Alterations of Digestive Function I. Clinical Manifestations of Dysfunction Anorexia: lack of desire to eat. Vomiting: forceful emptying of stomach/intestinal contents. (may be associated with nausea and retching) Constipation: difficult defecation (or infrequent) Diarrhea: presence of loose, watery stools - acute - 24 hrs. – 14 days - persistent - 14 – 30 days - chronic - longer than 4 weeks Abdominal pain: may be acute or chronic GI bleeding: Upper GI: esophagus, stomach, duodenum Lower GI: jejunum, ileum, colon or rectum II. Disorders of Motility A. Dysphagia Difficulty swallowing. Most common cause: esophageal obstruction. Distention/spasm of esophageal muscles during drinking or eating = pain at the level of obstruction. Treatment: Dependent on cause. Eat small meals. Take fluid with meals. B. GERD Reflux of acid and pepsin or bile salts from the stomach into esophagus that causes esophagitis. Risk Factors: Age Obesity Hiatal hernia Chemicals that relax the LES Symptoms: Heartburn Acid regurgitation Dysphagia Cough Pain (upper abdomen) *will worsen when you lie down or if intra-abdominal pressure increases. Diagnosis/Treatment: (via esophageal endoscopy) PPIs, antacids, weight reduction, elevation of head while sleeping. C. Eosinophilic Esophagitis Inflammatory disease of the esophagus characterized by an infiltration of eosinophils. Associated with asthma and food allergies. Symptoms: Dysphagia Vomiting Weight loss Diagnosis via endoscopy w/biopsy Treatment w/elimination diet and steroids D. Hiatal Hernia Protrusion (herniation) of the upper part of the stomach through the diaphragm into the thorax. Symptoms: (can be asymptomatic) Heartburn Dysphagia Epigastric pain Regurgitation similar to GERD may also cause chest pain Treatment: Eat small, frequent meals. Avoid recumbent position after eating. Weight control. Surgery E. Pyloric Obstruction Narrowing/obstruction of the pylorus. Maybe caused by peptic ulcer (or duodenal ulcers) Food may not enter the intestine (malnutrition) Symptoms: Fullness Pain (w/muscle spasms) Severe obstruction will lead to gastric distention. Vomiting (copious) (may lead to dehydration) Treatment: Suction of stomach contents – relieve distention PPI (Prilosec) Histamine receptor antagonists (Pepcid, Zantac) Surgery (pyloric stents) F. Intestinal Obstruction Caused by any condition that prevents the normal flow of chyme through the intestines. May be small or large obstructions. Classifications: (examples) Onset (acute v. chronic) Extent (partial v. complete) Location (intrinsic v. extrinsic) Treatment: (based on cause) Surgery required (immediate) for: - strangulation - complete obstructions - perforations III. Gastritis Inflammatory disorder of the gastric mucosa. Acute and chronic. Effects the mucosa. Symptoms: Pain Nausea Vomiting Fullness Treatment: Diet (bland) Smaller meals Avoid alcohol/aspirin IV. Peptic Ulcer Disease Ulceration of the protective mucosal lining of the lower esophagus, stomach, duodenum. Often caused by erosive factors: - NSAIDs (- PG synthesis) - H.pylori infection Risk Factors: Alcohol Smoking Age True ulcers penetrate the muscularis mucosae and can perforate the GI wall. Duodenal ulcers more common than gastric ulcers. Symptoms: Pain after eating. Chronic intermittent epigastric pain. Perforation/bleeding is a common complication. Treatment: Antacids (neutralize acid) Antibiotics (H.pylori) PPIs H2 receptor blockers V. Malabsorption Disorders A. Pancreatic Exocrine Insufficiency Deficient production of pancreatic enzymes required for digestion. May be caused by: - chronic pancreatitis - pancreatic carcinoma - cystic fibrosis Outcomes: fatty stool, vitamin deficiency, wt. loss B. Lactose Intolerance Lactase lacking – genetic defect. Inhibits breakdown of lactose. Symptoms: Gas Diarrhea Bloating Cramping pain Solution: Go lactose free. VI. Inflammatory Bowel Diseases A. Ulcerative Colitis Chronic inflammatory disease that causes ulceration of the colonic mucosa. Occurs most commonly in the rectum and sigmoid colon. Symptoms: (may include) Increased frequency of bowel movements. Bleeding Pain Bloody stool Treatment: Done with the goal of promoting healing of the mucosa; depends on severity. Includes steroids/immunomodulatory agents. B. Crohn Disease Idiopathic inflammatory disorder that affects any part of the GI tract. Inflammations begins in the intestinal submucosa. Ascending/transverse colon most common affected sites. (ileum of small intestine) Symptoms: Diarrhea Rectal bleeding Pain Weight loss Vitamin deficiencies if ileum is involved. Evaluation: Via imaging of small/large intestine. Treatment: Anti-TNF drugs (Enbrel, Humira) C. Diverticulitis Inflammation of the diverticula, herniations or outpocketings of the mucosa and submucosa through the muscle layers. (occur at weak points in intestinal wall) Associated with: - changes in GI motility - increased intracolonic pressure Symptoms: Cramping Pain Diarrhea/constipation Flatulence Treatment: Increased fiber Dietary changes D. Appendicitis Inflammation of the appendix, usually due to obstruction of the appendix lumen no drainage of the appendix bacterial infection. Symptoms: Pain (periumbilical) that intensifies (lower right quadrant) Nausea Vomiting Low grade fever Evaluate with: WBC count/visual image Treatment: Appendectomy Antibiotics VII. Disorders of the Liver A. Acute Liver Failure Impairment or necrosis of liver cells with preexisting liver disease. Acetaminophen overdose is the leading cause of acute liver failure in the US. May also be a complication of viral infection or metabolic liver disorders. Symptoms: Anorexia Vomiting Pain Jaundice Assess via liver function: Increased bilirubin, blood ammonia Treatment: Liver transplant B. Cirrhosis Irreversible, inflammatory fibrotic liver disease. Some causes: Hepatitis B, C Alcohol intake Idiopathic Prolonged exposure to drugs/toxins. Diagnosis: Patient’s history Clinical manifestations (jaundice, weight loss) Liver function tests Treatment Manage symptoms Liver transplantation C. Nonalcoholic Fatty Liver Disease (NAFLD) Infiltration of hepatocytes with fat, primarily triglycerides, in the absence of excessive alcohol intake. Associated with: - obesity - increased cholesterol and triglycerides - type 2 diabetes Most common chronic liver disease in US. Treat with diet and exercise. D. Viral Hepatitis Viral infection of the liver (fairly common). Different strains: different types of hepatitis. 5 types (A E) B,C,D are chronic Assessment: Via manifestations and blood tests for anti-HV antibodies. Treatment: (dependent on type) Immunoglobulin therapy Symptomatic support Interferon treatment VIII. Gallbladder A. Gallstones Formed from impaired metabolism of cholesterol, bilirubin, and bile acids. Contain calcium carbonate. Stones may become lodged in the cystic or common bile duct, triggering pain especially when eating a fatty meal. Pain starts within 30 minutes to hours after a fatty meal. Heartburn, discomfort, flatulence Assessment: (base on) Symptoms Imaging (conformation) Treatment: Remove gallbladder/stones. Balloon dilation of duct. Lithotripsy IX. Pancreas A. Pancreatitis Inflammation of the pancreas. Maybe acute or chronic. 1. Acute pancreatitis Usually due to obstruction of outflow of pancreatic juice. Also linked to alcohol, infection, drug use. Release of enzymes into pancreas. (auto digestion and inflammation) Pain, nausea, vomiting, increased serum lipase Fatal if not treated. Treatment aimed at stopping auto digestion and prevent further complications. 2. Chronic pancreatitis Progressive fibrotic destruction of the pancreas. Chronic alcohol abuse. Destruction of acinarcells and the pancreatic islets. Symptoms: Abdominal pain Weight loss Poor nutrient absorption Outcomes: Decreased pancreatic enzymes. Insulin-dependency (diabetes) Treatment: Cessation of alcohol intake. Cell transplant. Chronic pancreatitis is a risk factor for pancreatic cancer.