GIT

GASTROINTESTINAL SYSTEM BLOCK PROBLEM 1

MM ANATOMY,HISTOLOGY & BIOCHEMISTRY SALURAN PENCERNAAN ATAS

LO 1

HISTOLOGY

diFiore Atlas of Histology, 247

DIGESTIVE SYSTEM• Two groups of organs compose the digestive

system: – Gastrointenstinal (GI) tract or alimentary canal –

mouth, most of pharynx, esophagus, stomach, small intestine, and large intestine

– Accessory digestive organs – teeth, tongue, salivary glands, liver, gallbladder, and pancreas

• Histologic organization:– Mucosa:

• Epithelium, lamina propria, muscularis mucosa– Submucosa:

• connective tissue, vessels, and Meissners plexuses, some times mucous glands

– Muscularis externa: 2-3 layers of smooth muscle (plus skeletal muscle in esophagus), myenteric (Auerbach) plexus in between muscle layers

– Serosa and adventitia: Outermost layer of loose connective tissue and blood vessels. Call serosa if covered my mesothelium; adventitia otherwise

mucosa submucosa muscularis serosa

ORAL CAVITY

• Inner surface of the lips, cheeks, soft palate, surface of tongue, and floor of the mouth– Nonkeratinized stratified squamous epithelium– Lamina propria– Submucosa

• Gingiva and hard palate– Keratinized stratified squamous epithelium– Lamina propria

• Tongue: specialized mucosa with papillae

THE LIP

THE TONGUE

Junquiera, L. C. (2013) Basic Histology text & Atlas, 13rd edn. McGraw Hill, New York.

TONGUE PAPILLAE• There are four types:

fungiform

filliform

foliate

circumvallate

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MM FISIOLOGI MENELAN LO 2

The Digestive System

• The primary function of the digestive system is to transfer nutrients, water, and electrolytes from the food we eat into the body’s internal environment.

• There are four basic digestive processes : motility, secretion, digestion, and absorption.

• The digestive system consists of the digestive tract plus the accessory digestive organs.

• The accessory digestive organs include the salivary glands, the exocrine pancreas, and the biliary system , which is composed of the liver and gallbladder.

• The digestive tract wall has four layer. From the innermost layer outward, they are the mucosa, the submucosa, the muscularis externa, and the serosa.

• Four factors are involved in regulating digestive system function :

1. Autonomous smooth muscle function 2. Intrinsic nerve plexuses 3. Extrinsic nerves 4. GI hormones

Mouth

• Entry to the digestive tract is through the mouth or oral cavity. The opening is formed by the muscular lips.

• The palate , which forms the arched roof of the oral cavity, separates the mouth from the nasal passages.

• The tongue, which forms the floor of the oral cavity, is composed of voluntarily controlled skeletal muscle.

• The first step in the digestive process is mastication, or chewing, the motility of the mouth that involves the slicing,tearing, grinding, and mixing of ingested food by the teeth.

• Saliva, the secretion associated with the mouth, is produced largely by three major pairs of salivary glands that lie outside the oral cavity and discharge saliva through short ducts into the mouth.

• The most important salivary proteins are amylase, mucus, and lysozyme. They contribute to the functions of saliva, which are as follows :

1. Saliva begins digestion of dietary starches through action of the enzyme salivary amylase.

2. Saliva facilitates swallowing by moistening food particles, there by holding them together.

3. Saliva exerts some antibacterial action by a fourfold effect-first, by lysozyme.

4. Saliva serves as a solvent for molecules that stimulate the taste buds.

5. Saliva aids speech by facilitating movements of the lips and tongue.

6. Saliva plays an important role in oral hygiene by helping keep the mouth and teeth clean.

7. Saliva is rich in bicarbonate buffers, which neutralize acids in food and acids produced by bacteria in the mouth.

• Salivary secretion is continuous and can be reflexly increased.

• On average, about 1 to 2 liters of saliva are secreted per day.

• Salivary secretion may be increased by two types of salivary reflexes, simple and conditioned.

Pharynx and Esophagus

• The motility associated with the pharynx and esophagus is swallowing.

• Swallowing actually is the entire process of moving food from the mouth through the esophagus into the stomach.

• The two stages of swallowing : the oropharyngeal stage and the esophangeal stage.

MM PENYAKIT MENYEBABKAN DISFAGIA ( SWELLING)

LO 3

Dental Caries (Tooth Decay)Definition Is a common problem that occurs when acids in your mouth dissolve

the outer layers of your teeth. (*)Epidemiology Children aged 6 to 11 years and adolescents aged 12 to 19 years.

Dental caries also affects adults, with 9 out of 10 over the age of 20 having some degree of tooth-root decay. (**)

Etiology Bacteria (***)

Risk Factor Diet (food & drink high in carbohydrats), poor oral hygiene,Smoking and alcohol, dry mouth (***)

Sign & Symptoms

Toothache, tooth sensitivity (tenderness or pain), grey, brown or black spots, bad breath, an unpleasant taste in mouth (*)

Physical Examination

The early sign: chalky white appearance of the enamel surface.If the caries progresses: enamel surface becomes dark brown or black.A late sign: holes or cavites in the affected tooth. (****)

Lab Investigation

An x-ray to confirm. (****)

Dental Caries (Tooth Decay)Pathogenesis (*)

Mouth full of bacteria

Consume carbohydrats

Bacteria in plaque turn the carbohydrates → energy they need +

producing acid

The plaque soften the enamel, by removing

minerals from the tooth

The plaque and bacteria can reach the

dentine

The process of tooth decay speeds up.

Plaque and bacteria will enter the pulp

(contains nerves and blood vessels

Toothache

Dental Caries (Tooth Decay)Treatments •Flouride: early stage

•Fillings and crowns: if the decay is more extensive → replaces your missing enamel•Root canal treatment: if tooth decay has spread to the pulp (the soft centre of the tooth) → the pulp may have to be removed and replaced with an artificial pulp that will keep the tooth in place•Tooth extraction: tooth may be removed to prevent the spread of infection. (*)

Complications Gum disease (gingivitis), dental abscesses (**)

Prognosis Depends on the health of the patient, oral health practices and the extent of dental caries (***)

Prevention •Brush twice a day with a fluoride toothpaste•Clean the teeth daily with floss or interdental cleaner•Eat nutritious and balanced meals and limit snacking•Visit your dentist regularly for professional cleanings and oral examination•Check with your dentist about use of supplemental fluoride (****)

GlossitisDefinition Glossitis is a problem in which the tongue is swollen and changes

color, often making the surface of the tongue appear smooth. (*)Etiology Allergic reactions to oralcare products, foods, or medicine

Dry mouth due to Sjogren syndromeInfection from bacteria, yeast or viruses (including oral herpes)Injury (such as from burns, rough teeth, or bad-fitting dentures0Skin conditions that affect the mouthIrritants such as tobacco, alcohol, hot foods, spices, or other irritantsHormonal factors. (*)

Sign & Symptoms

Problems chewing, swallowing, or speakingSmooth surface of the tongueSore, tender, or swollen tonguePale or bright red color to the tongueRare symptoms or problems include: blocked airway, Problems speaking, chewing, or swallowing (*)

Treatments Good oral care. Brush your teeth thoroughly at least twice a day and floss at least once a day.Antibiotics or other medicines to treat infection.Diet changes and supplements to treat nutrition problems.Avoiding irritants (such as hot or spicy foods, alcohol, and tobacco) to ease discomfort. (*)

Prognosis Good oral care (thorough tooth brushing and flossing and regular dental checkups) may help prevent glossitis(*)

Micrognathia & macrognathia

1. Micrognathia a severely deficient jaw, most commonly affects the mandible. • Types: - Apparent micrognathia: this is not due to abnormality of

small jaw, in terms of size but rather due to an abnormal positioning or abnormal relation of one jaw to another, which produces illusion of micrognathia

- True micrognathia: it is due to small jaw. It is again classified as:

a. Congenitalb. Acquired

Sumber: Textbook of Oral Medicine 3th edition, 2014

Etiology

Congenital:- Congenital abnormalities: in many

instances, it is associated with other congenital abnormalities, particularly congenital heart disease and Pierre Robin syndrome (cleft palate, micrognathia and glossoptosis)

- Forceps delivery trauma: the use of forceps on either side of the head. If the joint, in this area, called the temporomandibular joint, is badly bruised, the mandible does not develop

Acquired:- Ankylosis- Mouth breathing- Agenesis of condyle- Posterior positioning


• Signs and Symptomps- Short upper jaw- Abnormal alignment of teeth


• Management:- Orthognathic surgery: recommended

treatment modality for micrognathia. This surgery is followed by orthodontic appliance to correct malocclusion


2. Macrognathia refers to the condition of abnormally large jaws. It is also called as ‘megagnathia’. • Etiology:- Pituitary gigantism: there is generalized increase in

the size of entire skeleton- Paget’s disease of bone: overgrowth of cranium and

maxilla occurs- Acromegaly: progressive enlargement of mandible

owing to hyperpituitarism in adultsSumber: Textbook of Oral Medicine 3th edition, 2014

• Clinical features:- prognathism: mandibular protrusion or proganthism is common

occurrence, which is due to disparity in the size of maxilla to mandible and posterior positioning of maxilla in relation to the cranium

- Mandible: mandible is measurably larger than normal. Increased mandibular body length

- Gummy smile: in certain patients with congenital abnormalities, there may be elongation of maxilla. There is much “show” when the patient smiles, so that there is so-called “gummy” smile. This is due to the upper jaw being too long

- Ramus: large ramus which forms less step angle with body of mandible- Chin: there is prominent chin button


• Management:- Osteotomy: resection of portion of mandible to decrease the length, followed by orthodentic treatment


MM PENYAKIT ( WHITE PATCHES )LO 4

Oral Candidiasis

Definition A condition in which candida albicans accumulates on the lining of your mouth. (*)

Symptoms -Creamy white lesions on your tounge, inner cheeks, and sometimes on The roof of your mouth, gums, and tonsils- A cottage cheese-like appearance- Redness or soreness- Slight bleeding- Cracking and redness at the corner of your mouth- A cottony feeling in your mouth- Loss of taste (**)

Risk Factors -Some health conditions HIV/AIDS, cancer, DM, vaginal yeast Infections- Undergoing chemotherapy or radiation treatment for cancer- Wearing dentures-Taking antibiotics or oral or inhaled corticosteroids (***)

Diagnosis Limited to your mouth looking at the lesionsIn your esophagus throat culture (swabbed with sterile cotton), endoscopic exam (*)

Treatment - Patient with late-stage HIV infection amfotericin B- Practice good oral hygiene- Try warm saltwater rinses. (**)

Prevention - Rinse your mouth- Brush your teeth at least twice a day and floss daily- Clean your dentures- See your dentist regularly- Watch what you eat- Maintain good blood sugar control if you have DM- Treat any vaginal yeast infections (***)

Leukoplakia Definition Leukoplakia is a white patch that develops in the mouth. (*)Epidemiology OL occurs in fewer than 1% of individuals.

OL is more common in men than in women (2:1) (*)Etiology Idiopathic (**)Risk Factor tobacco use, alcohol consumption, chronic irritation,

candidiasis, vitamin deficiency, endocrine disturbances, and possibly a virus. (**)

Sign & Symptoms

a white patch in the mouth that can't be removed by rubbing. (***)

Homogenous leukoplakia of the lingual versant of the

gingiva

Speckeled leukoplakia on the right retrocomisural

mucosa in a hard smoker

Verrucous leukoplakia on the floor of the mouth

Nodular leukoplakia of the soft palate

Treatments of Leukoplakia

• The main objective in oral leukoplakia's management of care is to detect and to prevent malignant transformation.

• the ceasing of the risk activities such as smoking

• histopathological evaluation

• surgical treatment

• The medical treatment uses local and systemic chemopreventive agents such as:– vitamin A and retinoids, – systemic beta carotene, – lycopene (a carotenoid), – ketorolac (as mouthwash), – local bleomycin, and– a mixture of tea used both

topically and systemically with a reduced benefit

MM PENYAKIT ( HEREDITARY )

LO 5

Esophageal Atresia Definition Esophageal atresia is a congenital defect

The upper esophagus ends and does not connect with the lower esophagus and stomach. Tracheoesophageal fistula (tef) is a condition in which an abnormal channel(fistula) connect the windpipe (tracea) to the tube that leads ffrom the mouth to the stomach ( esophagus)

Sign & Symptoms

Bluish coloration to the skin (cyanosis) with attempted feedingsCoughing, gagging, and choking with attempted feedingDroolingPoor feeding

Lab Investigation

Prenatal ultrasoundChest x-rays and other x-rays A special chest x-ray that is done after a nasogastric tube is put through the nose into the esophagus to the point where the esophagus stops

Esophageal atresia classification according to Gross of Boston :• Type A - Esophageal atresia without fistula or so-called pure esophageal atresia

(10%)• Type B - Esophageal atresia with proximal TEF (< 1%)• Type C - Esophageal atresia with distal TEF (85%)• Type D - Esophageal atresia with proximal and distal TEFs (< 1%)• Type E - TEF without esophageal atresia or so-called H-type fistula (4%)• Type F - Congenital esophageal stenosis (< 1%)

Esophageal AtresiaTreatments •Esophageal atresia is considered a surgical emergencyComplications •The infant may breathe saliva and other fluids into the lungs

→ aspiration pneumonia, choking, and possibly death.•Other complications may include:•Feeding problems•Reflux (the repeated bringing up of food from the stomach) after surgery•Narrowing (stricture) of the esophagus due to scarring from surgery

AchalasiaDefinition Achalasia is a primary esophageal motility disorder

characterized by the absence of esophageal peristalsis and impaired relaxation of the lower esophageal sphincter (LES) in response to swallowing. (*)

Epidemiology more common in middle-aged or older adults. (**)Etiology Unknown: viral infection may be responsible

Assosiated with autoimmune condition: Sjogren's syndrome, lupus or uveitis. (**)

Sign & Symptoms

Dysphagia (most common), Regurgitation, Chest pain , Heartburn, Weight loss. (***)

Lab Investigation

Barium swallowEsophageal manometry (the criterion standard) Prolonged esophageal pH monitoringEsophagogastroduodenoscopy. (***)

Achalasia:Treatments

Pharmacologic and other nonsurgical treatments• Administration of calcium

channel blockers and nitrates decrease LES pressure (primarily in elderly patients who cannot undergo pneumatic dilatation or surgery)

• Endoscopic intrasphincteric injection of botulinum toxin to block acetylcholine release at the level of the LES (mainly in elderly patients who are poor candidates for dilatation or surgery)

Surgical treatment• Laparoscopic Heller

myotomy, preferably with anterior (more common) or posterior (Toupet) partial fundoplication

• Peroral endoscopic myotomy (POEM)

• Patients in whom surgery fails may be treated with an endoscopic dilatation first

MM PENYAKIT (MOUTH ULCER )LO 6

Mouth UlcersDefinition Canker sores or mouth ulcers are normally small lesions that

develop in your mouth or at the base of your gums. They are annoying and can make eating, drinking, and talking uncomfortable. (*)

Etiology Canker sores, Gingivostomatitis, Herpes simplex (fever blister), Leukoplakia, Oral cancer, Oral lichen planus, Oral thrush. (**)

Sign & Symptoms

A painful sore or sores inside your mouth -- on the tongue, on the soft palate (the back portion of the roof of your mouth), or inside your cheeksA tingling or burning sensation before the sores appearSores in your mouth that are round, white or gray, with a red edge or borderIn severe canker sore attacks, you may also experience: Fever, Physical sluggishness, Swollen lymph nodes (***)

Types of Mouth Ulcers

• Simple canker sores. These may appear three or four times a year and last up to a week. They typically occur in people between 10 and 20 years of age.

• Complex canker sores. These are less common and occur more often in people who have previously had them.

• Mouth ulcers also can be a sign of conditions that are more serious and require medical treatment, such as:– celiac disease (a condition in which the body is

unable to tolerate gluten)– inflammatory bowel disease (IBD)– Bechet’s disease (a condition that causes

inflammation throughout the body)– a malfunctioning immune system that causes your

body to attack the healthy mouth cells instead of viruses and bacteria

– HIV/AIDs

Treatments of Mouth Ulcers

TREATMENTS• using a rinse of saltwater and

baking soda• covering mouth ulcers with

baking soda paste• using over-the-counter

benzocaine products like Orajel or Anbesol

• applying ice to canker sores• using mouth rinse that

contains a steroid to reduce pain and swelling

• using topical pastes

• placing damp tea bags on your mouth ulcer

• cauterizing or burn sealing the tissue with a chemical cauterizer like silver nitrate

• taking nutritional supplements like folic acid, vitamin B6, vitamin B12, and zinc

• trying natural remedies such as chamomile tea, echinacea, myrrh, and licorice

• using oral steroids

Mouth Ulcers

Complication• Cellulitis of the mouth, from

secondary bacterial infection of ulcers

• Dental infections (tooth abscesses)

• Oral cancer• Spread of contagious

disorders to other people

Prevention• There are steps you can take to reduce the

occurrence of mouth ulcers. Avoiding foods that irritate your mouth can be helpful. That includes :

• Acidic fruits like pineapple, grapefruit, oranges, or lemon, as well as nuts, chips, or anything spicy. Instead, choose whole grains and alkaline (nonacidic) fruits and vegetables.

• Try to avoid talking while you are chewing your food. Reducing stress and maintaining good oral hygiene and brushing after meals

• Soft bristle toothbrushes and mouthwashes that contain sodium lauryl sulfate.

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