                                                                      Spindle cell carcinoma – bulky, intraluminal mass of spindle cells, resembles a sarcoma
HEREDITARY NON-POLYPOSIS COLORECTAL CARCINOMA (HNPCC)                                                             Precursor squamous dysplasia – pleomorphism and increased N/C ratio – severe dysplasia leads to esophageal
Autosomal dominant, defect is in DNA repair mechanisms                                                                   squamous cell carcinoma in 3-4 years
Few adenomas develop, but those that do occur in proximal colon and have very large chance of becoming            May form TEF via tumor growth.
carcinoma                                                                                                         RISK
Most patients develop carcinoma by early 40s                                                                      Men = 4*women in USA
Recommended that these people get annual colonoscopy starting at age 25.                                          Common in China, Africa, USA blacks have 4* higher risk
JUVENILE POLYPOSIS SYNDROME (JPS)                                                                                 Average age of diagnosis is 60 years
Autosomal dominant, mutation in PTEN gene (tumor suppressor gene)                                                 Achalasia
Polyps are hamartomatous (normal epithelium in inflamed, edematous stromal tissue)                                Severe esophageal injury (lye stricture from suicide Drano attempt)
                                                                                                                  Plummer-Vinson syndrome
PEUTZ-JEGHERS SYNDROME                                                                                            Tylosis (hyperkeratosis of hands and feet)
Autosomal dominant, mutation of STK11, (tumor suppressor gene)                                                    Esophageal diverticula
Hamartomatous polyps, but no increase of GI carcinoma
Increase of ovary, breast, uterine, stomach cancers
                                                                                                                  GENETICS
Increased melanin in lips, oral mucosa, hands, genitalia                                                          p53 TSG mutation in 50%

COWDEN’S DISEASE                                                                                                  HX
same gene as JPS – PTEN (TSG), but different mutation                                                             Mostly asymptomatic.
unique hamartomatous polyps occur, but no increase of GI carcinoma                                                Late stage – weight loss, hemorrhage, dysphagia, aspiration of food (via TEF)
Increase of thyroid cancer                                                                                        PROGNOSIS
GARDNER’S SYNDROME                                                                                                poor – since most present at late stage – 5yr survival is 5%
Autosomal dominant
colorectal adenomas + osteomas and soft tissue tumors
TURCOT’S SYNDROME                                                                                                 GI Neoplasm – Gastric Adenocarcinoma
colorectal adenomas + CNS tumors                                                                                  PATHOLOGY
                                                                                                                  90% of gastric neoplasms are adenocarcinomas, but gastric adenomas are much rarer than colorectal
                                                                                                                  adenocarcinomas
GI Neoplasm – Esophageal Adenocarcinoma                                                                           Individual gastric adenomas carry MUCH higher risk of being carcinoma than colorectal polyps do.
                                                                                                                  Histology:
PATHOLOGY                                                                                                         - Intestinal type – similar to colorectal adenoma
10% of esophageal cancers.                                                                                        - Diffuse type – signet cell ring carcinoma, invades stomach wall (linitis plastica – loss of gastric pliability)
Begins as Barrett esophagus (esophageal squamous metaplasia to gastric columnar epithelia)                        Incidence of distal gastric cancer (antrum) is declining, but proximal gastric cancer and esophago-gastric junction
HGD (High grade dysplasia) is indication for prophylactic esophagectomy                                           cancers are increasing (Barrett’s esophagus?)
Gross features are similar to esophageal squamous cell carcinoma                                                  Associated with Metaplastic atrophic gastritis (MAG): (damage due to humoral and cellular attack)
Histological features are similar to gastric adenocarcinoma (since tissue was gastric metaplasia!)                - Autoimmune – AMAG – damage in body and fundus
RISKS                                                                                                             - Environmental – EMAG – damage in antrum
White males – 10-20x higher risk                                                                                  RISK FACTORS
Median age of diagnosis = 60s                                                                                     In USA, higher (2x) risk for blacks, hispanics, and Native americans
ETOH and smoking increase risk                                                                                    Inverse risk between socioeconomic status and gastric adenocarcinoma – poor people get it.
HX                                                                                                                Diet is strongly linked to gastric adenocarcinoma – nitrosamines bad. (Animal fat good)
Only ½ patients report long history of GERD                                                                       Smoking and ETOH are NOT linked to increased gastric adenocarcinoma
Symptoms begin insidiously, slowly progressing weight loss, dysphagia, odynophagia, chest pain, perhaps           Males twice as high as females
hemorrhage                                                                                                        Usually not apparent until 70s
                                                                                                                  Partial gastrectomy increases risk, but 25 years later
PROGNOSIS                                                                                                         Menetrier’s Disease – (cerebriform hyperplasia of gastric mucosa, w/out inflammation/infection)
Bad – 15% 5 year survival, due to late diagnosis
                                                                                                                  H. PYLORI
                                                                                                                  H. Pylori infection gives 2-6x higher risk for gastric cancer – unknown source.
                                                                                                                  Treatment of H. pylori in people without precancerous lesions may be good prevention. JAMA 2004, 291:187
GI Neoplasm – Esophageal Squamous Cell Cancer                                                                     GENETICS
PATHOLOGY                                                                                                         1st degree relatives have 2-3x risk
60-90% of esophageal carcinomas are squamous cell.                                                                p53 (TSG) mutated in 50%
Early cancers look like slight mucosal thickening w/ superficial erosion                                          E-cadherin mutated in 50%
Late cancers are fungating with central ulceration, or ulcerating in diffusely thickened esophageal wall.         Blood Group A much more likely to get gastric cancer
1/2 occur in middle esophagus, 1/3 in lower, and rest in upper. (Mary Beth’s Tits)
                                                                                                                  HX
Typical – nests of polygonal cells with well-defined cell/cell junctions, keratin pearl formation if well-

                                                                                                             10
Anything surgically curable is asymptomatic, thus never presents early enough for this option                           Most likely a carcinoid (neuroendocrine) tumor, lymphoma, or GIST
Weight loss, abdominal pain, nausea, anorexia.
Often metastasis are 1st node found:
      Virchow’s (supraclavicular)
      Sister Mary Joseph’s (periumbilical)
                                                                                                                        Glossary
      Krukenberg tumor (ovary)                                                                                          CELESTIN TUBE
      Blumer’s shelf (intraperitoneal)                                                                                  Palliative stent to hold the esophagus patent in a terminal cancer patient.
METASTASIS                                                                                                              COLIC
liver then lungs, also direct extension to peritoneum through gastric wall.                                             Intermittent, spasmodic, crampy abdominal pain, often seen in infants secondary to swallowing air, or in adults
PROGNOSIS                                                                                                               following meals.
Surgery only cure, gastric adenocarcinoma is resistant to chemo and radiation.                                          COLUMNS OF MORGAGNI
Stage 1 – 50%                                                                                                           Longitudinal folds immediately proximal to the dentate line w/ perianal glands at their bases.
Stage 2 – 30%
                                                                                                                        CONSTIPATION
Stage 3 – 13%
                                                                                                                        Trouble w/ stools - infrequent BM, hard stools, rectal irritation, etc., but patient is still able to pass flatus.
Note, in Japan, where incidence of gastric cancer is much higher, they do regular endoscopic screening, and have
a 5yr survival of 90%.                                                                                                  DENTATE LINE
                                                                                                                        Aka Pectineal line, or anorectal junction. Columnar cells w/ autonomic innervation proximal, and squamous cells
                                                                                                                        w/ somatic innervation distal. About 3-4cm superior to anal os.

GI Neoplasm – GIST                                                                                                      DYSENTERY
                                                                                                                        A disease marked by frequent watery stools, often with blood and mucus, and characterized clinically by pain,
PATHOLOGY                                                                                                               tenesmus, fever, and dehydration. Literally "Bad Bowel" (Dys = bad, Enteric = GI).
Gastro-Intestinal Stromal Tumor – spindle cell morphology
GIST of small intestine are most aggressive
                                                                                                                        FLATUS
                                                                                                                        Gas passed from anus. Normally 70% N2, from inhaled air. Other gasses include O2, CO2, H2, methane,
                                                                                                                        indole, and skatole. Indole and skatole give the characteristic fart odor. Typically 800-900mL of gas/day.
GI Neoplasm – Lymphoma                                                                                                  HAUSTRA
                                                                                                                        Folds created in colon by teniae coli.
MALT – Mucosa Associated Lymphoid Tissue Lymphoma
Arise in conjuction with H. Pylori infection                                                                            OBSTIPATION
Low grade can turn into high grade lymphoma                                                                             Refers to absence of stool and absence of flatus. Constipation is absence of stool only.

EATL – Enteropathy-Associated T Cell Lymphoma                                                                           PHLEGMON
Arises in patients w/ sprue like illness, usually have multiple non-healing ulcers in small intestine.                  The precursor to an abscess - contains all the same elements (bacteria, PMNs, necrotic tissue) but no collagen
                                                                                                                        wall.
                                                                                                                        Most phlegmons respond to antibiotics, but abscesses require drainage.
                                                                                                                        PYROSIS
GI Neoplasm – Overview                                                                                                  Water brash, aka heartburn (esophagitis).
PATHOLOGY                                                                                                               REGURGITATION
All dysplasia is at risk for becoming carcinoma, but HUGE variation based upon clinical presentation.                   Passive return of gastric contents to oropharynx.
Macroscopic appearance:
      - flat infiltrative carcinoma                                                                                     SINGULATUS
      - Ulcerated infiltrative carcinoma                                                                                Hiccup. Helps relieve some pain during reflux esophagitis (heartburn).
      - Exophytic/fungating carcinoma                                                                                   VOMITING
GI Neoplasm frequency in USA:                                                                                           Active return of gastric and duodenal contents through oropharynx.
      1. Colorectal
      2. Pancreatic
      3. Gastric
      4. Esophageal                                                                                                     Heartburn
POLYPS                                                                                                                  see GERD
Polyps – can be pedunculated (w/ stalk), and sessile (no stalk).
Adenomatous polyp – Adenoma - dysplastic epithelium
Hamartomatous polyp – benign epithelium and stromal tissue                                                              Hemochromatosis
Lymphoid polyp – lymphocytes
Lipoma – adipose tissue                                                                                                 see - HEME - RBC file.
Leiomyoma – benign smooth muscle tumor

                                                                                                                        Hemorrhoids
GI Neoplasm – Small intestine                                                                                           PATHOLOGY
PATHOLOGY
                                                                                                                   11
Caused by excessive straining during dumping, veinous stasis during pregnancy, portal hypertension,                      Often a Richeter’s hernia. Viscera through obturator canal compresses obturator nerve, causing paresthesias in
constipation.                                                                                                            anteromedial aspect of thigh (Howship-Romberg sign).
External - below anorectal line, somatic sensation, very painful.                                                        PANTALOON
INTERNAL                                                                                                                 Simultaneous occurrence of direct and indirect hernias, thus two bulges surround inferior epigastric vessels.
Internal - above anorectal line, painless.                                                                               SLIDING
1st degree - no prolapse, only visible w/ anoscope.                                                                      Any hernia in which a portion of the wall of the protruding peritoneal sac is made up of some intra-abdominal
2nd degree - prolapse w/ defecation, spontaneously return.                                                               organ.
3rd degree - prolapse w/ defectaion, require manual reduction.
4th degree - not reducible.
RX - banding for 2nd and 3rd degree, formal hemorrhoidectomy for 4th degree.
THROMBOSED EXTERNAL HEMORRHOID                                                                                           Hernia – Repairs
(1) Severe perianal pain - can be excised during 1st 24-48 hours [Lawrence], or 1st 72 hours [AFP, 4/02], else           MARCY
leave to self-resolve (7-10days). Close w/ dermal and subcutaneous sutures as infection rare due to rich vascular        Repair of indirect hernia where transversus aponeurosis around deep inguinal ring is tightened.
plexus.
                                                                                                                         MCVAY
(2) Rx w/ Sitz baths and narcotic analgesia.
                                                                                                                         Transversus aponeurosis is sewn laterally to Cooper’s ligament and anterior femoral sheath, to tighten the fascia
(3) Always prescribe stool softeners.
                                                                                                                         and deep inguinal ring opening.
                                                                                                                         BASSINI
                                                                                                                         Superficial repair for direct hernia where transversalis fascia is tightened down to the inguinal ligament.
Hernias – Overview                                                                                                       SHOULDICE
PATHOLOGY                                                                                                                Deeper repair for direct hernia where the transversalis fascia is incised, doubled over, and sewn to inguinal
Defect in abdominal wall allows portion of bowel or other internal viscera to extrude through opening.                   ligament inferiorly and sewn superiorly.
Men – 40% direct, 50% indirect, 10% femoral
Women – Directs are rare, 70% Indirect, 30% femoral
                                                                                                                         MESH REPAIR
                                                                                                                         Alleviates need to apply tension to already weakened structures. Usually uses polypropylene (Martex), or
Children – Almost all are indirect.
                                                                                                                         polytetrafluroethylene (Gore-Tex).
DIRECT
Hernia through Hesselbach’s triangle:
                                                                                                                         LAPAROSCOPIC REPAIRS
                                                                                                                         TAPP – Transabdominal Preperitoneal Repair – uses mesh and staples.
- inferior epigastric vessels
                                                                                                                         TEP – Totally Extraperitoneal Repair – balloon pushes peritoneum posteriorly so that mesh is attached without
– lateral border (falx) of rectus abdominus muscle
                                                                                                                         entering peritoneum.
– inguinal ligament
                                                                                                                         IPOM – Intraperitoneal Onlay Mesh – not popular.
Viscera actually forms outpouch which is still covered by visceral and parietal peritoneum, and transversalis
fascia.
INDIRECT
Hernia through deep inguinal ring, thus viscera descends inside spermatic cord.                                          Hiatal Hernia
Viscera is deep to internal spermatic fascia (continuation of transversalis fascia).                                     PATHOLOGY
UMBILICAL                                                                                                                Acquired sac-like dilation of upper stomach that protrudes superior to diaphragm.
Most commonly small (<1cm) and congenital. Unless incarcerated, best to leave until pre-school years, as it will         Sliding - 90%
likely close spontaneously. Other types include gastroschisis and omphalocele.                                           Rolling (paraesophageal) - 10%
                                                                                                                         80% of patients w/ GERD have a hiatal hernia.
INCISIONAL
Iatrogenic, due to incomplete closure of abdominal incision post-op. Most common cause is due to infection of            Hx
wound.                                                                                                                   Burning epigastric or substernal pain/tightness.
                                                                                                                         Worse when bent over, leaning forward, or supine.
SPIGELIAN
                                                                                                                         Antacids provide relief.
Herniation through semilunar line – just lateral to rectus abdominus at level of semicircular line of Douglas
                                                                                                                         May feel accompanying sensation of globus (lump in throat).
(arcuate line).
                                                                                                                         LABs
GRYNFELT’S
                                                                                                              th         Barium swallow
Herniation posteriorly through superior lumbar triangle, bounded by sacrospinalis, internal oblique, and 12 rib.
                                                                                                                         Endoscopy of BS equivocal.
PETIT’S                                                                                                                  RX
Herniation posteriorly through inferior lumbar triangle, bounded by lateral margin of latissimus dorsi, medial
                                                                                                                         Surgical Rx is fundoplication:
margin of external oblique, and iliac crest.
                                                                                                                         (1) Nissen - repair phrenoesophageal ligament, construct valve w/ gastric fundus.
RICHETER’S                                                                                                               (2) Hill - sew stomach to phrenoesophageal ligament
A hernia where only a portion of the bowel’s circumference actually herniates, thus the entire lumen is not              (3) Belsey Mark-IV cardioplasty - sew fundus up to diaphragm.
compromised.
LITTRE’S
Any groin hernia that contains Meckel’s diverticulum.                                                                    Hirschsprung's Disease
OBTURATOR                                                                                                                PATHOLOGY
                                                                                                                    12
Congenital lack of Meissner's (submucosal) plexus and Auerbach's myenteric (muscularis propria) plexus,               FLEX SIG
causing proximal colon to dilate and form toxic megacolon.                                                            Flexible sigmoidoscopy, allows visualization of last 30-65cm of colon (and rectum and anus).
                                                                                                                      Can detect 60% of colorectal neoplasms. Current recommendations are to use as screening study in everyone
                                                                                                                      over 50, every 3-5yrs.
Ileus
PATHOLOGY
Literally, loss of peristalsis w/out obstruction.                                                                     Infection – Intra-Abdominal
Causes include:                                                                                                       PATHOLOGY
- Recent surgery                                                                                                      Most infections of abdomen involve bacteria from GI tract.
- Gallstones                                                                                                          Mechanism for infection is:
- Severe illness (sepsis)                                                                                             - Break in GI mucosal barrier (perforated bowel)
- Hypothyroidism                                                                                                      - Diverticulitis
- Diabetes mellitus                                                                                                   - Appendicitis
- Medications - anti-cholinergics, opiates, etc.                                                                      - Inflammatory bowel disease
PE                                                                                                                    - Penetrating abdominal trauma
Decreased or absent bowel sounds.                                                                                     - Colon cancer
Abdominal distention, but no peritoneal signs.                                                                        - Intestinal surgery
                                                                                                                      - Spontaneous bacterial peritonitis
LAB
AXR - air fluid levels, distended loops of bowel.                                                                     MONOMICROBIAL INFECTIONS
                                                                                                                      (1) Cholecystitis (inflammation of gall bladder) - E. coli, other coliforms, Streptococci
RX                                                                                                                    (2) Spontaneous bacterial peritonitis (often along with ascites) - E. coli, other coliforms.
NPO                                                                                                                   (3) Pancreatitis - E. coli, other coliforms.
NG tube w/ LC suction prn.                                                                                            **Monomicrobial means antibiotic treatment.
Electrolyte replacement prn.
                                                                                                                      POLYMICROBIAL INFECTIONS
                                                                                                                      (1) Perforated ulcer or colon - Streptococci, E. coli, Bacteroides fragilis, other coliforms.
                                                                                                                      (2) Diverticulitis - E. coli, Bacteroides fragilis, Streptococci, other coliforms.
Ileus – Gallstone                                                                                                     (3) Appendicitis - same as above.
PATHOLOGY                                                                                                             (4) Liver Abscess - same as above.
Gallstone erodes a fistula from GB into duodenum.                                                                     **Polymicrobial infections mean that it is time to call the surgeon.
Responsible for 25% of non-strangulated small bowel obstructions in people > 70.
HX
(1) Hx of biliary colic                                                                                               IBD - Inflammatory Bowel Disease
(2) Intermittent obstruction                                                                                          PATHOLOGY
(3) Impaction                                                                                                         Unclear - likely combination of genetics and virus/bacteria, perhaps autoimmune
RX                                                                                                                    Bimodal peak age of onset - 15-25, 55-65
Celiotomy and enterolithotomy (extraction of stone from small bowel).                                                 Highly hereditary - 15% have 1st degree relative with IBD.
                                                                                                                      Higher incidence in Caucasians and Jewish people
                                                                                                                      Two main diseases (w/ overlap)
Ileus – Post-Surgical                                                                                                 - Crohn's
                                                                                                                      - Ulcerative colitis
PATHOLOGY                                                                                                             CROHN'S VS. UC
Bowel essentially goes to sleep after surgery.                                                                        (1) Diarrhea - severe, bloody in UC
Order – small bowel, stomach, colon. (colon goes to sleep last).                                                      (2) Perianal fistulas - common in Crohn's
                                                                                                                      (3) Bowel Obstruction - common in Crohn's
                                                                                                                      (4) Perforation - common in Crohn's
Imaging Studies                                                                                                       (5) Location:
                                                                                                                      Crohn's - always hits ileocolic region
ABDOMINAL SERIES                                                                                                      UC - colon only.
Refers to flat plate (supine) and upright (standing) x-rays of abdomen.                                               (6) Skip lesions - only in Crohn's, UC is continuous
Good for detecting pneumoperitoneum, bowel obstruction, paralytic ileus, appendicolith, etc.                          (7) Toxic megacolon - more common in UC.
BARIUM ENEMA
A test where contrast medium is pumped into bowel under pressure to fill entire organ.
Good for detecting tumors, diverticulosis, volvulus, and obstruction.                                                 IBD - Crohn's Disease
COLONOSCOPY
                                                                                                                      PATHOLOGY
Best diagnostic tool for colon, allows for theraputic procedures (polyp removal, hemorrhage control, etc.) and
                                                                                                                      Inflammation of terminal ileum/colon (ileocolic region almost always involved). Can involve other parts of small
biopsy.
                                                                                                                      bowel, stomach, esophagus, but rare.
                                                                                                                 13
Rectal sparing, patchy, diffuse lesions ("skip lesions").                                                               - Sclerosing Cholangitis
Aphthous ulcers are earliest lesion.                                                                                    - Erythema nodosum – Red leisons on anterior tibia
50% of patients will develop focal granulomas.                                                                          - Pyoderma gangrenosum – necrotic ulcer over skin
Progresses to transmural, granulomatous, inflammatory disease, w/ thickened bowel wall and enlarged mesenteric          - Arthritis
lypmh nodes. Cobblestone colonic mucosa w/ linear ulcerations.                                                          - Malnutrition
HX                                                                                                                      HX
Colicky pain in lower abdomen                                                                                           Chronic diarrhea, painful at times, usually bloody (hematochesia), fever, tachycardia (if lots of blood loss)
Diarrhea, abdominal pain (RLQ), perhaps w/blood, fever                                                                  Urgency prior to defecation, cramping, tenesmus (painful anal sphincter spasm in conjunction w/ urgent desire to
LABs                                                                                                                    defecate, resulting in passage of little fecal matter or urine)
String sign in small bowel w/ Barium AXR.                                                                               Hypovolemia, Hypoproteinemia

COMPLICATIONS                                                                                                           LABs
Intestinal obstructions and fistulas are complications.                                                                 "Lead pipe" colon w/ barium enema.
Risk of GI cancer is threefold in Crohn's patients.                                                                     COMPLICATIONS
COMORBID CONDITIONS                                                                                                     (1) Toxic megacolon - acute dilation to >6cm
(1) Anemia                                                                                                              (2) Carcinoma – 2% at 10yrs, 8% at 20yrs, 18% at 30yrs. Patients w/ UC for > 10yrs require yearly colonoscopy
(2) Hepatobiliary disorders:                                                                                            w/ biopsies taken every 10 cm.
- Fatty liver                                                                                                           RX - MEDICAL
- Hepatitis                                                                                                             (1) 70% of patients can be kept in remission w/ sulfasalazine, mesalamine, azathioprine
- Cirrhosis                                                                                                             (2) Corticosteroids often needed - particularly to induce remission during exacerbations.
- Sclerosing cholangitis - diffuse inflammation, leading to patchy stricturing of bile duct.                            (3) Antidiarrheals should be used cautiously (loperamide, aka immodium AD)
(3) Rheumatic:                                                                                                          RX - SURGICAL
- Arthritis - peripheral occurs in 10%                                                                                  Surgery is curative - 3 options:
- Ankylosing spondylitis - occurs in 5%                                                                                 (1) Brooke ileostomy - silver dollar size ring of ileum in RLQ
(4) Dermatologic:                                                                                                       (2) Kock pouch ileostomy - nickel sized nipple valve of ileum in LQ
- Erythema Nodosum (rashes), most commonly over tibia                                                                   (3) Ileal pouch - anal anastamosis - Ileal J pouch w/ ileo-anal joining. Soft, pasty, 5 stools per day. Pouchitis in
- Pyoderma gangrenosum - necrotic ulcer over skin                                                                       1/20 patients
(5) Ocular:
- Uveitis - inflammation of uveal tract (iris, ciliary body, choroid)
- Episcleritis - inflammation of connective tissue between sclera and conjunctiva
RX                                                                                                                      Intestinal Lymphangiectasia
Sulfasalazine - for mild to moderate UC - drug delivers 5-ASA (Acetyl Salicylic Acid) to colon, where it acts as        PATHOLOGY
NSAID                                                                                                                   Generalized dilation of small intestinal lymphatics.
Asacol - coated tables of 5-ASA released where pH>7, no sulfa                                                           Marked GI protein loss, thus hypoproteinemia
Pentasa - granules of 5-ASA released in time-dependent fashion, can treat small bowel and colon - good for
Crohns, no sulfa
Rowasa - enema, suppository formulation
Prednisone (PO) - moderate to severe colitis - to induce remission - but does not maintain remission                    Irritable Bowel Syndrome
Solumedrol/Hydrocortisone (IV) - glucocorticoids                                                                        HX
                                                                                                                        Altered bowel habits - often diarrhea alternating with constipation
                                                                                                                        Bloating, Relief of symptoms and pain with defecation.
                                                                                                                        Pain usually LLQ (splenic flexure syndrome)
IBD - Ulcerative Colitis                                                                                                Upper GI symptoms - Dyspepsia-like
PATHOLOGY                                                                                                               Diagnosis of exclusion - function rather than organic - stress major factor
Idiopathic, inflammatory process of mucosa and submucosa of colon and rectum.
                                                                                                                        RX
Crypt abscesses form - dilated, degenerated crypts filled w/ PMNs
                                                                                                                        For constipation - high fiber diet, fiber supplement (metamucil)
Also inflammatory polyps form (pseudopolyps) - areas of hanging mucosa adjacent to ulcerative lesions
                                                                                                                        For diarrhea - Anti-diarrheals - immodium, lomotil
3 types, based on geographical extent:
- Ulcerative proctitis - rectum alone
- Left-sided colitis (proctosigmoiditis) - rectum to splenic flexure
- Pancolitis - entire colon                                                                                             Ischemia (Acute Mesenteric Ischemia)
EPIDEMIOLOGY                                                                                                            PATHOLOGY
Higher incidence at higher latitudes – similar to Multiple Sclerosis.                                                   Sudden lack of blood flow to small bowel which overwhelms collateral circulation.
Perhaps genetic + infectious or autoimmune causes.
                                                                                                                        HX
Colonic carcinoma MUCH higher risk than for Crohns disease.
                                                                                                                        Pain out of proportion to physical signs
Additional ailments:
- Uveitis                                                                                                               LAB
- Ankylosing Spondylitis                                                                                                Mesenteric Angiography

                                                                                                                   14
RX                                                                                                                   "FLAG SIGN" - linear depigmentation of hair, during periods of most severe protein deficiency
Vasodilating agents                                                                                                  Muscle wasting, dermatosis (flaky paint lesions of skin)
Surgically remove dead bowel                                                                                         LAB
                                                                                                                     Anemia
                                                                                                                     *Note - we will often see normal or low BUN, urine specific gravity, and albumin, due to dehydration. In fact,
Ischemic Bowel Disease                                                                                               BUN and albumin are dangerously low, but severe dehydration is masking this.

PATHOLOGY                                                                                                            RX
                                                                                                                     Child quickly resumes normal dietary intake, but initially weight gain is slow since we must first form albumin
To affect small bowel, we have infarction of SMA (superior mesenteric artery) or branch of SMA. Bowel
                                                                                                                     and restore proper water compartment concentrations.
damage may be mucosal, mucosal + submucosal, or transmural. Transmural damage more common in small
bowel than colon due to difference in blood supply. If it does not reverse, surgery is mandatory.

                                                                                                                     Lactose Intolerance
Ischemia (Chronic Mesenteric Ischemia)                                                                               EPIDEMIOLOGY
PATHOLOGY                                                                                                            15% of caucasians
                                                                                                                     80% of Blacks and Latinos
Chronic lack of blood flow due to atherosclerosis
                                                                                                                     Nearly 100% of Asians and American Indians
HX
Chronic recurrent abdominal pain, precipitated by a meal (fear of eating), weight loss, atherosclerosis
                                                                                                                     PATHOLOGY
                                                                                                                     Lactase deficiency - non-absorbed lactose and water remain in GI lumen and cause osmotic diarrhea.
HX of MI, PVD, CVA
                                                                                                                     Also, bacteria break down undigested lactose and release H2 gas.
LAB                                                                                                                  Three types:
Angiogram                                                                                                            (1) Primary – most common. These adults can usually consume about 8-12 ounces of milk qD before symptoms
RX                                                                                                                   occur.
Angioplasty, surgical bypass                                                                                         (2) Secondary – following a GI illness which affects brush border (where lactase is located)
                                                                                                                     (3) Congenital – lifelong, no lactose tolerance. Very rare.
                                                                                                                     HX
Ischemic Colitis                                                                                                     Bloating
                                                                                                                     Cramps
PATHOLOGY                                                                                                            Flatulence
Acute lack of blood flow to colon overwhelming collateral circulation                                                Diarrhea – with large quantities of lactose containing foods.
HX                                                                                                                   LABs
Acute bloody diarrhea and abdominal pain in susceptible patient (atherosclerosis)                                    (1) Hydrogen breath test – Best test. Ingest 25-50g lactose, if breath [H] rises more than 20ppm, we have
LAB                                                                                                                  hypolactasia.
Flexible sigmoidoscopy or colonoscopy                                                                                (2) Lactose tolerance test – administer 1g/kg lactose, then obtain serial glucose levels. If symptoms occur and
                                                                                                                     [glucose] does not increase more than 20mg/dL, test is positive.
RX
Usually supportive, maintain BP, let body recover                                                                    RX
                                                                                                                     Avoid lactose in diet, oral lactase enzyme pills
                                                                                                                     Patients can often eat yogurt without problems.

Kaposi's Sarcoma
SUMMARY                                                                                                              Laxatives
PATHOLOGY                                                                                                            BULK FORMING
Bluish purple nontender macules, papules, or plaques anywhere in mouth or skin. Common in HIV patients.
                                                                                                                     EMOLLIENTS (SOFTENERS)
Kwashiorkor                                                                                                          HYPEROSMOLAR AGENTS
SUMMARY
protein calorie malnutrition, in conjunction with mostly carbohydrate diet                                           STIMULANTS
PE
Growth failure, muscle wasting, but normal subcutaneous fat (adequate caloric intake, just not correct type!)
Hepatomegaly (steatosis) due to TAG sythesis, severe edema (due to low serum albumin), protruding abdomen
       (due to hepatomegaly, ascites, abdominal muscle wasting).
Intestinal villous atrophy, nutrient malabsorption, diarrhea                                                         Leukemia
Severe apathy, growth failure, perhaps low intelligence (controversial)                                              SUMMARY
Low pulse, BP, temperature

                                                                                                                15
PATHOLOGY                                                                                                                   LABS
Diffuse, boggy, non-tender swelling of gums, may or may not be ulcerated. Gingival bleeding.                                Abdominal series.
                                                                                                                            Barium swallow
                                                                                                                            Meckel's scan - patient consumes Technitium pertechnetate which lights up gastric mucosa.
Lichens Planus                                                                                                              RX
                                                                                                                            Laparoscopic resection, even if found incidentally on other studies, since operative morbidity rates are low (2%).
SUMMARY
An injury to epidermis somehow causes immune system to think that epidermal cells are foreign. This results in
an infiltrative band of M0 and lymphocytes to appear at DE (Dermal-Epidermal) junction.
PATHOLOGY                                                                                                                   Megacolon (Toxic Megacolon)
oral - erosive ulcerated lesions leading to isolated white plaque, often accompanying striae.                               PATHOLOGY
                                                                                                                            Dilation of the colon with clinical deterioration, harbinger of impending perforation and sepsis.
                                                                                                                            Preciptated by narcotics, anticholinergics, opiate anti-diarrheal agents (loperamide, diphenoxylate, atropine),
                                                                                                                                   or testing - colonoscopy, barium enema
Malabsorption
DIFFUSE
Celiac Sprue, Whipple
                                                                                                                            Melanosis Coli (Cathartic Colon)
PATCHY
Lymphoma, amyloidosis, giardia
                                                                                                                            PATHOLOGY
                                                                                                                            Black colonic mucosa from excessive laxative use (anthraquinone cathartics). Pigment is lipofuscin.


Mallory-Weiss Syndrome                                                                                                      MEN-1 (Multiple Endocrine Neoplasia Syndrome), aka Wermer’s
PATHOLOGY
Esophageal tear, generally at GE junction. Usually due to prolonged emesis, associated with ROH and hiatal                  Syndrome
hernia.                                                                                                                     PATHOLOGY
Usually superficial and not excessive hemorrhage.                                                                           hyperplasia or tumor of thyroid, parathyroid, adrenal cortex, pancreatic islets, or pituitary.
                                                                                                                            May manifest as ZE (pancreatic) chief complaint.

Marasmus
SUMMARY                                                                                                                     Menetrier's Disease
Global starvation                                                                                                           PATHOLOGY
PE                                                                                                                          Cerebriform (brain like w/ gyri and sulci) enlargement of rugae of stomach, surface hyperplasia, body glandular
Growth failure, decreased body fat (and total weight), muscle wasting (especially gluteal), wrinkled face,                        atrophy, and protein loss. Called giant fold disease, due to hyperplasia of mucosal epithelial cells w/out
       "little old man" appearance.                                                                                               infection/inflammation. Same appearance as ZE syndrome
Pale, cold, patchy brownish pigmentation, frequent infections.
Usually listless, but may be alert on PE
RX                                                                                                                          Mucocele of the Appendix
Food, but it takes time for them to thrive. Usually grow out, becoming slightly obese, then grow up. (body has
                                                                                                                            PATHOLOGY
reduced metabolic rate and decided to stop growing to conserve limited food - it takes time to reverse this)
                                                                                                                            Dilated mucus filled appendix - neoplastic or non-neoplastic


Meckel's Diverticulum                                                                                                       Mucosal Prolapse
PATHOLOGY                                                                                                                   PATHOLOGY
Remnant of vitelline, or oomphalomesenteric duct.
                                                                                                                            Solitary rectal ulcer on anterior rectal wall in young adults
Rule of 2s: 2% of population, 2-3 inches long, w/in 2 feet of ileocecal valve, 1/2 have gastric or pancreatic tissue
which secrete acid/enzymes and lead to ulceration, bleeding, infection
HX
Ileus - most common (31%)                                                                                                   Necrotizing Enterocolitis
COMPLICATIONS                                                                                                               PATHOLOGY
Hemorrhage                                                                                                                  most common GI emergency in neonates.
SBO                                                                                                                         Occurs at 2-4 days of age, in premature, low birth weight neonates who are being formula fed
Diverticulitis                                                                                                              Terminal ileum, cecum, and ascending colon affected w/ edema, hemorrhage, necrosis.
Perforation
Umbilical-ileal fistula

                                                                                                                       16
                                                                                                aka aphtous ulcers, recurrent aphtous stomatitis. Caused by immunodysregulation, decreased mucosal integrity,
Nutritional Assessment                                                                                 or increased antigenic exposure. 3 types - major, minor, and herpetiform. Usually found on non-
PREALBUMIN                                                                                      keratinized
Hepatic synthesis.                                                                                     oral mucosa.
T1/2 = 2 days.                                                                                  Dental Caries
Level correlates with nutritional status and patient outcomes:
                                                                                                Infectious disease mediated by oral flora, where pH is lowered by lactacte production to 2.5 to 3. Saliva raises
<5mg/dL = poor prognosis
                                                                                                       pH back to normal but may take 60min or more. Xerostomia and sugars (refined and natural) exacerbate
5-10mg/dL = aggressive nutritional support needed.
                                                                                                disease.
10-15mg/dL = provide some nutritional support and monitor level
                                                                                                       Chewing gum helps, as well as certain fats, milk, unsweetened chocolate, and fluoride levels in water of
>15mg/dL = normal
                                                                                                0.7 to
Failure to improve at least 4mg/dL in 8 days is a very poor sign.
                                                                                                       1ppm
(1) False high readings of prealbumin:
                                                                                                Actual disease is progressive proteolysis and destruction of enamel and dentin, possible septicemia.
- ETOH – destroyed hepatocytes leak pre-albumin
- Prednisone                                                                                    Erythroplakia
- Progesterone                                                                                  Red patch which cannot be classified as any other disease. High incidence of dysplasia (bad, metaplasia okay),
(2) False low readings of prealbumin:                                                           may
- Zinc deficiency                                                                                    represent squamous cell carcinoma
ALBUMIN                                                                                         Fungal Infections
T1/2 = 20 days, not good indicator of acute nutrition status or changes w/ intervention.        PAS stained hyphae, thickening of parakeratin. Candidiasis is the most common.
                                                                                                Thrush = Candidiasis, creamy white plaque on buccal mucosa, tongue, and palate. Often appears during
TRANSFERRIN                                                                                     treatment with antibiotics and/or                                          immunosuppressants, as
T1/2 = 10 days, too long for good indication of acute status or changes w/ intervention.
                                                                                                suppression of normal flora/immunity allows fungal overgrowth.
                                                                                                Hemangioma
                                                                                                Benign proliferation of blood vessels, appearing as bluish purple mass or strawberry appearance.
Obstruction - Large Bowel                                                                       Herpes Simplex Virus
PATHOLOGY                                                                                       Acutely infected cells exhibit acantholysis, nuclear clearing, nuclear enlargement - Ballooning Degeneration,
Complete - No flatus or stool for >12 hours.                                                    multinucleated eosinophilic cell formation (Tzanck Cells).
If patient has colon >12cm on AXR, laparotomy is performed.
                                                                                                Human Papilloma Virus
Most bowel obstruction is SBO, not LBO.
                                                                                                Benign wart like growths. Histologically shows koilocytes – pyknotic (shrunken), dense, hyperchromatic nuclei
LBO is only 10-15%, and most common site is sigmoid colon.
                                                                                                with a large clear halo. Rx - Excision
Causes:
(1) Adenocarcinoma - 65%                                                                        Leukoplakia
(2) Scarring associated w/ diverticulitis - 20%                                                 White patch - (flat lesion greater than 1cm) or plaque (raised lesion greater than 1cm) which cannot be
(3) Volvulus - 5%                                                                               characterized
                                                                                                      as any other disease. Hyperkeratosis thickened spinous layer. Strictly a clinical definition.
COMPLICATIONS
                                                                                                      Usually precancerous
Perforation
Peritonitis
Sepsis
WORKUP                                                                                          Peptic Ulcer Disease
Plain films (Flat plate upright and decubitus).                                                 PATHOLOGY
Colonoscopy                                                                                     H. pylori infection, NSAIDs, stress, etc.
RX                                                                                              H. Pylori - Xmission is fecal-oral (swimming pool), lives in mucus layer above gastric epithelium. Contains
IV fluids                                                                                       urease enzyme which hydrolyzes urea to release ammonia (base), neutralize acid, and permit HP survival. H.
NPO, NG tube                                                                                    pylori secretes "vacuolating cytotoxin" and mucinase which damages gastric epithelium, leads to chronic
Observe for spontaneous resolution. If not, resection.                                          inflammation, gastritis, ulcer. H. Pylori also damages D cells in antrum of stomach which secrete somatostatin
Remember - mortality of 30% of people w/ cecal perforation.                                     (inhibits gastric acid secretion). Type O blood gets duodenal ulcers more frequently.
                                                                                                DVX
                                                                                                - Empirical algorithm - if less than 45 w/ no warning signs (anemia, guaiac stool positive, hematemesis,
Ogilvie's Syndrome                                                                              dysphagia,
                                                                                                weight loss) then treat as if gastritis. If warning signs or >45, EGD (esophagoduodenoscopy).
PATHOLOGY                                                                                       - Tests for H. pylori - serum ELISA (95% specific), CLO test from biopsy, Breath test for radiolabelled CO2
Localized paralytic ileus of colon (usually right side) w/out mechanical obstruction.           (from
RX                                                                                              radiolabelled urea - released by urease)
Long rectal decompression tube.                                                                 - Gastric ulcer - pain worse after eating. Acid level low (due to feedback from hole in stomach)
                                                                                                - Duodenal ulcer - pain better after eating. Acid level too high.
Oral Pathology                                                                                  HX
                                                                                                Burning, knawing epigastric pain.
Aphtous Stomatitis
                                                                                           17
LAB                                                                                                                      PE
EGD if >45 or if warning signs - GOLD STANDARD.                                                                          Fever
H. Pylori serum ELISA assay. 95% specific.                                                                               Significant tenderness over entire abdomen, involuntary guarding, rebound tenderness
Breath testing - Carbon-13 or 14 labelled urea is ingested, then breath monitored for carbon-13 or 14 in CO2.            Hypoactive or absent bowel sounds
CLO test - Endoscopic biopsy placed onto gel with urea and phenol red. If urease from H. Pylori present,                 Abdominal distension
      urea hydrolyzed to ammonium (NH4+), and gel turns red.                                                             LABs
RX                                                                                                                       Leukocytosis
Triple therapy for H. Pylori - Bismuth, Metronidazole, Tetracycline                                                      RX
MOC therapy (best) - Metronidazole, Omeprazole, Clarithromycin                                                           Antibiotics
also, Amoxicillin 1000mg, Clarithromycin 500mg                                                                           May require surgical drainage
Histamine-2 receptor inhibitors (ranitidine, famotidine, cimetidine) or omeprazole 20mg. BID
RX – 1 DAY THERAPY
Eradication of H. pylori (and reduction in symptoms of dyspepsia) were identical in this 1 day therapy vs. 7 day
therapy. The regimen used was:
                                                                                                                         Plummer-Vinson Syndrome
- 2 tablets of 262mg Bismuth subsalicylate (Pepto-Bismol) qid                                                            PATHOLOGY
- 500mg Metronidazole qid                                                                                                Development of an esophageal web in a patient with iron-deficiency anemia.
- 2g Amoxicillin suspension qid                                                                                          aka Paterson-Kelly syndrome.
- 60mg lansoprazole (prevacid) q once
                                                                                                                         HX
Source – Arch Int Med 2003: 163; 2079
                                                                                                                         Dysphagia
                                                                                                                         PE
                                                                                                                         Atrophic glossitis
Peptic Ulcer vs. Carcinoma                                                                                               RX
GROSS INSPECTION                                                                                                         Iron for anemia.
Tough to distinguish. Often a peptic ulcer will have smooth base, punched out margins.                                   Esophageal bougie to fracture the webs.
Carcinoma will have raised lip borders.


                                                                                                                         Pneumatosis Cystoides Intestinalis
Periodontal Disease                                                                                                      PATHOLOGY
PATHOLOGY                                                                                                                Localized or diffuse air filled vesicles in submucosa of intestine - due to dissection of air around great vessels and
Chronic inflammatory destructive disease affecting teeth, periodontal ligament, and alveolar bone, leads to              their abdominal branches in patients with COPD, or presence of gas forming bacteria in bowel wall.
loosening
      and eventual loss of teeth. Acute destructive phase mediated by bacteria. Risk factors - poor oral hygeine,
      smoking, immune deficiencies, diabetes, or drug induced - Phenytoin, Ca Channel blockers, Cyclosporine
                                                                                                                         Polyps
                                                                                                                         See “GI Neoplasm – Colorectal Subtypes”
Peritonitis - Focal
PATHOLOGY
Usually due to a focal process such as appendicits or infected/inflamed diverticulum.                                    Pseudomembranous Colitis
HX                                                                                                                       PATHOLOGY
Presents more indolently and subtly than generalized peritonitis.                                                        Gray/yellow membranes form on epithelial surface w/ fibrin, mucin, and PMN infiltrate.
First symptom is vague "pain" sensation caused by visceral peritoneum irritation.                                        Caused by antibiotic use removing normal flora and allowing Clostridium difficile to proliferate.
When parietal peritoneum becomes involved, pain can be localized.                                                        ETIOLOGY
PE                                                                                                                       (1) All antibiotics can lead to C. diff colitis, but worst offending agents are PCNs, Cephalosporins, and
Fever                                                                                                                    Clindamycin (all agents which kill most anaerobes but NOT Clostridium difficile).
                                                                                                                         (2) PPI use can increase risk of infection in patients taking antibiotics, but probably doesn’t cause C. diff by
LABs
                                                                                                                         itself.
Leukocytosis
                                                                                                                         HX
                                                                                                                         Profuse diarrhea

Peritonitis - Generalized                                                                                                RX
                                                                                                                         Metronidazole
PATHOLOGY                                                                                                                Vancomycin for resistant cases
Infection/inflammation of the peritoneum (mesentery).
                                                                                                                         RX – ADJUNCTIVE
HX                                                                                                                       Spread by spores which are resistant to ROH – need good hand washing to wash off spores.
N/V

                                                                                                                    18
                                                                                                                        Oral cavity - leukoplasia, erythroplasia, and ulcerated lesions. Comprises more than 90% of oral cancers. No
Pyloric Stenosis                                                                                                              genetic predisposition. Major risk factors are alcohol and tobacco.
PATHOLOGY
congenital, more frequent in boys
Hypertrophy of pyloric sphincter, results in projectile vomiting in 1st 2 weeks of life, and palpable mass
cured by surgical incision of pyloric sphincter                                                                         Steatorrhea
                                                                                                                        PATHOLOGY
                                                                                                                        Malabsorption causes fatty stool (Greasy with foul odor)
                                                                                                                        Causes include:
Salivary Gland Pathology                                                                                                (1) Pancreatic disease - lack of pancreatic lipase.
Mucocele                                                                                                                (2) Hypersecretion of gastrin - low duodenal pH inactivates pancreatic lipase
Rupture of salivary duct and leakage into surrounding soft tissue.                                                      (3) Lack of bile acids:
Ranula                                                                                                                  - Obstruction of flow from liver to GB to intestine.
Mucocele in floor of mouth, has appearance of frog belly.                                                               - Ileal resection which prevents recirculation and leads to decreased supply of bile acids.
                                                                                                                        (4) Intestinal mucosal problem:
Xerostomia                                                                                                              - Bacterial overgrowth
Decreased salivary gland flow. Promotes formation of dental caries.                                                     - Decreased number of intestinal cells for lipid absorption.
                                                                                                                        (5) Lack of Apolipoprotein B
                                                                                                                        HX
Scleroderma                                                                                                             Symptoms - weight loss, diarrhea, dermatitis, edema
PATHOLOGY                                                                                                               PE
Collagen vascular disorder involving esophagus, leading to atrophy and fibrosis of smooth muscle in lower               Stool is foul smelling, floats, and yellowish-gray.
      2/3 of esophagus. Creates weak, incompetent LES. Symptoms include dysphagia, heartburn.                           LABs
                                                                                                                        Elevated PT (lack of Vitamin K absorption), low albumin, anemia
                                                                                                                        Fecal fat test is most reliable.
Siderosis                                                                                                               D-Xylose test measures absorption in duodenum and jejunum
                                                                                                                        Can also do upper endoscopy w/ small bowel biopsies
PATHOLOGY
Excess accumulation of iron in body.
Ferritin – normal soluble storage protein for iron. Present in cytoplasm of all cells, and some in circulation.
Hemosiderin – normal insoluble storage protein for iron, product of ferritin breakdown.                                 Stercoral Ulcers
                                                                                                                        PATHOLOGY
                                                                                                                        Arise from pressure necrosis of mucosa by hard, impacted feces, occur in rectosigmoid colon.
Spontaneous Bacterial Peritonitis
PATHOLOGY
Bacteria in peritoneal space cause generalized peritonitis (infection/inflammation).                                    Toxins
Often in people with diseased livers:                                                                                   SUMMARY
Usually, if a bacteria migrates from colon up to duodenum to hepatic duct to liver, the RE (Reticuloendothelial)        Drug effect is included in DVX of ALL liver injuries.
system of M0 chews it up. With diseased livers, bacteria can migrate out to bloodstream and into intra-
abdominal space (peritoneum).                                                                                           INTRINSIC TOXINS
                                                                                                                        directly toxic to hepatocytes - cause injury to anyone exposed.
HX
Fever, chills, abdominal pain                                                                                           IDIOSYNCRATIC TOXINS
see "Peritonitis - Generalized"                                                                                         Toxicity is unpredictable, due perhaps to expression of a gene (having or not having a certain enzyme?)
LABs
>250PMNs/mm3 is strong indication for SBP.
RX                                                                                                                      Ulcers - Duodenal
If culture yields 1 microbe (usually E. Coli) - then treat w/ Antibiotics.                                              PATHOLOGY
If culture yields multiple microbes, call the surgeon to repair the perforated bowel, etc.                              Largest problem is excess cephalic phase (ACh) of acid secretion.
Antibiotic = cefotaxime (possibly w/ aminoglycoside)                                                                    RX
                                                                                                                        90% can be treated medically - H2 block, PPI, antacids, H. pylori eradication.
                                                                                                                        Acid reducing procedure in extreme cases:
Squamous Cell Carcinoma                                                                                                 - Truncal vagotomy, antrectomy, and pyloroplasty
                                                                                                                        - Selective vagotomy + pyloroplasty
SUMMARY                                                                                                                 - Proximal gastric vagotomy
Oral Cavity - red, white, and ulcerous is squamous cell until proven otherwise.
PATHOLOGY

                                                                                                                   19
                                                                                                                         Sources - Rapidly growing fresh fruits, veggies, citrus fruits
Ulcers - Gastric                                                                                                         Symptoms - Anorexia, weakness, joint pain, follicular hyperkeratosis, Perifollicular hemorrhage, bleeding gums,
PATHOLOGY                                                                                                                pupura, fractures, subperiosteal hemorrhage
3 types:                                                                                                                 Vitamin D Deficiency, or Ca deficiency
I - lesser curvature of stomach
                                                                                                                         Children - Rickets - Subperiosteal hemorrhage, deformation of weight bearing bones, fractures
II - gastric ulcer and duodenal ulcere
                                                                                                                         Adults - Osteomalacia, osteoporosis, fractures
III - pyloric/pre-pyloric
                                                                                                                         We can either have Vita D resistant rickets, or Vita D dependent rickets (due to Vita D3 deficiency)
*Note - treat types II and III like duodenal ulcer.
                                                                                                                         Vitamin E
RX                                                                                                                       Sources - veggies, seed oils
All gastric ulcers require EGD and biopsy to rule out cancer.
                                                                                                                         Symptoms - hemolytic anemia, muscle necrosis, weakness, possible neurological dysfunction
Only 50% will heal w/ medications (H2 block, PPI, antacids, sucralfate, misoprostol)
Graham patch - omental tag used to cover ulcer.                                                                          Vitamin K
Surgery:                                                                                                                 Sources - soybeans, alfalfa, spinach, tomatoes
- if perforation is less than6 hours old - plicate (oversew) the ulcer and perform truncal vagotomy.                     Symptoms - hemorrhage, long PT
- if > 6hrs old, plicate the ulcer but no vagotomy.                                                                      Zinc
SURGICAL INDICATIONS                                                                                                     Sources - Meat, shellfish, absorption diminshed by phytic acid
I CHOP:                                                                                                                  Symptoms of deficiency:
Intractable ulcer                                                                                                        - Vesicular and bullous eruption on hands, feet, perineum
Cancer                                                                                                                   - Maculopapular rash around mouth, eyes
Hemorrhage                                                                                                               - Alopecia (hair loss),
Obstruction                                                                                                              - Taste and smell abnormalities (hypogeusia = blunting of sense of taste)
Perforation                                                                                                              - Hypogonadism, growth delay, anorexia
                                                                                                                         - Low alk phos (zinc dependent enzyme)
                                                                                                                         Essential Fatty Acid
Vitamin and Nutrient Deficiencies                                                                                        - Linoleic acid 18:2(9,12)
                                                                                                                         - Linolenic acid 18:3(9,12,15)
Vitamin A                                                                                                                Symptoms of deficiency:
Sources - carotenoids (bright vegetables, sweet potatoes), dark leafy green veggies                                      - Scaly dermatitis
Symptoms - Night blindness, xerophalmia (excessively dry eyes), Hyperfollicular keratosis                                - Alopecia
Squamous metaplasia of trachea, bronchi, renal pelvis, conjunctiva, tear ducts. Keratomalacia (corneal softening)
Excess vitamin A – "HALF ASSD" HA, Arthralgia, Liver damage, Fatigue, Alopecia, Skin changes, Sore throat,
Degeneration of bone
Thiamin (Vita B1) - Beriberi                                                                                             Volvulus
Sources - wide range, but absent in polished rice and ROH. Deficiency develops in 2 weeks. Raw fish, shellfish,
      tea leaves inhibit absorption                                                                                      LARGE BOWEL
Symptoms - cardiac and neurologic beriberi, Wernicke's encephalopathy - confusion, weakness, ataxia                      70% sigmoid, 30% cecal.
      Korsakoff's syndrome - poor memory, confabulation                                                                  Accounts for 5-10% of cases of LBO.
      Cardiac failure                                                                                                    Common in patients in mental institutions and nursing homes.
Dry beriberi – peripheral neuropathy                                                                                     Barium enema shows "bird's beak".
Wet beriberi – high output cardiac failure                                                                               Rx is rectal tube decompression, or resection if dead bowel.
Vitamin B2 (Riboflavin)
seborrhea (scaly, greasy lesions), glossitis, angular stomatitis
Pellagra (Niacin Deficiency)                                                                                             Whipple
4 Ds - dermatitis, diarrhea, dementia, death. Casal's necklace                                                           PATHOLOGY
Niacin can be synthesized, but hard to meet requirements w/out intake                                                    Inflammation of bowel wall, infiltration by macrophages with rod shaped bacteria - Tropheryma Whippelii.
Vitamin B4 (Biotin)                                                                                                      Bowel wall becomes thickened and edematous, and malabsorption ensues.
Scaling dermatitis                                                                                                       Look for PAS-positive macrophages in intestinal mucosa.
Vitamin B6 (pyridoxine)
GABA deficiency (neurologic dysfunction)
seborrhea, glossitis, angular stomatitis
Vitamin B12 (cobalamin)
megaloblastic anemia w/ neurologic dysfunction – often from pernicious anemia
Folate Deficiency
Megaloblastic anemia
Vitamin C (Ascorbic acid)


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Description: gastro intestinal Contemporary Report abdominal muscle