manifestations of gastrointestinal diseases copy
TRANSCRIPT
Manifestations Manifestations of of
GastrointestinGastrointestinal Diseasesal Diseases
Celso M. Fidel MD,FPSGS,FPCSCelso M. Fidel MD,FPSGS,FPCS
Diplomate Philippine Board of Diplomate Philippine Board of SurgerySurgery
What are These Manifestations?What are These Manifestations? 1. PAIN1. PAIN
2. FEVER2. FEVER
3. ANOREXIA3. ANOREXIA
4. HEARTBURN and DYSPEPSIA4. HEARTBURN and DYSPEPSIA
5. DYSPHAGIA5. DYSPHAGIA
6. NAUSEA and VOMITING6. NAUSEA and VOMITING
7. ABDOMINAL DISTENTION, 7. ABDOMINAL DISTENTION,
ERUCTATION and FLATULENCEERUCTATION and FLATULENCE
8. CONSTIPATION8. CONSTIPATION
9. DIARRHEA9. DIARRHEA
What are These Manifestations?What are These Manifestations? 10. ILEUS 10. ILEUS
11. INTESTINAL OBSTRUCTION11. INTESTINAL OBSTRUCTION
a. Partial Obstruction and Pseudo-obstructiona. Partial Obstruction and Pseudo-obstruction
b. Mechanical Obstructionb. Mechanical Obstruction
c. Closed Loop Obstructionc. Closed Loop Obstruction
d. Colon Obstructiond. Colon Obstruction
12. GASTROINTESTINAL BLEEDING12. GASTROINTESTINAL BLEEDING
a. Upper GI Bleedinga. Upper GI Bleeding
b. Lower GI Bleedingb. Lower GI Bleeding
13. JAUNDICE 13. JAUNDICE
I PainI Pain
Most common symptom of GIT diseaseMost common symptom of GIT disease
Three kinds have been described in gen.Three kinds have been described in gen.
1. Superficial or Cutaneous pain1. Superficial or Cutaneous pain
2. Deep pain from:2. Deep pain from:
MusclesMuscles
TendonsTendons
JointsJoints
FasciaFascia
3. Visceral pain3. Visceral pain
I PainI Pain Two Types of PainTwo Types of Pain
1. Somatic Pain 2. Visceral Pain1. Somatic Pain 2. Visceral Pain
Pathway: Pathway: A-delta fibers A-delta fibers Autonomic C-type fibers Autonomic C-type fibers
Receptor: Receptor: Parietal, Muscle Parietal, Muscle Visceral Visceral and Skinand Skin
Specific Specific Well localized Well localized Poorly localized Poorly localized
Description Description Sharp Sharp Cramping, Gnawing Cramping, Gnawing
Stimulus: Stimulus: Inflammation, Inflammation, Distention, Traction Distention, Traction PressurePressure
PainPain Un-referred Visceral PainUn-referred Visceral Pain
ANSANS innervations:innervations: bilateral hence pain is midline bilateral hence pain is midline
except:except: Kidneys Kidneys Ureters Ureters Cecum Cecum Ascending colonAscending colon Descending colonDescending colon Sigmoid colonSigmoid colon
PainPain Un-referred Visceral PainUn-referred Visceral Pain Midline location is the result of Midline location is the result of
embryologic development of Gut embryologic development of Gut EpigastricEpigastric- Foregut:- Foregut: OropharynxOropharynx 22ndnd portion of duodenum portion of duodenum Liver Liver SpleenSpleen PancreasPancreas
PainPain Un-referred Visceral PainUn-referred Visceral Pain Periumbilical- Midgut:Periumbilical- Midgut: Distal duodenumDistal duodenum JejunumJejunum IleumIleum AppendixAppendix Ascending colonAscending colon Proximal transverse colonProximal transverse colon
Hypogastric- Remainder of Hindgut= Colon Hypogastric- Remainder of Hindgut= Colon
down to down to ccloacaloaca
PainPain
REFERRED PAINREFERRED PAIN Result of afferent neurons that Result of afferent neurons that
innervate two entirely separate innervate two entirely separate anatomically distinct structures anatomically distinct structures that have a that have a common embryologiccommon embryologic
originorigin
PainPain
REFERRED PAINREFERRED PAIN
44thth Cervical Nerve RouteCervical Nerve Route
1. Parietal peritoneum of the 1. Parietal peritoneum of the
diaphragmdiaphragm
2. Area around the shoulder2. Area around the shoulder
3. Supraclavicular hollow3. Supraclavicular hollow
e.g. e.g. Kehr signKehr sign= Pain underneath the = Pain underneath the diaphragm felt at the tip of the diaphragm felt at the tip of the shouldershoulder
PainPain
REFERRED PAINREFERRED PAIN
Thoracic Afferents T6-T8Thoracic Afferents T6-T8
Innervates :Innervates :
1. Right sub-scapular area1. Right sub-scapular area
2. Biliary tree2. Biliary tree
3. Liver 3. Liver
4. Peri-pancreatic area 4. Peri-pancreatic area
PainPain
REFERRED PAINREFERRED PAIN
1010thth Thoracic Nerve Route Thoracic Nerve Route
Irritation to the kidney or ureterIrritation to the kidney or ureter
e.g. In male= Flank and genital e.g. In male= Flank and genital
pain classically testicular painpain classically testicular pain
In females this is referred to the In females this is referred to the labia labia
Acute Abdominal PainAcute Abdominal Pain Clinical ManifestationsClinical Manifestations
Sudden Onset =more likely surgicalSudden Onset =more likely surgical
Gradual Onset= inflammatory processGradual Onset= inflammatory process
or slower progressive obstructionor slower progressive obstruction
Nausea and Vomiting 6-12 hours afterNausea and Vomiting 6-12 hours after
onset of pain=Obstruction lower GITonset of pain=Obstruction lower GIT
Acute Abdominal PainAcute Abdominal Pain Clinical ManifestationsClinical Manifestations
ForegutForegut and and MidgutMidgut inflammation inflammation
often followed by: often followed by:
AnorexiaAnorexia
Nausea Nausea
vomitingvomiting
Sensory afferents carried by Vagal fibers Sensory afferents carried by Vagal fibers
Acute Abdominal Pain Acute Abdominal Pain Physical ExaminationPhysical Examination
InspectionInspection
Scaphoid = NormalScaphoid = Normal
Distention= AbnormalDistention= Abnormal
Thin Individuals= bowel loops seenThin Individuals= bowel loops seen
Acute Abdominal Pain Acute Abdominal Pain
AuscultationAuscultation
Absent =No bowel sound in a minuteAbsent =No bowel sound in a minute
1. Ileus 1. Ileus
2. Hypokalemia2. Hypokalemia
3. Peritonitis 3. Peritonitis
4. Hypomagnesemia4. Hypomagnesemia
5. Mesenteric thrombosis5. Mesenteric thrombosis
6. Narcotic Overdose6. Narcotic Overdose
Acute Abdominal PainAcute Abdominal Pain
AuscultationAuscultation
HypoactiveHypoactive
1. Hypokalemia 1. Hypokalemia
2. Inflammation2. Inflammation
3. Ischemic bowel disease3. Ischemic bowel disease
Acute Abdominal PainAcute Abdominal Pain
AuscultationAuscultation
HyperactiveHyperactive
1. Early small bowel obstruction 1. Early small bowel obstruction
2. Diverticulitis2. Diverticulitis
PercussionPercussion
PalpationPalpation
Acute Abdominal PainAcute Abdominal Pain Laboratory EvaluationLaboratory Evaluation
CBCCBC
UrinalysisUrinalysis
Blood Chemistry e.g. Amylase; Liver Blood Chemistry e.g. Amylase; Liver
function testfunction test
Pregnancy TestPregnancy Test
ECGECG
Acute Abdominal PainAcute Abdominal Pain
Radiologic Examination Radiologic Examination
1. Pneumoperitoneum1. Pneumoperitoneum
2. Calculi 2. Calculi
3. Ileus3. Ileus
4. Air fluid level4. Air fluid level
5. Aerobilia5. Aerobilia
6. Fat lines6. Fat lines
Acute Abdominal PainAcute Abdominal Pain UltrasoundUltrasound 1. Suspected Pancreatic 1. Suspected Pancreatic 2. Hepatobiliary disease2. Hepatobiliary disease 3. Phlegmon3. Phlegmon 4. Abscess4. Abscess 5. Pseudocyst5. Pseudocyst 6. Gynecologic Problem that mimics GIT6. Gynecologic Problem that mimics GIT diseasedisease
Acute Abdominal PainAcute Abdominal Pain UltrasoundUltrasound (F.A.S.T.) detecting Hemoperitoneum(F.A.S.T.) detecting Hemoperitoneum in Blunt Traumain Blunt Trauma 1. Sensitivity of 93.4%1. Sensitivity of 93.4%
2. Specificity of 98.7%2. Specificity of 98.7%
3. Accuracy of 97.5%3. Accuracy of 97.5%
Acute Abdominal PainAcute Abdominal Pain Surgical Decision MakingSurgical Decision Making
1. Usually made by History1. Usually made by History
2. Physical Examination is confirmatory2. Physical Examination is confirmatory
3. Laboratory tests are focused on the 3. Laboratory tests are focused on the
suspected diagnosissuspected diagnosis
Acute Abdominal PainAcute Abdominal Pain Nature of Surgical Decision Making inNature of Surgical Decision Making in
Acute Abdomen does not require Acute Abdomen does not require
specific diagnosis, butspecific diagnosis, but
1. Plan of action1. Plan of action
2. Indication for the operation2. Indication for the operation
3. Timing and Approach3. Timing and Approach
Intermittent and Recurrent Abdominal PainIntermittent and Recurrent Abdominal Pain
1. Various Hematologic disorders produce 1. Various Hematologic disorders produce
abdominal painabdominal pain
2. Clinical Manifestations relate to the2. Clinical Manifestations relate to the
occurrence of crisis; anemia; jaundice;occurrence of crisis; anemia; jaundice;
splenomegaly; and cholelithiasissplenomegaly; and cholelithiasis
3. Due to disturbed gastrointestinal motility3. Due to disturbed gastrointestinal motility
or alternating areas of spasm andor alternating areas of spasm and
dilatation dilatation
Chronic Abdominal PainChronic Abdominal Pain If persistent-- is a clear pathophysiologicIf persistent-- is a clear pathophysiologic
abnormality such as:abnormality such as:
1. Chronic pancreatitis1. Chronic pancreatitis
2. Pancreatic Malignancy2. Pancreatic Malignancy
3. Colonic Malignancy 3. Colonic Malignancy
May arise from the abdominal wallMay arise from the abdominal wall
1. Iatrogenic peripheral nerve injuries1. Iatrogenic peripheral nerve injuries
2. Hernias 2. Hernias
3. Myofascial Pain Syndrome 3. Myofascial Pain Syndrome
Intractable Abdominal PainIntractable Abdominal Pain
1. Challenging and sometimes a frustrating1. Challenging and sometimes a frustrating
problem problem
2. Opiate Analgesics, if given in sufficient2. Opiate Analgesics, if given in sufficient
dosage, usually can control abdominaldosage, usually can control abdominal
pain, however risk of addiction is pain, however risk of addiction is alwaysalways
there undermining patient’s ability tothere undermining patient’s ability to
function effectivelyfunction effectively
3. In Properly selected patients, 3. In Properly selected patients, interruptioninterruption
of pain pathway (Splanchnicectomy) isof pain pathway (Splanchnicectomy) is
suggested suggested
II FEVERII FEVER
Not dangerous unless it is unusually highNot dangerous unless it is unusually high
Often a postoperative event often:Often a postoperative event often:
1. A Thermostat reset1. A Thermostat reset
2. Response to intraoperative body cooling2. Response to intraoperative body cooling
3. Result of Normal Cytokine Activation3. Result of Normal Cytokine Activation
II FEVERII FEVER
Indication of Illness such as:Indication of Illness such as:
1. Infection1. Infection
2. Inflammation2. Inflammation
3. Autoimmune Disease 3. Autoimmune Disease
4. Neoplasia4. Neoplasia
If persistent, indicative of infectious complicationIf persistent, indicative of infectious complication
II FEVERII FEVER
PathophysiologyPathophysiology
Inflammatory Response activates Inflammatory Response activates Cytokines Cytokines that are locally released in the brain or intothat are locally released in the brain or into the bloodstream the bloodstream peripherally acting on theperipherally acting on the hypothalamus hypothalamus in Endocrine fashion in Endocrine fashion
II FEVERII FEVER
PathophysiologyPathophysiology Activated Macrophages also liberates Activated Macrophages also liberates
pyrogenspyrogens 1. Interleukin 1. Interleukin 2. TNF2. TNF 3. Interferon3. Interferon Upward resetting of a thermoregulatory Upward resetting of a thermoregulatory Apparatus,triggering 2 physiologic Apparatus,triggering 2 physiologic
mechanisms:mechanisms: 1. Vasoconstriction1. Vasoconstriction
2. Increase Heat production by shivering2. Increase Heat production by shivering
II FEVERII FEVER
Clinical ManifestationClinical Manifestation
Those of GIT origin=Infection in the Those of GIT origin=Infection in the
Abdominal CavityAbdominal Cavity
Monomicrobial infections include:Monomicrobial infections include:
1. Biliary Tract Infection1. Biliary Tract Infection
2. Spontaneous or Primary Peritonitis2. Spontaneous or Primary Peritonitis
II FEVERII FEVER
Clinical ManifestationClinical Manifestation
Intraabdominal Sepsis > polymicrobialIntraabdominal Sepsis > polymicrobial
Fever of reactivated Crohn’s diseaseFever of reactivated Crohn’s disease
Established Infection postop 10-20%Established Infection postop 10-20%
20% of unknown origin 2ndary to CA.20% of unknown origin 2ndary to CA.
III AnorexiaIII Anorexia
Complicates many diseasesComplicates many diseases
Indicates a significant degree of Indicates a significant degree of inflammationinflammation
Common in liver disease, through CNS Common in liver disease, through CNS mechanism, probably mediated at leastmechanism, probably mediated at least in part by Ammonia & Neuropeptide Y.in part by Ammonia & Neuropeptide Y.
III AnorexiaIII Anorexia
Common cause is Carcinoma, usually Common cause is Carcinoma, usually with significant tumor burdenwith significant tumor burden
Postoperatively associated with loss of Postoperatively associated with loss of taste, especially in diarrhea whose zinctaste, especially in diarrhea whose zinc stores are chronically low. stores are chronically low. Give 220Give 220 mgs mgs daily and taste returns in 10 days to 3 weeks.daily and taste returns in 10 days to 3 weeks.
III AnorexiaIII Anorexia
PathophysiologyPathophysiology
Complex and Multifaceted. In AnimalsComplex and Multifaceted. In Animals
independent variables alter food intake:independent variables alter food intake:
1. Changes in glucose utilization rate1. Changes in glucose utilization rate
2. Changes in rate of lipid metabolism2. Changes in rate of lipid metabolism
3. Alteration in 3. Alteration in brain & peripheral peptides.brain & peripheral peptides.
4. Imbalance in plasma & brain amino profiles4. Imbalance in plasma & brain amino profiles
5. Increase & decrease neurotransmitter activity5. Increase & decrease neurotransmitter activity
6. Alteration in Cytokine levels 6. Alteration in Cytokine levels
III AnorexiaIII Anorexia
PathophysiologyPathophysiology
Hypothalamus is feeding center of the brain Hypothalamus is feeding center of the brain
Lateral area lesions = anorexiaLateral area lesions = anorexia
Ventro-medial region lesions causes Ventro-medial region lesions causes
hyperphagia and obesityhyperphagia and obesity
Vagal afferentsVagal afferents,, important in important in communicatingcommunicating
peripheral nutrition related information fromperipheral nutrition related information from
the GIT or from Glucose sensitive cells in the the GIT or from Glucose sensitive cells in the
liverliver
III AnorexiaIII Anorexia
PathophysiologyPathophysiology
Galanin located in several brain regions Galanin located in several brain regions appear to selectively stimulate fat intakeappear to selectively stimulate fat intake
According to Glucostatic hypothesis of feeding,According to Glucostatic hypothesis of feeding,
increased use of glucose signal satiety, andincreased use of glucose signal satiety, and
decreased glucose metabolism is associateddecreased glucose metabolism is associated
with hungerwith hunger
III AnorexiaIII Anorexia
PathophysiologyPathophysiology
The discovery of obese gene protein( leptin)The discovery of obese gene protein( leptin)
provides a proposed mechanism for modula-provides a proposed mechanism for modula-
tion of food intake and body weight that istion of food intake and body weight that is
directly related to adipose tissue mass. Leveldirectly related to adipose tissue mass. Level
of circulating leptin increase as the amount of circulating leptin increase as the amount
of adipose tissue increases of adipose tissue increases
III AnorexiaIII Anorexia
PathophysiologyPathophysiology
Elevated activity in Serotonin neurons Elevated activity in Serotonin neurons
also inhibit feeding; reducing serotoninalso inhibit feeding; reducing serotonin
levels usually increases the amount oflevels usually increases the amount of
feeding elicited by orexigenic agentsfeeding elicited by orexigenic agents
III AnorexiaIII Anorexia
PathophysiologyPathophysiology
Carbohydrate intake appears to be underCarbohydrate intake appears to be under
Neuropeptide Y controlNeuropeptide Y control
Adrenalectomy reduces feeding elicited Adrenalectomy reduces feeding elicited
by intrahypothalamic Neuropeptide Yby intrahypothalamic Neuropeptide Y
or nor epinephrine or nor epinephrine
III AnorexiaIII Anorexia
CANCER AnorexiaCANCER Anorexia
Results from tumor-induced aberrationsResults from tumor-induced aberrations
of neurochemical mechanisms thatof neurochemical mechanisms that
normally control hunger and satietynormally control hunger and satiety
Weight loss & Cachexia have significantWeight loss & Cachexia have significant
negative prognostic implicationsnegative prognostic implications
III AnorexiaIII Anorexia
CANCER AnorexiaCANCER Anorexia
Weight loss of Weight loss of 10-15 %10-15 % during 3 to 4 during 3 to 4
months is one of two prime indicatorsmonths is one of two prime indicators
that a patient may be nutritionally orthat a patient may be nutritionally or
immunologically impairedimmunologically impaired
IV HEARTBURN AND DYSPEPSIAIV HEARTBURN AND DYSPEPSIA
Substernal burning associated w/ bitter tasteSubsternal burning associated w/ bitter taste
Normal individuals experience this when lying Normal individuals experience this when lying down or bending over after overeating & down or bending over after overeating & gastric capacity is exceededgastric capacity is exceeded
IV HEARTBURN AND DYSPEPSIAIV HEARTBURN AND DYSPEPSIA
Esophagus is normally protected by:Esophagus is normally protected by:
1. Competent Lower esophageal sphincter1. Competent Lower esophageal sphincter 2. Rapid Esophageal clearing of reflux material2. Rapid Esophageal clearing of reflux material
3. Neutralization of refluxed acid by bicarbonate3. Neutralization of refluxed acid by bicarbonate rich salivarich saliva 4. Intact mucosal diffusion barrier4. Intact mucosal diffusion barrier
Most common clinical abnormality of Most common clinical abnormality of esophageal motility is incompetence of LESesophageal motility is incompetence of LES
IV HEARTBURN AND DYSPEPSIAIV HEARTBURN AND DYSPEPSIA
Dyspepsia is a non specific term givenDyspepsia is a non specific term given
to a collection of symptoms involving:to a collection of symptoms involving:
1. Esophagus 1. Esophagus
2. Stomach 2. Stomach
3. Duodenum3. Duodenum
4. Biliary Tree 4. Biliary Tree
5. Pancreas5. Pancreas
IV HEARTBURN AND DYSPEPSIAIV HEARTBURN AND DYSPEPSIA
It is a postprandial complaint involving:It is a postprandial complaint involving:
1. Substernal pressure1. Substernal pressure
2. Epigastric distress2. Epigastric distress
3. Nausea3. Nausea
4. Bloating4. Bloating
Three (3%) Three (3%) of these patients have anginaof these patients have angina
IV HEARTBURN AND DYSPEPSIAIV HEARTBURN AND DYSPEPSIA
Work-up should include:Work-up should include:
1. Cineflouroscopy1. Cineflouroscopy
2. Contrast Radiography2. Contrast Radiography
3. Upper GI series3. Upper GI series
4. Endoscopy and Biopsy4. Endoscopy and Biopsy
IV HEARTBURN AND DYSPEPSIAIV HEARTBURN AND DYSPEPSIA
Manometry if esophageal spasm isManometry if esophageal spasm is
suspectedsuspected
Relationship of symptoms to eating and Relationship of symptoms to eating and
other activities may give clues to theother activities may give clues to the
diagnosisdiagnosis
V DYSPHAGIA V DYSPHAGIA
Disturbances in swallowing can beDisturbances in swallowing can be
categorized according to the etiologies:categorized according to the etiologies:
1. Degenerative1. Degenerative
2. Functional2. Functional
3. Inflammatory3. Inflammatory
4. Mechanical4. Mechanical
5. Autoimmune5. Autoimmune
6. Neoplastic6. Neoplastic
Odynophagia= Painful swallowingOdynophagia= Painful swallowing
VI NAUSEA AND VOMITING VI NAUSEA AND VOMITING
1.1. May be related or unrelated to diseases May be related or unrelated to diseases
of the gastrointestinal tractof the gastrointestinal tract
2. Vomiting may result whenever any part2. Vomiting may result whenever any part
of the GIT excessively irritated, over-of the GIT excessively irritated, over-
distended, or excitabledistended, or excitable
3. Duodenal distention is a particularly 3. Duodenal distention is a particularly
potent potent stimulus for vomitingstimulus for vomiting
4. Vagal and Sympathetic afferents carry4. Vagal and Sympathetic afferents carry
impulses from the GIT to the bilateralimpulses from the GIT to the bilateral
vomiting center in the medullavomiting center in the medulla
VI NAUSEA AND VOMITINGVI NAUSEA AND VOMITING
Rapidly changing directions of motionRapidly changing directions of motion stimulate receptors in the labyrinthinestimulate receptors in the labyrinthine apparatus, impulses are carried into theapparatus, impulses are carried into the vestibular nuclei into the cerebellum tovestibular nuclei into the cerebellum to vomiting center vomiting center
VI NAUSEA AND VOMITINGVI NAUSEA AND VOMITING
Ischemia to the vomiting center in:Ischemia to the vomiting center in: 1. Increased intracranial pressure1. Increased intracranial pressure 2. Anemia2. Anemia
3. Vascular occlusion3. Vascular occlusion 4. Shock4. Shock
5. Severe pain 5. Severe pain
VI NAUSEA AND VOMITINGVI NAUSEA AND VOMITING
A variety of antibiotics directly affectingA variety of antibiotics directly affecting
the GIT may cause nausea & vomiting:the GIT may cause nausea & vomiting:
1. Erythromycin1. Erythromycin
2. Bactrim2. Bactrim
3. Neomycin3. Neomycin
VI NAUSEA AND VOMITINGVI NAUSEA AND VOMITING
Acute Nausea and Vomiting due to:Acute Nausea and Vomiting due to:
1. Inflammation or infectious agents1. Inflammation or infectious agents
affecting the GITaffecting the GIT
2. Neoplastic disease2. Neoplastic disease
3. Mechanical obstruction at any level3. Mechanical obstruction at any level
VII ABDOMINAL DISTENTION,ERUCTATION AND VII ABDOMINAL DISTENTION,ERUCTATION AND FLATULENCEFLATULENCE
Most of these patient’s are Aerophagics;Most of these patient’s are Aerophagics;
they swallow too much Air when theythey swallow too much Air when they
eat too quickly or talk too much wheneat too quickly or talk too much when
they eat. Hyperactive bowel sounds is they eat. Hyperactive bowel sounds is
the rule.the rule.
VII ABDOMINAL DISTENTION,ERUCTATION AND VII ABDOMINAL DISTENTION,ERUCTATION AND FLATULENCEFLATULENCE
Chronic Eructation may be an indicationChronic Eructation may be an indication
of chronic pathologyof chronic pathology
Lactase deficiency can result in Lactase deficiency can result in Eructation Eructation
and Flatulenceand Flatulence
VIII CONSTIPATIONVIII CONSTIPATION Most often Mechanical in originMost often Mechanical in origin In trauma with retroperitoneal hematomaIn trauma with retroperitoneal hematoma Can be a result of:Can be a result of: 1. Psychologic factor1. Psychologic factor Improper trainingImproper training
2. Dietary constituents2. Dietary constituents
3. Laxatives & drugs3. Laxatives & drugs
VIII CONSTIPATIONVIII CONSTIPATION
Can be a result of:Can be a result of: 4. Neurogenic causes4. Neurogenic causes a. Tabes Dorsalis a. Tabes Dorsalis b. Multiple Sclerosisb. Multiple Sclerosis c. Spinal Cord Tumorc. Spinal Cord Tumor
5. Decreased skeleto-muscular power5. Decreased skeleto-muscular power
IX DIARRHEAIX DIARRHEA Pathophysiological MechanismsPathophysiological Mechanisms
1. Luminal secretion of solute or water1. Luminal secretion of solute or water
2. Exudation or the loss of protein, blood and 2. Exudation or the loss of protein, blood and
mucusmucus
3. Osmotic retention of water3. Osmotic retention of water
4. Abnormal or disordered contact between 4. Abnormal or disordered contact between
chyme and the absorptive surface of bowelchyme and the absorptive surface of bowel
History is important in ascertaining whether History is important in ascertaining whether
this is new, chronic, or recurrent problemthis is new, chronic, or recurrent problem
X ILEUSX ILEUS Three TypesThree Types
1. Adynamic or inhibition ileus1. Adynamic or inhibition ileus
a. Most Commona. Most Common
b. Inhibition of normal neuromuscular activityb. Inhibition of normal neuromuscular activity
2. Spastic Ileus with a tightly contracted bowel2. Spastic Ileus with a tightly contracted bowel
without propulsive activitywithout propulsive activity
3. Ischemic Ileus from either low flow( non-3. Ischemic Ileus from either low flow( non-
occlusive ischemia) or vascular occlusionocclusive ischemia) or vascular occlusion
Coordinated motility is impossible becauseCoordinated motility is impossible because
of dying musculatureof dying musculature
X X ILEUSILEUS Adynamic ileus occurs after a variety ofAdynamic ileus occurs after a variety of
abdominal operationsabdominal operations
1. Gastric ileus last approximately 2 days1. Gastric ileus last approximately 2 days
2. Colonic ileus last for approximately 3-4 days2. Colonic ileus last for approximately 3-4 days
3. In the normal postoperative course, the 3. In the normal postoperative course, the smallsmall
bowel continues to functionbowel continues to function
XX ILEUSILEUS
If ileus is prolonged possible causes includes:If ileus is prolonged possible causes includes:
1. Metabolic1. Metabolic
2. septic2. septic
3. Mechanical or inflammatory3. Mechanical or inflammatory
XI INTESTINAL OBSTRUCTIONXI INTESTINAL OBSTRUCTION ClassificationClassification
1. Extra luminal( including adhesions and 1. Extra luminal( including adhesions and
Neoplastic DiseaseNeoplastic Disease
2. Intra luminal( such as gallstone 2. Intra luminal( such as gallstone ileus & strictureileus & stricture
3. Intra mural( such as crohn’s disease3. Intra mural( such as crohn’s disease
Small bowel obstruction secondary to adhesionSmall bowel obstruction secondary to adhesion
constitutes 60-80%constitutes 60-80%
Hernia constitutes 15-20%Hernia constitutes 15-20%
Colonic Obstruction due to CA is 60%Colonic Obstruction due to CA is 60%
XI INTESTINAL OBSTRUCTIONXI INTESTINAL OBSTRUCTION
Partial Obstruction and Pseudo-obstructionPartial Obstruction and Pseudo-obstruction
Chronic Nausea and VomitingChronic Nausea and Vomiting
When intestinal, bowel sounds reflect When intestinal, bowel sounds reflect amphoricamphoric
fluid filled bowel loopsfluid filled bowel loops
Succussion spasm when pylorus & duodenumSuccussion spasm when pylorus & duodenum are obstructedare obstructed
XI INTESTINAL OBSTRUCTIONXI INTESTINAL OBSTRUCTION
Partial Obstruction and Pseudo-obstructionPartial Obstruction and Pseudo-obstruction Chronic intestinal pseudo-obstruction involvesChronic intestinal pseudo-obstruction involves abnormalities in:abnormalities in: Intestinal muscle( myopathic)Intestinal muscle( myopathic)
Nervous system( myenteric) e.g. Chagas’Nervous system( myenteric) e.g. Chagas’ disease and infiltrative diseasesdisease and infiltrative diseases
XI INTESTINAL OBSTRUCTIONXI INTESTINAL OBSTRUCTION Partial Obstruction and Pseudo-obstructionPartial Obstruction and Pseudo-obstruction
1. Pseudo-obstruction postop is most dangerous1. Pseudo-obstruction postop is most dangerous
Vagotomized patientsVagotomized patients
Intestinal OperationIntestinal Operation
2. Early recognition of Pseudo-obstruction is2. Early recognition of Pseudo-obstruction is
critical to proper therapycritical to proper therapy
a. Biopsy of intestine may or may not reveala. Biopsy of intestine may or may not reveal
loss of myenteric plexiloss of myenteric plexi
b. Full thickness rectal biopsy( Hirschsprung’sb. Full thickness rectal biopsy( Hirschsprung’s
Disease) is suspectedDisease) is suspected
XI INTESTINAL OBSTRUCTION XI INTESTINAL OBSTRUCTION Mechanical ObstructionMechanical Obstruction
1. Physiologic derangement if intact blood supply1. Physiologic derangement if intact blood supply
a. Accumulation of fluid and Gas above thea. Accumulation of fluid and Gas above the
point of obstructionpoint of obstruction
b. Altered bowel motility leading to systemicb. Altered bowel motility leading to systemic
derangementderangement
2. Gamble showed that mortality in simple type2. Gamble showed that mortality in simple type
was due to:was due to:
a. Loss of fluid and electrolytes by vomitinga. Loss of fluid and electrolytes by vomiting
b. Sequestration of fluid in obstructed bowelb. Sequestration of fluid in obstructed bowel
XI INTESTINAL OBSTRUCTIONXI INTESTINAL OBSTRUCTION Mechanical ObstructionMechanical Obstruction 3. After 48 hours, rate of entry of water into the3. After 48 hours, rate of entry of water into the intestinal lumen increases as a consequenceintestinal lumen increases as a consequence of blood to lumen fluxof blood to lumen flux 4. Prostaglandin release in response to bowel4. Prostaglandin release in response to bowel distention, increases secretion to obstructeddistention, increases secretion to obstructed loopsloops 5.Interference with the mesenteric blood supply5.Interference with the mesenteric blood supply is the most serious complication of intestinalis the most serious complication of intestinal obstructionobstruction
XI INTESTINAL OBSTRUCTIONXI INTESTINAL OBSTRUCTION Close loop ObstructionClose loop Obstruction 1. Both afferent & efferent limbs are obstructed1. Both afferent & efferent limbs are obstructed
2. Rapid progression of strangulation of blood2. Rapid progression of strangulation of blood supply before manifestations of obstructionsupply before manifestations of obstruction becomes obviousbecomes obvious
3. Abdominal distention does not occur3. Abdominal distention does not occur
XI INTESTINAL OBSTRUCTIONXI INTESTINAL OBSTRUCTION Colon ObstructionColon Obstruction 1. Fluid and Electrolyte sequestration progresses1. Fluid and Electrolyte sequestration progresses more slowlymore slowly
2. Progressive distention is the most dangerous2. Progressive distention is the most dangerous aspect of non-strangulated colon obstructionaspect of non-strangulated colon obstruction
XI INTESTINAL OBSTRUCTIONXI INTESTINAL OBSTRUCTION Clinical ManifestationsClinical ManifestationsThe distance of the obstruction from the The distance of the obstruction from the ligamentligament
of Treitz can be ascertained by:of Treitz can be ascertained by:
1. How long before vomiting takes place after1. How long before vomiting takes place after
the onset of painthe onset of pain
2. The nature of the vomitus2. The nature of the vomitus
XI INTESTINAL OBSTRUCTIONXI INTESTINAL OBSTRUCTION Clinical ManifestationsClinical Manifestations
Cardinal Signs and Symptoms of IntestinalCardinal Signs and Symptoms of Intestinal
Obstruction:Obstruction:
1. Crampy Abdominal Pain 1. Crampy Abdominal Pain
2. Nausea & Vomiting2. Nausea & Vomiting
3. Obstipation 3. Obstipation
4. Abdominal Distention4. Abdominal Distention
XII GASTROINTESTINAL BLEEDINGXII GASTROINTESTINAL BLEEDING
1. 1. Has high morbidity & mortality particularly inHas high morbidity & mortality particularly in the elderlythe elderly
2. Accurate diagnosis is critical before significant 2. Accurate diagnosis is critical before significant amounts ( 4-6 units) of blood has been lostamounts ( 4-6 units) of blood has been lost
3. Bleeding represents the initial symptoms of3. Bleeding represents the initial symptoms of gastrointestinal disease in more than 1/3 ofgastrointestinal disease in more than 1/3 of patients & in 70% there is no history ofpatients & in 70% there is no history of bleeding episodebleeding episode
XII GASTROINTESTINAL BLEEDINGXII GASTROINTESTINAL BLEEDING
4.Eighty( 80%) will stop spontaneously without4.Eighty( 80%) will stop spontaneously without interventionintervention
5. 5. Flexible endoscopy and arteriography play anFlexible endoscopy and arteriography play an interesting role in the diagnostic & therapeuticinteresting role in the diagnostic & therapeutic managementmanagement
XII GASTROINTESTINAL BLEEDINGXII GASTROINTESTINAL BLEEDING TerminologiesTerminologies
1. 1. HematemesisHematemesis is vomiting of bloodis vomiting of blood, , either either
digested digested in the stomach or fresh & unalteredin the stomach or fresh & unaltered
22. . MelenaMelena is the per anal passage of stools is the per anal passage of stools with altered blood that are black and tarrywith altered blood that are black and tarry
3. 3. HematocheziaHematochezia is the passage of liquid is the passage of liquid blood or blood clots of varied brightness or blood or blood clots of varied brightness or color, maroon to bright redcolor, maroon to bright red
XII GASTROINTESTINAL BLEEDINGXII GASTROINTESTINAL BLEEDING TerminologiesTerminologies As little as As little as 50-60m50-60ml of blood produce melenal of blood produce melena
Melena can persist for Melena can persist for 5-7 days 5-7 days after a 2-unitafter a 2-unit (significant) bleed(significant) bleed
Approximately 10 ml bleeding/ day (Guaiac +) Approximately 10 ml bleeding/ day (Guaiac +)
XII GASTROINTESTINAL XII GASTROINTESTINAL BLEEDINGBLEEDING Upper GI Bleeding Upper GI Bleeding Bleeding above the ligament of Treitz Bleeding above the ligament of Treitz include: include: 1. Esophagitis 1. Esophagitis 2. Esophageal Varices2. Esophageal Varices 3. Gastritis 3. Gastritis 4. Peptic Ulcer 4. Peptic Ulcer 5. Mallory Weiss5. Mallory Weiss 6. Gastric Carcinoma 6. Gastric Carcinoma 7. Hemobilia7. Hemobilia
XII GASTROINTESTINAL XII GASTROINTESTINAL BLEEDINGBLEEDING
Upper GI Bleeding Upper GI Bleeding 8. Stress Ulcer ( Documented Risk Factors)8. Stress Ulcer ( Documented Risk Factors) a. Multiple System Trauma a. Multiple System Trauma b. Hypotensionb. Hypotension c. Respiratory Failure c. Respiratory Failure d. Sepsisd. Sepsis e. Jaundice e. Jaundice ff. Burns . Burns g. Renal Failureg. Renal Failure hh. Recent Surgery. Recent Surgery
XII GASTROINTESTINAL BLEEDINGXII GASTROINTESTINAL BLEEDING Lower GI Bleeding Lower GI Bleeding Bleeding below the ligament of Treitz Bleeding below the ligament of Treitz includes:includes: 1. Diverticulitis1. Diverticulitis
2. Angiodysplasia2. Angiodysplasia
3. Ulcerative Colitis3. Ulcerative Colitis
4. Malignancy4. Malignancy
XII GASTROINTESTINAL BLEEDINGXII GASTROINTESTINAL BLEEDING
Lower GI Bleeding Lower GI Bleeding Work-upWork-up 1. Rectal Examination1. Rectal Examination 2. Proctosigmoidoscopy2. Proctosigmoidoscopy
3.Technetium 99 scan (Tag RBC)3.Technetium 99 scan (Tag RBC)
4. Arteriography 4. Arteriography 5. Barium Enema 5. Barium Enema
XIII JAUNDICEXIII JAUNDICE GIT related CausesGIT related Causes:: 1. Increased pigment production secondary to1. Increased pigment production secondary to tissue infarctiontissue infarction
2. Inflammatory disease; e.g. spontaneous2. Inflammatory disease; e.g. spontaneous peritonitisperitonitis
3. Appendicitis, complicated by coliform 3. Appendicitis, complicated by coliform organismorganism
can give jaundice without pyelephlebitican give jaundice without pyelephlebiti
4. Ampullary Carcinoma or Carcinoma of the4. Ampullary Carcinoma or Carcinoma of the duodenumduodenum