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