C:\Fakepath\Gi Part 1 Revised

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  • 1. GASTROINTESTINAL DISORDERS Fe A. Bartolome, MD, FPASMAP Department of Pathology Our Lady of Fatima University

2. CLASSIFICATION OF GI DISEASES 3. Impaired Digestion & Absorption

  • Diseases of the stomach, intestine, biliary tree & pancreasdisrupt nutrient digestion and absorption
  • Examples:
    • Gastric hypersecretory syndromes (e.g. Zollinger-Ellison syndrome)
      • Damage intestinal mucosa
      • Impair pancreatic enzyme activation
    • Lactase deficiency
      • Most common intestinal maldigestion syndrome
    • Biliary obstruction from stricture or neoplasm
    • Chronic pancreatitis or pancreatic CA

4. Altered Secretion

  • Gastric acid hypersecretion
    • Zollinger-Ellison syndrome, G cell hyperplasia, duodenal ulcer disease
  • Decreased or absent gastric acid secretion
    • Atrophic gastritis or pernicious anemia
  • Fluid loss through impaired absorption or enhanced secretion
    • Inflammatory and infectious small-intestinal and colonic diseases
    • Laxative abuse
    • Endocrine neoplasias with secretion of vasoactive intestinal polypeptide (VIP)

5. Altered Gut Transit

  • Mechanical obstruction
    • Esophagus acid-induced stricture or neoplasm
    • Stomach PUD or gastric cancer
    • Small intestines
      • Adhesions most common
      • Crohns disease, radiation-induced strictures, malignancy
    • Colon
      • Colon cancer most common
      • Inflammatory strictures in patients with inflammatory bowel disease

6. Altered Gut Transit

  • Disordered gut motor function
    • Achalasia impaired esophageal body peristalsis
    • Gastroparesis symptomatic delay in gastric emptying of solid or liquid meals due to impaired gastric motility
    • Injury to enteric nerves or intestinal smooth muscleintestinal pseudo- obstruction
    • Impaired colonic propulsionconstipation

7. Immune Dysregulation

  • Celiac disease mucosal inflammation due to ingestion of gluten-containing grains
  • Eosinophilic esophagitis and gastroenteritis
  • Ulcerative colitis & Crohns disease
  • Bacterial, viral, and protozoal ileitis and colitis in selected patients

8. Impaired Gut Blood Flow

  • Gastroparesis may result from blockage of the celiac and superior mesenteric arteries
  • Intestinal and colonic ischemia more common; may be due to:
    • Arterial thrombosis or embolus
    • Venous thrombosis
    • Hypoperfusion from dehydration, sepsis, hemorrhage or reduced cardiac output

9. Neoplastic Degeneration

  • All GI regions are susceptible to malignant degeneration to varying degrees
  • Most GI cancers are carcinomas, but lymphomas & tumors of other cell types are also observed
  • Colorectal CA most common in U.S.
  • Gastric CA worldwide & esp. in certain regions in Asia
  • Esophageal CA associated with chronic acid reflux & extensive alcohol and tobacco use

10. Disorders without Obvious Organic Abnormalities

  • Irritable bowel syndrome, functional dyspepsia, non-cardiac chest pain, functional heartburnno abnormalities on biochemical or structural testing
  • With altered gut motor function
  • Exaggerated visceral sensory responses to noxious stimulation may cause discomfort
  • Patients may exhibit significant emotional disturbances on psychometric testing

11. Symptoms of Gastrointestinal Disease Common Causes of Common GI Symptoms Abdominal Pain Appendicitis Gallstone disease Pancreatitis Diverticulitis Ulcer disease Esophagitis GI obstruction Nausea & Vomiting Medications GI obstruction Motor disorders Functional bower d.o. Enteric infection Pregnancy Endocrine disease Diarrhea Infection Poorly absorbed sugars Inflam. Bowel dse. Microscopic colitis Fxnal bowel disorder Celiac dse. Pancreatic insuff. GI Bleeding Ulcer disease Esophagitis Varices Vascular lesions Neoplasm Diverticula HemorrhoidsObstructive Jaundice Bile duct stones Cholangio- carcinoma Cholangitis Sclerosing cholangitis Ampullary stenosis Ampullary CA Pancreatitis 12. Symptoms of Gastrointestinal Disease Common Causes of Common GI Symptoms Abdominal Pain Inflammatory bowel dse.Functional bowel d.o. Vascular disease Gynecologic causes Renal stone Nausea & Vomiting Motion sickness CNS disease Diarrhea Hyper- thyroidism Ischemia Endocrine tumor GI Bleeding FissuresInflammatory bowel dse. Infectious colitis Obstructive Jaundice Pancreatic tumor 13. Abdominal Pain

  • GI disease and extraintestinal conditions involving the GUT, abdominal wall, thorax or spine
  • Visceral painmidline in location and vague in character
  • Parietal painlocalized and precisely described
  • Most common causes are IBS and functional dyspepsia

14. Abdominal Pain

  • Other causes:
    • Inflammatory
      • Peptic ulcer, appendicitis, IBD, diverticulitis, infectious enterocolitis
      • Gallstone disease, pancreatitis
    • Non-inflammatory
      • Mesenteric ischemia
      • Neoplasia

15. Heartburn

  • Burning sub-sternal sensation
  • Result from excess gastroesophageal reflux of acid

Nausea and Vomiting

  • Mechanical obstruction of upper gut
  • Others: gastroparesis & intestinal pseudo-obstruction; IBS and functional disorders of upper gut

16. Altered Bowel Habits

  • Constipation
    • Infrequent defecation
    • Straining with defecation
    • Passage of hard stools
    • Sense of incomplete fecal evacuation
    • Causes:
      • Obstruction
      • Motor disorders of colon
      • Medications
      • Endocrine diseases (hypothyroidism and hyperparathyroidism)

17. Altered Bowel Habits

  • Diarrhea
    • Frequent defecation
    • Passage of loose or watery stools
    • Fecal urgency
    • Sense of incomplete evacuation
    • Causes:
      • Inflammatory (+) pus in stool
        • IBS constipation, diarrhea, or alternating bowel pattern; (+) fecal mucus
      • Infectious
      • Malabsorption (+) steatorrhea
      • Medications

18. GI Bleeding

  • Upper GI bleed (+) melena or hematemesis
    • Most common causes are:ulcer disease, gastroduodenitis, and esophagitis
  • Lower GI bleed passage of bright red or maroon stools
    • Most common causes are:hemorrhoids, anal fissures, diverticula, ischemic colitis, and arteriovenous malformations
  • Chronic slow GI bleed(+) iron deficiency anemia

19. Other Symptoms

  • Dysphagia, odinophagia & unexplained chest pain esophageal disease
  • Weight loss, anorexia, fatigue neoplastic, inflammatory, gut motility, pancreatic, small bowel mucosal, and psychiatric conditions
  • Extraintestinal symptoms
    • IBD hepatobiliary dysfunction, skin & eye lesions, arthritis
    • Celiac disease dermatitis herpetiformis

20. ESOPHAGEAL DISORDERS 21. Signs and Symptoms of Esophageal Disease

  • Heartburn
    • Most commonly due to GERD
  • Dysphagia for solids alone
    • Symptom of an obstructive lesion
    • Examples: esophageal cancer, esophageal web, stricture
  • Dysphagia for solids and liquids
    • Signify motility disorder
      • Oropharyngeal (upper esophageal)
        • Striated muscle dysmotility
        • Dermatomyositis, myasthenia gravis, stroke
      • Lower esophageal
        • Smooth muscle dysmotility
        • Systemic sclerosis, achalasia

22. Esophageal Atresia

  • Incomplete development
  • Thin, non-canalized cord replaces a segment of esophagus, causing mechanical obstruction
  • Proximal and distal blind pouches connect to the pharynx and stomach, respectively
  • Occurs most commonly at or near the tracheal bifurcationusually associated with fistula connecting the upper or lower esophagealpouches to a bronchus or the trachea

23. Esophageal Atresia: Types 24. EA with distal TEF EA with proximal TEF Isolated EA EA with double TEF Isolated TEF 25. Esophageal Atresia

    • Fistulae can lead toaspiration, suffocation, pneumonia, and severe fluid and electrolyte imbalances
      • Abdominal distention in NBair in stomach from fistula
      • Regurgitation of food
    • EA associated with congenital heart defects, GU malformations, and neurologic disease

26. Esophageal Stenosis

    • Incomplete form of atresia
    • Esophageal lumen markedly reduced in caliber due tofibrous thickening of the wallpartial or complete obstruction
    • May involve any part of the GIT esophagus & SI most commonly affected

27. Esophageal Stenosis

    • Associated with atrophy of the muscularis propria & secondary epithelial damage
    • Causes:
      • Congenital occasional
      • Inflammation and scarring
        • Most common
        • Due to GERD, irradiation or caustic injury
    • Progressive dysphagia

28. Congenital esophageal stenosis in a young man with long-standing dysphagia and occasional superimposed food impactions. Double-contrast esophagogram shows an area of mild narrowing in the mid-esophagus with distinctive ring-like indentations (ringed esophagus) (arrows) in the region of the stricture. 29. Nutcracker Esophagus

  • High-amplitude esophageal contractions
  • Outer longitudinal layer of smooth muscle contracts before the inner circular layer of smooth muscles lack of coordination
  • Cause periodic short-lived esophageal obstruction

30. Diffuse esophageal spasm

  • Cause increased esophageal wall stress
  • Result in functional obstruction
  • Can cause small diverticulae to form

31. Diffuse esophageal spasm produces intermittent contractions of the mid and distal esophageal smooth muscle, associated with chest symptoms. Patient experienced chest pain during examination 32. Esophageal diverticulae

  • Small mucosal outpouchings
    • True diverticulae with true muscularis
    • Pseudodiverticulae lack true muscularis

33. 34. Esophageal diverticulae: Types

  • Zenkers Diverticulum
  • Pharyngoesophageal diverticulum
  • Occurs in older women
  • Posteriorly at site of Killian's dehiscence = superior boundary is thyropharyngeal muscle and inferior boundary is cricopharyngeal muscle
  • Pulsion diverticulum
  • False diverticulum = herniation of mucosa and submucosa through muscular layer

35.

  • Traction Diverticulum
  • Mid-esophageal diverticulum
  • May be formed in response to pull from fibrous adhesions following lymph node infection (usually TB)
  • Or, may form from increased intraluminal pressure and be pulsion diverticula
  • True diverticulum = contains all 3 esophageal layers

36.

  • Epiphrenic Diverticulum
  • Location is usually in distal esophagus on lateral esophageal wall, right > left
  • Often associated with hiatal hernia
  • Pulsion diverticulum
  • False diverticulum

37. Esophageal mucosal webs

  • Uncommon ledge-like protrusions of mucosa
  • Women > 40 y/o
  • Often associated with:
    • Gastroesophageal reflux
    • Chronic graft-versus-host disease
    • Blistering skin diseases
  • Most common inupper esophagus (at level of cricopharyngeus or C5-C6)
  • Main symptom isdysphagia associated with incompletely chewed food

38. Barium esophagram demonstrates a thin membrane arising from the anterior wall of the cervical esophagus at the level of C5-C6 without circumferential involvement of the lumen characteristic for an esophageal web An upper esophageal web (arrow) in a patient with Plummer-Vinson syndrome. 39. Esophageal mucosal webs

  • Patterson-Brown-Kelly or Plummer-Vinson Syndrome
      • Iron deficiency anemia
      • Stomatitis
      • Glossitis
      • Dysphagia
      • Spoon-shaped nails
      • Esophageal webs

40. Atrophic glossitis Esophageal web Hypochromic, microcytic anemia 41. Koilonychia (spoon-shaped fingernails) Cheilitis (rhagades, angular stomatitis) 42. Esophageal rings

  • Similar to webs but circumferential and thicker
  • Include mucosa, submucosa, and in some cases, hypertrophic muscularis propria
  • If present in distal esophagus, above the gastroesophageal junction; covered by squamous mucosa A rings
  • If located at squamocolumnar junction (Z line) of lower esophagus & with gastric cardia-type mucosa on undersurface B rings (Schatzki rings)

43. Esophageal A-ring due to muscular contraction. It varies during examination and may not persist. 44. The esophageal B-ring is located at the squamocolumnar junction, also termed the 'Z' line. The appearance does not change during the examination. 45. Achalasia

  • Triad:
    • Incomplete LES relaxation
    • Increased LES tone
    • Aperistalsis of the esophagus
  • Impaired smooth muscle relaxationincreased tone of LES
  • Primary idiopathic; failure of distal esophageal inhibitory neurons
  • Secondary Chagas disease, diabetic autonomic neuropathy, malignancy, amyloidosis, polio, surgical ablation

46. LEFT: Dilated esophagus (arrows) appears as long, well-defined structure paralleling heartRIGHT: Dilated esophagus usually deviates to right, narrowing (arrow) at hiatus. 47. Esophageal Causes of Hematemesis 48. Mallory-Weiss Syndrome

  • Longitudinal tears near the gastro-esophageal junction; superficial lacerations
  • Usually associated with severe retching or vomiting due to acute alcohol intoxication

49. Boerhaave Syndrome

  • Distal esophageal rupture and mediastinitis
  • Occurs rarely; catastrophic
  • Causes:
    • Endoscopy (~75% of cases)
    • Retching
    • Bulimia
  • Complications:
    • Pneumomediastinum
      • Air dissects into subcutaneous tissue
      • Produces a crunching sound (Hammans crunch) on P.E.
    • Pleural effusion contains food, acid, amylase

50. Chemical Esophagitis

  • Alcohol, corrosive acids or alkalis, excessively hot fluids, heavy smoking
  • Generally causes only self-limited pain, particularly with swallowing
  • Complications:hemorrhage, stricture, perforation

51. Corrosive esophagitis. This is a vinegar-induced esophageal burn. The patient had a fish bone in her throat. She ingested vinegar in an attempt to dissolve the fish bone but to no avail; this led to corrosive esophagitis. 52. Pill-induced Esophagitis

  • Occurs when medicinal pills lodge and dissolve in the esophagus rather than passing into the stomach
  • Frequently occurs at the site of strictures that prevent passage of luminal contents

53. Infectious Esophagitis

  • Frequently in debilitated or immuno- compromised individualscommonlyHSV, CMV, or fungi (Candidiasis mos