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GIT diseases
Esophagus
Dysphagiadifficulty in swallowing sensation that the food „stops“ in the oesophagus
Causedisorder of oesophagus motility – neuro-muscular problems – multiple sclerosis, myasthenia gravis, Parkinson disease...obstruction tumorpsychogenic – phagophobia
painful swallowing
Causedisorder of motilityobstruction infectionreflux oesophatitis
Odynophagia
Achalasiadisorder of esophageal motilitydefect of ezophagus peristalsis
Causedefect of ezophagus wall innervation
Signs and symptomsdificulty swallowingregurgitationchest pain
burning sensation in esophagus
CauseGERD
Pyrosis
DefinitionsGastroesophageal reflux (GER) – involuntary movement of gastric (sometimes also duodenal) content to the esophagus normal physiological process – 1- 4x/h during 3 h after eating
Gastroesophageal reflux disease (GERD) – chronic damage of the esophagus caused by a GER
Causesabnormal relaxation of the lower esophageal sphincter (LES) triggers – fat, chocolate, onion, alcohol, peppermint...
hiatal hernia protrusion of the upper part of the stomach into the thorax through a
tear or weakness in the diaphragm - change in the LES position – change in the LES tonus
Protective mechanismstonic contraction of lower esophageal sphincterperistalsisneutralization of acidic content by saliva
Gastroesophageal Reflux Disease - GERD
EsophagusdiaphragmHIS-angleA - normal anatomyB – hiatal hernia pre-stageC - sliding hiatal hernia D - paraesophageal type
Symptoms
Main symptomsPyrosis – heartburn – chest painRegurgitationDysphagia, odynophagiaSalivationNausea, vomiting
Other symptomsChronic cough Laryngitis, pharyngitisAsthma
Oral symptomsTeeth hypersensitivityErosion of dental enamel
GERD complications
Reflux esophagitis erosions, ulcers
Barrett´s esophagus metaplasia – replacement of
the epithelial cells from squamous to columnar
premalignant condition
Esophageal adenocarcinoma
Stomach
Definitionulceration in the upper GIT stomach proximal part of duodenum esophagus
CausesHelicobacter pylori (70 – 90%)Nonsteroidal anti-inflammatory drugs – aspirin, ibuprofen...Gastrinoma - Zollinger-Ellison syndrome hyperproduction of gastrin from pancreatic or
extrapancreatic (e.g. duodenal) tumourur stress
Risk factorssmokingspices
Peptic Ulcer Disase - PUD
Disrupted equilibrium between aggressive and protective mechanisms
Aggressive factorshydrochloric acid secreted by parietal cells stimulated by gastrin, acetylcholin, histamine...
pepsin produced by conversion of pepsinogen proteplytic activity
Protective mechanismsmucusprostaglandins stimulation of mucus secretion stimulation of bicarbonate secretion blood flood regulation healing of mucosa
bicarbonate
Pathogenesis
abdominal pain gastric ulcer – diffuse, pain exacerbation after eating, radiation
to the back duodenal ulcer – localized epigastric pain, after eating pain
relieves
dyspepsia
bloating, abdominal fullness
salivation
nausea, vomiting
hematemesis, melena
signs of anemia
loss of appetite, weight loss
Symptoms
a gram-negative bacteriumin various areas of the stomach, mainly antrum> 60% of population - seropositivitycauses duodenal (80 – 100%), gastric (80%) ulcers and gastric cancerover 80% of individuals infected with the bacterium are asymptomaticcauses inflammation, damage of epithelial cells, reparation
produces enzyme urease metabolise urea to CO2 and ammonia alkalisation of stomach environment defence of H.pylori against acid ammonia – toxic for epithelium proteases phospholipases cell damage Cytotoxins ...
Helicobacter pylori
NSAIDscauses duodenal (5%), gastric (25%) ulcersinhibition of cyclooxygenase – production of prostaglandins
Stressacute ulceration after stress – burns, trauma...main symptom – GIT bleedingcause – ischemia of mucosa
Smoking acid secretion prostaglandin and bicarbonate production
Genespositive family history – mainly duodenal ulcer incidence in patients with type 0 blood - duodenalHLA- B5 antigen - duodenal
Coffee, alcohol ...coffee - acid secretion
Complications
Bleeding erosion of the vessels
Perforation peritonitis pancreatitis
Penetration to other organs liver pancreas
Gastric outlet obstruction scarring and swelling narrowing in the duodenum vomiting
Cancer
Intestines
DefinitionsMalabsorption – abnormal absorption of nutrients by gut mucosaMaldigestion – abnormal digestion of nutrients
Causespancreatic insuficiency pancreatitis carcinoma cystic fibrosis
cholestasis obstruction
specific deficits lactase deficiency
systemic diseases celiac disease
infection Whipple´s disease
inflammation Crohn disease
Malabsorption
Symptoms
diarrhoea, steatorrhea, flatulence, paingrowth retardationweight loss
Specificedema – in protein deficiencyanemia – in Fe, folic acid, B12 deficiencyosteoporosis – in vit. D deficiencybleeding – in vit. K deficiencyjoint pain – Whippley´s disease
Malabsorption
Definitiona condition of having three or more loose or liquid bowel movement per day, often with perinal discomfort and sometimes with stool incontinetia
MechanismsInactivation of pancreatic enzymes (lipase) – low pH in duodenum, upper jejunum fat in colon is converted by bacterial enzymes to hydroxy fatty acids inhibition of absorption + stimulation of secretionDamage of the mucosain upper small intestine (infections, toxins)Altering of bacterial luminal floraIncrease of intracellular cAMP - increase of secretionInhibition of particular ion absorption abnormal amount of water secreted by intestine
Diarrhea
Secretory diarrheaaccumulation of the liquit in the gut lumen increased secretion and /or decreased absorption, no structural damagemechanism: secretion of Cl- ions secretion of Na+ ions secretion of the water, fecal liquid is isoosmoticCholera toxin
Osmotic diarrheawatery diarheacause: maldigestin (pancreatic diseases, Celiakia), laxatives lactose intolerance...
Exudative diarrheablood and/or pus in the stoolinflammatory bowel diseases – Crohn´s disease, ulcerative colitis
Motor diarrhea motility od bowelsdiabetic neuropathy, vagotomy
Inflammatory diarrheaviral, bacterial, parasitic diseases
Dysenterytipe od diarrhea in which there is blood visible in the stoolsShigella, Salmonela...
Diarrhea Classification
Definitiona condition of infrequent bowel movement, with difficulties during defecation and sensation of incomplete bowel evacuation
Causesirritable bowel syndromediet – low fibre diet, low lliquid intakedrugs – opioids, diuretics, antidepressants, antihistamines, antispasmodics...metabolic - hypercalcemia, hypothyroidism, diabetes mellitus , cystic fibrosisstructural and functional abnormalities - spinal cord lesions, Prkinsonism, colon cancer, anal fissures...functional abnormalities – anismus (obstructed defecation, a malfunction of the external anal sphincter, during defecation normal is relaxation in anismus contraction), Hirschsprung´s disease (absention of enteric nerves – ganglion cells)Psychological - fear of pain, fear of public restrooms
Constipation
Definitiona bowel disorder characterized by chronic abdominal pain, discomfort, bloating, change in the consistency and/or frequency of defecation (diarrhea, constipation) without any detectable organic cause
Classificationdiarrhea-predominant (IBS-D) – pain + diarrheaconstipation- predominant (IBS-C) – pain + constipation alternating stool pattern (IBS-A). pain + diarrhea alternationg with constipation
Irritable Bowel Syndrome (IBS)
Causesunknownpost- infectious
PathophysiologyDisorganized motility dysfunction – brain-gut axis irregular motor activity of the small intestine,
muscle spasm, fast or slow contractions...Increased sensitivity to stimuli motility of bowels defect in visceral pain processing
Irritable Bowel Syndrome (IBS)
Possible causes of IBS
Symptoms
Irritable Bowel Syndrome (IBS)
Definitiona multifactorial inflammatory disease of the intestines (ileum, large intestine) that may affect any part of the GIT (from mouth to rectum), with a variety of GIT and extraGIT symptoms
Causeautoimmune processgenetical predisposition (mutation of NOD2 gene) + external factor (bacterias, milk protein)risk factors: smoking, contraceptives
Crohn´s disease
Gastrointestinal symptoms abdominal pain diarrhea, fecal incontinenceflatulence, bloating, intestinal discomfortnausea, vomitingperianal discomfort (itchiness, pain), fistula, abscess around the anusmouth – aphtous ulcers,ezophagus – dysphagia stomach - pain
Systemic symptomsgrowth failureloss of apetite, wight lossfevermalabsorption
Extraintestinal symptoms eye (uveitis)skin inflammation - erythema nodosum, pyoderma gangrenosumspondyloarthopathyautoimmune hemolytic anemiafinfers deformityosteoporosisneurological symptoms – seizures, peripheral neuropathy, headache
Symptoms of Crohn´s disease
perianal fistulas perianal fissura
erythema nodosum
pyoderma gangrenosum
uveitis
Symptoms of Crohn´s disease
bowel obstruction, fistulae, abcesses, perforation, bleedingintestinal strictures and adhesionsinfectionmalnutrition, malabsorptionsmal intestinal cancer
Complications of Crohn´s disease
Definitionan chronic inflammatory bowel disease (colon)
Causeunknownautoimmune processgenetical predisposition environmental factors
diet - fiber contentprotective factor: breastfeeding
Ulcerative colitis
Gastrointestinal symptoms diarrhea with blood or mucusabdominal pain, crampsmouth aphtous ulcers
Systemic symptomsloss of apetite, wight loss
Extraintestinal symptoms joints – arthritiseye - uveitisskin - erythema nodosum, pyoderma gangrenosumliver – pericholangitis, fatty liverblood – hemolytic anemia, tromboembolic disease (rare)
Symptoms of ulcerative colitis
Symptoms of Inflammatory Bowel DiseaseSymptoms
Diarrhea
Rectal Bleeding
Constipation
Abdominal Symptoms
Fever
Loss of appetite, weight loss, and impaired growth in children
Abnormal defecation
Anal ulcers and fistulas
Neurologic or psychiatric symptoms
Ulcerative Colitis
Recurrent diarrhea is very common, but onset may be very gradual and mild or it may not be present. Feces may also contain mucus.
Blood is almost always present in stools. It may be readily visible or visible only using a microscope (called occult blood).Bleeding not as common as in UC, but can occur.
Constipation can be a symptom of UC, but not as common as diarrhea. Can occur during flare-ups. May occur when the inflamed rectum triggers a reflex response in the colon that causes it to retain the stool.
Pain is not prominent symptom, but can vary. May cause vague discomfort in the lower abdomen, an ache around the top of the hipbone, or cramps in the middle of the abdomen. Severe pain can occur during flare-ups. Vomiting and nausea.
May occur with severe attacks.
Often not evident in mild or even moderately severe UC. Occasionally impairs growth in children and teenagers.
Symptoms may be mild or severe.
Almost never a symptom.
No.
Crohn's Disease
Recurrent diarrhea is fairly common.
Bleeding not as common as in UC, but can occur.
Constipation in Crohn's disease is usually a symptom of obstruction in the small intestine.
Main symptom is recurrent episodes of pain in the lower right part of the abdomen or above the pubic bone. Often preceded by and relieved by defecation. Bloating, nausea, and vomiting may also occur. Intestinal pain may also be an indication of a serious condition, such as an abscess, or a perforation of the intestinal wall.
Usually low-grade. Spiking fever and chills indicates complications.
Common. Typical weight loss is 10 - 20% of normal. Commonly impairs growth in children and teenagers
Can occur in active stages.
Fistulas and ulcers around the anus may be early symptoms.
May be early signs of Crohn's disease when accompanied by gastrointestinal problems
Definitionbowel obstruction
Causesmechanical obstruction tumours inflammatory bowel disease – Crohn dis. feces atresia gallstones intestinal adhesion
muscle paralysis – inhibition of motility postsurgical ileus acute pancreatitis peritonitis myopathy neuropathy strangulation metabolic diseases
Ileus
Mechanismdefect in all functions – transport, secretion, absorption, digestion, immunityhypoperfusion hypoxia autodigestion
Symptomsmoderate, diffuse abdominal discomfort or painconstipation abdominal distension nausea, vomiting, especially after meals lack of bowel movement and/or flatulence excessive belching
Ileus
Liver
Icterus
• yellowish pigmentation of the skin, sclera and the mucous membranes caused by hyperbilirubinemia
over 22 mol/l - hyperbilirubinaemiaunconjugated bilirubinconjugated bilirubin
over 35 mol/l - icterus
haemoglobin
RES
haem
globin bilirubin
blood
bilirubin
liver
conjugation of bilirubin
bile
intestine
urobilinogen urobilin
bilirubin productionhaemolytic icterus
conjugation of bilirubinGilbert’s diseaseCrigler-Najjar syndromeLucey-Driscoll syndromeneonatal icterus
excretion of bilirubin to bileDubin-Johnson syndromeRotor syndromehepatocellular icterus
intra- a extrahepatic biliar obstructiongallstones, carcinomas
Disorders of bilirubin metabolism
unconjugatedbilirubin
conjugatedbilirubin
Retention of unconjugated bilirubin
Gilbert’s syndrome (Familiar unconjugated nonhaemolytic hyperbilirubinaemia)
mild disorder of uptake of bilirubin to hepatic cells and conjugation mild hyperbilirubinaemia good prognosis
Hemolytic icterus haemolysis - congenital - red cell enzymes or membrane
defects, haemoglobin defects - acquired - toxins, incompatible blood transfusion
Retention of unconjugated bilirubin
Neonatal icterus low activity of UDP-glucuronyl transferase icterus - maximum 5. - 7. day
Lucey-Driscol syndrome partial absence of
UDP-glucuronyl transferase without CNS damage
Crigler-Najjar syndrome absence of UDP-glucuronyl transferase brain damage - kernicterus (acute bilirubin encephalopathy)
mental retardation fatal condition treatment -phototherapy
kernikterus
Retention of conjugated bilirubin
Hepatocellular icterus hepatitis toxins, alcohol, drugsuptake of bilirubin in hepatic cells and/or conjugation
and/or excretion of bilirubin to bile unconjugated bilirubin and/or conjugated bilirubin transaminases (ALT, AST), ALP and GGT
Dubin-Johnson syndrome disorder of membrane transport of bilirubin from hepatic cells
to bile
Rotor syndrome milder form of Dubin-Johnson syndrome
Retention of conjugated bilirubinObstructive icterus
intra- or extrahepatic biliary obstruction gallstones, carcinomas, cirrhosis, inflammation, drugs
acholous stool
Acute liver insufficiency
Rapid liver failure – rapidly developed after first signs of liver disease
Causeshepatitisalcohol abusedrugs – paracetamol, aspirintoxins – mycotoxins, intoxication with mushroomsWilson disease
MechanismInflammation - necrosis
Complicationsliver encephalopathy – comaimpaired protein synthesis – edema, coagulopathiesrenal failureSIRS
Liver insufficiency
Chronic liver insufficiency
CausesViral - hepatitisToxins and drugs – alcohol Wilson diseasehemochromatosisautoimmune hepatitisheart failure
Complicationsliver encephalopathy – comaportal hypertension – ascites, esophageal, rectal - varicescoagulopathy – bleedingcancer
Liver insufficiency